Responding to challenges people face in relation to complex trauma and mental health crisis
Projects
THIS Institute Fellowship: Investigating mental health practitioners’ referral decisions to mental health services for people attending the Emergency Department for self-harm: A mixed methods enquiry
City St George’s Lead: Professor Rose McCabe
Funder: THIS The Health Care Improvement Studies Institute, £118,308
Duration: October 2023 to September 2026
Prospective student: Mimi Suzuki
Background: More than 700,000 people die by suicide annually (GBD, 2020). The strongest predictor of suicide is self-harm, defined as self-poisoning or self-injury irrespective of intent. In England, around 220,000 people present to the Emergency Department (ED) with self-harm each year (Hawton, et al., 2007). A psychosocial assessment is routine care for those who present with self-harm. Mental health practitioners (MHP) assess the person’s needs and risks (of harm to self others) and decide immediate care (discharge or inpatient admission) and/or referral to mental health services (NICE).
However, service access criteria create systemic barriers to access mental health services for those presenting to ED with self-harm. Those with a diagnosis of personality disorder or alcohol misuse (Allsopp & Kindeman, 2021), risk-level that is too high or low, needs that are complex (Beale, 2021), or present frequently, are often excluded from services. Limited access is linked to a deterioration in mental health and repeated attendances to the ED (O’Keeffe et al., 2021) contributing to the £162 million hospital costs for self-harm annually (Tsiachristas et al., 2017). Service users report help-seeking as ‘futile’ (De Leo et al., 2022) with some dying by suicide after repeated service contacts (Flynn et al., 2020).
MHPs in ED take on the role of ‘gatekeepers’ deciding on services offered based on ‘tacit knowledge’ acquired through immersion in practice - knowledge about service criteria and ‘types’ of cases and who is likely to benefit from care - alongside technical knowledge informed by their training (Brummell et al. 2016; Dixon-Woods, 2006). Greater reliance on tacit knowledge can lead to bias towards exclusion (Liberati et al., 2022), reflected in psychosocial assessments (Bergen, McCabe et al. in prep), and medical notes, when practitioners formulate their referral decisions (Beale, 2021).
There is a need to understand MHPs’ decision-making based on tacit knowledge and the impact on subsequent mental health journeys for people presenting to the ED with self-harm.
Research Questions (RQs):
- What is the existing evidence on how MHPs make referral decisions to mental health services for those who present to the ED for self-harm?
- How do MHPs make referral decisions to mental health services, and how is that recorded in the medical records and in the ED psychosocial assessment?
- What is the impact of practitioner referral decisions to mental health services on patient mental health journeys?
Setting: This PhD will be embedded in a NIHR programme grant led by McCabe (ASSURED – Improving outcomes in patients who self-harm), supporting its feasibility. It will run alongside the ASSURED trial, recruiting from a number of EDs. Established partnerships with clinical staff will enable access to participants and video data of psychosocial assessments collected as part of the trial. Ethical approval has been granted in to video-record psychosocial assessments in the ED.
Find out more here: Mimi Suzuki - THIS Institute - The Healthcare Improvement Studies Institute
Evaluating and refining new mental health peer worker training modules for underserved populations
City St George’s Lead: Professor Steve Gillard
Funder: NIHR / DHSC Department of Health and Social Care, £9,720
Duration: February 2023 to September 2024
This project aims to support implementation, dissemination and increased accessibility of applied outputs from the NIHR-funded Programme Development Grant, ENRICHMENT (NIHR202616), led by the PI and adopted by the Mental Health theme within the North Thame ARC. ENRICHMENT was awarded as a follow-on to the ENRICH Programme Grant for Applied Research (RPPG-1212-20019) which developed and trialled manualised guidance and training for the implementation of peer support into mental health services. ENRICHMENT is using data from the original ENRICH programme, plus new primary data, to revise the existing training programme and produce new training modules in 1) race, culture and peer support, 2) peer support in Complex Emotional Needs services, and 3) trauma-informed peer support.
The original ENRICHMENT grant funded data collection and analysis, and coproduction of the training modules with the support of a Lived Experience Advisory Panel. This work will be completed to timeline by 30 March 2023, the end of the funded research. The specific aims of this project will be to further refine the training modules through delivering them in mental health NHS Trusts in the North Thames area and then conducting focus groups with participants (peer workers) and trainers (senior peer leaders) or peer to produce final version of the new modules. At the end of the project, we will make the new modules available to peer support services within all mental health NHS Trust in North Thames and beyond (parallel work is underway with East London Foundation NHS Trust to make the full ENRICH guidance and training programme widely available across the NHS).
We have good working links with peer support services in East London Foundation NHS Trust, North East London Foundation NHS Trust and Camden & Islington Foundation NHS Trust, and will explore opportunities to extend the project to Essex Partnership University Foundation NHS Trust. We will begin the project by identifying a pool of peer trainers (senior peer leaders) within each trust with whom we will conduct train-the-trainer sessions to support delivery of the new modules. We will then co-deliver our new modules with local trainers to a cohort of current peer workers within each Trust, running each module at least twice (in different Trusts). After delivery we will collect end of session feedback and hold focus groups exploring accessibility, feasibility of delivery, structure and content of each module with both trainees and trainers, using those data to produce a final version of each module following a final round of feedback from trainers and our Lived Experience Advisory Panel.
Developing and evaluating a new care pathway to improve outcomes for people with complex trauma (PATHWAY): mixed method development work leading to a programme of applied research
City St George’s Lead: Professor Steve Gillard
Funder: NIHR / DHSC Department of Health and Social Care, £66,541.66
Duration: September 2022 to July 2024
People with histories of complex trauma – including enduring experiences of violence and abuse, often beginning in childhood – can experience relationship difficulties, emotional dysregulation and poor mental health. A high proportion of people using secondary mental health services have underlying complex trauma, especially those with diagnoses of psychosis, Emotionally Unstable Personality Disorder and major depression.
While there is an increasing range of evidence-based treatments for complex trauma, in practice people using mental health services are unlikely to be assessed for trauma and experience considerable barriers to accessing appropriate care. Mental health services can be experienced as re-traumatising, discouraging trauma survivors from accessing NHS mental health care.
The aim of our future programme grant will be to develop and evaluate a new care pathway to improve outcomes for people using mental health services who have underlying complex trauma. In this programme development grant we aim to coproduce a logic model and outcomes framework that informs the scope of a high-quality programme, addressing the following preliminary research and methodological questions:
- What are the range of outcomes (including economic) impacted by a trauma-informed approach to care?
- What are the existing care pathways for complex trauma survivors?
- How do pathways differ for disadvantaged (minority ethnic and socio-economic) groups?
- How do we identify people meeting criteria for complex trauma from electronic patient records?
- How do we sensitively interview trauma survivors about their experiences of mental health services?
Workpackage 1 is a rapid evidence synthesis identifying a full range of outcomes, at individual and service level, relevant to robust evaluation of trauma-informed care.
Workpackage 2 will be a clinical records study, building on existing research using Natural Language Processing, to a) develop an approach to identifying people who meet criteria for complex trauma from electronic patient records, and b) identify and capture diagnosis and service use histories from a range of adults with complex trauma (n=200) from each of two mental health NHS Trusts to describe typical trauma care provision and pathways, including for disadvantaged groups.
Workpackage 3 will be a qualitative study interviewing trauma survivors (up to 24) and conducting focus groups with clinical staff (up to 32 in 4 groups) providing current trauma care – recruited from the NHS and community-sector services – to identify outcomes of introducing trauma-informed care, experiences of existing pathways, and the barriers and facilitators of accessing trauma treatment.
Critical interpretive synthesis involving survivors and clinicians will bring together findings from all workpackages to develop the logic model and outcomes framework. A Lived Experience Advisory Group of trauma survivors will coproduce all aspects of the research and co-evaluate the impact of survivor involvement on the research.
We aim to deliver study outputs within a year, building a team combining research, survivor and clinical expertise with NHS and community-sector providers to take forward our programme grant application. This research potentially improves identification of people with complex trauma and more appropriate methods for conducting research with trauma survivors. Research outputs will be communicated through our academic, clinical, policy and survivor networks.
ENRICH into practice: informing the successful introduction of peer workers into mental health services (ENRICHMENT)
City St George's Lead: Professor Steve Gillard
Funder: NIHR / DHSC Department of Health and Social Care, £106,432.50
Duration: June 2021 to July 2025
Background
Peer support is rapidly being introduced into mental health services internationally. Increasing numbers of people with personal experiences of using mental health services are being employed as peer workers, driven by healthcare workforce policy. Evidence suggests that receiving peer support can improve personal recovery, empowerment and strengthen social networks, outcomes associated with longer term clinical recovery.
However, systematic reviews indicate that these benefits are not always realised, with other research suggesting that appropriate training and support for peer workers is not always in place. The complexities of how peer support might work in different cultural contexts, and in specialist clinical services are little understood. These issues all impact the implementation of peer support into practice and therefore limit potential patient benefit.
The ENRICH programme (RP-PG-1212-20019) developed and trialled a peer worker intervention to improve outcomes of psychiatric discharge. Results indicate that while there was no overall effect on readmission (our primary outcome), people who engaged with a minimum level of peer support were significantly less likely to be readmitted, as were black participants. Qualitative data suggested that support from peer workers who had used similar clinical services might be beneficial.
Aims and Objectives
This study aims to build on learning from ENRICH to understand the best way to implement peer support and so maximise patient benefit. We will coproduce an online version of the ENRICH handbook, training manual and fidelity index, with enhanced guidance on implementing peer support in mental health services, and new training modules on diversity and peer support in complex needs services.
Development work questions
The study asks:
- what implementation factors are associated with service user engagement with peer support?
- how is peer support best implemented to maximise benefits for people from Black and Minority Ethnic (BAME) communities?
- how is peer support best implemented to maximise benefits in different clinical settings?
Development work plan
WP1 (months 1-7): update the ENRICH systematic review, conducting a rapid synthesis of data addressing implementation issues in peer support, including in different cultural and clinical contexts.
WP2 (months 1-7): conduct additional analyses of trial data (n=590), exploring predictors of engagement with peer support, including the impact of matching peer worker and participant by ethnicity and diagnostic group. Conduct further analyses of qualitative interview data with peer workers, service users they supported and their supervisors (n=79), exploring experiences of support for peer workers, diversity and peer support in different clinical settings.
WP3 (months 7-12): conduct additional in-depth interviews (n=32) to develop focused understanding of specific implementation questions raised in WPs1-2.
WP4 (months 8-18): work with lived experience and clinician advisory panels to coproduce and test, using findings synthesised from WPs1-3, our applied outputs.
Anticipated Impact and Dissemination
We will use our clinical, service user and policy networks to promote access to new guidance and training. Applied outputs will improve implementation of peer support in the NHS, maximising patient benefit including in BAME groups and complex needs services. Academic outputs will inform future efficacy and implementation studies of peer support.
Find out more here: ENRICH into practice: informing the successful introduction of peer workers into mental health services (ENRICHMENT) - NIHR Funding and Awards
Trauma-informed care in the emergency department for patients who self-harm
City St George's Lead: Aneta Zarska (PhD student)
Team: Kirsten Barnicot, Mary Lavelle and Rose McCabe (supervisors)
Funder: City St George's, University of London
Summary: Emergency Departments are often the first point of contact with the healthcare system following a self-harm episode or a suicide attempt. However, patients presenting with mental health issues often describe that the ED environment can trigger fears and traumatic memories (re-traumatization), and that ED staff approach them in ways that exacerbate the stress they are already experiencing.
A trauma-informed approach (TIC) to care for patients at suicide/self-harm risk appears very relevant due to the strong associations between trauma exposure and suicidality/self-harm. However, the infusion of TIC across EDs in the UK has not yet been explored/established, and there has been a lack of attention to the potential benefits of TIC for patients who self-harm. The PhD project aims to fill in this gap with four interlinked projects.
Firstly, a systematic review will evaluate
- training interventions for generalist ED providers
- psychosocial interventions delivered by ED generalists when treating patients presenting with self-harm and suicidality
- the extent to which the interventions’ components align with those of TIC.
Secondly, qualitative interviews with UK emergency department staff will examine ED providers’ understanding of the link between trauma and self-harm/suicidality, and their experiences and perspectives regarding TIC, with a specific focus on patients presenting with self-harm.
Thirdly, qualitative interviews with people presenting to the emergency department will explore their experiences of self-harm and treatment in the ED, with a specific focus on the traumatic nature of these experiences. Finally, we will reach consensus on the principles of trauma-informed care in the ED for patients who present with self-harm by inviting key stakeholders, comprising of both ED staff and service users, to reflect on and reach agreement on this issue using a Delphi approach.