Adopting a trauma-informed approach to care in pharmacy
Trauma is an almost universal experience and yet so often the signs remain invisible. As the gateway to care, community pharmacy should adopt a comprehensive approach to trauma-informed care.
In clinical settings, the concept of trauma suggests an injury caused by violence or accident, but this physical representation is only one aspect of trauma and not something that every person has experienced. More widespread is the mental, physical, social, and emotional trauma resulting from experiences such as violence, abuse, neglect and even war.
In 1998, the US-based Adverse Childhood Experiences (ACE) study showed that, of the 9,500 people that responded to a survey, 30% reported substance use in their household; 27% reporting physical abuse; 25% sexual abuse; 17% emotional neglect; 13% emotional abuse; 9% physical neglect; and 14% reporting seeing their mother treated violently.
In addition, research has shown that people in low socioeconomic groups and from black and minority ethnic communities are more at risk of traumatic events.
What is trauma-informed practice?
The impact of trauma can be long-lasting, limit a person’s ability to function, and have a negative impact on future health and wellbeing.
The UK government’s working definition of trauma-informed practice is: an approach to health and care interventions which is grounded in the understanding that trauma exposure can impact an individual's neurological, biological, psychological and social development.
Read more: The pharmacist's role in suicide prevention
Being trauma informed is therefore about recognising that when someone has experienced some form of trauma it can negatively impact their ability to feel safe or develop trusting relationships with healthcare professionals. Pharmacists can use this mindset to create culturally sensitive and safe services that people affected by trauma feel comfortable accessing.
Proponents say trauma-informed practice is also about not pathologising trauma and convincing people there is something 'wrong' with them, but instead seeing beyond their presenting behaviours or symptoms to consider what they need.
Why is it important for HCPs to be trauma informed?
Trauma-informed practice is particularly important in healthcare settings such as community pharmacy for several reasons.
“Healthcare provision is a personal and sometimes uncomfortably intimate experience for anybody”, says a spokesperson from The Flying Child – a community interest company offering training on childhood sexual abuse (CSA) to professionals and providing peer support services for men and women who have experienced CSA. “Survivors of abuse and trauma are statistically more likely to experience health issues, both physical and emotional, over the course of their lives, and so seek support,” they tell C+D.
“These interactions with healthcare providers often come at a time of fear and vulnerability for a patient. Coupled with a perceived (and often actual) power imbalance between patient and provider, this is often reminiscent of the abusive relationship or trauma previously experienced, meaning access to care can itself be traumatic, reduced or entirely prevented if not acknowledged,” they explain.
Key principles of trauma-informed practice
There are six principles of trauma-informed practice:
Safety – prioritising the physical, psychological and emotional safety of patients and staff
Trustworthiness – creating transparency in an organisation’s policies and proceduresin order to build trust among staff, patientsand the wider community
Choice – supporting patients in shared decision-making, choice and goal setting
Collaboration – to overcome challenges and actively involvepatients in service delivery
Empowerment – givingpatients and staff a strong voice in decision-making, at both individual and organisational level
Cultural consideration – moving past cultural stereotypes and biases based ongender, sexual orientation, age, religion, disability, geography, race or ethnicity
Approach in community pharmacy
The most personal conversations pharmacy staff used to have with customers were around topics like emergency contraception but, says Ade Williams, Director and Superintendent Pharmacist of the M J Williams Pharmacy Group, “As the reach of the pharmacy profession expands into ever more clinical areas we are becoming more exposed to the trauma in people’s lives, and some of the lived experience of trauma that exists in our own lives.”
“Kindness, empathy, understanding and trust are the most important aspects of a TI approach in any setting”, says the Flying Child spokesperson., “Trauma-responsive staff will have a deeper understanding of the links between trauma and physical or mental health, the signs of emotional distress and the confidence to broach ‘difficult’ subjects, respond effectively, and signpost, in the event of disclosure,” they say.
Specifically, initial interactions with staff are fundamental. “The feeling that we might be judged for the help we require is often enough to prevent a patient seeking support”, says Flying Child.. “Indelicate questions, a judgemental, or critical response to a request can easily exacerbate that feeling. Particularly where behaviours carry a societal stigma – such as addiction or self-harm – privacy should be considered when discussing treatment, medication, or prevention. An acknowledgement of this, rather than a blanket disapproval, is a much more effective way of changing the conversation to a supportive one that benefits both parties.”
Upskilling pharmacy staff
As with any practice concept, training is vital.
“It is often staff on the tills, for example, who first interact with the customer”, says the Flying Child spokesperson, “so if this first conversation is a positive, empathetic, and understanding one, the survivor is more likely to trust the process they are going through, reducing anxiety, avoiding retraumatisation, and ultimately making the whole experience a more positive one. On the other hand, getting it wrong at this first encounter will mean that the survivor might not engage with any support, refuse treatment, or simply not come back.”
While the School of Health Sciences at The University of Manchester includes teaching and learning around trauma-informed healthcare in its pharmacy degree (and midwifery, social work, nursing, and psychology courses) not all pharmacy education covers trauma-informed angles.
“For a long time, I’ve been saying that community pharmacy needs to take better ownership of mental health in our populations”, says Williams, “which starts with every community team having access to mental health first aid training to know how to look after themselves and their patients.
Williams also calls for pharmacy degree programs to keep pace with practice in a proactive way to ensure pharmacists understand the impact of trauma on patients. The industry also needs to revisit policies to ensure that trauma is not impacting the pharmacist or the way in which the patient is treated.
The Centre for Pharmacy Postgraduate Education (CPPE) offers a number of learning resources that all community pharmacy professionals can access to develop their skills to provide a trauma-informed approach to care. These include resources on safeguarding children and vulnerable adults, domestic abuse, several mental health resources, as well as learning that focuses on suicide awareness and transgender healthcare.
Promoting your trauma-informed pharmacy practice
For pharmacies wanting to promote their trauma-informed practice there are several ways to ensure customers and patients feel that they are in a safe and empathetic space.
“Survivors need to know that the pharmacy is a place where their experiences can be acknowledged”, says Flying Child. Advertising that fact with signage or posters, much in the way domestic violence and coercive control have been recently highlighted, would be a positive step, they say. This ‘passive’ method of signposting can be important because survivors often do not want to talk about their trauma but do want specialist support in an anonymous format. Announcing you are trauma informed/responsive can go some way to building trust and allaying fear.
Staff should show that they are trauma informed by knowing how to react to questions or disclosures [related to trauma] and have access to resources that point at local specialist support, as well as the national help lines from larger providers. Having knowledge of the local support phone numbers and websites, for example, is important as they can be difficult to find, and a victim/survivor might not be in a safe situation to search for them at home themselves.
“Sometimes being local can feel like a more appropriate and supportive option than accessing larger, more faceless support nationally, and third sector peer support is also a good idea,” Flying Child tells C+D.
NHS Education for Scotland (NES) has some well-established workforce goals around trauma-informed practice. It says that “Trauma is everyone’s business and every member of the workforce has a role to play in understanding and responding to people affected by trauma”. In community pharmacy this doesn’t mean that every staff member needs to be a trauma expert, but it does mean that everyone has their own important trauma-informed role to play.
CPPE resources to develop a trauma informed approach to care
Office of Health Improvement and Disparities’
e-learning for healthcare
NHS Education for Scotland (NES) National Trauma Training Programme
The Flying Child – Community interest company offering training on CSA to professionals, as well as providing peer support services for men and women who have experienced childhood sexual abuse.
NAPAC - National association for people abused in childhood.
Rape Crisis – England and Wales rape and sexual violence support service.
Survivors Trust – An umbrella organisation with members in varying support services, nationally and locally.
1 in 6 – Support service for men experiencing sexual trauma.
Mankind - For men in England and Wales affected by unwanted sexual experiences.