The current coronavirus public health crisis is impacting everyone, in ways, only a few weeks ago few of us could have imagined. Tragically, for many children and vulnerable adults in particular, this summer may be the defining event in their lives; as they are trapped in adverse circumstances, unable to readily access the network of support usually available to them.
Now more than ever it is important to consider the subject of childhood adversity, trauma and how we acknowledge and talk about such experiences.
In recent months, the “ACEs movement” has attracted some criticism, and while I understand the sentiment of much of this critique and share some specific concerns about potential unintended consequences, I believe that the increased dialogue about ACEs and the possibilities for mitigation and prevention is a good thing.
Central to this movement and to trauma-informed practice is the shift from asking what’s wrong with someone to asking what happened to them.
With a clear rationale, adequate planning, organisational preparation and commitment, appropriate training and ongoing support for staff, offering help-seeking people the chance to talk about their life experience in the context of an appropriate assessment process can be enormously helpful. And for many practitioners, asking people sensitive questions about their lives will not be out of the ordinary.
The benefits of disclosure
We know that ACEs and traumatising experiences in adult life are incredibly common, and while people frequently recover or don’t have any lasting negative consequences at all, many people do suffer significant and multiple health and social problems as a result.
Asking help-seeking service users about their significant life experiences helps to make sense of things and provide insight into how their past may be affecting their current wellbeing. Often people don’t link what happened to them (or is still happening to them) with their current pain or difficulties.
If you can build trust and ask someone about their lives, they are often willing to tell you in the interests of achieving some kind of improvement to their wellbeing or relief from their problems.
However, I have found in my own clinical practice that while the research suggested that most of my clients would have experienced some kind of childhood adversity or subsequent trauma, very few volunteered this information unless asked directly.
Jamie Pennebaker’s work on the expressive writing paradigm over the last two decades or so shows that keeping secrets and other forms of emotional suppression are bad for your health and are linked to increased rates of illness including some types of cancer, heart disease and various inflammatory conditions. For further reading on the stress-disease connection I recommend ‘Opening up by writing it down.’ By Pennebaker and Smyth, 2016, Guilford Press and ‘When the body says no.’ by Gabor Mate 2003, Wiley.
Not only by sharing adversity and trauma can people experience emotional and physical benefits, but by allowing people to open up and discuss the relevance of such events, we are able (in partnership) to make informed choices about the support that may or may not be required. For me, the ACE questionnaire is a tool that facilitates this process.
Routine enquiry, targeted enquiry and screening – One of these things is not like the others
According to the NHS website “Screening is a way of identifying apparently healthy people who may have an increased risk of a particular condition… so that early treatment can be offered, or information given to help them make informed decisions.”
However, in contrast, routine or targeted ACE enquiry is offered to people who are already experiencing health/ emotional/ social issues and are help seeking.
For example, routine enquiry about adverse childhood experiences is an appropriate approach for services like a drug and alcohol team, where we can reasonably assume from the data that there would be a high prevalence of ACE or adult trauma within that population. There would be a routine offer and the service user would make an informed choice about whether to talk about ACE as part of their assessment.
Targeted enquiry would involve choosing a particular cohort of service users and would make sense in the context of a GP practice for example, where based on local or research evidence, there would be a focus on a particular patient group.
For more about ACE enquiry in primary care please read my recent editorial, ‘Addressing adverse childhood experiences: implications for professional practice’ in the British Journal of General Practice and refer to this evaluation of the REACh (Routine Enquiry about Adversity in Childhood) approach to ACE enquiry in 3 GP practices in Lancashire.
Routine or targeted ACE enquiry in my practice (and the way I teach others to do it), is part of a routine assessment process, which uses a questionnaire purely as a means of facilitating disclosure in the context of a person-centred conversation. There is no scoring!
The goals of early help and informed choices are shared with screening. However, that is where the similarity ends; this is assessment, not screening; it is not a test and it is not intended to assign a risk value to someone or determine who gets help and who doesn’t.
The questionnaire is there to ensure consistency of approach between workers and to promote clarity for service users. We know from research on disclosure of abuse, that more specific questions and the use of questionnaires lead to higher rates of disclosure compared to standard psychiatric interviews (1, 2).
In addition, people that don’t want to say out loud what happened to them can simply indicate on paper if an experience applies to them and several service users have reported to me that seeing a questionnaire made them realise that their experiences were significant, must be common and that it wasn’t just them that this had happened to.
The importance of training and support for practitioners
Reading this blog which critiques the idea of screening for ACEs, caused me to reflect. Particularly on comments about the level of training and experience professionals who speak with children and adults about painful issues should have.
In my experience, staff across our multi-agency workforce talk to people about very personal and painful issues every day.
Of course, not all practitioners are professionally qualified and trained to the same level nor do they have the same degree of experience, confidence or competence. There will always be variation in practice, skills, competence and attitudes across our workforce. Best practice always lies across a continuum.
We also know from multiple studies that that good therapeutic alliance appears to be a crucial factor in the effectiveness of psycho-social interventions and that the quality of the alliance is more predictive of positive outcomes than the type of intervention (3-5). In other words, the quality of the relationship and a shared understanding of a person’s problems and goals are fundamental to effective therapeutic work of any kind. As Irvin D. Yalom, renowned psychiatrist and existential therapist famously wrote, “It’s the relationship that heals.” (see p. 112 of Loves Executioner and other tales of psychotherapy)
Nonetheless, we can, and should, work to mitigate the impact of this knowledge and skill variation across our workforce; and adopting an approach similar to the Scottish Government’s Trauma Training Framework would be a great leap forward for many organisations.
Being clear which knowledge, skills and competencies our staff need in responding to clients affected by trauma is an important area for organisational and professional development and supports the notion of trauma informed practice.
ACE enquiry is not an alternative to best practice – it contributes to it
The process of ACE enquiry does not replace the established and evidence-based offer of a service or team. It is part of an attempt to better meet the needs of clients, to provide the opportunity and space to hear them, to acknowledge their truth and demonstrate acceptance.
I also believe that asking about life events, good and bad, is part of our duty of care to people seeking our help, and an extension of our safeguarding responsibilities. Where there is a high likelihood of our service users experiencing childhood adversity and / or subsequent trauma, we should ask if any of these things have happened, and crucially if they are still happening.
My co-author of the BJGP editorial, Dr Peter Cairns, wrote a companion piece expanding on his experience of implementing ACE enquiry in his GP practice, which provides a fitting conclusion:
“Finally, at the heart of ACE enquiry must be the idea of being clinically effective for our patients. I don’t know what form our ACE enquiry will take in the future, whether we stick with the current questions, whether we score it, whether we see it is as an individual or population level intervention. I do know that it offers an alternative way into our communities, particularly into those populations where ‘business as usual’ has achieved depressingly little over several decades. ACE enquiry is not an alternative to data driven innovation or hard-nosed clinical practice; it is complementary to it. It equips us with new tools and updated science to help us explain phenomena we see every day, to feed what should be a natural curiosity to better understand what happens to our patients and why.”
Join the conversation. You’ll find me on Twitter @warren_larkin and LinkedIn.
1. Wurr CJ1, Partridge IM. (1996) The prevalence of a history of childhood sexual abuse in an acute adult inpatient population. Child Abuse Negl. 1996 Sep;20(9):867-72.
2. Dill DL1, Chu JA, Grob MC, Eisen SV. (1991) The reliability of abuse history reports: a comparison of two inquiry formats. Compr Psychiatry. 1991 Mar-Apr;32(2):166-9.
3. Martin D. J., Garske J. P., Davis M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. J. Consult. Clin. Psychol. 68, 438–45010.1037/0022-006X.68.3.438
4. Shirk S. R., Karver M. (2003). Prediction of treatment outcome from relationship variables in child and adolescent therapy: a meta-analytic review. J. Consult. Clin. Psychol. 71, 452–46410.1037/0022-006X.71.3.452
5. Karver M. S., Handelsman J. B., Fields S., Bickman L. (2006). Meta-analysis of therapeutic relationship variables in youth and family therapy: the evidence for different relationship variables in the child and adolescent treatment outcome literature. Clin. Psychol. Rev. 26, 50–6510.1016/j.cpr.2005.09.001