Routine Enquiry about Adversity in Childhood (REACh) programme
The REACh Model
REACh aims to raise awareness amongst professionals and the public about long term outcomes of childhood adversity and trauma. This is achieved by establishing and supporting organisational practice and culture change by embedding REACh within every appropriate assessment.
REACh involves, as part of the model of delivery, one or two-day training on why, when and how to enquire safely and sensitively, alongside organisational support, helping teams to navigate potential risks and challenges and to ensure appropriate staff support is in place.
The model has five key elements.
Stage one is a co-produced audit and evaluation of an organisations readiness to engage in routine enquiry. This helps to identify any potential systemic barriers and supports organisational buy-in.
Stage two involves consideration of change management processes and a review or design of an organisations specific systems and processes required to support effective and safe enquiry.
Stage three, is the delivery of REACh training, which is tailored to the organisations specific needs, in terms of content and delivery methods.
During stage four, the REACh team offer time-limited follow-up support to the organisation, including consultation and supervision for staff and leadership teams, to ensure effective implementation.
Finally in stage five, the team support the organisation to evaluate the implementation of REACh, to assess practice change and the impact on their service and service-users.
In 2014, evaluation of the experiences and insights of staff trained in REACh revealed a number of positive impacts on professional practice and client outcomes (Pearce et al., submitted manuscript). For instance, REACh training inspired practitioners to develop an trauma-informed understanding of clients’ experiences, resulting in clinical practice changes, which, in turn, facilitated more lasting change for clients. It was found that enquiries encouraged clients to make links between their past and their present situation, enabling them to accurately identify the right support for them, at the right time. The research findings also suggested that not all clients required, or wanted referrals for psychological or other practical support in relation to their disclosure. In the majority of cases, therapeutic conversations with practitioners seemed to be sufficient to encourage meaningful change.
In 2015, an independent evaluation of the REACh programme (Real Life Research, 2015) found that Reach training equips practitioners with the knowledge and tools to conduct routine enquiry effectively with the people they support. All practitioners who attended the training reported that it was useful, enjoyable and increased their knowledge and awareness of childhood adversity and trauma, including its widespread impacts. REACh was found to initiate earlier intervention, as a result of speedier disclosures. Importantly, practitioners reported no issues with implementing REACh in their practice and reported no increase in service need following the enquiries made. Participants and managers felt that they were able to create with the individual a more appropriate intervention plan if they have enquired about previous experiences, dealing with the root cause of presenting issues rather than the ‘symptom’.
In 2016, a qualitative evaluation explored the impact of REACh on parents accessing an early help family support team (Simpson-Adkins and Daiches, submitted manuscript). Results demonstrated that all parents agreed to engage in enquiries. Although the process of disclosure was emotive, parents’ post-disclosure reflections resulted in a process in which they re-evaluated their parental goals, roles and priorities. This re-evaluation appeared to initiate a drive to parent differently, propelled by their desire to give their child a better start in life. These results demonstrated that, without any post REACh intervention, parents appeared to engage in a self-determined process of post-disclosure behaviour change, alongside a number of positive impacts, such as increased mentalizing capacity (Allen and Fonagy, 2006) and experiences comparable to post-traumatic growth (Tedeschi and Calhoun, 2004). These impacts resulted in reports of improved relationships between parents and their children.
Most recently, in 2018, Public Health Wales published an evaluation of the feasibility and acceptability of using REACh to facilitate asking about a history of ACEs in a large multi-site GP practice in North West England. The findings explore practitioner experiences of delivery and potential impacts on patients. 218 patients participated and findings indicate that there was a very high level of acceptability to both patients and staff. There was no observed increase in service need following enquiry and 70% of patients who responded to the post enquiry survey, said they felt their appointment was improved because the GP/ Nurse understood their childhood better. In addition, the study found that people with two or more ACEs had worse physical and mental health compared to patients with no ACEs promoting the authors to conclude, “The higher prevalence of both physical and mental health problems among adult general practice patients with ACEs highlights a clear need to respond to wider determinants and examine a more trauma-informed approach in primary care.” Specifically, people with two or more ACEs were 2.5 times more likely to have Asthma, 3 times more likely to have multiple chronic long term conditions and 3.5 times more likely to have mental health problems. In addition 67% of patients with ACEs reported that this was the first time they had ever told a professional about them. When compared with the three months prior to REACh, 43.5% of patients with ≥2 ACEs actually attended the practice less in the three months following ACE enquiry, and 89.1% showed reduced medication use over the same period. The authors concluded, “This proof of concept report provides initial support for the acceptability of ACE enquiry in general practice among both patients and practitioners, who identified it as a means of improving the patient-practitioner relationship and better understanding wider determinants for health and wellbeing.” The full report can be found here http://www.aces.me.uk/in-england/