Trauma-informed care and PTMF reduce self-harm, isolation and restraint in the acute inpatient psychiatric setting

A recent study published in Frontiers in psychology suggests that adopting a Trauma-Informed Care (TIC) approach in inpatient psychiatric settings can significantly reduce self-harm and the use of isolation and restraint.

The researchers, led by clinical psychologist Faye Nikopaschos, attribute this reduction to weekly staff training on psychological stabilization and the use of the Power Threat Meaning Framework (PTMF). The PTMF provides an alternative to the prevailing disease/diagnosis-centred approach in hospital settings, focusing on the lived experiences of service users.

Nikopaschos and his team say:

“The findings suggest that PTMF team training and psychological stabilization training may contribute to significant reductions in self-harm and restrictive interventions (isolation and restraint) in adult mental health departments.”

Illustration of the PTMF framework by psychologist Juliet Young (@Juliet_Young1)
Illustration of the PTMF framework by psychologist Juliet Young (@Juliet_Young1)

The study aimed to evaluate the impact of TIC, applied through PTMF and staff psychological stabilization training, in an inpatient psychiatric facility. The team measured and compared the frequency of self-harm, isolation and restraint in a National Health Service adult inpatient mental health unit in London, both before and after the implementation of the TIC. Data were collected from two wards, starting with 23 and 22 service users and decreasing to 18 in each over the duration of the study.

Data collection started in July 2017, before the introduction of ICT. The team introduced ICT in July 2018, and data collection continued for the next four years through June 2022. They introduced two trauma-informed practices, PTMF Team Formulations and Psychological Stabilization Training, across both departments in July 2018.

Two staff members conducted weekly PTMF formulations. While service users were not physically present during these one-hour sessions, they were briefed, asked for consent, and asked to lead the team on what to consider in the meetings. Service users received feedback after the meetings.

The researchers created a stabilization manual that guided the psychological stabilization training provided to staff in each department. The team engaged in weekly hour-long meetings to discuss topics such as self-compassion, calming and safety, mindfulness, effective communication, breathing and relaxation, food and sleep, distraction and distance, activities that are enjoyed, grounding, and maintaining well-being.

During the five-year study period, there were 257 self-harm incidents, of which 93 occurred in the year before the TIC was implemented and 164 in the following four years. After the introduction of the TIC, the monthly average of self-harm episodes decreased from 7.75 to 3.42, a reduction of 55.91%. Each year following the introduction of TIC there has been a further decrease in self-harm incidents, from 13.98% in the first year to 89.25% in the fourth year.

The study recorded 474 cases of isolation, of which 123 before the TIC and 351 after. The average monthly prison sentence decreased from 10.25 to 7.31 after the TIC, a reduction of 22.66%. The most significant decrease occurred in the second year after the introduction of the TIC, with a reduction of 41.46%. However, prison terms increased slightly in the third and fourth years due to staff shortages due to COVID-19, but remained below pre-TIC levels.

The researchers noted 812 cases of restraint during the study, of which 193 occurred before the TIC and 619 after. The average monthly use of the restrictions decreased by 19.82%, going from 16.08 to 12.90, after the TIC. Just like the lockdown data, the use of restrictions was lowest in the first two years following the introduction of TIC, but increased in the third year due to staff illness caused by COVID-19 and decreased again in the fourth year.

The authors acknowledged some limitations to their study. First, service users and medical personnel were not involved in the initial design of the project. However, there are efforts to change this in ongoing projects. Secondly, the medical staff were not involved in the creation of the interventions. Third, the absence of a control group means that the observed changes in self-harm, restraint, and isolation cannot be conclusively attributed to TIC. Finally, the reduction of bed places during the research could also have influenced the results.

In conclusion, they stated:

“This service evaluation outlines a new model for Trauma Informed Care (TIC), which includes Power Threat Meaning Framework (PTMF) team formulation and psychological stabilization training. The results suggest that the implementation of this model can contribute to significant and sustained reductions in episodes of self-harm, isolation and restraint in an adult inpatient mental health setting and highlight the benefits of TIC in this setting.

Researchers argue that understanding psychological distress requires addressing issues of power, as done in the PTMF. Past research has found that many psychologists are dissatisfied with the current focus on DSM diagnoses, but are unfamiliar with alternatives such as PTMF. Academics have also advocated for the use of PTMF in the education of mental health nurses.

However, some scholars warn that ICT approaches may be an excuse to simply continue the diagnosis/disease-centred models in a language more attractive to service users. Furthermore, others have argued that TIC risks re-traumatizing some service users.

In conclusion, this study provides compelling evidence for the potential benefits of implementing Trauma-Informed Care (TIC) in acute inpatient psychiatric settings. The use of the Power Threat Meaning Framework (PTMF) and staff psychological stabilization training appears to significantly reduce instances of self-harm, isolation and restraint.

While some have raised concerns about the use of ICT, the dramatic decrease in harmful incidents within this study points to a promising departure from the traditional disease-focused approach. The authors call for more research and advocate broader training in ICT and PTMF among psychiatric health care providers, suggesting this as a viable and effective pathway to improve patient care in mental health settings.

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Nikopaschos F, Burrell G, Clark J, and Salgueiro A (2023) Trauma-Informed Care in Mental Health Wards: The Impact of Power Threat Meaning Framework group formulation and psychological stabilization on self-harm and restrictive interventions. Frontiers in psychology. 14:1145100. doi:10.3389/fpsyg.2023.1145100 (Link)


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