Spotting trauma before it leads to drama

Monica O'Carroll has learned to consider the ‘bigger picture’ when dealing with a client who exhibits challenging behaviour, and attributes her change in outlook to trauma awareness training

Monica O'Carroll has learned to consider the ‘bigger picture’ when dealing with a client who exhibits challenging behaviour, and attributes her change in outlook to trauma awareness training.

The course showed how past trauma can often be the root of symptoms such as anxiety, phobias, self-harm, abusive behaviour or withdrawal. However, it taught her that dealing with the source of a problem does not necessarily lead to overnight change.

‘Sometimes, as practitioners, we have a referral and we like to see it through with a finished product at the end,’ says Ms O’Carroll, a senior community learning disability nurse at Hertfordshire County Council Health and Community services.


‘But it’s also seeing it in a holistic way. The course made me realise that it might involve a much longer piece of work than just seeing through the problem raised in the referral; that might lead on to a more detailed piece of work or a further referral to therapeutic services.’

The course, commissioned by her employers, was designed and delivered by Respond, a learning disability charity founded in 1991 to lessen the effect of trauma and abuse on people with learning disabilities. Its services include psychotherapy for people with learning disabilities, advice and support for staff and family members, and training for carers and professionals. The charity’s psychotherapists recently conducted trauma assessments for 21 former residents of the now closed Winterbourne View, for example.

'Trauma history'

Respond chief executive Noelle Blackman says that many of the people who end up in assessment and treatment services do so because a ‘trauma history’ has not been picked up.

The likelihood is that the challenging behaviour is put down to someone’s learning disability, rather than recognised as potentially having its origins in early or repeated trauma. If the person’s behaviour is related to feelings about previous experiences, but that is not acknowledged, the cycle continues.

‘Certainly when abusive things happen in settings where people who depend on others to provide care get abused instead, then they have definitely experienced trauma, and we are not convinced that this is considered when the person moves on somewhere else, so we are constantly re-traumatising people,’ says Blackman.

Real pain

Abuse aside, people with learning disabilities often experience traumatic lives and an understanding that some of their challenging behaviour is a manifestation of real pain is useful for clients and staff, she argues.

‘If we can recognise that, and recognise that some behavioural responses are trauma responses and we behave in a way that recognises that, and helps the person to be less traumatised, and de-traumatised…

‘In a sense what you get is a trauma cycle: if you don’t recognise the trauma, the staff become more traumatised, and everything becomes dramatic and there are huge over-responses to behaviour. The staff can begin to feel angry and aggressive because they’re not recognising what cycle they’re involved in so they are re-traumatising people without realising that’s the cycle they’re involved in.’

Emotional shock

Ms Blackman defines trauma as the emotional shock that someone experiences following a terrible event that involves an actual or perceived threat to one’s physical or mental wellbeing.

‘Trauma can also occur in response to witnessing a similarly terrible event involving someone else, or when being given sudden shocking news about a relative or someone you know well. For the event to be traumatic the person’s response must involve intense fear, helplessness or horror, and must overwhelm the normal coping mechanisms.

‘The shock of experiencing a traumatic event can have a physiological as well as a psychological impact.’

Pilot course

Formerly a drama therapist, Ms Blackman approached Hertfordshire County Council in 2013 about piloting a course for learning disability nurses. The local authority invited senior social workers and band 6 community nurses within its integrated service to apply. A group of six – two learning disability nurses and four social workers – went to the charity’s offices in London to take the course one day a week for six months in 2014.

Ms O’Carroll says that the course was academically demanding and emotionally taxing at times, but it was rewarding to gain a better understanding of the negative spiral that clients and staff feel if an underlying problem is not recognised.

The course introduced core psychodynamic ideas, including the impact learning disabilities can have on some individuals and/or their families, the concept of vicarious trauma – essentially the knock-on effect on professionals as a result of working with traumatised individuals and the impact on an organisation. The students also learned about systems and the need to ensure staff receive appropriate support and supervision.


Ms O’Carroll says: ‘Staff working with people with challenging behaviour on a daily basis can find the experience overwhelming, become burnt out and end up leaving their jobs or become detached. This affects the service user, where they’re either not supported or their life of turmoil and change is being continued because of staff team turnover. So if staff can be supported to understand where the behaviour has come from, using reflective practice under a skilled supervisor, that really makes a difference.’

If staff can be supported to understand where the behaviour has come from, using reflective practice under a skilled supervisor, that really makes a difference

Ms O’Carroll says trauma awareness gives an understanding that things one might not even consider traumatic can be so for someone with a learning disability. ‘Often we talk about grief, yet our service users can be excluded from the grieving process, so that they don’t get “upset”. But it means their grief is not being addressed and it can have a much more devastating impact at a later date.’


Ms Blackman says the premise of the course was that the staff could then impart their understanding of trauma awareness in the workplace. ‘We might expect them to say “this looks like behaviour that is connected to trauma, so let’s think about this person’s life story together, let’s try and put all the pieces together, let’s look at some of the triggers. Do they seem to have a connection? How can we work to make this person feel safe?” To connect up and allow trauma to be an element of thinking around this person.’

More than a year on, the challenge is how a handful of senior practitioners can champion this across the wider integrated service, which includes more than 30 nurses working across seven community learning disability teams.

Ms O’Carroll and three other former course participants – one moved to another role and another into management – meet one afternoon most weeks to discuss ways to disseminate their knowledge into wider practice. Trauma awareness presentations have been delivered to teams and they are now starting to take referrals from colleagues via the transforming care team for case consultation, drawing on their acquired knowledge. Staff will be asked to identify three significant areas of difficulty and asked what outcomes they hope to see.


‘It’s about the awareness and the understanding, and sometimes just saying that it’s not going to change significantly, immediately,’ Ms O’Carroll says. ‘It is about understanding how positive change happens and how it can take a long time, and reassuring staff about that.’

Hertfordshire County Council strategic lead nurse for health and community services Alison Fitzgerald says the work chimes with the Transforming Care agenda and colleagues have been struck by the change in the practitioners who took part. It was Fitzgerald who made the case to the council leadership to take part in the pilot training course, jointly funded by the local authority and the Department of Health, in a bid to improve the experience and health outcomes of people with learning disability, and to provide an innovative training opportunity for experienced staff.

Ms Fitzgerald says she and Ms Blackman are looking at the ‘next step’, when more senior staff are sent on the training. The council has ensured that Respond, which has received two further course commissions from elsewhere in the country, continues to provide Ms Fitzgerald and her colleagues with monthly supervision..


With greater awareness of the history of trauma and loss, which may underlie a person’s behaviour, may come a greater demand on resources to ensure that clients’ identified needs are met, such as an increase in referrals to counselling. Could this prove a road block to their aims in an era of austerity? Ms Fitzgerald argues that the approach looks at long-term support, rather than short bursts of work with short-term outcomes.

‘If it’s right for the person and helps contain that person in the way they should be supported and living in a good way, and it will eventually lead to that person not having to have readmissions or breakdowns, there is actually a cost benefit. Supporting someone in the right way within a system they are familiar with where they are getting the right support, is much better. Although it might be more costly in one way, in the longer term, the cost will reduce.’






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