Trauma and Trauma-Informed Care in Early Intervention in Psychosis: State of Implementation and Provider Views on Challenges
Abstract
Objective:
Although trauma is increasingly recognized as a major risk factor for psychosis and for its link to treatment outcomes, the landscape of trauma-related practices in specialized early psychosis services in the United States and other countries remains only poorly characterized. Research documenting the perspectives of frontline providers is also lacking. The primary goals of this study were to document the state of trauma-related policy implementation in early intervention in psychosis (EIP) programs and to gather provider perspectives.
Methods:
This was a mixed-methods project involving an international EIP provider survey, followed by in-depth provider interviews. The survey was disseminated in Australia, Canada, Chile, the United Kingdom, and the United States. In total, 164 providers, representing 110 unique sites, completed the survey. Frequencies were calculated for responses to survey items, and open-ended responses were analyzed with a systematic content analysis.
Results:
The survey findings suggested low implementation rates for a variety of assessment and support practices related to trauma and trauma-informed care. Coding of open-ended responses revealed numerous concerns and uncertainties among providers regarding the relationship between trauma and psychosis and the state of the EIP field.
Conclusions:
An expansion of research and service development aimed at better meeting the trauma-related needs of young people with psychosis is essential, with implications for EIP outcomes and service user and staff experiences.
HIGHLIGHTS
•
Trauma assessment and treatment are underused within specialized early psychosis services.
•
Providers of early intervention in psychosis (EIP) described how gaps in EIP policy implementation, knowledge, and training affect their ability to assess and manage trauma in early psychosis contexts.
•
Diagnostically driven inclusion and exclusion criteria may lead services to focus narrowly on classic psychosis symptoms, leaving trauma assessment and treatment options underdeveloped.
There is increasing consensus regarding the significant role of trauma in psychosis. In the context of first-episode psychosis (FEP), which affects relatively young people, studies indicate that traumatic experiences are prevalent in the FEP population and that adverse experiences in childhood are connected to an increased likelihood of developing a psychotic disorder (1–3). Trauma is also understood to influence the content of psychosis (4). Childhood trauma is a significant predictor of poor FEP outcomes on measures of functioning and psychotic experiences (5–7). The intersection of trauma with aspects of structural adversity, such as involvement with the criminal legal system, demands skillful assessments to understand needs and appropriate treatment of individuals with FEP (6). Moreover, treatment within mental health systems and psychotic experiences themselves are recognized as sources of trauma that need attention (8, 9).
Internationally, guidelines for treating individuals with early psychosis recommend trauma assessment and treatment (10–14). Consensus-based principles for trauma-informed early intervention in psychosis (EIP) services have also been developed (15). Trauma-focused psychotherapy is now being tested in clinical trials specifically for FEP (16–18), building on existing research (19–22). EIP service users’ perspectives highlight the challenges of discussing trauma and the importance of professionals’ sensitivity to the presence of trauma (23). Little is known, however, about the state of trauma-related care in practice, with potentially significant implications for EIP outcomes, as well as consumer and clinician experience of EIP services. This study focused on the reporting of EIP providers regarding the implementation of trauma-focused assessments, interventions, and policies within EIP. This particular focus represents one component of a larger effort to understand the current state of EIP outcomes, policies, and practices in the context of racial-ethnic differences, structural determinants of health, and trauma. Findings regarding racial-ethnic differences and social determinants of EIP outcomes were previously reported (24).
Methods
Study Design
This mixed-methods study was conducted in three phases. First, informal EIP provider interviews were conducted to develop a provider survey. Second, the survey was piloted and reviewed by an independent group of EIP providers and then finalized and disseminated online. Recruitment methods included e-mails sent to all program directors publicly listed in available national and international directories (including listings available through the International Early Psychosis Association, Prodromal and Early Psychosis Network in the United States, Early Psychosis Intervention Ontario Network in Canada, and the Early Intervention in Psychosis Network in the United Kingdom). Finally, we also disseminated flyers to known national and regional EIP leaders and via national and regional early psychosis Listservs and newsletters. The survey was active between September 2017 and January 2019. The study was approved by the University of South Florida Institutional Review Board. Participants gave informed consent online.
Participants
The survey targeted providers working in specialized EIP services. A total of 164 participants completed the survey and were included in the analyses. Participants represented programs in 110 unique cities or catchment areas (e.g., National Health Service trusts) in Australia, Canada, Chile, the United Kingdom, and the United States. The survey was available only in English, but oral translation into Spanish was offered.
Survey Items and Measures
The text of all survey questions included in this study is available in the online supplement to this article. Participant demographic characteristics included age, race-ethnicity, gender, highest degree completed, and program role. Program variables comprised location of the program, model followed, and inclusion of peer workers, vocational specialists, and family peers or partners.
The survey included an item regarding the perceived etiology of psychosis. “Providers and researchers conceptualize the causes or origins of psychosis in a variety of ways. Please mark the extent to which you think the following factors contribute to psychosis.” Factors included neurochemistry, genetics, individual trauma, and background adversity (e.g., poverty or living in a dangerous neighborhood) and were rated on a 3-point scale (1, no factor; 2, moderate factor; and 3, major factor). Trauma-related policies and practices were assessed with yes-or-no questions regarding integration of formal trauma or childhood adversity assessments, trauma-focused interventions, and integration of policy focused on trauma-informed care. Six open-ended questions asked about the demographic mix of the program’s client population, the role and influence of trauma, and related concerns and perceived programmatic or training needs. Perceived personal and team capacities to provide trauma-related care in early psychosis services were assessed with nine questions whose response options included 1, strongly agree; 2, agree; 3, somewhat agree; 4, neither agree nor disagree; 5, somewhat disagree; 6, disagree; and 7, strongly disagree. (Items were reverse scored for analyses; see the online supplement .)
Analysis of Close-Ended Questions
Quantitative variables were exported from Qualtrics into Stata, version 17. A minimum “unique location count” of programs was generated on the basis of self-reported program name, city, and state, province, or region. Frequencies were computed for roles and key program policy and practice variables and distributions reported for the full sample.
Analysis of Open-Ended Questions
Open-ended (i.e., free) responses were imported into Atlas.ti software for qualitative analysis. A systematic content analysis approach was adopted with the goal of comprehensively coding all open-ended responses. Both a priori and emergent codes were used; examples of a priori codes include those directly tied to survey questions (e.g., “higher disengagement attributed to childhood abuse” and “higher disengagement attributed to nonchildhood trauma”). Emergent codes reflected areas and topics identified through open coding, such as “tensions distinguishing trauma-induced psychosis from nontrauma-related psychosis.” The codebook was developed through an initial open coding round with a subset of the data, refined, tested in a new sample, and then finalized. After conducting formal reliability checks (Cohen’s κ=0.85), we coded the remaining survey responses. As an additional safeguard to ensure that no relevant codes were missed, we conducted systematic keyword searches. This process yielded only a very small number of additions and corrections.
Results
Sample
The program affiliations, roles, and demographic characteristics of the survey participants are listed in Table 1. Overall, the 164 participants represented 110 unique EIP locations (i.e., cities, towns, or health service regions), including 77 sites in the United States, 18 in the United Kingdom (including England, Scotland, and Wales but not Northern Ireland), 10 in Canada (primarily in Ontario and Quebec), four in Australia, and one in Chile. To put these numbers in context, at the time the survey was completed, there were an estimated 254 EIP programs in the United States, 35 EIP programs in Australia, 60 trusts or boards with EIP services in the United Kingdom, 80 EIP programs in Canada, and one EIP program in Chile (25–30). Penetration by country thus ranged from 100% in Chile to 30% in the United States, 30% in the United Kingdom, 13% in Canada, and 11% in Australia.
| Variable | N | % |
|---|---|---|
| Affiliation or treatment model | ||
| OnTrackNY | 44 | 27 |
| NAVIGATE | 18 | 11 |
| Early Psychosis Prevention and Intervention Centre | 21 | 13 |
| Early Assessment and Support Alliance | 8 | 5 |
| Ohio Best Practice for Schizophrenia Treatment | 8 | 5 |
| Open Dialogue | 4 | 2 |
| U.K. National Health Service | 31 | 19 |
| Montreal Early Psychosis Intervention | 3 | 2 |
| Ontario Early Psychosis Intervention | 8 | 5 |
| Yale Specialized Treatment Early in Psychosis | 2 | 1 |
| Massachusetts Department of Health’s Prevention & Recovery in Early Psychosis | 3 | 2 |
| California Family Services Agency/Felton | 3 | 2 |
| Blended or hybrid model | 11 | 7 |
| Role | ||
| Therapist or psychologist | 42 | 26 |
| Psychiatrist or nurse practitioner (medication prescribers) | 24 | 15 |
| Case managers (including nurse case managers and vocational support staff) | 29 | 18 |
| Directors and team supervisors | 54 | 33 |
| Peer workers | 8 | 5 |
| Research or evaluation staff | 7 | 4 |
| Race-ethnicity | ||
| Hispanic/Latinx | 20 | 12 |
| East Asian | 3 | 2 |
| South Asian | 3 | 2 |
| Southeast Asian | 2 | 1 |
| African American/Black | 7 | 4 |
| Caucasian/White | 122 | 74 |
| Middle Eastern | 1 | 1 |
| Multiracial | 6 | 4 |
| Female gender | 107 | 65 |
| Highest level of education | ||
| Secondary school | 1 | 1 |
| Some college | 3 | 2 |
| Bachelor’s degree | 27 | 16 |
| Master’s degree | 85 | 52 |
| Doctorate (Ph.D., M.D., or Psy.D.) | 48 | 29 |
| Age (M±SD years) | 41.7±10.2 |
Close-Ended Items
Trauma and etiology.
The ratings of factors involved in the possible etiology of early psychosis are reported in Table 2. Neurochemistry, sensitivity to psychosocial stress, and individual trauma were all rated as major factors in the etiology of psychosis by >50% of the respondents, and genetics or epigenetics and background adversity were rated as major factors by ≥40% of respondents.
| Not a factor | Moderate factor | Major factor | |||||
|---|---|---|---|---|---|---|---|
| Factor | Total N | N | % | N | % | N | % |
| Neurochemistry or brain-based problems or dysfunction | 133 | 6 | 5 | 46 | 35 | 81 | 61 |
| Genetics or epigenetics | 132 | 6 | 5 | 63 | 48 | 63 | 48 |
| Sensitivity to psychosocial stress | 131 | 3 | 2 | 51 | 39 | 77 | 59 |
| Individual trauma (e.g., sexual abuse, bullying) | 132 | 2 | 2 | 57 | 43 | 73 | 55 |
| Background adversity (e.g., poverty, living in a dangerous neighborhood) | 132 | 10 | 8 | 69 | 52 | 53 | 40 |
a
Ns slightly varied by factors because of missing data due to some participants skipping questions.
Trauma assessment and training.
Responses to questions about assessment of trauma and training in trauma-informed FEP care are summarized in Table 3. Only a minority of the 110 programs reported formal assessments of trauma or targeted provider training sessions on the role of trauma in early psychosis. Explicit trauma-informed care policies were in place at just 42% of programs, with 56% of programs referring clients to external programs for trauma-related concerns.
| Program features | N | % |
|---|---|---|
| Formal assessment of trauma | 43 | 39 |
| Targeted training on trauma in the context of early psychosis | 38 | 35 |
| Training on trauma in general, not specific to psychosis | 42 | 38 |
| Capacity to provide trauma-focused interventions | 56 | 51 |
| Has made changes or adaptations to trauma-related policies since trauma-informed care started | 35 | 32 |
| Refers clients outside (to external programs) for trauma-related concerns | 61 | 56 |
| Has formal policies concerning trauma-informed care | 46 | 42 |
Exclusion criteria.
More than half of the programs surveyed (53%, N=58) excluded clients with a primary dissociative disorder, and close to half (48%, N=53) excluded clients “whose primary concern [was] related to trauma or PTSD.”
Perceived personal and team capacities to provide trauma-focused or trauma-informed care.
Mean scores for responses to questions about trauma-related care provided in the surveyed EIP programs are reported in Table 4. Overall, most mean scores were around 4 (neither agree nor disagree), with the more marked exception of perceived personal need for additional trauma-related training (mean=6.2, indicating stronger agreement).
| Itema | Score (M±SD) |
|---|---|
| Providers in [my] program often struggle to figure out how to work with traumatic experiences. | 4.4±1.6 |
| Supervisors are generally knowledgeable about the ways in which trauma impacts on psychosis. | 4.4±1.6 |
| Staff consistently make efforts to integrate trauma-informed techniques into the treatment of clients with an identified trauma history. | 5.2±1.4 |
| I believe that, in general, the field of early intervention should be allocating more resources to the clinical intersections of trauma and psychosis. | 4.6±1.3 |
| I personally feel like I would benefit from more training or guidance specific to working with trauma in the context of early psychosis. | 6.2±1.1 |
a
Responses to items were scored on a Likert scale ranging from 1 to 7, with higher scores indicating greater agreement.
EIP Providers’ Concerns About Unmet Trauma-Related Needs
In total, 124 participants responded to the prompt inviting perspectives on current EIP program strengths or limitations in meeting the needs of clients with trauma histories. Just over half (52%, N=65) voiced specific concerns about current trauma-related policies or practices in EIP, noting these concerns both at the systems level (N=35 of 65) and within their program (N=36 of 65). As captured by several representative quotations below, many participants conveyed frustration that although trauma was nominally recognized as an important factor in psychosis, they were given no concrete tools or guidance to address it in EIP care.
Trauma has come up with a variety of our clients [but] with no structured policy in place. We have been urged to read about trauma in the population but without any clear treatment guidance. It often feels as if we are ignoring trauma until we cannot anymore.[There are] insufficient protocols and treatment. Further, there are no clear indicators or tools which would indicate focusing on trauma versus [FEP] modules embedded in such programs as NAVIGATE [a manualized EIP model].
Another set of responses revolved around the complex relationship between trauma and psychosis and challenges of distinguishing between or treating co-occurring symptoms of psychosis and trauma:
There hasn’t been enough done to help clinicians differentiate the impact of complex trauma symptoms from psychotic symptoms.My view is that most of the clinicians do not have the appropriate training and do not want to cause more harm by not doing it “properly.” We tend to refer to other agencies, but we tend to lose clients that way as well. They would prefer to have all their needs addressed with the EPI [early psychosis intervention] program. I feel like we view trauma as a separate thing, but I think that it is more like concurrent disorders now, where you have to treat the addiction and mental health problem at the same time. We should be equipped to deal with trauma and psychosis at the same time.I think that the connections between trauma and psychosis are incredibly deep and that the divide between the two means that people are often understood through one lens or another depending on the orientation/perspective of the clinician rather than the reality of the experience of the individual.
A few providers also specifically stressed the ramifications of confusions regarding trauma and trauma-related disorders versus psychosis in the context of initial assessments.
One key barrier in meeting the needs of clients with trauma histories has to do with the nature of clinical assessments and the diagnostic criteria of EIP programs, because these factors rely on [a] false divide between the two and often force a conceptualization that relies on either trauma or psychosis as if the two could be meaningfully separated.
Some providers felt that EIP programs’ explicit focus on psychosis also risked pushing trauma into the background; moreover, close to half of the providers reported that a primary diagnosis of posttraumatic stress disorder (PTSD) or another trauma-related disorder, even if psychotic symptoms were present, would lead to exclusion from EIP care.
In the program where I worked, we would have to assign psychotic spectrum diagnoses in order to be able to offer services, and at times this meant that the role of trauma was placed in the background in a way that was inaccurate to the reality of the person’s experience.
Finally, some providers felt that standard psychosis-focused therapeutic approaches, including cognitive-behavioral therapy for psychosis (CBTp), were not necessarily optimal for treating trauma-related symptoms or entangled trauma and psychosis.
In terms of training, we were trained in CBTp and consistently asked for more specific training around trauma but were never provided it. I saw this as an enormous shortcoming in the training program that reflected a profound misunderstanding of the nature of the problems we were trying to address.I continue to be surprised and astounded by the way trauma and psychosis can interact and manifest [as] an unexpected change in presentation. I feel limited by my lack of training. I feel that if psychotic symptoms begin to clear and it is evident that PTSD or dissociation disorders are underlying [other symptoms], it seems that the groups and activities we have may not really meet the needs of the client.
In response to the survey prompt regarding unmet clinician or programmatic needs related to trauma, as well as structural disadvantage and cultural diversity, 48 of the 124 respondents delineated specific areas: development and dissemination of trauma-focused interventions tailored to early psychosis (56%, N=27), interventions focused on broader structural disadvantage (21%, N=10), and high-quality training designed to cover the intersection of and relationship between trauma and psychosis (52%, N=25).
[For trauma-focused intervention development], [t]he field needs an evidence-based approach for treating trauma in the context of psychosis. That might include trauma resulting from a psychotic episode, psychotic symptoms apparently triggered by a traumatic event, or coexisting symptoms of psychosis and trauma. As far as I understand, no such treatment exists.[To address structural and community disadvantage], [t]here is a need for more community psychology–level interventions that support people living in deprived areas. There is too much emphasis on individual therapy interventions, even within [early intervention programs], which [are] more inclusive of family and systems [than of] a number of other areas.[In regard to trauma training], I think calling more attention to the need for trauma-integrated care is necessary. Educating clinicians on the ways in which trauma is likely impacting their case conceptualizations and subsequent treatment response[s] may help to call more attention to this issue.
Discussion
To our knowledge, no publications or reports have documented the state of trauma-related care and policy implementation in EIP services. In this study, we found that more than half of the providers surveyed internationally noted concerns about trauma-related EIP policy and practice. Across the countries surveyed, a minority of EIP providers indicated that trauma was formally assessed and trauma training received or that their programs had made trauma-related policy changes. About half of the respondents indicated that their program had the capacity to provide trauma-specific interventions, and half reported referring clients outside their services for trauma-related treatment. Respondents placed similar emphasis on biomedical and psychosocial etiologies for psychosis.
The results from the survey, combined with those from the responses to the open-ended questions, suggest that trauma-related care and guideline implementation are inadequate in many EIP services. The precise origins of this deficiency are not clear, but respondents mentioned barriers also reported in general psychosis services, including insufficient organizationally driven components such as training (31, 32). The service context appeared to be challenging for providers, who noted the need for more nuanced and specific training for both trauma assessment and treatment. Additionally, diagnostically driven exclusion criteria that include dissociation and PTSD suggest that providers may be forced to foreground either psychosis or trauma, as opposed to working with the complex nuances of their coexistence, as noted by Chadwick and Billings (31). Finally, it is possible that although guidelines for trauma-informed care or trauma-specific treatments may exist, these guidelines are insufficient for supporting services or clinics in implementing such care and treatments. This lack of guideline implementation has been a problem for trauma-informed care in specific service settings (i.e., forensic or inpatient) that need to adapt general principles and procedures of such care to their particular setting (33).
Limitations of our approach included variable response rates (by country) to the survey, with particularly low rates from Australia and Canada. We did not have sufficient data to make meaningful comparisons among countries. Although one response was from Chile, information is lacking regarding the FEP landscape in other South American countries and on other continents, including European countries other than the United Kingdom. Generalizability is likely higher for those countries with higher response rates and higher participation overall. In more decentralized contexts such as the United States, between-state heterogeneity in EIP services is high, and we could not determine to what extent our findings would hold across the United States. We nevertheless believe that with ≥30% response rates from the United States, United Kingdom, and Chile, our findings suggest policy and practice gaps. Although four participants reported using an Open Dialogue treatment model, our survey did not capture rates of family or community intervention use, potentially missing information on approaches that are sensitive to intergenerational trauma. In a separate article (24), we document gaps in EIP care related to cultural diversity and structural disadvantage, but more work will be needed to better capture how gaps in diversity- and structural disadvantage–related practices and policies intersect with the omissions in trauma-informed care reported here. Only 5% of the respondents were peer workers; in the future, it will also be critical to better document client and supporter perspectives regarding optimal trauma-related care in the context of EIP, including perspectives from racial and cultural minority groups. We did not investigate differences in respondent perspectives by race-ethnicity. It is possible that our results reflect the biases of the majority White/Caucasian respondent pool; for example, such biases may include the perception that adversity is least important in psychosis etiology.
Conclusions
The EIP services surveyed had low rates of trauma-informed care guidelines and treatment implementation. Recovery from FEP may be affected by trauma histories, particularly given that the interaction of such past trauma experiences with traumatic aspects of mental health treatment has not yet been adequately studied or mitigated. More training is needed for staff in the area of trauma assessment and treatment to improve client outcomes, perhaps also with an added benefit of reducing provider burnout and high staff turnover in EIP services. Our findings point to the need for greater attention to the development and evaluation of user-centered, culturally sensitive, and trauma-focused interventions; clearer delineation of EIP-specific, trauma-informed care principles; and research evaluating the implementation and adaptation of trauma-related practices. A model of trauma-informed care for early psychosis has been developed and found to be satisfactory for young people (23, 34, 35), but more research is needed to determine its effectiveness in EIP services. EIP service setup may also need to be revisited: Should EIP services comprehensively address trauma-related needs or should EIP and trauma-specific services collaborate more closely?
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Information & Authors
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Published In
History
Received: 13 December 2022
Revision received: 21 February 2023
Accepted: 28 March 2023
Published online: 17 May 2023
Published in print: December 01, 2023
Keywords
Authors
Competing Interests
The authors report no financial relationships with commercial interests.
Funding Information
Dr. Bendall is supported by the Melbourne Ronald Philip Griffiths Fellowship. Dr. Sarpal receives funding from NIMH (R01 MH-124705).
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