Something is indeed cooking… The Trauma-Informed Approach (TIA), which emerged in the 1990s (Bloom, 2013) has gained traction over the past 20 years, with staff training being a key intervention used in efforts to implement it in the UK (Purtle, 2020). What prompted this enthusiasm towards the TIA was research demonstrating the high prevalence of trauma across society, which is highly correlated with poor mental health, and constitutes a costly public health issue (Sweeney et al., 2018). 

Given that this is only new, we do not assume that  you are familiar with the term… so let’s take a step back and provide some definitions. A good starting point is getting familiar with the Four “Rs” (SAMSHA, 2014)- realising the widespread impact of trauma, recognising its signs and symptoms in clients and staff, responding by integrating knowledge and resisting retraumatisation. Understanding TIA involves recognising its aim: to promote a more sympathetic approach to meeting the needs of service with trauma experiences, rather than treat trauma symptoms. The former is based on the fundamental shift from “What is wrong with you?” to “What happened to you?”, which guides the TIA is guided by core principles of safety, trust, collaboration and empowerment. These principles are crucial for preventing retraumatisation, where individuals become traumatised again, often due to power imbalances in mental health services (Sweeney et al., 2018). Such imbalances may be redolent to past experiences of abuse and lead to feelings of disability and helplessness in the service user, making them vulnerable to retraumatisation. Therefore, collaboration promotes an understanding of what both parties find helpful, preventing retraumatisation and its negative impacts on patient well-being and service workload.

Current Research Limitations & Gaps

Now, while we did not expect you to know what TIA is, we do assume that you are familiar with the phrase “Rome wasn’t built in a day”. This is relevant, as we are not yet in the position to provide you with a full recipe on how to implement TIC successfully. This issue can be attributed to research limitations regarding, for example, staff training interventions:

• Focus on evaluating how trauma-informed people are post-intervention, rather than what aspects of interventions led to those results. For example, evaluations measure effectiveness based on numbers of restraints used by staff (Purtle, 2020). It is like evaluating how good something tastes, without having any idea how it was made. You know it tastes good, but would not be able to recreate it, or improve it as it would require making changes to the process, which you are unaware of.
• Post-test administered right after the intervention (Purtle, 2020): No indication of long-term retention of knowledge that meaningfully impacts staff and client outcomes.
• Training under evaluation being implemented simultaneously with other interventions (Purtle, 2020): Creates ambiguity regarding whether changes in staff behaviour are attributable to training or exposure to other interventions.
• Gap: Time (length of training attendance) and its impact on training effectiveness has not been investigated.

These limitations and gaps obscure our understanding of whether training effectiveness and what exactly makes it effective.

Our Aims & Approach

An intervention that has not been evaluated yet, is the training sessions carried out by the Camden and Islington Trauma Informed Network (CITIN). Given the limitations and gap- related to time- of the current research, our study, employing the Kirkpatrick model of evaluation, aimed to contribute to the effort of TIA implementation, by evaluating the CITIN training and specifically assessing training “ingredients” that may lead to effective training. The levels of the model, namely;  reaction (how well training is received/ valued), learning (gained new knowledge/ skills) and behaviour (applies learning into practice) offer a more structured evaluation process, enabling the isolation of effective training aspects. Attendees completed a questionnaire:

1. Indicating their attendance (ticking how many of the provided training sessions they had attended)
2. Responding to items corresponding to the Kirkpatrick levels, on a 5-point Likert scale
3. Answering open-ended questions, aimed at increasing our understanding of the nature of participants’ ratings

What We Found:

1. The CITIN staff training was effective, with statistically significant- meaning that they are real and not due to chance- high participant ratings across reaction, knowledge, and behaviour levels. Open-ended responses revealed that participants’ comments attributed to the 3 Kirkpatrick model levels tested. For instance, the high overall rating for reaction aligned with participants finding the content “interesting”, “relevant”, and “thought-provoking”, with positive feedback on the quality and expertise of speakers. Additionally, participants reported constantly “learning new information” and practical strategies, demonstrating enriched knowledge. They also underscored the practical applications of the training in their life and work with people who have experienced trauma, indicating behaviour change.
2. People needed more chances to reflect on the content they had been exposed to through more time provided for questions, or access to the training material following training. It only makes sense right? In this blog we spent a whole paragraph explaining what TIA means… imagine having to understand it to then actually be able to apply it to your work.
3. No significant relationship was detected between length of attendance and effectiveness ratings, meaning that number of sessions attended did not influence the ratings provided by the participants.

Limitations

• Absence of pre-questionnaire data (due to the ongoing nature of the CITIN training for three years): limited ability to directly compare pre- and post-training ratings, which would have provided stronger evidence that the positive outcomes observed are indeed attributed to the training.
• Small sample size: limits its generalisability (the extent to which the findings can be applied to other populations or settings) and means that it might have not had enough power (the ability to detect true effects if they exist) to detect relationships, such as the one between length of attendance and learning effectiveness.
• Self-report Biases: Participants may have answering what is desirable rather than true, or inaccurate perceptions of changes knowledge or behaviour following training, decreasing validity of findings.

To wrap it up…

No, not a tortilla, just this blog… We hope you are leaving us knowing that training is an effective intervention in implementing the TIA, and with a better understanding of how it does so, successfully. Kirkpatrick’s levels can be seen as ingredients to successful TIA implementation recipe; a training process that is well perceived, increases knowledge and induces behavioural change, can lead to positive outcomes. According to our results, sprinkling some time for reflection of training content into the TIA intervention stirring-pot will help too! Now that we think about it, due to our cooking references, you are probably leaving us quite hungry too… but hey, hungry and more knowledgeable… We think it’s worth it!