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Nursing interventions for adults following a mental health crisis: A systematic review guided by trauma‐informed principles. Int J Mental Health Nurs. (Authors) Nizum, N., Yoon, R., Ferreira‐Legere, L., Poole, N. and Lulat, Z. (2020).

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Abstract and Figures

There exists a growing need for health and service providers to respond to persons in a manner that recognizes the prevalence and impact of trauma in individuals and prevent inadvertent re‐traumatization in the routine process of care. The experience of mental health crisis in of itself can have traumatic and impactful effects on individuals. Trauma‐informed approaches to care offer a framework to provide crisis intervention responses that are based on the acknowledgement of the prevalence and impact of trauma and define trauma not by the event per se, but by the impact of an experience of trauma. The integration of trauma‐informed principles in the context of crisis intervention is a current practice gap. In order to inform a portion of a best‐practice guideline for registered nurses and the interprofessional team, a systematic literature review was conducted to primarily identify nursing interventions within four weeks of a mental health crisis, with a secondary focus on identifying particular interventions that included trauma‐informed principles. The systematic review yielded 21 quantitative and qualitative studies related to nursing interventions for mental health crisis, 10 of which referred to one or more principles of trauma‐informed approaches. There was a lack of studies on nursing interventions explicitly linked to implementation of trauma‐informed principles, highlighting future research needs and focused efforts to integrate trauma‐informed principles into crisis intervention practices.
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Nursing interventions for adults following a men-
tal health crisis: A systematic review guided by
trauma-informed principles
Nafsin Nizum,
Rosanra Yoon,
Laura Ferreira-Legere,
Nancy Poole
and Zainab Lulat
Guideline Development Methodologist, Registered Nurses’ Association of Ontario,
Nurse Practitioner, The Jean
Tweed Centre,
Former Guideline Development Methodologist, Registered Nurses’ Association of Ontario, Toronto,
Ontario; and
Centre of Excellence for Women’s Health, Vancouver, British Columbia, Canada
ABSTRACT: There exists a growing need for health and service providers to respond to persons
in a manner that recognizes the prevalence and impact of trauma in individuals and prevent
inadvertent re-traumatization in the routine process of care. The experience of mental health crisis
in of itself can have traumatic and impactful effects on individuals. Trauma-informed approaches
to care offer a framework to provide crisis intervention responses that are based on the
acknowledgement of the prevalence and impact of trauma and define trauma not by the event per
se, but by the impact of an experience of trauma. The integration of trauma-informed principles in
the context of crisis intervention is a current practice gap. In order to inform a portion of a best-
practice guideline for registered nurses and the interprofessional team, a systematic literature
review was conducted to primarily identify nursing interventions within four weeks of a mental
health crisis, with a secondary focus on identifying particular interventions that included trauma-
informed principles. The systematic review yielded 21 quantitative and qualitative studies related
to nursing interventions for mental health crisis, 10 of which referred to one or more principles of
trauma-informed approaches. There was a lack of studies on nursing interventions explicitly linked
to implementation of trauma-informed principles, highlighting future research needs and focused
efforts to integrate trauma-informed principles into crisis intervention practices.
KEY WORDS: best-practice guideline, mental health crisis, mental health nursing, trauma-
Correspondence: Nafsin Nizum, Guideline Development Methodologist, Registered Nurses’ Association of Ontario, 158 Pearl Street, Tor-
onto, Ontario M5H 1L3, Canada. Email:
Authorship Statement: All persons who meet authorship criteria are listed as authors, and all authors certify that they have participated
sufficiently in the work to take public responsibility for the content, including participation in the concept, design, analysis, writing, or revi-
sion of the manuscript. N. Nizum, L. Ferreira-Legere, and Z. Lulat conducted the systematic review. N. Nizum, N. Poole, and R. Yoon
drafted the manuscript. N. Nizum, R. Yoon, L. Ferreira-Legere, N. Poole, and Z. Lulat revised the manuscript critically for important intel-
lectual content.
Conflicts of Interest: The authors declare that they have no competing interests.
Funding Source: This work was funded by the Ontario Ministry of Health and Long-Term Care.
Nafsin Nizum, RN, MN.
Rosanra Yoon, NP, MN, PhD.
Laura Ferreira-Legere, RN, MScN.
Nancy Poole, PhD, MA, Dip.C.S., BA.
Zainab Lulat, RN, MN.
Accepted December 15 2019.
©2020 Australian College of Mental Health Nurses Inc.
International Journal of Mental Health Nursing (2020) , doi: 10.1111/inm.12691
Crises are subjective experiences that threaten and
overwhelm a person’s ability to deal with the situation
using their normal problem-solving abilities, coping
mechanisms, or current resources (Caplan 1961; East-
ham et al. 1970; James & Gilliland 2001). The over-
whelming experience can have detrimental effects on
mental health, including intense feelings of personal
distress (e.g. panic, numbness, anger, numbness,
depression) (Jakubec 2014; Substance Abuse and Men-
tal Health Services Administration [SAMHSA] 2009).
This mental health response can bear implications on
physical health (e.g. headaches, loss of appetite, shak-
ing) as well as changes in functioning (e.g. inability to
meet basic needs or unusual behaviour) (Jakubec 2014;
SAMHSA 2009). The precipitating events of a mental
health crisis can vary and may include disruption in
personal relationships, support systems or living
arrangements; loss of autonomy, death of a loved one,
the onset of illness, victimization or experience of natu-
ral disasters (Jakubec 2014; SAMHSA 2009). Experi-
encing a mental health crisis may also lead to long-
term harm, such as the potential risk of post-traumatic
stress disorder (Poole, Urquhart & Jaisura, 2013;
SAMHSA 2009). The harmful short-term and potential
long-lasting effects of a mental health crisis call for
timely and effective interventions. More importantly,
there is a need for providers to be responsive to per-
sons experiencing crisis in a trauma-informed way, in
order to minimize re-traumatization and reduce further
emotional and psychological harm. Nurses, in particu-
lar, are in a unique position to respond to mental
health crisis as they may care for persons in various
healthcare settings (within and outside mental health
settings), and across the care continuum. Furthermore,
professional nursing standards of care emphasize build-
ing relationships based on trust, compassion, and
patient-centredness. Thus, enacting trauma-informed
principles has the potential to strengthen nurseclient
relationships and improve outcomes.
Personal histories of trauma are pervasive among
individuals seeking help for mental health and/or sub-
stance use concerns (Harris & Fallot 2010; SAMHSA
2014). Past trauma can have lasting effects on both the
psychological and physical health of individuals, fami-
lies, and communities (Bateman, Henderson & Kezel-
man 2013; Poole et al. 2013). Historically, health and
social services have not integrated an awareness of
trauma into routine processes of care, resulting in
inadvertent re-traumatization or misinterpretation of
behaviours and responses to triggers (Harris & Fallot
2010). Consequently, there is recognition of the need
for services and providers to become responsive to the
impact of trauma through trauma-informed)
approaches (Bateman et al. 2013; SAMHSA 2014).
Trauma-informed approaches to service delivery
acknowledge the prevalence and impact of trauma and
are based on trauma-informed principles applied uni-
versally across systems of care to resist re-traumatiza-
tion. Trauma-informed principles of practice include
the following: promoting safety, trustworthiness and
transparency, fostering collaboration and mutuality,
supporting empowerment, choice and control, provid-
ing opportunity for peer support, and generating
awareness and responsiveness to cultural, historical,
and gender issues (SAMHSA 2014). Although the prin-
ciples of trauma-informed practice (such as choice, col-
laboration, safety, empowerment) can be found as
guiding principles of existing frameworks of patient-
centred care and recovery-oriented practice, what is
unique in trauma-informed practice is that these prin-
ciples are enacted and framed from a reference point
of recognizing the impact and the widespread preva-
lence of trauma. In essence, the principles of trauma-
informed practice are held together by trauma aware-
ness that influences how the principles of choice and
collaboration are enacted when one appreciates the
impact of trauma in the person’s context. Trauma-in-
formed approaches do not require extensive history
taking and disclosure of trauma, and are particularly
relevant and helpful in the immediacy of crisis situa-
tions where the priority is to attend to and be respon-
sive to the person’s needs for emotional, psychological,
and physical safety.
More recently, trauma-informed frameworks, princi-
ples, and approaches have been integrated into services
and systems addressing child welfare, homelessness,
mental health and substance use, criminal justice, edu-
cation, and primary care (Akin, Strolin-Goltzman &
Collins-Camargo, 2017; Branson et al. 2017; Green
et al. 2015; Howell, Thomas & Crosby, 2018; Kirst
et al. 2017; Williams, 2016). However, there is greater
potential for the widespread understanding and use of
trauma-informed approaches relevant to crisis interven-
tions. Currently, there is a lack of evidence-based guid-
ance for health and services providers, in particular
registered nurses, on what is required to provide crisis
interventions for individuals, and more specifically, how
crisis interventions can be provided in a trauma-in-
©2020 Australian College of Mental Health Nurses Inc.
formed way. To our knowledge, there has been no sys-
tematic review conducted examining to what extent
trauma-informed principles are integrated in nursing
interventions for mental health crisis and its subse-
quent impact on individuals. Thus, the primary aim of
this review is to synthesize the available literature on
nursing interventions for mental health crisis, with a
secondary aim to identify trauma-informed principles
within the literature on mental health crisis interven-
tions, in order to inform a portion of an evidence-based
guideline for registered nurses and the interprofes-
sional team.
In June 2016, fifteen experts in the area of crisis
response and/or trauma-informed approaches convened
for the development of a best-practice guideline on cri-
sis intervention guided by trauma-informed principles
(Registered Nurses’ Association of Ontario 2017). The
guideline panel consisted of experts from diverse disci-
plines such as nursing, medicine, social work, the jus-
tice system, research, and persons with lived
experience. The guideline was developed for registered
nurses and other members of the interprofessional
team. The guideline aimed to include healthcare inter-
ventions that are within registered nurses’ scope of
practice (based on Canadian licensure), acknowledging
that some nursing interventions would have overlap
with interventions provided by other members of the
interprofessional team (for instance, social workers,
counsellors, and physicians). Expert panel members
were consulted throughout the guideline development
process and determined recommendations for the best-
practice guideline based on findings from systematic
reviews. Four systematic reviews were conducted to
inform the best-practice guideline. This paper will
report on the findings from one systematic review
Records idenfied through database searching
(n = 36 381)
Records aer duplicates removed
(n = 25 833)
Records screened
(tle and abstract)
(n = 25 833)
Addional records idenfied by panel
(n = 37 )
Records excluded
(n = 25 303)
Full-text records
assessed for relevance
(n = 530)
Full-text records
(n =400)
Studies included
(n =21)
Full-text records
assessed for quality
(n =130)
Full-text records
(n = 109)
FIG. 1: Article Review process Flow Diagram. Flow diagram adapted from D. Moher, A. Liberati, J. Tetzlaff, D. G. Altman, and The PRISMA
Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. BMJ 339, b2535,
©2020 Australian College of Mental Health Nurses Inc.
guided by the research question: ‘What are effective
and trauma-informed interventions that can be utilized
by registered nurses with adults experiencing crisis?’
The systematic review used and adhered to the
PRISMA guidelines for reporting systematic reviews
(Moher et al. 2009). A protocol for this systematic
review was also registered on the PROSPERO website
(Protocol number: CRD42016046142).
Crisis intervention is an action-oriented, situation-fo-
cused short-term response to re-establish immediate
coping skills, provide support, promote a sense of con-
trol and self-efficacy, restore pre-crisis functioning, and
provide access to further services and resources (Dass-
Brailsford 2007; Hoff 1995). For the purposes of our
systematic review, crisis interventions included any
nursing healthcare intervention (i.e. not limited to
mental health interventions). Studies of interest were
restricted to nursing interventions as the target audi-
ence for the best-practice guideline is predominately
nurses. Additional health or social service providers
may have a larger scope of practice specific to their
licensure that is beyond the focus of this review. Fur-
ther, crisis interventions included support provided
immediately and up to four weeks after a crisis event.
The time frame was chosen as an attempt to narrow
the focus of the literature on interventions that was for
an acute crisis event, as well as to be in alignment with
general expert consensus on an appropriate timeframe
for practice. Further, trauma-specific interventions,
which require extensive history taking and disclosure of
trauma and are therefore provided by practitioners
with specialized knowledge and skill to treat the conse-
quences of trauma (Poole et al. 2013), were not in
scope. The research question was intentionally broad in
an effort to include a variation of effective interven-
tions that nurses and the interprofessional team could
perform within the first four weeks of a crisis event.
Results are reported through narrative synthesis of the
included studies.
Search strategy and screening
The search strategy was developed by a health science
librarian in consultation with the authors, and with
consideration of key terms identified by the expert
panel. The search strategy was created to encompass
two research questions that were similar in nature:
research question one ‘What are effective and
trauma-informed interventions that can be utilized by
registered nurses with adults experiencing crisis?’ and
research question two ‘What are effective and trauma-
informed interventions that can be utilized by registered
nurses to mitigate or prevent future crisis in adults?.
The health science librarian conducted a literature
search in November 2016 for peer-reviewed articles
published in the last five years, in the following seven
academic health databases: MEDLINE, ePub & in Pro-
cess, Embase, Cochrane CT, Cochrane SR, PsycInfo,
and CINAHL. The search was restricted to the last five
years as per organizational protocol to develop guidelines
with the most up-to-date and contemporary literature.
The search strategy included MEDLINE MeSH head-
ings and keywords that were relevant to crisis (such as
‘stress disorders’ OR ‘psychological trauma’ OR ‘life
change events’ OR ‘distress’) and crisis intervention
(such as ‘crisis intervention’ OR ‘psychiatric emergency
services’ OR ‘early medical intervention’ OR ‘secondary
care’). The two search strings were combined using the
Boolean operator AND. Similar search terms were used
when searching all seven databases. The full search strat-
egy for the MEDLINE database, including all search
terms and applied limits, can be found in Supplementary
File S1. The expert panel was also invited to submit
hand-searched articles from their personal libraries,
which underwent the same screening process as article
identified from the literature search.
The search yielded 36, 381 studies from all databases
and an additional 37 articles were identified by the
panel. The inclusion criteria specific to both research
questions were as follows: studies that (i) had a primary
focus on crisis intervention(s) that occurred within four
weeks after the crisis event, (ii) focused on adults, aged
18 and older, (iii) were nursing interventions, (iv) were
inclusive of all patient outcomes, and (v) were inclusive
of all health settings; (vi) studies that followed a qualita-
tive and/or quantitative design; (vii) systematic or litera-
ture reviews that included a search strategy; (viii) studies
published in an English peer-reviewed journal; and (ix)
studies that were accessible for retrieval. Articles were
required to report on crisis intervention(s); however, it
was not mandatory for articles to include or explicitly
state the use of a trauma-informed principle. When
applicable, the six key principles fundamental to trauma-
informed approaches as outlined by SAMHSA (2014)
were identified in crisis intervention studies. Disserta-
tions, commentaries, narratives, non-English studies,
studies published prior to January 2011, and unpub-
lished literature were excluded.
After duplicate removal, there were 25, 833 studies
that were divided among three reviewers, ensuring that
©2020 Australian College of Mental Health Nurses Inc.
each title was screened independently by two reviewers.
Discrepancies were resolved by the third reviewer. Five
hundred and thirty full-text articles answered the two
research questions and met the inclusion criteria. During
relevance review, the articles were divided among three
reviewers, ensuring that each full text was reviewed in
duplicates and a third reviewer resolved discrepancies.
At this stage, studies were more closely examined to
address research question one. Studies were excluded
for the following reasons: they did not follow a research
methodology (no evidence of a methods section); inter-
ventions were outside nursing scope of practice; inter-
ventions included exposure therapy, or reimagining,
rewriting, or retelling the traumatic event; interventions
took place four weeks after the crisis event; it was not
clear whether participants experienced a crisis; partici-
pants were under the age of 18; focused on primary pre-
vention of crisis; medical crisis related to physiological
processes; interventions were trauma-specific (rather
than trauma-informed); not retrievable or not published
in English.
Data extraction and quality appraisal
Twenty-one studies met the inclusion criteria and were
included for data extraction and quality appraisal, and
results were reported through narrative synthesis. The
systematic review process is summarized in (Fig. 1).
Meta-analysis could not be conducted due to hetero-
geneity in the interventions and outcomes. Study
details (such as study type, objective, method, setting,
sample, outcome measures, results) of the 21 articles
were extracted in data tables. At this point, studies
were examined if they included trauma-informed prin-
ciple(s) and the specific trauma-informed principles
were extracted in the data tables. For quality appraisal,
inter-rater reliability was established wherein 20% of
included studies were independently quality appraised
in duplicate by two reviewers. There was a high level
of agreement between the reviewers, indicated by a
sufficient kappa score of 0.86. Thus, the remaining
studies were divided equally between reviewers for
independent quality appraisal. Studies were quality
appraised using validated and published assessment
tools. For systematic and literature reviews, studies
were appraised using the Assessment of Multiple Sys-
tematic Reviews (AMSTAR), which assesses the com-
prehensiveness and rigour of reviews (Bruyere
Research Institute 2017). Randomized controlled trials
(RCT), casecontrol, cohort and cross-sectional, and
qualitative studies, were appraised using the Critical
Appraisal Skills Program (CASP UK), which assesses
potentials for bias (CASP UK 2008). Finally, mixed-
methods studies were appraised using the Mixed Meth-
ods Appraisal Tool, which assesses the rigour of both
qualitative and quantitative aspects of a study (Pluye
et al. 2011). A prior established point system was used
to give each study a quality appraisal score, with points
given when studies adhered to the components of its
respective quality appraisal tool. The individual study
quality appraisal scores were then converted to a per-
centage and based on a scoring system, rated as strong
(>82.5%), moderate (62.582.4%), or weak (<62.4%).
The 21 studies varied in design and included: system-
atic reviews (n=4), a literature review (n=1), RCTs
(n=3), observational studies (n=3), quasi-experimen-
tal studies (n=3), and qualitative studies (n=6). The
settings of the studies included Canada, the United
States, Europe, Asia, and Australia. Of the 21 studies,
four were rated strong in quality (19%), eleven were
rated moderate quality (52%), and six were rated weak
quality (29%). Further details of the studies included
can be found in Tables 1, 2, and 3.
As the definition for crisis and nursing healthcare
interventions was kept broad in the inclusion criteria,
the included studies were heterogeneous in nature, with
various interventions and outcomes measured. The
majority of the studies did not explicitly utilize trauma-
informed principles for crisis interventions within the
four weeks of a crisis event. Only two studies (one litera-
ture review and qualitative study) explicitly aimed to
identify or report on trauma-informed crisis interven-
tions (Lewis-O’Connor & Chadwick, 2015; Muskett
2014). In the remaining nineteen articles, elements of
trauma-informed approaches were either mentioned
within crisis interventions in quantitative studies (n=7),
elicited from patient perspectives in receiving crisis
interventions in qualitative studies (n=5) or were not
evident (n=7). In quantitative studies analysing effec-
tiveness of interventions, outcomes focused on mental
health symptoms and/or access to referrals/care. Fur-
thermore, the populations across the studies varied.
Explicit trauma-informed approaches in crisis
One literature review of weak quality aimed to identify
studies for observable and practical trauma-informed
©2020 Australian College of Mental Health Nurses Inc.
nursing care that could be readily adopted in acute
mental health settings (Muskett, 2014). However, the
article was descriptive and did not measure the effec-
tiveness of trauma-informed interventions. Articles in
the review highlighted the nurses’ role in being emo-
tionally supportive with persons who have significant
trauma histories, and being inclusive and honouring
participation of persons and families in care decisions
(Muskett 2014). The author noted that multiple articles
focused on reducing the rates of restraint and seclu-
sion as a key outcome for trauma-informed care. Fur-
ther, the focus of acute mental health inpatient
settings on risk management, illness assessment, and
medical stabilization also deemphasized the importance
of therapeutic relationships and ‘talking therapies’ with
patients (Muskett 2014). Features of care reported as
contributing to revictimization included, staff focusing
on non-interactive tasks, appearing disinterested or dis-
respectful, and not making an effort to empower cli-
ents as decision-makers in their own care (Muskett
2014). In this particular review, the principles of
ensuring physical and psychological safety, making
decisions through collaboration, and mutuality were
Further, one qualitative study of moderate quality
explored perspectives in care approaches by persons
who had experienced gender-based violence (Lewis-
O’Connor & Chadwick 2015). The study used a
trauma-informed, relationship-based framework to
guide a quality improvement initiative at a gender-
based violence-specific clinic. Patients stated that they
were well cared for and felt safe during their visit, but
many reported ‘long waits’ and ‘confusion’ about what
to do after their acute care visit (Lewis-O’Connor &
Chadwick 2015). Furthermore, some participants
expressed concerns about the need for, and the con-
sent process surrounding, evidence collection (Lewis-
O’Connor & Chadwick 2015). The authors recognized
that it is important for patients to understand the bene-
fits and limitations of evidence collection so that they
are fully informed in decision-making, which from a
trauma-informed lens means that trauma-informed
principles of safety and collaboration in decision-mak-
ing were enacted (Lewis-O’Connor & Chadwick 2015).
TABLE 1: Characteristics and findings of studies with explicit trauma-informed principles
Study type &
Quality rating Setting Sample Intervention Control
principle Key findings
and qualitative
approach to
patient care
in mental
and psychological
safety, making
decisions through
collaboration and
With the exception of specific
training and screening
recommendations, effective
trauma-informed care in acute
inpatient settings involves the
use of strategies that most would
consider basic ingredients of
contemporary, effective mental
health care. Trauma-informed
care starts with, and goes to the
heart of, the enabling nature of
the nurseclient relationship,
and the value services place
upon client-centred care.
Study type,
quality rating Setting Sample
principles embedded
within service
received Key findings
O’Connor &
310 survivors of
Interviews All trauma-informed
Patients affected by gender-based violence
require an improved coordinated and
trauma-informed approach. Explicit
consent related to evidence collection is
needed and not all patients who have
been sexually assaulted should have
evidence collected.
©2020 Australian College of Mental Health Nurses Inc.
TABLE 2: Characteristics and findings of quantitative studies
Study type &
quality rating Setting Sample Intervention Control
principle Key findings
Brief crisis interventions
Li & Hu, 2012 Randomized
107 family members of
patients in a vegetative
state (intervention group:
n=54 & control group:
Brief single psychological
session group intervention
with four steps
No intervention Building of
strengths and skills
The intervention group
improved significantly more
than the control group on
most subscale measures for
psychological distress,
including somatization,
behaviour, depression, and
et al., 2015
floor, United
30 admitted suicide
attempt survivors
(intervention group:
n=15 & control group:
Teachable Moment Brief
Intervention (TMBI)
Usual care Ensuring
safety and making
decisions through
collaboration and
Patients in the TMBI group
rated the intervention as
‘good’ to ‘great’ in all items
related to satisfaction. The
TMBI group experienced
greater improvements in
motivation to address their
problems and improvements
on reasons for living compared
to the control group.
Van Oenen
et al., 2016
287 patients with acute
and severe psychosocial or
psychiatric problems
referred in the middle of
a crisis(intervention group:
n=72 and control group:
Every session,immediate
feedbackobtained from
patients about progress in
their functioning and about
the therapeutic alliance and
this was discussed by the
therapist and the patient
Usual care
obtained every
six weeks
without feeding
results back to
the patient or
No trauma-
Patients with psychiatric
problems and severe distress
seeking emergency psychiatric
help did not benefit from
direct feedback.
Post-Disaster Interventions
Dieltjens et al.,
review, Strong
5 practice guidelines, 2
systematic reviews
identifying 0 studies, and
0 individual studies
Psychological first aid (PFA) No PFA Ensuring physical
and psychological
safety, building of
strengths and skills
The scientific literature on
psychological first aid available
to date does not provide any
evidence about the
effectiveness of PFA
interventions. Currently, it is
impossible to make evidence-
based guidelines about which
practices in psychosocial
support are most effective to
help disaster and trauma
©2020 Australian College of Mental Health Nurses Inc.
TABLE 2: (Continued)
Study type &
quality rating Setting Sample Intervention Control
principle Key findings
Fox et al.,
50 peer-reviewed journal
articles and 8
organizational guidelines
PFA No PFA Ensuring physical
and psychological
safety and building
of strengths and
skills through
Adequate scientific evidence
for psychological first aid is
lacking but widely supported
by expert opinion and rational
Haga et al.,
453 parents of the Utøya
Proactive early outreach
programme included both
municipal interdisciplinary
psychosocial crisis teams and
a designated contact person
for each survivor, their
families, and the families of
the deceased
No control
No trauma-
Engagement with the contact
person was associated with use
of a family doctor, but not
with mental health specialists.
North &
review, Weak
222 unique articles on
disaster and emergency
mental health response,
interventions, and services
Mental health interventions to
individuals appropriate to
their needs in the wake of a
No mental
health response
No trauma-
In post-disaster settings, a
systematic framework for case
identification, triage, and
mental health interventions
should be integrated into
emergency medicine and
trauma care responses.
Telecommunication and Computer-Based Interventions
Gelkopf et al.,
142 callers Crisis intervention hotline,
but offers also continuous
therapeutic interventions (i.e.
psychosocial education, self-
help tools)
No control
Building of
strengths and skills
making decisions
collaboration and
Results show a significant
decrease in functioning
problems following the
telephone intervention. A
significant decrease was also
found in post-traumatic stress
et al., 2015
after, weak
241 patients Telephone-based low-intensity
No control
Building of
strengths and skills
and making
decisions through
collaboration and
Patients had a significant
improvement in depression,
anxiety and functioning at
follow-up compared to initial
assessment and patients (80%)
experienced reductions in the
frequency of suicidal ideation.
©2020 Australian College of Mental Health Nurses Inc.
TABLE 2: (Continued)
Study type &
quality rating Setting Sample Intervention Control
principle Key findings
Chavan et al.,
3273 callers 24-hour suicide prevention
No control
No trauma-
Since the helpline was set up,
there was a decline in the
number of suicides in the
following years: compared to
the 130 suicides in year 2003,
the total number of suicides in
the city was 75 in 2004, 89 in
2005, 80 in 2006, 82 in 2007,
83 in 2008, 75 in 2009, 71 in
2010, and 105 in 2011.
Furber et al.,
45 patients in intervention
group157 patients in
control group
Individually tailored text
messages alongside telephone-
based psychotherapy
Building of
strengths and skills
making decisions
collaboration and
There were no significant
differences in clinical
outcomes between participants
who received SMS and those
in the control group.
Nielssen et al.,
Australia 2599 enrolled in online
The MindSpot Clinic provides
remote screening assessments
and therapist-guided
treatment for anxiety and
No control
No trauma-
Around 0.6% of people
seeking assessment or
treatment by MindSpot were
referred to local mental health
services for urgent face-to-face
Crisis intervention for people living with major mental illnesses
Berrino et al.,
Prepost test
with control,
Hospital in
200 patients meeting
DSM-IV borderline
personality disorder
criteria (100 in control
group and 100 in the
treatment group)
Short-term hospitalization in a
crisis intervention service
individual psychotherapy
intervention provided by
experienced supervised nurses
Treatment as
usual assigned
to treatment
according to the
judgement of
Making decisions
collaboration and
During the 3-month follow-up,
the total number of days in
supplementary standard
inpatient treatment and crisis
intervention at the general
hospital after discharge was
significantly less in the
intervention group (194 and
23, respectively) than in the
comparison group
et al., 2012
UK and
2 RCTs Crisis interventions for adults
with borderline personality
disorder (BPD) in any setting
No crisis
No trauma-
There is no RCT-based
evidence for the management
of acute crises in people with
BPD, and therefore, we could
not reach any conclusions
about the effectiveness of any
single crisis intervention.
©2020 Australian College of Mental Health Nurses Inc.
Brief crisis interventions
Three RCTs of moderate quality utilized brief interven-
tion for persons who had experienced a crisis event. The
studies examined outcomes of patient satisfaction, readi-
ness to change problematic behaviours, reasons for living
and suicidal ideation, psychological symptoms, social role
functioning, and interpersonal relationships. Compo-
nents of brief intervention varied throughout the studies;
however, brief crisis interventions that considered
trauma-informed principles had positive outcomes (Li &
Xu 2012; O’Connor et al 2015), as opposed to brief crisis
interventions that did not consider trauma-informed
principles (Van Oenen et al. 2016). A brief, group psy-
chological session for relatives of patients in a vegetative
state was associated with a decrease in psychological
symptoms such as somatization, obsessivecompulsive
behaviour, depression, and anxiety compared to the con-
trol group who did not receive the intervention (Li & Xu
2012). The brief single-session group intervention was in
the format of a critical incident stress debriefing, which
included participants describing what happened and
their first thoughts concerning the event, discussing their
emotional reactions, and receiving training to increase
coping abilities (Li & Xu 2012). In another RCT, a teach-
able brief intervention for persons who attempted sui-
cide was associated with greater patient satisfaction,
improvement in motivation to address their problems,
and significant improvements on reasons for living com-
pared to the group who received usual care (O’Connor
et al. 2015). The majority of patients in both groups
reported no desire for suicide at the one-month assess-
ment (O’Connor et al. 2015). The teachable moment
brief intervention involved a functional assessment, crisis
planning, and discussion of further outpatient mental
health services (O’Connor et al. 2015). Overall, the stud-
ies that examined brief interventions for crisis events uti-
lized trauma-informed principles of ensuring
psychological safety, establishing a collaborative relation-
ship (O’Connor et al. 2015), and offering training to
increase coping abilities (Li & Xu 2012; O’Connor et al.
One RCT investigated the efficacy of immediate
feedback during brief therapy session in the treatment
of patients with acute and severe psychosocial or psy-
chiatric problems referred in the middle of a crisis.
The intervention group received immediate feedback
during brief therapy sessions, wherein therapists pro-
vided feedback to patients every session, and together,
they discussed the patient’s progress and their thera-
peutic alliance (Van Oenen et al. 2016). In the
comparator group, feedback was obtained every six
weeks without feeding results back to the patient or
the therapist. Neither the intervention nor the com-
parator incorporated trauma-informed principles. It
was found that patients did not benefit from direct
feedback when compared to the control group (Van
Oenen et al. 2016).
Post-disaster interventions
Four articles focused on crisis response interventions
in the context of disasters. Two systematic reviews
specifically focused on the effectiveness of psychologi-
cal first aid (PFA) as form of supportive response that
can be carried out by any responders, from trained lay
responders, to mental health specialists and presumably
nurses (Dieltjens et al. 2014; Fox et al. 2012). PFA
includes facets of trauma-informed principles such as
ensuring physical and psychological safety and building
of strengths and skills (Dieltjens et al. 2014; Fox et al.
2012). The systematic reviews (one quality appraised to
be strong and the other as moderate) concluded that
there is inadequate scientific evidence for PFA effec-
tiveness; however, PFA is widely supported by expert
opinion and one of very few described brief crisis
interventions available for interveners to draw upon
(Dieltjens et al. 2014; Fox et al. 2012).
Another systematic review, which was rated weak in
quality, explored the evidence on identification and
triage to appropriate services for individuals who have
experienced community disasters (North & Pfeffer-
baum 2013). The study did not identify trauma-in-
formed principles among the primary studies it
analysed, and concluded that processes for case identi-
fication, triage, and mental health interventions need to
be incorporated into emergency medicine and trauma
care responses (North & Pfefferbaum, 2013). Lastly,
one strong quality cross-sectional study aimed to inves-
tigate the effectiveness of an early outreach programme
for parents of young survivors of a massacre (Haga
et al. 2015). Haga et al. (2015) did not incorporate any
trauma-informed principles within the intervention but
found that early outreach visits by the crisis team were
associated with follow-up to a family doctor, but not
with mental health specialists.
Telecommunication and technology-based
Five studies explored the effectiveness of telephone,
text messaging, and Internet-based interventions for
©2020 Australian College of Mental Health Nurses Inc.
crisis intervention. The studies focused on outcomes of
mental health symptoms, referral to care, number of
suicide ideation or suicide, and functioning. The major-
ity of the quantitative studies found that care delivered
through telecommunication and technology-based
modalities had positive outcomes in the areas of symp-
tom reduction and referral to appropriate healthcare
services (Bidargaddi et al. 2015; Chavan, Garg & Bhar-
gava 2012; Furber et al. 2014; Gelkopf et al., 2015;
Nielssen et al. 2015).
Two weak quality studies (one observation and one
prepost study with no control) and one moderate qual-
ity descriptive study specifically explored the use of tele-
phones to provide crisis interventions (Bidargaddi et al.,
2015; Chavan et al. 2012; Gelkopf et al. 2015). The inter-
vention components were variable and included all or
some of the following aspects: brief counselling, symp-
tom management strategies and skill building, and
opportunities for face-to-face support (i.e. visits from cri-
sis intervention teams) (Bidargaddi et al. 2015; Chavan
et al. 2012; Gelkopf et al. 2015). Two of the three studies,
which included trauma-informed principles of collabora-
tion between provider and patient and promoting skill
building, demonstrated positive outcomes including
reductions in anxiety, suicidal ideation, and post-trau-
matic stress symptoms and improvements in functioning,
social adjustment, and overall health (Bidargaddi et al.
2015; Gelkopf et al. 2015). The remaining moderate
descriptive study, which did not include any trauma-in-
formed principles, was associated with a reduction in a
number of suicides in the city (Chavan et al., 2012).
One weak prepost study (with control group)
explored the impact of between-session text messaging
as an adjunct to telephone-based psychotherapy, which
included skill building regarding self-regulation (Furber
et al. 2014). However, text messaging did not demon-
strate statistically significant differences in outcomes
between the intervention and control group (Furber
et al. 2014). One retrospective, observational study,
that did not include any trauma-informed principles,
found that an Internet-based mental health service
(that provided screening assessments, therapist-guided
treatment for anxiety and depression, and referrals to
local services), resulted in appropriate and timely refer-
rals in crisis situations (Nielssen et al. 2015).
Crisis intervention for people living with
borderline personality disorder
Two studies aimed to explore the effectiveness of crisis
interventions in persons living with borderline
personality disorder (Berrino et al. 2011; Borschmann
et al. 2012). One weak prepost study investigated the
effectiveness of a short-term intensive inpatient treat-
ment in a psychiatric crisis unit among patients who
were in the emergency room for deliberate self-harm
(Berrino et al. 2011). The crisis intervention program
included cognitive and affective support with an aim to
integrate/move away from the stress disorder; help to
express emotions; convey insight on repetitive patterns
of idealized masochistic attachment; focus on life
events involving separation, loss and mourning; and
involve the family/close friends to facilitate communica-
tion among them. Therapy also involved trauma-in-
formed principles of facilitating a therapeutic alliance,
while also developing a working alliance and teaching
the patient and their families adapted coping beha-
viours (Berrino et al. 2011). At three-month follow-up,
rates of repeated deliberate self-harm and hospitaliza-
tion were lower in the intervention group (8% repeated
deliberate self-harm and 8% psychiatric hospitalization,
versus 17% and 56% in the control group who received
usual care) (Berrino et al., 2011). One systematic
review reported on two ongoing RCTs for the manage-
ment of acute crises in people with borderline person-
ality disorder, and thus was not able to report on
definitive conclusions (Borschmann et al., 2012).
Patient perspectives of crisis interventions from
qualitative studies
Five qualitative studies explored the perception of per-
sons who experienced crisis and their preferences and/
or values for the care they received or hoped to
receive. Four moderate qualitative studies explored
perceptions and experiences of persons with regard to
crisis response services. One moderate qualitative study
in particular explored perceptions of how police and
mental health providers worked together (Evangelista
et al. 2016). Persons who experience crisis commented
on the benefit of a joint police mental health clinical
team response (Evangelista et al. 2016). Interview
themes revealed that persons appreciated the team’s
communication strategies, their ability to de-escalate
the crisis, their ability to be proactive in providing
assistance, their quick response under pressure, and
their ability to effectively handover information to the
emergency department or psychiatry staff, and help
persons to achieve their preferred outcome (Evange-
lista et al. 2016). Persons also identified areas for
improvement such as reducing the visible presence of
the police officers, the need for further training and
©2020 Australian College of Mental Health Nurses Inc.
education in mental health for police officers, and the
need for intensive follow-up and communication with
their usual point of care after being approached by the
team (Evangelista et al. 2016).
One study explored person’s experiences with a
strength-based crisis intervention service in which crisis
management workers collaborate with the client to
determine the key life area(s) to focus on for improve-
ment, so they are able to live at their optimal level of
independence while utilizing community supports
appropriately (Hootz et al. 2016). Persons’ experiences
were generally positive, with participants identifying
that they appreciated the support from staff and were
learning steps to attain new skills and increasing their
TABLE 3: Characteristics and findings of qualitative studies
rating Setting Sample
Data col-
Trauma-informed prin-
ciples embedded within
service received Key findings
et al., 2016
Moderate Melbourne,
12 mental health
consumers who had
direct contact with
joint police and mental
health services
Ensuring physical and
psychological safety,
making decisions
through collaboration
and mutuality
Consumers expressed benefits of
receiving service including their
ability to communicate and des-
escalate the crisis. Suggestions for
areas of improvement included
reducing the visible presence of
the police officers, need for
further training and education in
mental health for police officers
and the need for intensive follow-
et al., 2013
Moderate Community
mental health
19 mental health users
with major mental
Interviews No trauma-informed
principles mentioned
Being believed, taken seriously,
listened to and seen was
emphasized as an important part
of a trusting relationship.
Participants also expressed a
strong wish to help themselves
through the crisis and expressed
that lack of communication and
dialogue in mental crisis was a
recurring issue.
Hootz et al.,
Moderate Canada 14 clients and 7
service providers
with 14
Ensuring physical and
psychological safety,
making decisions
through collaboration
and mutuality.
Clients’ experiences regarding staff
were mixed and most participants
felt that they were learning skills
to increase their independence
Sands et al.,
Moderate Adult mental
health triage
services in
75 mental health
No trauma-informed
principles mentioned
Participants appreciated access
and timeliness of services and for
the most part, had positive
experiences with telephone mental
health triage services. Some
participants felt that they needed
to escalate their concerns in order
to receive services.
Tetterton &
Strong Not specified 2 women (63 and
65 years old)
Interviews No trauma-informed
principles mentioned
Interview findings lend themselves
to effective interventions such as
welcoming and engaging the
client, encouraging and supporting
the telling of one’s story, assisting
in the process of empowerment,
and providing appropriate
information regarding support
©2020 Australian College of Mental Health Nurses Inc.
independence, both on a personal and financial level
(Hootz et al. 2016). Another study explored the percep-
tion of persons accessing telephone-based mental
health triage services in Australia (Sands et al. 2016).
In general, persons expressed that they benefitted from
a 24-hour telephone-based mental health triage service,
‘valued prompt attention and easy access to crisis ser-
vices, especially when feeling suicidal’ and felt that the
service provided help options, strategies, and advice
(Sands et al. 2016). While most aspects of the service
were favoured, some participants felt that they needed
to escalate their concerns in order to receive services
(Sands et al. 2016).
Further, in terms of crisis response, persons living
with major mental illnesses valued meeting familiar,
trusted providers who knew what the individual’s needs
in periods of crisis (Gudde et al. 2013). Other impor-
tant elements of a trusting relationship included being
believed, taken seriously, and listened to (Gudde et al.
2013). Persons also described experiences of treatment
decisions being made too quickly, without dialogue and
time for reflection. Many persons emphasized the need
for providers to pay more attention to patient experi-
ences and their problem-solving strategies to facilitate
decision-making in treatment planning (Gudde et al.
2013). In a strong quality qualitative study, authors
summarized effective interventions based on responses
of older women who experienced gender-based vio-
lence (Tetterton & Farnsworth 2011). Effective inter-
ventions included welcoming and engaging the person
through an open and reassuring professional stance,
encouraging and supporting the telling of one’s story,
and assisting in the process of empowerment through
listening, supporting, and providing appropriate infor-
mation regarding support services (Tetterton & Farns-
worth 2011).
The purpose of this systematic review was to synthesize
evidence regarding nursing interventions within the
first four weeks of a mental health crisis. Our sec-
ondary aim was to identify crisis interventions that
align with trauma-informed principles that are based
on an awareness of the widespread prevalence and
impact of trauma. The results of the systematic review
highlight the lack of research on nursing interventions
for mental health crisis while also demonstrating an
overall lack of studies that explicitly link trauma-in-
formed principles within a crisis intervention context.
The lack of literature may signify a gap in interventions
that can be conducted by registered nurses. Despite
the ability of registered nurses to connect with persons
along the spectrum of care, which makes nurses well-
suited to intervene with proper clinical skill, there
remains a paucity of research measuring the outcomes
of these interventions.
In the 10 studies that referred to one or more ele-
ments of trauma-informed principles, 7 studies demon-
strated efficacy through positive results or positive
experiences elicited from patients in relation to brief
interventions, technology- and computer-based inter-
ventions, and broader crisis and trauma-informed ser-
vice programming. The trauma-informed principles in
crisis interventions varied, with some of the key princi-
ples in interventions being related to building strengths
and skills through empowerment, or making decisions
through collaboration and mutuality. It is also likely
and important to note that use of those trauma-in-
formed principles may not have been intentional, as
the authors did not specifically denote this approach
within their intervention description. This may be
attributed to the fact that the principles of trauma-in-
formed care are not considered novel or unique in iso-
lation, and are often underlying of a patient-centred
framework. However, the strength lies in the compre-
hensive and conscious integration of the principles in
unison to create a true trauma-informed approach to
Nevertheless, our findings support the benefit of
nurses enacting key principles and relational aspects of
interventions that are experienced by the persons in
crisis to be safe, responsive, empowering, and collabo-
rative. In particular, first-hand experiences from the lit-
erature highlight that persons value prompt attention,
having trusting relationships with providers, being
active members in decision-making, learning skills to
empower themselves, and receiving appropriate infor-
mation for further supports. In this way, a trauma-in-
formed lens to crisis intervention allows nurses to
acknowledge the experiences, strengths, and prefer-
ences for care, as well as the evidence for effective cri-
sis responses. However, a more explicit connection and
articulation of enacting principles of trauma-informed
practice within a crisis intervention context for the pur-
pose of being more aware and responsive to impacts of
trauma is lacking.
Trauma-informed frameworks, principles, and
approaches are being integrated into services and sys-
tems addressing child welfare, homelessness, mental
health and substance use, criminal justice, education,
and primary care in ways that are intentional and aim
©2020 Australian College of Mental Health Nurses Inc.
to be responsive to trauma prevalence and impact and
reduce/minimize inadvertent re-traumatization. In
these interventions, immediate trauma responses are
noticed, how these responses are likely linked to past
experiences is understood, and non-judgemental, com-
passionate, and non-traumatizing support is provided.
Clearly more evidence on trauma-informed approaches
to supporting people in crisis across all these systems
of care is required so that the lessons arising can be
applied in all settings by nurses and other providers. It
is to note however that through a trauma-informed
lens, a crisis event is not defined by the event per se,
but by the impact. As such, trauma-informed
approaches to crisis can be applied universally in all
crisis as an approach to prioritizing psychological and
emotional safety based on the acknowledgement of the
prevalence and impact of trauma. It is also important
to realize that reactions and/or impacts of crisis for a
person may also be a cumulative response to prior
From a practice perspective, core principles of col-
laboration and choice, trustworthiness and trans-
parency, safety, peer support, and understanding of
gender, historical, and cultural issues may seem intu-
itive and constitute basic taken-for-granted foundations
of clinical practice. However, what is evident in the
results of the systematic review is that no studies exam-
ined nursing interventions for crisis with all of the prin-
ciples collectively enacted as a driving framework,
including the recognition and awareness of trauma. As
a registered nurse, without an appreciation of the total-
ity of the principles, there is a risk for losing sight of
the presence and impact of trauma for both providers
and person experiencing crisis. Furthermore, a trauma-
informed framework affords the opportunity for a com-
mon understanding and approach to service delivery
across sectors and service providers, which is relevant
in the case of crisis intervention, as it often involves
multisectoral collaboration across one or more service
providers. Going forward, there is an opportunity for
studies to examine effectiveness of crisis interventions
from an integrated trauma-informed framework that
examines not only outcomes, but important trauma-in-
formed processes of care that are associated with
improved outcomes for persons in crisis as well. Fur-
ther, more research is required to understand the
impact of trauma-informed principles when it is inte-
grated into crisis interventions relating to brief inter-
ventions, telecommunication and technology-based
strategies, post-disaster management, and crisis inter-
ventions for those living with underlying mental illness.
The systematic review identified several gaps in the
literature. Most notably, it highlighted the need for fur-
ther research in the area of trauma-informed crisis
interventions, specifically for nurses, and their practice.
There was also a lack of exploration of crisis support
needs and preferences in ethnically and sexually
diverse men, women, and transgender persons. There
were no studies exploring holistic interventions with
indigenous persons and the need to recognize historical
trauma as trauma requiring holistic and culturally rele-
vant approaches. More research is also needed that
explores effective crisis interventions for those living
with severe mental illness and addictions. Finally, there
were no studies identified on effective strategies for
assessment by a registered nurse of a person experienc-
ing crisis.
The systematic review is not without limitations.
Despite reviewing extensive literature, the possibility
remains that other studies related to the topic may not
have been identified and reviewed. The literature was
also heterogeneous, and therefore, a meta-analysis
could not be conducted. As the review was limited to a
nursing scope of practice, there are certainly additional
bodies of literature with more advanced intervention
approaches that may include medication prescribing or
advance psychotherapy. Further, because unpublished
literature was not part of the literature review, findings
may not be representative of all work in the field. In
addition, since reviewers determined the trauma-in-
formed principles referred to in some studies, conclu-
sions could be subject to interpretation as this may not
have been intentional by the study author(s). Finally,
results may be difficult to generalize due to the small
sample sizes and the variation in populations among
This systematic review provides an important assess-
ment of the current available evidence and points to
opportunities and gaps for future research and evalua-
tion regarding nursing interventions for mental health
crisis from a trauma-informed practice lens. The inte-
gration of trauma-informed principles within quantita-
tive studies that explored effectiveness of nursing
interventions for mental health crisis across various
high-risk groups demonstrated improvements in mental
health symptoms and access/referral to care. Further-
more, qualitative study findings reaffirm person’s values
and requests for providers and services that consider
trauma-informed principles. There was a lack of studies
©2020 Australian College of Mental Health Nurses Inc.
on crisis intervention explicitly linked to trauma-in-
formed principles that can be undertaken by registered
nurses, highlighting future research needs and more
conscious efforts to integrate trauma-informed princi-
ples to crisis intervention practices.
This review and the associated best-practice guideline
primarily inform the work of registered nurses, in addi-
tion to other health providers, first responders, and
peer support workers to provide evidence-based
trauma-informed crisis interventions. The review sup-
ports a principle-based approach to providing brief
intervention, as well as technology-assisted interven-
tions in the period immediately following crises, includ-
ing those arising from disasters, with an emphasis on
supporting the active involvement of persons experi-
encing crisis in ways that are connective, empowering,
collaborative, skill-building, and strengths-based. Inte-
gration of a trauma-informed framework to crisis inter-
vention that is driven by the core principles of safety
(psychological, emotional, physical), trust, choice, col-
laboration, and shared power allows providers to bring
to awareness an acknowledgement of the prevalence
and impact of trauma in the lives of individuals and
communities but also to recognize the signs of the
impact and respond in ways that seek to avoid re-
traumatization through routine processes of care
(SAMHSA 2014). A trauma-informed approach to crisis
intervention helps to ground clinical interventions on a
common understanding that prioritizes not only what
intervention is provided to persons in crisis but how
we provide interventions in ways that feel safe and pro-
mote resilience.
The authors would like to thank UHN HealthSearch for
the systematic search, Sabrina Merali for the oversight in
the development of the best practice guideline as co-
lead, the expert panel for their guidance in the develop-
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... There is no universally accepted definition of TIC; however, the most commonly cited definition communicates that it as an approach to raise awareness of the impact of trauma, recognize trauma symptoms or responses, respond at both the individual and system level with traumaspecific knowledge and resist re-traumatization; this is collectively known as the four 'R's' (Substance Abuse and Mental Health Services Administration, 2014). The principles of TIC have been emphasized as a critical factor in translating TIC in practice (Fleishman et al., 2019;Nizum et al., 2020). However, there is a lack of consensus on the principles of TIC, with a number of organizations and peer-reviewed papers citing various principles, that is, Harris and Fallot (2001), Elliot et al. (2005), Bateman et al. (2013) and the Substance Abuse and Mental Health Services Administration (2014). ...
... In Australia, at both state and federal levels, TIC has been identified as a priority in several strategic plans and recommendations from public inquiries and TIC research Isobel, Wilson, Gill, Schelling, & Howe, 2020;National Mental Health Commission, 2014;Productivity Commission, 2020). The implementation of TIC in acute mental health settings is reported to have positive outcomes regarding improved experiences of care for consumers of mental health (Nizum et al., 2020), staff wellbeing (Fleishman et al., 2019;Simons et al., 2020), decreases in seclusion and restraint (Azeem et al., 2017;Bendall et al., 2021), involuntary mental health treatment and other coercive practices (Mihelicova et al., 2018;Palfrey et al., 2018). Despite these assertions, there remains a wide variation in the implementation, education, measurement and evaluation of TIC (Champine et al., 2019). ...
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Trauma-informed care has gained increasing popularity in mental health services over the past two decades. Mental health nurses remain one of the largest occupations employed in acute mental health settings and arguably have a critical role in supporting trauma-informed care in this environment. Despite this, there remains a limited understanding on how trauma-informed care is applied to the context of mental health nursing in the hospital environment. The aim of this study was to explore what it means for mental health nurses to provide trauma-informed care in the acute mental health setting. The study design was qualitative, using van Manen's (Researching lived experience: human science for an action sensitive pedagogy. State University of New York Press, 1990) approach to hermeneutic phenomenological inquiry. A total of 29 mental health nurses participated in this study. There were three overarching themes that emerged; these entail: embodied trauma-informed milieu, trauma-informed relationality and temporal dimensions of trauma-informed mental health nursing. The study found that for mental health nurses, there are elements of trauma-informed care that extend far beyond the routine application of the principles to nursing practice. For mental health nurses working in the acute setting, trauma-informed care may offer a restorative function in practice back to the core tenants of therapeutic interpersonal dynamics it was once based upon.
... Treatment incorporating traumainformed principles-namely, promoting safety, trustworthiness and transparency, fostering collaboration and mutuality, supporting empowerment, choice and control, providing opportunity for peer support, and generating awareness and responsiveness to cultural, historical, and gender issues is needed. This is highly warranted when dealing with sudden, unexpected grief such as the loss of a child (Nizum et al., 2020). ...
... The PMHN, along with other healthcare providers such as psychiatric social workers and advanced practice nurses (APNs), should educate staff involved in the care of fathers and provide support and referral sources for staff that may have difficulty providing grief care. Trauma-informed approaches could be applied for grieving fathers (Nizum et al., 2020). The most beneficial commodity that a healthcare professional can offer to a grieving family is a nonjudgmental, deep sense of caring and personal involvement. ...
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Introduction: The effects of grief on fathers that have experienced perinatal loss merit further exploration. Aim: The purpose of this paper is to draw attention to the experience of grief felt by fathers when facing perinatal loss. A father's grief and loss are frequently unrecognized and underappreciated by healthcare professionals who customarily attend only to the needs of mothers. Results: Data for this study was based on a couple's lived experience. This is a co-authored piece by a husband and wife. This literature suggests that the lack of resources for fathers might result in unresolved grief which if prolonged could be expressed in potential losses during subsequent pregnancies. Implications for practice: Content from a review of the literature provides evidence helpful in addressing the recognition and management of grief in fathers experiencing perinatal losses. The grief and any related trauma due to prenatal losses can be managed in fathers with different methods, including support services, counseling, and if needed psychotherapy and pharmacotherapy. Psychiatric-mental health nurses can play an important role in the recognition and management of grief and planning interventions to support grieving fathers.
... 6 Suicide literacy might require understanding for traumainformed care, as a recent systematic review found a lack of research explicitly linking trauma-informed care principles within nursing crisis intervention. 7 We acknowledge the complexity between top-down and bottom-up mechanisms needing clarity when addressing our suggestions. At the coal face, males who maintain stoicism or avoid help-seeking might not perceive this as problematic. ...
Emergency care teams need to organize their response to crises around shared assessment procedures. This chapter describes how MBT can inform emergency care when a crisis is handled by the multidisciplinary team of mental health practitioners in psychiatric emergency settings. Development of the formulation according to mentalizing principles creates compassionate care in emergency settings. The chapter outlines the key factors that commonly contribute to the development of a crisis, and includes a discussion of the centrality of loss of mentalizing and collapse of agency of the self that are part of any acute crisis. Focusing on all of these aspects of a psychiatric emergency can de-escalate an immediate crisis and pave the way for planning how to prevent a recurrence in the future. Understanding of the triggers that can lead to a crisis and development of a plan for reducing the risk of recurrence are illustrated with clinical examples, and the four steps of MBT-informed emergency care are described.
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Background: Nurses are among the individuals who are under various forms of stress and physical and psychological harm due to the nature of their occupation. Objectives: The present study aimed to investigate the mediating role of self-compassion in the relationship between spiritual intelligence and hope in female nurses. Methods: The method of the current research was descriptive-correlational. In this research, 183 female nurses of Neyshabur hospitals were selected by convenience sampling method in 2019. Participants completed King’s Spiritual Intelligence Questionnaire (2008), Snyder’s Hope Questionnaire (2000), and Neff’s Self-Compassion Scale (2003). The data were analyzed using SPSS software version 24, descriptive statistics (mean, standard deviation, frequency, and frequency percentage), path analysis method, and Pearson correlation coefficient. Results: The mean (SD) age of participants was 35.22(5.91) years. Spiritual intelligence and self-compassion were predictors of hope in female nurses (p
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Intimate partner violence (IPV) and child maltreatment (physical, emotional, sexual abuse, neglect, and children’s exposure to IPV) are two of the most common types of family violence; they are associated with a broad range of health consequences. We summarize evidence addressing the need for safe and culturally-informed clinical responses to child maltreatment and IPV, focusing on mental health settings. This considers clinical features of child maltreatment and IPV; applications of rights-based and trauma- and violence-informed care; how to ask about potential experiences of violence; safe responses to disclosures; assessment and interventions that include referral networks and resources developed in partnership with multidisciplinary and community actors; and the need for policy and practice frameworks, appropriate training and continuing professional development provisions and resources for mental health providers. Principles for a common approach to recognizing and safely responding to child maltreatment and IPV are discussed, recognizing the needs in well-resourced and scarce resource settings, and for marginalized groups in any setting.
Conference Paper
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This study aims to study the impact of the strategic environmental survey on crisis management, as health organizations, including the researched hospital, suffer from a lack of available resources and allocations to face crises, lack of adequate experience, necessary methods and rapid remedies in managing these crises in light of conditions of uncertainty from external and internal environmental factors, A random sample was chosen from the medical staff at Mohammed Al-Musawi Hospital for Children in Dhi Qar to conduct the study, which amounted to 67 samples to test a set of main and sub-hypotheses that specialized in analyzing correlation and impact relationships, where a group of families was used. Statistical analysis for data analysis and processing using the SPSS V.26 program and the Amos V.25 program. These studies have reached conclusions, the most important of which is a strong correlation between strategic environmental survey and crisis management, and that there is a significant impact of external and internal environmental factors in dealing And the rapid response to those crises, and in light of these conclusions, a set of recommendations was formulated, the most important of which is the need for health organizations management to take care of external and internal environmental factors to deal quickly with crises, and the necessity of forming pre-committees to deal with crises, learn from them and increase the awareness of individuals it. Keywords: Strategic Environmental Scanning, Crisis Management.
Background At our inpatient psychiatric hospital, which cares for children and adolescents, internal data of use of seclusions and holds as crisis interventions for immediate behavioral health issues demonstrated that we were using these too often. Aims Benchmarking indicated that we were at the 75% in use of these measures, and it became an organizational goal to reduce the use of these strategies in order to reduce the risk of retraumatization to an already traumatized child. Methods We used the Iowa Model for Evidence Based Practice–Revised to initiate an evidence-based practice project introducing and hardwiring Trauma Informed Care to the staff and institution. This involved implementing six core strategies specifically designed to reduce the use of crisis interventions. Results Data obtained at 6 months revealed a 40% reduction in the use of holds and seclusions, and at 12 months, this change was sustained and even improved, reducing the use of these approaches by another 9%. Furthermore, the culture in the institution was changed, and Trauma Informed Care became the norm. Conclusions Evidence-based practice is a viable approach to change the culture and improve patient outcomes in inpatient psychiatric care of children and adolescents. Further investigation is warranted to determine the specific patient and staff experiences of being cared for, and caring within, the context of trauma-informed care.
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Objective: The U.S. Department of Justice has called for the creation of trauma-informed juvenile justice systems in order to combat the negative impact of trauma on youth offenders and frontline staff. Definitions of trauma-informed care have been proposed for various service systems, yet there is not currently a widely accepted definition for juvenile justice. The current systematic review examined published definitions of a trauma-informed juvenile justice system in an effort to identify the most commonly named core elements and specific interventions or policies. Method: A systematic literature search was conducted in 10 databases to identify publications that defined trauma-informed care or recommended specific practices or policies for the juvenile justice system. Results: We reviewed 950 unique records, of which 10 met criteria for inclusion. The 10 publications included 71 different recommended interventions or policies that reflected 10 core domains of trauma-informed practice. We found 8 specific practice or policy recommendations with relative consensus, including staff training on trauma and trauma-specific treatment, while most recommendations were included in 2 or less definitions. Conclusion: The extant literature offers relative consensus around the core domains of a trauma-informed juvenile justice system, but much less agreement on the specific practices and policies. A logical next step is a review of the empirical research to determine which practices or policies produce positive impacts on outcomes for youth, staff, and the broader agency environment, which will help refine the core definitional elements that comprise a unified theory of trauma-informed practice for juvenile justice. (PsycINFO Database Record
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Rogers, Bobich, and Heppell’s (2016) case study illustrating the successful application of an "Incredible Years" intervention with a 4-year-old girl and her family in the context of a homeless shelter provides an opportunity to consider the intersecting perspectives of infant and early childhood mental health and trauma-informed care. Cathy’s exposure to intimate partner violence, her mother’s chronic depression, and her homelessness occurred during the critical developmental stages of prenatal development and the first four years of life, impacting her developing understanding of relationships and her emotion regulation. A trauma-informed perspective provides an understanding of the links between Cathy’s history of trauma and her presenting symptoms of tantrums, aggression, and “moodiness,” leading to recommended parenting strategies that support co-regulation and eventually self-regulation of emotions. Although the Incredible Years intervention was successful in reducing Cathy’s symptoms, the addition of trauma-focused interventions may have the added benefit of helping Cathy to directly play and talk about her experience, together with her mother, so that both can understand and integrate their traumatic experiences and her mother can restore her role as a “protective shield” for her family. Finally, the opening provided by implementation of a successful parenting intervention could lead to a broader consultation aimed at creating a trauma-informed organization within the transitional living shelter.
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Both trauma-informed practices and trauma-specific services have been developed to meet the needs of individuals seeking services for mental health and substance use disorders. These approaches involve an acknowledgement of an individual’s inter-related experiences of trauma, mental health, and substance use problems in all aspects of service delivery, and focus on enhancing consumer safety and control. Although trauma-informed practices and trauma-specific interventions have been repeatedly identified as critical to service provision in this area, there is little understanding of how these practices and interventions are delivered and experienced from the perspectives of service users and providers. The purpose of this study was to explore facilitators and barriers in implementing trauma-informed practices and delivering trauma-specific services in mental health and addiction service settings through qualitative interviews with service providers, consumers and research experts. Based on thematic analysis of in-depth interviews with 19 participants (including service providers, research experts and consumers), a number of key facilitators and challenges to implementation of trauma-informed practices and services emerged. Key facilitators included: organizational support, community partnerships, staff awareness of trauma, a safe environment, peer support, the quality of consumer-provider relationships, consumer and provider readiness to change, and staff supports. Challenges included: provider reluctance to address trauma, lack of accessible services, limited funding for programs/services, and staff burnout. Key areas of change identified in the study point to the need for increased intersectoral collaboration and support, greater system-wide trauma awareness and provider training in order to enhance the ability of trauma-informed practices and -specific services to meet the complex needs of this population.
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Background Immediate patient feedback has been shown to improve outcomes for patients in mild distress but it is unclear whether psychiatric patients in severe distress benefit equally from feedback. This study investigates the efficacy of an immediate feedback instrument in the treatment of patients with acute and severe psychosocial or psychiatric problems referred in the middle of a crisis. MethodsA naturalistic mixed diagnosis sample of patients (N = 370) at a Psychiatric Emergency Centre was randomised to a Treatment-as-Usual (TAU) or a Feedback (FB) condition. In the FB condition, feedback on patient progress was provided on a session-by-session basis to both therapists and patients. Outcomes of the two treatment conditions were compared using repeated measures MANCOVA, Last Observation Carried Forward and multilevel analysis. ResultsAfter 3 months, symptom improvement in FB (ES 0.60) did not significantly differ from TAU (ES 0.71) (p = 0.505). After 6 weeks, FB patients (ES 0.31) actually improved less than TAU patients (0.56) (p = 0.019). Conclusions Patients with psychiatric problems and severe distress seeking emergency psychiatric help did not benefit from direct feedback. Trial registrationDutch Trial Register, NTR3168, date of registration 1-9-2009
Background: People diagnosed with borderline personality disorder (BPD) frequently present to healthcare services in crisis, often with suicidal thoughts or actions. Despite this, little is known about what constitutes effective management of acute crises in this population and what type of interventions are helpful at times of crisis. In this review, we will examine the efficacy of crisis interventions, defined as an immediate response by one or more individuals to the acute distress experienced by another individual, designed to ensure safety and recovery and lasting no longer than one month. This review is an update of a previous Cochrane Review examining the evidence for the effects of crisis interventions in adults diagnosed with BPD. Objectives: To assess the effects of crisis interventions in adults diagnosed with BPD in any setting. Search methods: We searched CENTRAL, MEDLINE, Embase, nine other databases and three trials registers up to January 2022. We also checked reference lists, handsearched relevant journal archives and contacted experts in the field to identify any unpublished or ongoing studies. Selection criteria: Randomised controlled trials (RCTs) comparing crisis interventions with usual care, no intervention or waiting list, in adults of any age diagnosed with BPD. Data collection and analysis: We used standard methodological procedures expected by Cochrane. Main results: We included two studies with 213 participants. One study (88 participants) was a feasibility RCT conducted in the UK that examined the effects of joint crisis plans (JCPs) plus treatment as usual (TAU) compared to TAU alone in people diagnosed with BPD. The primary outcome was self-harm. Participants had an average age of 36 years, and 81% were women. Government research councils funded the study. Risk of bias was unclear for blinding, but low in the other domains assessed. Evidence from this study suggested that there may be no difference between JCPs and TAU on deaths (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.06 to 14.14; 88 participants; low-certainty evidence); mean number of self-harm episodes (mean difference (MD) 0.30, 95% CI -36.27 to 36.87; 72 participants; low-certainty evidence), number of inpatient mental health nights (MD 1.80, 95% CI -5.06 to 8.66; 73 participants; low-certainty evidence), or quality of life measured using the EuroQol five-dimension questionnaire (EQ-5D; MD -6.10, 95% CI -15.52 to 3.32; 72 participants; very low-certainty evidence). The study authors calculated an Incremental Cost Effectiveness Ratio of GBP -32,358 per quality-adjusted life year (QALY), favouring JCPs, but they described this result as "hypothesis-generating only" and we rated this as very low-certainty evidence. The other study (125 participants) was an RCT conducted in Sweden of brief admission to psychiatric hospital by self-referral (BA) compared to TAU, in people with self-harm or suicidal behaviour and three or more diagnostic criteria for BPD. The primary outcome was use of inpatient mental health services. Participants had an average age of 32 years, and 85% were women. Government research councils and non-profit foundations funded the study. Risk of bias was unclear for blinding and baseline imbalances, but low in the other domains assessed. The evidence suggested that there is no clear difference between BA and TAU on deaths (RR 0.49, 95% CI 0.05 to 5.29; 125 participants; low-certainty evidence), mean number of self-harm episodes (MD -0.03, 95% CI -2.26 to 2.20; 125 participants; low-certainty evidence), violence perpetration (RR 2.95, 95% CI 0.12 to 71.13; 125 participants; low-certainty evidence), or days of inpatient mental health care (MD 0.70, 95% CI -14.32 to 15.72; 125 participants; low-certainty evidence). The study suggested that BA may have little or no effect on the mean number of suicide attempts (MD 0.00, 95% CI -0.06 to 0.06; 125 participants; very low-certainty evidence). We also identified three ongoing RCTs that met our inclusion criteria. The results will be incorporated into future updates of this review. Authors' conclusions: A comprehensive search of the literature revealed very little RCT-based evidence to inform the management of acute crises in people diagnosed with BPD. We included two studies of two very different types of intervention (JCP and BA). We found no clear evidence of a benefit over TAU in any of our main outcomes. We are very uncertain about the true effects of either intervention, as the evidence was judged low- and very low-certainty, and there was only a single study of each intervention. There is an urgent need for high-quality, large-scale, adequately powered RCTs on crisis interventions for people diagnosed with BPD, in addition to development of new crisis interventions.
Stigma experienced by drug users by their healthcare professionals can be a barrier to treatment engagement, which in turn affects mortality and morbidity rates. Attribution theory suggests that stigma will be greatest whenever drug use is attributed to factors within personal control. Here, clients (n = 76) and healthcare professionals (n = 62) identified features that characterize good and bad clinical interactions, and responded to a vignette about a drug user who attributed his use to personal control or situational factors. Healthcare professionals completed the vignette and drug users gave their best guess of how healthcare professionals would react to this vignette. Clients and professionals held overlapping prototypes of clinical interactions. Clients overestimated both how negative healthcare professionals’ reactions would be, and the extent to which healthcare professionals’ reactions would accord with attribution theory. Despite healthcare professionals’ believing they are acting in nonstigmatizing ways, they may engender stigma in clinical situations more than they realize. Discrepancies between professionals’ hypothetical responses and clients’ anticipation of these responses are discussed in terms of the influence of self‐stigma and societal understandings of drug use and control. Attribution theory only offers a limited explanation for these discrepancies, because professionals’ beliefs about drug users are complex. Implications for theories of stigma and engagement with services are discussed, and the importance of clients’ anticipation of stigma is highlighted as a primary target for addressing treatment disengagement. Anti‐stigma campaigns may also benefit from changing their focus from individuals’ attributions to holistically addressing discrepant conceptions of treatment.
Students in the middle grades experience tremendous development in various domains. However, childhood trauma can significantly impede this development, further exacerbating the functioning of our most vulnerable student populations. This article aims to describe the use of trauma-informed teaching as a form of middle-level, social justice education, providing a description of trauma, as well as how traditional classroom management and instruction can affect traumatized students. This article also provides narratives of current and emerging models of trauma-informed teaching, connecting them to the goals of social justice education, and providing practical strategies for implementing such practices in middle-level schools and classrooms.
Trauma and behavioral health problems among children in foster care are significant and prevalent, affecting their well-being and permanency. Despite the wide scope and magnitude of social and emotional problems among youth in out-of-home care, few child welfare systems have an integrated service response into their routine procedures and practices. This paper describes three federally-funded statewide demonstration sites, which represent northeast, south, and Midwest regions of the U.S., and that aimed to implement trauma and evidence-informed initiatives. Applying implementation science frameworks, we share our experiences with three key stages of implementation: exploration, installation, and initial implementation. During the exploration stage, each state engaged community stakeholders in a comprehensive data mining process to define the needs of children in care and relevant gaps in the evidence-informed service array. To respond to trauma and behavioral health needs of children, these states' initiatives established implementation plans for screening, functional assessment, data-driven case planning, ongoing progress monitoring, and service array reconfiguration. Each state's distinct installation and initial implementation experiences are described as well their shared successes and challenges. While vast differences existed within the administrative and policy context of these three states, the study demonstrates both unique and common experiences of successes and setbacks. Across the exploration, installation, and initial implementation, these analyses revealed six themes of common successes to include collaboration, building consensus, conducting trainings, teaming, optimizing opportunity, and establishing data systems. Additionally, nine themes of common challenges were workforce, turf, client voice, data sharing, coaching and support for fidelity, time, competing priorities, momentum, and policies and leadership. Implications for practice, policy, and future research are discussed.
When mental health crisis situations in the community are poorly handled, it can result in physical and emotional injuries. The purpose of this study was to ascertain the experiences and opinions of consumers about the way police and mental health services worked together, specifically via the Alfred Police and Clinical Early Response (A-PACER) model, to assist people experiencing a mental health crisis. Semi-structured in-depth interviews were conducted with 12 mental health consumers who had direct contact with the A-PACER team between June 2013 and March 2015. The study highlighted that people who encountered the A-PACER team generally valued and saw the benefit of a joint police-mental health clinician team response to a mental health crisis situation in the community. In understanding what worked well in how the A-PACER team operated, consumers perspectives can be summarized into five themes: communication and de-escalation, persistence of the A-PACER team, providing a quick response and working well under pressure, handover of information, and A-PACER helped consumers achieve a preferred outcome. All consumers acknowledged the complementary roles of the police officer and mental health clinician, and described the A-PACER team's supportive approach as critical in gaining their trust, engagement and in de-escalating the crises. Further education and training for police officers on how to respond to people with a mental illness, increased provision of follow-up support to promote rehabilitation and prevent future crises, and measures to reduce public scrutiny for the consumer when police responded, were proposed opportunities for improvement.