What happened to you? Changing how we think about trauma and neglect

6 min readNov 10, 2020

‘Tell me about your childhood’ sounds like the start of every TV scene with a therapist.

*Originally published by the New Yorker*

And yet studies show that when doctors write-up and code patient notes, they’re more likely to focus on a diagnosis rather than a patient’s life and social context. Why is that, and does it matter in terms of how patients are treated? Can we really expect more from an overwhelmed system and time-poor clinicians? Can tech help reduce the burden and reduce waiting times for support? These are just some of the questions raised in today’s article on trauma and neglect.

Next week 👉 Why do I snooze my alarm? Addressing behaviour change and loneliness

If you just landed here — this article is part of a ten-part series providing bite-sized expert insights on mental health topics (from world-class speakers via Zinc) and my thoughts on the role tech can play in addressing these themes (part of my day job at Kamet). All smart ideas come from the speakers and my peers — all poor phrasings and misunderstandings are my own.

What you’ll learn from this article 🧠

Our expert speakers on this topic, Professor Peter Kinderman and Akiko Hart, discussed the topics of trauma, abuse and neglect. Big idea 1: moving from a disease-centric model of mental health to a biopsychosocial model (i.e. asking ‘what happened’ not ‘what’s wrong’). Big idea 2: the political challenges of discussing the daily injustices experienced by those with poor mental health. Our discussion centred on what we could practically do about these situations and how realistic our expectations are of those working within mental health services. Technology thoughts range from ways to improve our ability to sit with pain rather than trying to ‘fix’ problems, tech to reduce pressure on clinicians, and enabling access to ‘non-traditional’ mental health support.

The big ideas 💡

Peter Kinderman: we can move from a disease-centric model of mental health to a biopsychosocial model which recognises individuals’ wider contexts. If we only ask ‘what’s wrong’ we don’t think more broadly about ‘what happened’. Trauma doesn’t have to be major — it can be small, subtle activities that influence your interpretation of the world, like a parent’s attitude. We’re wired to think about the ‘exceptions’ — those who seem to have strong resilience despite adversity, and identify a biological silver bullet. However, experiences can be more explanatory of our mental health than pure biological, causal models. Despite this, we see under-coding of psychosocial adversity by clinicians: there is an emphasis on capturing the diagnosis rather than the wider context (e.g. low-income, threat of job loss, history of spouse or partner violence)
Akiko Hart: The politics of violence and abuse. Whilst there is growing conversation of these topics, it’s hard to talk about abuse and neglect within our mental health services. There are daily inequities: neglect, casual cruelty, being treated as ‘less than’. We link mental health to irrationality; for example someone paranoid about the government following them is less likely to be believed if they are being stalked. And ubiquitous waiting lists are a form of neglect. At the same time, there’s an acknowledgement that there simply isn’t enough time, reflective space or support for those working in the system.

Discussion points 🗪

Are we asking too much of mental health services? Clinicians and support staff are overwhelmed — often the ‘backstop’ of emergency services, with limited budgets and huge, unmatched demand. Clinical education is disease-focused, time with patients is limited, and systemic factors such as diagnosis-based reimbursement make it entirely understandable that you might code a diagnosis first. We also need to consider whether those at the front line are sufficiently supported to sit with the trauma they might hear about on a daily basis; with reflective time and space to improve their own mental health.
How do we support acute trauma? It can be difficult to access secondary, specialist mental health services based on a single trauma — more likely to get access to IAPTs than dissociation services which are expensive and not easily referred. It’s important to practice psychological first aid (is an individual safe, has transport, funding?) with some best practice from the Israeli military services’ 6Cs approach. It’s important to have psychologically-informed contact points (e.g. in schools, social services) to communicate and identify traumas

Technology thoughts 💻

Can technology help us to overcome our innate wiring to ‘fix’ others’ pain, and let us sit with it? I’m a huge believer in Shout — a volunteer-led crisis text line which provides a 2 month training course for its volunteers to learn the framework of a supportive conversation. Things I didn’t expect — like simply letting someone feel heard — are hugely impactful. The technology also provides multiple forms of oversight — including coaches and supervisors who can see in real time the risk-level of each conversation and intervene where necessary. Other companies like Form support us to talk about our mental health with those in our trusted circle — enabling the ‘what happened’ conversation in a new way — whilst fellow Pioneer Freya is building re;mind, personalised wellbeing support to help you rebuild after trauma
How can we reduce pressure on clinicians and support workers? As we know that services are significantly over-stretched, how might we try to give clinicians some of their time back? One opportunity is to improve the efficiency of in-person visits. Thymia are using a combination of video, gaming and speech to enable faster baseline assessments, whilst companies like Suki are digital assistants for doctors, writing up notes and auto-populating EHRs. Another, more disruptive, opportunity is to offer digital therapeutics to patients earlier in the patient journey (e.g. Sleepio, digital CBT for insomnia). Digital therapeutics address challenges on the patient side by removing waiting lists, a form of neglect, and also lighten the burden on professionals: there is only 1 CBT therapist available for every c. 1,000 people living with insomnia.
How can we re-think how we define ‘mental health support’? If an individual’s business is failing, impacting their marriage, leading to depression, is access to a business mentor an appropriate intervention? Social prescribing enables GPs, nurses and other primary care professionals to refer people to a range of local, non-clinical services. In even more simple terms, what will make one person feel better is different to others. Betterspace is a marketplace that enables employees to discover new ways to improve their wellbeing — moving away from a one-size-fits-all approach

Reading list 📚

Speaker bios 🔈

Professor Peter Kinderman is Professor of Clinical Psychology at Liverpool University. A past President of the British Psychological Society and an internationally acclaimed author and speaker on mental health. His recent 2019 book is ‘A Manifesto for Mental Health: Why we need a Revolution in Mental Health Care’.
Akiko Hart is the CEO of the National Survivor User Network, a network of people who have and do experience mental distress who want to change things for the better. Akiko has previously worked as Director of Mental Health Europe, and is a Committee Member of the English Hearing Voices Network. Akiko is one of the UK’s leading campaigners and advocates for people with lived experiences of mental health difficulties.

If you’ve made it this far, thanks for reading! You can find out more about why I’m writing this series here. Have something to add, want to give your views or just continue the conversation? Hit me up on email / LinkedIn / Twitter.