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Background and Definitions


Trauma - This term is widely used but in this context refers to a ‘stressful event or situation (either short or long lasting) of exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost everyone’ (ICD-10 1994). This is usually subdivided into two types of adverse and abusive life events (Terr 1991).

Type 1 trauma

Type 2 or Complex trauma

Sudden and unexpected events which are experienced as isolated incidents such as road traffic accidents, rapes or terrorist attacks. This can happen in childhood or adulthood.

This term refers to traumatic events which are repeated, interpersonal and often (although not always) occur in childhood. This includes all forms of childhood abuse which is chronic and cumulative such as childhood sexual abuse, childhood physical abuse, witnessing domestic abuse and neglect. Domestic abuse is the most common experience of complex trauma in adulthood.

Survivor - Someone who has lived through traumatic events.

Abuse - Abuse can take a number of forms; emotional/verbal, physical and sexual but is always something that happens within a relationship, usually with someone who you know. Examples include childhood sexual abuse, childhood physical abuse, neglect.

Adverse Childhood Experiences (ACE) - This is an increasingly used term which describes the experience of range of adversity in childhood including abuse, neglect but also parental substance misuse, parental separation or incarceration, parental mental illness and living in care.

Adverse Childhood Events Key Points

How common is this?

Living through abuse and trauma is more common than often previously recognised. The World Health Organisation reports that 20% of girls and up to 10% of boys experience sexual abuse in their childhood. In some specialist services, prevalence rates are often much higher, for instance 75% of women and men in substance misuse services report abuse and trauma in their lives (WH0 2014).

It is now a well-researched and robust finding that survivors of trauma and complex trauma are at higher risk of a range of health, mental health and social difficulties (e.g. WHO 2014ScotPHN 2016). It is important to stress; this does not mean any particular individual survivors will develop these difficulties but that they are at a higher risk and that the more trauma and complex trauma that is experienced by individuals, the higher the risk becomes. It is now well recognised that there is a common pattern of mental health difficulties which has been called Complex Post Traumatic Stress Disorder. Following many years of research this is to be included in the International Classification of Diseases (ISD-11) which is due to be published in 2017.

A recent survey in Wales (2015 Public Health Wales NHS trust), replicated the international research and found that those with 4 or more experiences of adversity and abuse in childhood were

  • 4x more likely to be a high risk drinker
  • 6x more likely to have had or caused an unintended teenage pregnancy
  • 6x more likely to smoke
  • 14x more likely to be a victim of violence
  • 15x more likely to be a perpetrator of violence
  • 16x more likely to have used heroin
  • 20x more likely to be incarcerated

The development of these high risk health behaviours is easier to understand when viewed through the lens of being a survivor. For individuals affected this is likely to be complex and unique but overall we can start to think about these risky behaviours being a result of the impact of trauma or an attempt to cope with this impact.

Why is this relevant to my work?

Survivors experience two significant areas of difficulty in relation to their health

1.       Increased risk of health and social difficulties because of the direct and indirect consequences of their experience

Direct impacts might include; difficulties in developing safe and trusting relationships, post traumatic stress difficulties, disruptions to education, lack of capacity to develop skills in managing distress and emotional reactions (due to being subjected to ‘insurmountable challenges’ which overwhelm survivors coping strategies, particularly for those effected in childhood). Indirect impacts can include; unsafe coping strategies developed to managed their distress, this can include reliance on alcohol or drugs, self harm and an impact on their eating patterns and all of these can have long term health and mental health harming consequences. Poorer relationships with others is crucial as we know that safe and supportive relationships are a key predictor of resilience in the face of difficulties that is turning insurmountable challenges into manageable ones (Couper and Mackie 2016).

2.       Difficulties accessing services or maintaining access with services

This is again a complex area, but some elements which might be important include difficulties with trusting staff, difficulties with procedures that involve touch, not feeling understood by services and frequent disengagement for instance difficulties attending appointments.

This project will involve a number of elements which together have the goal of achieving improving outcomes for survivors of abuse and trauma across Scotland through effective, targeted and evidence based training and skills development.


Project Plan

 Trauma Project Plan


The goal of the first year of this project is to map the current evidence base for the most effective ways of supporting survivors of trauma and complex trauma. This will create a Knowledge and Skills Framework which will

  • help staff to build their understanding of their strengths and areas for development across all tiers of service delivery from non-specialist to specialist services.
  • be designed to also support managers to understand the training needs of their teams.
  • help trainers be able to design curriculum which are informed by the best evidence base.
  • inform the development of a National Training Strategy which identifies key training and skills gaps and develop or commission training to support this.

This project will be underpinned by a number of principles

  • Evidence based

It is central to the development of this project that the recommendations arising are evidence based wherever possible and evidence informed where there are gaps in the evidence.

  • Tiered

Trauma and complex trauma is everyone’s business, but not everyone has to be a trauma expert. The project will develop tiers to help staff and service providers identify what their needs are in order to provide the most effective care, support and treatment for survivors where this might be relevant.

  • Implementation Science

Recent research shows that training alone is not sufficient to ensure new knowledge and skills are embedded in practice. The Implementation Science approach has delineated the elements which is most likely to see evidence based practice delivered with fidelity and therefore most likely to benefit survivors. This literature will inform the planning of this process.

To build our understanding of the Scottish context, 3 scoping exercises are being completed in year 1.

  • Services scoping

This is designed to understand the current levels of training in the workforce in Scotland, who the main training providers are and what are the strengths, gaps and barriers in training in this area.

  • Survivors scoping

This is designed to help the team understand what survivors themselves value and what they think are the key Knowledge and Skills required for provide effective services across the tiers.

  • Trainers scoping

This is designed to understand the current capacity for training in the area in Scotland and what the current priorities and models being used.

Year two and three

The project will use the Knowledge and Skills Framework for Trauma and Complex trauma to develop a National Trauma Training Strategy. This will inform targeted commissioning and delivery of training that meets identified needs.

The impact of the project will be evaluated.

The overall project is supported by a Short Life Reference Group of colleagues and partners which includes

  • Argyll and Bute Rape Crisis Service
  • Children 1st
  • Health Scotland
  • NHS Education for Scotland
  • NHS Greater Glasgow and Clyde The Anchor Trauma Service
  • NHS Lanarkshire EVA services
  • Roshni
  • Scottish Government Mental Health Strategy
  • Scottish Government Child Protection
  • Scottish Government Survivor Scotland
  • Scottish Social Services Council
  • Stop it now!
  • Survivor representatives