Implementing Trauma-Informed Care-Settings, Definitions, Interventions, Measures, and Implementation across Settings: A Scoping Review.

Traumatic experiences can have long-lasting negative effects on individuals, organizations, and societies. If trauma is not addressed, it can create unsafe cultures with constant arousal, untrusting relationships, and the use of coercive measures. Trauma-informed care (TIC) can play a central role in mitigating these negative consequences, but it is unknown how and in which way(s) TIC should be implemented. Our objective was to conduct a scoping review that systematically explored and mapped research conducted in this area and to identify existing knowledge about the implementation of TIC. The search was conducted on the CINAHL, Cochrane, Embase, ERIC, Medline, PsycINFO, and Web of Science databases, and more than 3000 empirical papers, published between 2000 and 2022, were identified. Following further screening, we included 157 papers in our review, which were mainly from the USA, Australia, New Zealand, and Canada, focusing on study settings, methodologies, and definitions of TIC, as well as the types of interventions and measures used. This review shows that TIC is a complex and multifaceted framework, with no overarching structure or clear theoretical underpinnings that can guide practical implementations. TIC has been defined and adapted in varied ways across different settings and populations, making it difficult to synthesize knowledge. A higher level of agreement on how to operationalize and implement TIC in international research could be important in order to better examine its impact and broaden the approach.

A feasibility study of the transdiagnostic self-injury interview.

OBJECTIVES: The Transdiagnostic Self-injury Interview (TSI) is a new measure that assesses the onset, frequency, methods, and severity of non-suicidal self-injury. The aims were to demonstrate the feasibility of a TSI validation study, and to investigate TSI's criterion validity, clinical correlates, and interrater reliability. MATERIALS AND METHODS: Recruiting sites were psychiatric in- and outpatient units. Feasibility targets included number of participants completing the study, TSI completion time, total participation time, participants experiencing exacerbation of symptoms, along with other targets. Criterion validity was evaluated using the Deliberate Self-Harm Inventory (DSHI). Clinical correlates were examined with the Columbia-Suicide Severity Rating Scale (C-SSRS), the Personal and Social Performance Scale, the Affective Lability Scale-18, and the Brief Trauma Questionnaire. Interrater reliability was evaluated with video recordings and written material. RESULTS: Fifty participants were included. The majority were women (76%) and had a mean age of 31.3 years (SD: 10.4). Schizophrenia (44%) and schizoaffective disorder (18%) were the most prevalent diagnoses. TSI took an average 9.3 min to complete and the total participation time was on average less than one hour. One participant experienced an exacerbation of self-injury ideation (without the need of intervention). A significant correlation was found between TSI and DSHI (r: 0.94, p-value: < 0.001). TSI was correlated to C-SSRS ideation intensity and ideation frequency but not suicidal attempts. TSI was not significantly correlated to other measures. Interrater reliabilities were statistically significant. CONCLUSIONS: The results support the feasibility of a TSI validation study, which is needed to validate TSI in different settings and across diagnoses.

Psychological adjustment following mechanical restraint in individuals with schizophrenia.

AIM: While it is known that being mechanically restrained during hospitalization can, in severe cases, lead to PTSD in individuals with mental illness, less is known about why some develop posttraumatic stress reactions following restraint while others do not. This study examined whether the amount of exposure to mechanical restraint and patients' interpretations of the episodes' centrality to their identity were related to symptoms of PTSD in individuals with schizophrenia. METHODS: We asked 20 individuals to recall mechanical restraint episodes and rate them on centrality to identity. They also completed scales measuring symptoms of posttraumatic stress, depression, trauma history, and were rated on positive and negative symptoms. Objective information about the number of times they had been restrained was obtained through Danish health registries. RESULTS: Amount of exposure to mechanical restraint was not significantly related to PTSD symptoms, potentially due to limitations of our small sample. However, interpreting episodes as more central to identity was. This relationship remained significant when controlling for trauma history, positive symptoms, and depression. CONCLUSION: The results suggest that clinically significant levels of PTSD are common in this population, and that considering patients' subjective interpretations of restraint episodes, and not merely the objective facts surrounding them is important for patients' psychological adjustment.

Clinical validation of ratings on the six-item Positive and Negative Syndrome Scale obtained via the Simplified Negative and Positive Symptoms Interview.

BACKGROUND: The six-item version of the Positive and Negative Syndrome Scale (PANSS-6) has shown promise as a brief measure of the severity of core symptoms of schizophrenia. However, since all prior analyses of the PANSS-6 were based on data extracted from studies using the full 30-item PANSS (PANSS-30), it remains unknown whether it is possible to obtain valid information for the PANSS-6 ratings via a brief interview, such as the Simplified Negative and Positive Symptoms Interview (SNAPSI). AIMS: We aimed to validate the PANSS-6 ratings obtained via the SNAPSI using the PANSS-6 scores extracted from the PANSS-30 ratings obtained via the comprehensive Structured Clinical Interview for PANSS (SCI-PANSS) as the gold-standard reference. METHODS: The PANSS-6 ratings based on the SNAPSI and the PANSS-30 ratings based on the SCI-PANSS were conducted by independent raters with established inter-rater reliability. RESULTS: Seventy-seven inpatients with schizophrenia (Mage = 35.1 ± 11.7 years; males = 57%; paranoid schizophrenia = 75%) participated in the study. The intraclass correlation coefficient (ICC) of the PANSS-6 total scores obtained using the SNAPSI and the PANSS-30-derived PANSS-6 total scores via the SCI-PANSS was 0.77 (p < 0.001). The ICC for the PANSS-6 total score and the PANSS-30-derived PANSS-8 (Andreasen's remission criteria) was 0.75 (p < 0.001). Spearman's rank correlation coefficient for changes in PANSS-6 total scores via the SNAPSI and changes in PANSS-30-derived PANSS-6 total scores was 0.70 (p < 0.001). CONCLUSIONS: Using the SNAPSI to rate the PANSS-6 enables a focused and brief assessment of the severity of core symptoms of schizophrenia, which facilitates measurement-based care and clinical decision making in the treatment of schizophrenia.

Psychological adjustment in care providers following restraint of psychiatric patients.

Mental healthcare providers face many difficult interactions with patients that can be emotionally demanding and have adverse effects on their well-being. Recent theoretical models suggest that the interpretation of stressful episodes may be more important for psychological adjustment than the nature of the episodes. This study examined whether care providers' interpretations of mechanical restraint episodes were related to their adjustment. We asked 80 mental healthcare providers to recall mechanical restraint episodes and to rate them on centrality to identity and positive and negative influence on self-understanding. They also completed scales measuring current symptoms of post-traumatic stress, depression, life satisfaction, and well-being. The results showed that care providers who interpreted mechanical restraint episodes as having a central negative influence on their identity experienced more symptoms of post-traumatic stress. Care providers who gave higher ratings of positive self-change following episodes reported more well-being. Our findings suggest, that considering care providers' subjective interpretations of episodes and not merely the objective facts surrounding them is critical if we wish to mitigate the negative emotional impact of episodes.

Narrative Identity, Metacognition, and Well-Being in Patients With Schizophrenia or HIV.

It has been proposed that schizophrenia reflects disturbances in personal identity, which include sense of personal agency, sense of belonging within a social group, and metacognition. Less is known about how these different processes are related to one another and to well-being outcomes. To study this, we measured themes of agency and communion in narrative identity in 29 individuals with schizophrenia and 29 individuals with HIV. All participants had previously been assessed on metacognitive abilities using the Indiana Psychiatric Illness Interview (IPII) and completed scales measuring hopelessness and self-esteem. For the present study, themes of agency and communion were coded from the IPII transcripts. Results indicated that participants with schizophrenia had lower levels of agency and communion compared with participants with HIV. More presence of agency and communion themes were related to better metacognitive abilities as well as less hopelessness and higher self-esteem across groups. Agency predicted variance in hopelessness after controlling for metacognitive abilities. The results suggest that although the construction of narrative identity may depend on metacognitive abilities, agency themes predict outcomes beyond metacognition.

Themes of unfulfilled agency and communion in life stories of patients with schizophrenia.

We examined themes of agency and communion in life stories of individuals with schizophrenia. Twenty-four individuals diagnosed with schizophrenia and 24 control participants matched on age, gender, and education described their life stories in a free format. The life stories were coded for the presence of agency and communion themes and whether or not the themes captured fulfillment of agency and communion needs. In addition, the temporal macrostructure was coded. Individuals with schizophrenia described their life stories with similar levels of temporal macrostructure as controls, but they expressed more themes focusing on unfulfilled agency and communion needs. We suggest possible avenues for using these insights to improve recovery in schizophrenia.

Inter-rater reliability of ratings on the six-item Positive and Negative Syndrome Scale (PANSS-6) obtained using the Simplified Negative and Positive Symptoms Interview (SNAPSI).

PURPOSE: The six-item version of the Positive And Negative Syndrome Scale (PANSS-6) is a brief rating scale focusing on core symptoms of schizophrenia. In order to facilitate rating of PANSS-6 and selected items from other common psychiatric rating scales, we recently developed the Simplified Negative and Positive Symptoms Interview (SNAPSI). The objective of the present study was to test the inter-rater reliability of PANSS-6 ratings obtained using the SNAPSI. MATERIALS AND METHODS: Using the SNAPSI, seven raters (psychiatrists, first-year psychiatry residents and psychologists) performed a total of 56 PANSS-6 ratings of 12 in- or outpatients with schizophrenia. As a measure of inter-rater reliability, we calculated the intra-class correlation coefficient (ICC, ≥0.75 = excellent, 0.40-0.74 = fair to good, <0.40 = poor) for the PANSS-6 total score and individual item scores. Furthermore, for the PANSS-6 total scores obtained by the six noncertified PANSS raters, we calculated the median deviation from the PANSS-6 total scores obtained by the only certified PANSS rater. RESULTS: The ICC for the PANSS-6 total score was 0.74 (F = 2.84, p = .03). The ICCs for the six individual PANSS-6 items ranged from 0.45 (N6 - Lack of spontaneity & flow of conversation) to 0.76 (P3 - Hallucinatory behavior). The PANSS-6 total scores obtained by the six noncertified PANSS raters deviated by a median of 12.7% (interquartile range: 6.2-20.0) from the PANSS-6 total scores obtained by the certified PANSS rater. CONCLUSIONS: We found a good level of inter-rater reliability of PANSS-6 ratings obtained using the SNAPSI for seven raters with varying levels of clinical and research experience.

A decline in self-defining memories following a diagnosis of schizophrenia.

PURPOSE: Receiving a diagnosis of schizophrenia can be a profound life transition that often has a negative influence on the patient's sense of self. The present study is the first to examine how self-defining memories are temporally distributed around age at diagnosis of schizophrenia. METHOD: 25 patients and 25 matched control participants identified 3 self-defining memories from their lives. In addition, participants were assessed with standardized interviews and questionnaires on negative and positive symptoms as well as tests of cognitive function. RESULTS: Patients' self-defining memories increased in the years leading up to diagnosis and declined abruptly in the years immediately following diagnosis. The pre-diagnosis increase in self-defining memories was not attributable primarily to a rise in disease-related recollections. CONCLUSION: The sharp post-diagnosis memory decline suggests that patients find it difficult to establish new or evolve existing definitions of self. Implications for models of schizophrenia and for clinical practice are discussed.

Life story chapters and narrative self-continuity in patients with schizophrenia.

The present study compared life story chapters and self-defining memories in 25 patients with schizophrenia and 25 matched controls. All participants were tested on neurocognition and rated on symptoms. Participants identified and rated life story chapters and self-defining memories on emotional valence, causal coherence, and self-continuity. Temporal coherence and temporal macrostructure were also assessed. Patients rated their life story chapters as more negative compared to controls, but there were few significant differences regarding temporal coherence, temporal macrostructure, and ratings of causal coherence and self-continuity. In patients, poorer neurocognitive function and higher degree of negative symptoms were related to less causal coherence and lower self-continuity in relation to chapters. In general, few differences were found between the patients and the controls. This may be due to the highly structured method used to assess life stories or to the fact that our patient group was cognitively well-functioning.

A 3.5 year diary study: Remembering and life story importance are predicted by different event characteristics.

Forty-five participants described and rated two events each week during their first term at university. After 3.5 years, we examined whether event characteristics rated in the diary predicted remembering, reliving, and life story importance at the follow-up. In addition, we examined whether ratings of life story importance were consistent across a three year interval. Approximately 60% of events were remembered, but only 20% of these were considered above medium importance to life stories. Higher unusualness, rehearsal, and planning predicted whether an event was remembered 3.5 years later. Higher goal-relevance, importance, emotional intensity, and planning predicted life story importance 3.5 years later. There was a moderate correlation between life story importance rated three months after the diary and rated at the 3.5 year follow-up. The results suggest that autobiographical memory and life stories are governed by different mechanisms and that life story memories are characterized by some degree of stability.