FIGURE 1 Applying an Adverse Childhood Experience (ACE) lens to practice.
Jo Ramessur-Williams*, Annemarie Newbury*, Michelle A. McManus*, Sally A. Rivers*
DOI: http://dx.doi.org/10.35502/jcswb.99
ABSTRACT
Across the United Kingdom, vulnerability is the biggest area of demand for police. However, evidence demonstrates that some forces may not be equipped to respond to the volume and nature of this demand. Beyond their statutory duties, operational police are often unaware of how to best respond to vulnerability within their roles. For many police officers and staff, there is limited training available to develop the skills needed to provide frontline support to vulnerable individuals and to signpost and refer to agencies who can provide the appropriate needs-based services. The Early Action Together (E.A.T.) program is delivering transformational change across Wales to support police and partners who wish to adopt a whole-systems response to vulnerability that enables early intervention and prevention. Drawing on the evidence around Adverse Childhood Experiences (ACEs) and the impact these early experiences can have on life outcomes, training is delivered to police and partners to embed ACE- and trauma-informed approaches into everyday practice. Evaluation of the training is already evidencing some key benefits of using this approach, with officers identifying and applying root-cause understanding of crime and harm and developing public understanding of existing early intervention assets and pathways of support in their local area. However, careful consideration and planning are required to ensure that these approaches continue to be embedded beyond the life of the program.
Key Words: Vulnerability, trauma, early intervention, organizational change, public health, whole systems approach
Across the United Kingdom, police are responding to a high level of non–crime-related demand (~83%; College of Policing, 2015), including incidents concerning public safety and welfare. Often the first point of contact, the police and the wider policing family are required to respond to a diverse range of vulnerabilities, including mental health, substance misuse, homelessness, and learning disabilities.
Although a large volume of police demand is related to vulnerability, it is becoming increasingly clear that police services are not equipped to appropriately respond to this level and type of demand, with existing responses, training, and systems targeted more towards criminality (Ford, Evans, Newbury, Meredith, & Roderick, 2017a). Whilst frontline officers attempt to address the needs of vulnerable individuals through police referrals (e.g., Public Protection Notifications [PPNS] and Multi Agency Referral Forms [MARFs]), many of these referrals do not meet statutory thresholds and subsequently result in no further action (Ford et al., 2019). This leads to a high level of repeat demand on police services, with vulnerable people unable to receive the support they need. Officers have reported challenges engaging with these individuals and identifying the right pathways of support for them, as well as frustrations working with partner agencies which are perceived to be falling short of their responsibility to provide support (Ford et al., 2017a). Often, police are knowingly providing inappropriate responses to vulnerable individuals at a time when they fall under significant scrutiny from the media and both governing and inspecting bodies; however, this continues to be the approach with limited options available to them.
Recent data has evidenced a high prevalence of poor well-being within the police workforce (Home Office, 2018), with a recent survey highlighting that ~79% of respondents experienced mental health difficulties during the preceding 12 months (Elliott-Davies, 2018). Poor well-being can lead to a range of maladaptive coping mechanisms, including health harming behaviours, drug and alcohol misuse, and in some cases, suicide (Mind, 2015). This suggests that often the most vulnerable people within our society are supported by professionals who themselves are vulnerable. Police well-being can be affected by the “emotional labour” of the job, including experiences of traumatic incidents with a lack of appropriate support mechanisms in place (e.g., recovery time) and “organizational stressors,” including excessive workloads, organizational culture and expectations, and low level of managerial and peer support (Johnson et al., 2005).
Following research on Adverse Childhood Experiences (ACEs), there has been a drive to take a more public health approach to vulnerability, recognizing the implications of early childhood experiences from a health perspective. Police frequently respond to ACEs, such as abuse (i.e., physical, emotional, or sexual abuse) and parental incarceration, mental ill-health, domestic abuse, and substance misuse. However, training on these topics tends to be limited and delivered to more specialized roles (e.g., investigative roles; Johnson et al., 2019).
There is much debate regarding the use of ACEs within policing and wider criminal justice services and the risk of potential misuse of ACEs through checklists and thresholds (Bateson, McManus, & Johnson, 2019). More specifically, there are concerns that officers might use ACE scores as criteria for referral to intervention services, rather than the preferred approach of using their understanding of ACEs and the importance of protective factors to simply inform risk assessments. Although much research has established a “dose-response relationship” between the number of ACEs and increased negative outcomes for those self-identifying as having four or more ACEs (e.g., health harming behaviour, crime, victimization, poor health), there is limited evidence regarding how ACEs should be used to inform decision making on appropriate support and interventions (e.g., Bellis, Lowey, Leckenby, Hughes, & Harrison, 2014; Bellis et al., 2016). Furthermore, there is limited evidence of how awareness of ACEs can benefit and provide resilience to front line staff delivering first responses to vulnerable people and even less evidence of how understanding and awareness of ACEs can have a positive impact on officers as individuals outside the workplace. This is a particularly important area for consideration, with the prevalence of ACEs in the general population suggesting that many police officers and staff are likely to have ACEs of their own.
In response to the evidence on the link between ACEs, vulnerability, and everyday challenges faced by police, the Home Office funded a program of transformation designed to take a public health all-Wales approach to policing vulnerability. The program aims to embed trauma-informed practice into everyday interactions with the public, using an ACE lens to identify when someone may have experienced ACEs, how these may impact on life outcomes and presenting behaviours, and what resilience or protective factors that individual may have (see Figure 1).
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FIGURE 1 Applying an Adverse Childhood Experience (ACE) lens to practice. |
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The Early Action Together program (E.A.T.) was developed from findings of an initial, smaller-scale police innovation project delivered in South Wales (The Early Intervention Project, 2016–2018), which has now been scaled up and rolled out on a national level across the four forces and partner agencies in Wales. The E.A.T program aims to develop a Wales-wide approach to training and practice for addressing vulnerability by developing systems, processes, and interventions to enable more effective responses by police and partners through early intervention and prevention. Each force in Wales is required to deliver an ACE- and trauma-informed training program to frontline police officers and staff, embed a 24/7 single integrated service to respond to vulnerability, develop cross-sector working arrangements between police and non-statutory partner agencies, and test interventions specific to a thematic area of choice (e.g., social navigation and serious violence).
Key to achieving the above objectives is the development and implementation of a training program for professionals to ensure they have the appropriate knowledge and skills to respond to vulnerability using an ACE- and trauma-informed approach.
The training package has been developed in three distinct but complementary phases, including “what,” understanding the issues presented, “so what,” operationalizing knowledge into practice, and “now what,” putting the learning into practice on a local level. The training has been developed for delivery to frontline police and partner agencies as a one-day course to provide an introduction to ACEs and trauma and further develop tactical skills to enable police to respond to individuals with trauma. This is followed up by ongoing support with training facilitators to allow the learning to be applied to practice, with guidance tailored to the local arrangements and individual roles within the force.
During interviews with police within operational roles, there was a call for training to be delivered by experts external to the police to provide a greater depth to their learning (Ford et al., 2017b). The training is delivered through an independent ACE coordinator service positioned within Barnardo’s (a UK-based children’s charity) and comprised of professionals with diverse backgrounds working with vulnerability. Furthermore, the training is attended by local partners (e.g., education, health, local authority) to develop a shared understanding of ACE-informed approaches and to enable cross-agency learning.
The training allows for open discussions around vulnerability that provide a safe place for learners to share experiences of working with vulnerable individuals and the challenges of providing support within their role. Drawing on the research evidence, the training introduces the concept of ACEs, the national prevalence of ACEs, and the incremental impact they can have on health and well-being across an individual’s life course. Fundamentally, it seeks to make a shift from the narrative what is “wrong” with individuals to what is “strong” with them, introducing the notion of ACEs from a strength-based rather than deficit-based position. Brain function in stressful situations is discussed in detail in efforts to demonstrate that individuals’ behaviours can be a direct result of experiences they have been exposed to in earlier life, and these behaviours are often hardwired rather than intentional or deliberate. The introduction of this research evidence helps learners to realize how common ACEs are and seeks to normalize them. The training also presents opportunities to mitigate the impact of ACEs, with discussions on the importance of developing resilience to protect against negative life outcomes.
With the real and ever present risk of exposure to vicarious trauma, well-being, personal resilience, and group discussion on simple but effective coping mechanisms and de-escalation techniques are a golden thread throughout the training day.
The final element of the training covers what learners need to do differently in a policing context. Here the benefits of early intervention are emphasized, and participants discuss how they can apply learning to practice in their own local areas, understanding localized pathways and community-based assets and the difference they can make within their communities. Learning outcomes are enhanced by the use of case studies and appropriate and complementary film clips which seek to reinforce the messages.
To ensure the training is pitched at the right level across different roles and ranks and uses appropriate mechanisms for delivery, it has been extensively evaluated. The evaluation measured the impact on the learner’s knowledge and awareness, confidence, and attitudes towards working with vulnerability and captured feedback from officers in attendance. As part of the Police Innovation project, an evaluation of the initial training pilot was carried out to test the fidelity of the package delivered to 151 response and neighbourhood officers in South Wales. Findings of the evaluation informed further development and delivery, which has now been scaled up and rolled out on a national level across Wales (Newbury et al., 2019). Further testing of the training will assess delivery to a more diverse police cohort, including different force areas, roles, ranks, and policing teams. Continued evaluation allows for efforts to be made to maximize the benefit of the training to frontline staff and to provide an evidence base to support future delivery of the training post–program life.
It is anticipated that the benefits of the training will be widespread both for vulnerable individuals within our society and for police officers and staff and the organization itself. Findings are demonstrating that, for many learners, ACEs is not a new concept; however, the training provides a conceptual framework to understanding behaviours and potential consequences arising from certain experiences (Ford, Newbury, Meredith, Evans, & Roderick, 2017c). Multi-agency delivery allows for the development of a universal understanding of the challenges faced, the underlying causes of problem behaviour, a shared language, and consistent approaches to responding to vulnerability. This can improve the quality of police referrals to partner agencies as well as partner relationships. The training can provide initial steps towards reducing frustrations between organizations and allow for a more concerted approach to responding to vulnerability.
Furthermore, it develops a greater understanding of how to support vulnerable people without re-traumatizing them, leading to more positive interactions with the public and reducing negative outcomes (e.g., use of force and punitive measures). Within the findings, the benefits of a greater understanding have also been noted in daily interactions with family and peer relationships, evidenced in open responses within the post-training questionnaire:
At home, my 5-year-old and I have both been exposed to numerous ACEs through the course of our lives and this training has been such an eye opener as to how to give my little girl further understanding and support at home. (Communications Operator, Welsh Police Force)
I believe my partner may have grown up in an environment where she would have four or more ACEs. But [she] has overcome them—this should help me understand and support her better. (Police Constable, Response, Welsh Police Force)
Having an improved understanding of pathways for support beyond statutory process and a bank of local resources to draw on gives learners more options and ways to support individuals. It is hoped that this will reduce the risk of those vulnerable people who do not reach the threshold for statutory intervention from falling through the gaps or placing a high demand on police services as repeat callers. In addition, attendees are demonstrating improved confidence and use of professional judgement working with vulnerability, more favourable attitudes towards providing support within their role, and greater clarity in their understanding of their role responding to vulnerability.
The training can help a force take great strides towards improving the well-being of its members. Open discussions on the challenges within their role and how these impact on their well-being start to develop a culture within the police where talking about well-being can become normalized. Furthermore, information on resources to develop personal resilience and discussion on coping strategies and access to support can empower police and partners to seek support when needed without the barriers that have been articulated to researchers during the course of this program (Johnson et al., 2019). Ultimately, improved well-being can increase job satisfaction and result in less sickness, reduced potential for individuals to engage in health-harming behaviours, a higher degree of productivity, and greater job satisfaction.
Improved outcomes on an individual staff level can lead to wider organizational benefits. A reduction in inappropriate referrals and repeat demands can create significant savings in the cost of processing police referrals, estimated at £4 million a year (Ford et al., 2017b). Furthermore, providing more positive responses to individuals can result in a reduction in crime demand associated with ACEs (e.g., anti-social behaviour [ASB], violence, domestic abuse). This, coupled with improved information sharing between agencies and more collaborative working practices, can enable benefits beyond the police, with organizational improvements extending to wider criminal justice services (e.g., prison, probation, youth justice services) and statutory agencies (e.g., social services and health).
However, whilst there are many benefits to be noted, with the generational nature of ACEs, it is anticipated that many of the benefits of the training will not be observed within the time frame of the program, or even within the current generation.
Sadly, it is often the case that the momentum built during programs of change is lost once the funding comes to an end. The appetite for sustained change will depend on the ability to demonstrate cashable and non-cashable benefits. Therefore, there is a need to ensure that the impact on individuals, as discussed, continues to be collated and shared to help leaders understand the wider, less tangible benefits that the program has achieved. The training and further work of the program are now being developed and delivered across sectors (i.e., wider criminal justice agencies, education and housing) to allow for concerted cross-agency responses to ACEs. Shared approaches will better enable sustained delivery of the learning and implementation of practice.
However, the training is just the starting point, and whilst there are many benefits to be observed, it needs to be combined with further efforts to address vulnerability through collaborative working practices and systems development. System review and process redesign will be a critical factor in embedding the learning and transformation into practice. The Early Action Together program has been delivered using the principle of building into, not on top of, existing systems and processes. Therefore, it is anticipated that the learning outcomes from the program will be sustained beyond March 2020. With further evaluation of the training to demonstrate the benefits for professionals and organizations, there is a real opportunity for this training to become part of universal core well-being or induction training for all staff which becomes embedded into policy and strategy.
To be able to deliver a program of transformation across Wales, it is integral to upskill the workforce and provide the right knowledge and tools to respond to vulnerability in the desired way. This training package aims to do just that, with further efforts to address the well-being of the police work-force and allow them to have the personal resilience needed when responding to traumatic incidents and supporting those with trauma. Extensive evaluation is underway to fully assess the impact of the training. However, early findings are already demonstrating positive results. The benefits of the training are more notable for individual officers, but there is the potential for significant benefits to organizations over a longer period of time. For this to happen, it is important to ensure practice is sustained beyond the life of the program.
This program of work was funded through the Home Office Police Transformation Fund. We would like to thank the participants who contributed to research and evaluation activity, including police and local multi-agency staff working across the four police force areas: South Wales, Gwent, Dyfed Powys, and North Wales Police. We would also like to thank the ACE Coordinator Service, Barnardo’s Cymru, for allowing the research team full access to all elements of the ACE TIME training sessions for evaluation. This work was funded by the Home Office Police Transformation Fund (PR-105)
The authors have no conflicts of interest to declare.
*Policy and International Health, World Health Organization (WHO) Collaborating Centre on Investment for Health & Well-being, Wales.
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Journal of CSWB, Vol. 4, No. 2, August 2019