Trauma-informed Practice

Trauma can arise from single or repeated adverse events that threaten to overwhelm a person’s ability to cope. When it is repeated and extreme, occurs over a long time, or is perpetrated in childhood by care-givers it is called complex trauma.

Two thirds of people presenting to mental health services, inpatient and outpatient, have a lived experience of child physical or sexual abuse. Other causes of complex trauma include emotional abuse, neglect, family violence, living with a parent with a mental illness or who abuses substances, war and refugee trauma, separation and loss. In Australia 5 million adults have been affected by childhood trauma.

Many trauma survivors show remarkable resilience. However many are left struggling day to day with their health, wellbeing, emotions, relationships, and sense of self and identity. Complex trauma affects not only its victims but those with whom they are in contact as well as the children they go on to have.

Research has established that trauma is a major public health problem. Yet within current systems it is frequently unrecognised, unacknowledged, and unaddressed. Many of those affected have been inadvertently re-traumatised in systems of care lacking the requisite knowledge and training around the particular sensitivities, vulnerabilities and triggers of trauma survivors.

Trauma Informed Practice is a strengths-based framework which is founded on five core principles – safety, trustworthiness, choice, collaboration and empowerment as well as respect for diversity. Trauma informed services do no harm i.e. they do not re-traumatise or blame victims for their efforts to manage their traumatic reactions, and they embrace a message of hope and optimism that recovery is possible. In trauma informed services trauma survivors are seen as unique individuals who have experienced extremely abnormal situations and have managed as best they could.

Becoming trauma informed necessitates a cultural and philosophical shift across every part of a service and is applicable to all human and health service systems. Trauma informed systems understand the dynamics of traumatic stress, survivors in the context of their lives and the role of coping strategies. They feature safety from harm and re-traumatisation, emphasise strength building and skill acquisition rather than symptom management, and foster true collaboration and power sharing between workers and those seeking help at all service levels.

Studies have shown that programs that utilize a trauma-informed practice model report a decrease in symptoms, an improvement in consumers’ daily functioning, and decreases in the use of hospitalization and crisis intervention.

Trauma-informed services do not cost more than standard services and report more successful collaboration with all stakeholders, enhanced skills, and a greater sense of self-efficacy among consumers, improved staff morale, fewer negative events, and more effective services and positive outcomes.

We need to embed trauma informed practice within all health and human service systems to provide appropriate trauma-informed services to those needing them. The provision of trauma informed services must also be supported by trauma specific services, which provide specific interventions to address the consequences of trauma.

For more information see ASCA Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery www.asca.org.au/guidelines and www.asca.org.au/workshops

The Role Medical Practitioners play

Interview Life Matters Feb 27th Dr Cathy Kezelman ABC Radio National discussing the role medical practitioners play in helping adults who have been victims of childhood sexual abuse

http://www.abc.net.au/radionational/programs/lifematters/surviving-child-abuse/5282264

ASCA Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery

Along with Dr. Pam Stavropoulos, ASCA Head of Research and Clinical Practice I co-authored a set of Practice Guidelines.

ASCA’s Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery present the collective wisdom of the last two decades of national and international research in the trauma field. They are poised to revolutionise possibilities for recovery for the large numbers of people with unresolved “complex trauma” – child abuse in all its forms, neglect, family and community violence and other adverse childhood events.

They establish insights that optimism about recovery from complex trauma is warranted, and that childhood trauma can be resolved.

The Guidelines were launched on October 2012 by Hon Mark Butler MP, Australian Federal Minister for Mental Health and Ageing at Parliament House, Canberra

www.asca.org.au/guidelines

Trauma, Trauma Frameworks and Being “Trauma-Informed”

Trauma, Trauma Frameworks and Being “Trauma-Informed”

On the 7th August 2013 the Clearinghouse convened a forum about trauma-informed practice, jointly hosted with the Australian Centre for Study of Sexual Assault (ACSSA)

We invited an assembled panel of experts in the area to address the topic: In what ways can service interventions re-traumatise survivors of previous trauma?

I delivered a keynote address, before the panel discussed a range of issues around dealing with trauma and the need to be ‘trauma-informed’ in practice situations. A Q&A session allowed practitioners and service representatives to further engage the panel on a range of important issues.

The forum was an excellent opportunity to learn from practitioners operating in a range of settings and culturally diverse environments about how they each work with trauma in their own settings. Themes discussed included: how trauma affects the body and mind, how to recognise and address the impacts of trauma in young children, how services may inadvertently replicate power differentials and practices that can re-traumatise clients, and what needs to happen to ensure that all services become ‘trauma-informed’.

To find all presentations go to:
http://www.adfvc.unsw.edu.au/other_publications.htm

To link to my keynote address go to:

Presentation – complex trauma

The following presentation was given at Inaugural Conference, Westmead Psychotherapy Program for Complex Traumatic Disorders, 10th November 2011. It is available on registration at psychevisual http://www.psychevisual.com/

http://www.psychevisual.com/Video_by_Cathy_Kezelman_on_Responding_to_the_needs_of_consumers_with_complex_trauma_histories_a_consumer_perspective.html

 

This presentation, “Responding to the needs of consumers with complex trauma histories a consumer perspective” focuses on the needs of adult survivors of child abuse, highlighting the frequent failures of the current system to identify them and respond appropriately. Using her personal journey of recovery from complex trauma at the core of which is childhood abuse, Cathy explores the distinguishing features of complex trauma presentations. In so doing she stresses the need to respond holistically to each person with full awareness of their lived experience. She highlights the need for the research of the last thirty years to be incorporated into practice with a trauma-informed approach to care bringing better outcomes for consumers with complex trauma histories.

A trauma informed approach in the Family Court Sytem

The following presentation was given at a seminar entitled: Child abuse in Family law – a silenced epidemic. The seminar was convened at NSW Parliament House Nov 2011

I’m going to speak about trauma, childhood trauma in particular but  trauma in general because trauma permeates the lives of the children about whom
we’re talking today. It is also a feature of the lives of many parents going  through the family law system; some is all too unavoidable as families break
down but the trauma inherent in the process is being repeatedly compounded by a system which fails to prioritise protecting our children. Other speakers have
focussed on the changes needed to prioritise child safety; I’d like to talk about  the human cost of trauma and the system’s multiple failures to mitigate its
effects.

Sadly one cannot travel through life without experiencing trauma. It’s  a feature of life. However, generally speaking the more trauma to which one is
subjected, the more repeated the incidents, the younger the age and the fewer  the supports, the greater the potential for more substantial and longer-lasting
effects.

All trauma can invoke a sense of fear, helplessness, and horror. All  trauma can overwhelm a person’s resources for coping. However trauma which is repeated,
prolonged and extreme and which occurs during the crucial developmental years can be especially damaging. Trauma which is interpersonal,  perpetrated by one human being  on another as occurs in child abuse, in all its forms, as well as domestic violence and in the case of a child, which is most often inflicted by a person charged with the child’s care is a primary betrayal.
This combination of ongoing trauma exposure and the developmental impact of such exposure typifies what is known as complex trauma.

The effects of complex trauma are cumulative. In the first 3-5 years  the brain grows most rapidly with further growth spurts at puberty. In fact it
continues to grow and develop until a person is in their twenties and so trauma  during this entire period affects basic neuro-chemical processes and the
structure, function and growth of the brain. Research in fact shows that such trauma can potentially affect brain development right through the life cycle.

Children whose parents are going through the family court  system are subjected to family breakdown, loss, abandonment, conflict and sometimes
additionally face homelessness and poverty through their changed family circumstances. Their world has been shattered and along with it their sense of
trust, of safety and stability is challenged. When they are sexually assaulted, molested,  criticised, humiliated, beaten  or manipulated, violated, exposed to domestic violence or otherwise exploited their trauma is compounded.

They live in fear and become confused. A person they love and who is meant to love, nurture and protect them is hurting them.  They don’t know who to trust or where to turn.
One parent is the source of pain and angst and the other, is often traumatised,  feeling helpless, out of control and struggling to cope.

It goes without saying that every effort  must be made to minimise the trauma to which all individuals are subjected, and  this applies especially to children. Our systems must show zero tolerance to abuse  and family violence as a matter of urgency. However our systems and workers  must also become trauma-informed. What do I mean by this?

All workers and professionals need to be educated about the effects of trauma at different stages of the life cycle.  Systems must always consider the possibility of trauma, be trained to recognise  it and respond appropriately to its impacts. To date our judicial and welfare  systems and even our health system have generally failed in this regard. The  costs of this failure are substantial.

By way of  illustration I would like to share a bit of my personal story. I am a survivor of child sexual and emotional abuse. I am also a doctor by training.

As a medical  practitioner, one would assume that I was informed about trauma and its  effects. Nothing was further from the truth! When I had my breakdown I didn’t  have a clue what was happening and nor did my medical colleagues. In fact they bolted faster than anyone. As one of them said to me, “You’re not becoming one of  those mental health patients are you?”

There’s no doubt  that I was struggling. From being fiercely independent, a successful GP ,  mother of 4, the quintessential superwoman I became decimated by severe  anxiety, panic attacks, nightmares and flashbacks. I didn’t know what  flashbacks were but from one minute to the next I’d be a 45 year old mother of
4 to a 4 year old in abject terror, in agony and horror, my body undergoing all  sorts of agonising and unintelligible contortions.

I spent 2 years in  bed, immobilized by a relentless blackness of mood. I struggled with suicidal  thoughts and then gestures. Yet I was lucky; I found a therapist who was  trauma-informed. She understood my trauma and its effects. She was able to  listen, hear, empathise, and validate my experiences as I made sense of my  history.  Acknowledging and appropriately  addressing my complex trauma was core to my recovery. Anything less would have,  at worst, seen me lost to suicide, or at best barely functioning in my daily  life.

As a child I experienced repeated traumas.  I lived in fear; I didn’t feel safe. I didn’t have anyone who could help  explain what was happening to me.  I  learnt to deny my feelings and my thoughts.  I felt worthless and bad and focussed on simply surviving. Children who  feel safe and secure learn to rely on their feelings and thoughts. They value  themselves and develop strategies for responding to different situations rather  than reacting to them.

When a child experiences trauma,  the parent or caregiver of a child, whose environment is secure can relieve the child’s fear and distress, and help restore a sense of safety and control. If  the parent is themselves distressed and overwhelmed, the child will be similarly overwhelmed. When this happens repeatedly or worse still if the  parent or caregiver is the source of the distress, the child cannot process what is happening.

A child exposed to the repeated trauma of  child abuse often becomes hyper-vigilant, anxiously anticipating the next episode. If the child is unable to grasp what is happening, or do anything about it, and no one else is there to intervene, the child will go immediately from fear to a (fight/flight/freeze) response without being able to learn from the experience.  The child might  dissociate/space out or stay agitated and as a result learn to ignore their emotions and/or their thoughts. They can’t make sense of what they are  experiencing or learn to respond appropriately to different situations.

Children who have experienced insecure  attachments also have trouble relying on others. They utilise a range of childhood defences to try and manage their extreme emotions.  Their excessive anxiety, rage and an intense  desire to be taken care of are often matched by behaviours which push those
seeking to help them away. Such children can be easily triggered by any  reminder of the trauma – sensations, physiological states, images, sounds,  situations. These reminders often throw the child back into the original trauma  and they behave as if they are experiencing the trauma all over again. When
workers and health professionals are not trauma informed they are likely to label such children as “oppositional”, ‘rebellious”, “unmotivated”, and
“antisocial” and punish rather than support them.  The same applies to these children when they  become adults.

Child abuse establishes lifetime patterns  of fear and mistrust, chronic feelings of hopelessness, and can affect a  person’s relationship with themselves, others and the world, their ability to regulate  their emotions, settle intense emotions down, nurture and care for themselves  and manage subsequent stress in a focussed way. The Adverse Childhood Experiences (ACE) study extensively studied at the  impacts of childhood exposure to traumatic stress – all forms of abuse and  neglect as well as that of family dysfunction i.e. mother experiencing domestic  violence, loss of biological parent.

The more adverse childhood events the greater the likelihood of adopting  different coping strategies e.g. smoking, alcohol and drug use, overeating that
put adult physical health at risk as well as mental health repercussions such  as depression, suicide attempts, self-harming behaviours such as cutting and
burning, dissociation, and re-enactments such as engaging in abusive  relationships. Whilst challenging, in  the context of trauma these behaviours make perfect sense.

It can be very hard for children and adults abused as children to speak out and seek help. They are often silenced through shame, fear and conditioning. Disclosure will only occur in an environment of support and safety. Anyone interacting with child, adolescent or adult who has been subjected to trauma
must be educated about the effects of trauma on development and be trained to understand the particular vulnerabilities and sensitivities of trauma survivors.

Child safety officers, court personnel, lawyers, police, mental  health workers and even health professionals often have little awareness about trauma
and its complex presentations. We need to urgently address these deficiencies and minimise the possibilities for further traumatisation within our systems. Trauma informed care involves the provision of services that do no harm – e.g., that do not re-traumatise or blame victims for their efforts to manage their traumatic reactions.

Creating a system of care in which a child and family members can move on from their trauma means creating safe trauma informed systems with proactive networks of support. It also means establishing services which can respond appropriately to the trauma which people have experienced.

There is a lot we can do. Substantial research has shown that with the right working through even the trauma of extreme early experiences can be
resolved. Just as the damaging experiences change the brain in ways which are  negative for subsequent functioning, so new different and positive experiences,
change the brain in ways which are conducive to health. Trauma survivors need to receive the right help and support so they can make sense of their lives and
reclaim their health and wellbeing. This not only applies to children but to their parents and other family members as well. In fact although we know that
the effects of trauma are trans-generational; that is that children are negatively impacted by the unresolved trauma of their parents we also know that
if parents work through their trauma, their children can go on to form secure attachments and also do well.

There is a lot we can do. It is time to translate the research of the last thirty years into practice. To minimise the trauma to which all individuals
are subjected, especially our children and be aware of how to mitigate its effects when it has occurred. This applies to all our systems, including the
Family Court and all of those who work within it and are associated with it and its functions.

  Kezelman C (2011)  A trauma-informed approach in the Family Court system