Trauma Informed Care and Practice – youth mental health

Creating a Culture of Prevention and Wellbeing – a Professional Development Day seminar on Youth mental Health Day September 2011

Trauma-informed Care and practice
(Youth Mental Health)

 

 

I plan to speak with you today about trauma and especially trauma in  childhood and its impact on youth mental health. I would like to highlight how
awareness of trauma and its impact, and responsiveness to it can make a  significant difference to the lives of young Australians. We are living in a
changing political environment and one which has a greater focus on mental  health than ever before. This focus is long overdue. However responses to mental
health issues still are not on par with those to physical illnesses. However  inroads are being made all the time.

 

Mark Butler the first ever federal minister for mental health recently announced  a number of new initiatives and funding opportunities and they were most
welcome. However trauma and its impacts did not receive a Guernsey within those  announcements. Planning and funding for individuals impacted by trauma
histories continues to fall perilously short of what’s needed. Whilst trauma is  core to the difficulties of many Australians and awareness of it pivotal to
their sustained recovery, in services, trauma per se is seldom identified or  addressed. This leaves many individuals struggling and without the right help
they will continue to struggle with their daily functioning from childhood  through adolescence to adulthood and right into old age.

 

It is rare to travel through life without experiencing trauma and the  spectrum of trauma that can impact the human condition is vast. Any traumatic experience has the potential to  invoke fear, helplessness, and horror, and overwhelm a person’s resources for  coping. However today I would like to talk about trauma of childhood abuse, which  can be characterised as complex trauma.

 

 Complex  trauma refers to trauma which is compounded and cumulative. It is most often  interpersonal i.e. perpetrated by one human being on another, intentional and  of early life onset.   So the individual  experiences multiple, chronic, and/or extreme developmentally adverse traumatic  events (e.g., sexual, emotional or physical abuse, witnessing and experiencing  domestic violence, neglect, community violence), often within the child’s  care-giving system.

 

Other stressors occur in  childhood, for example traumatic medical and surgical procedures, accidents,  war trauma and civil unrest. However most trauma begins at home with up to 80%  of child maltreatment perpetrated by a child’s parents. Child abuse is of course not only  perpetrated within the immediate family but within the extended family and by  other adults in positions of trust and in regular contact through school,  church, sporting groups or other community activities.

 

While health practitioners  and workers happily ask about developmental milestones and the family’s medical  history obtaining information about childhood trauma, abuse, neglect and other  exposures to violence has not been routine. Perhaps this reluctance parallels  the social taboos and stigma which have further prevented those who have lived  with childhood trauma from receiving the help and support they need to live  healthy engaged lives.

 

Traumatic  childhood experiences are not only extremely common but they also have a  profound impact on diverse areas of functioning. Children with alcoholic  parents, parents with a mental illness, who are abused or neglected in some way  or who live in a family violence situation struggle to feel safe and secure.

 

The impacts of  their trauma are often pervasive and multifaceted, and can include depression  and a range of mental health impacts, various medical illnesses, as well as a  variety of impulsive and self-destructive behaviours. All of the presentations need  to be considered in the context of the lived experience of their trauma,  regardless of their age. This is the basis of a trauma-informed approach to  care which I’ll talk about later.

 

To date our health  system generally has failed in this regard. Rather than approaching individuals  holistically services and practitioners have approached people in a piecemeal way.  All workers and professionals need to remain cognisant of the possible impacts  of traumatic stress and the systemic internal disorganization it often causes.

 

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, the impact of which I have
grappled with for 13 years. My story of recovery and beyond has been chronicled  in a memoir entitled Innocence Revisited – a tale in parts.

 

As a medical practitioner, one would assume that I was informed about  trauma, its effects on mental health and how to address the impact. Nothing was
further from the truth!

I was a GP in Sydney for twenty years. I worked hard juggling the  demands of practice with being married with 4 children and a foster child. Back
then I could, do most things relatively easily.

In April 1998 when I was in my mid 40’s my niece was killed in a car  accident. I grieved for her, as one would expect and grieving takes as long as
it takes. As other members of my family started to come to terms with their  loss I was becoming more distressed. I started to feel anxious and then had my
first panic attack. I thought I was going to die! The panic attacks became more  frequent, the anxiety generalized and I grew depressed. Then came the
nightmares and flashbacks as the trauma stored in my subconscious unlocked.

 

Soon I could barely function. I was forced to leave work setting myself  a 4 month sabbatical – that was 13 years ago. After that my world collapsed.

I spent most of the next 2 years in bed, completely immobilized,  battling a relentless blackness of mood. I struggled with suicidal thoughts and
then gestures. The antidepressants the psychiatrist prescribed helped take the  edge off my mood at times, but it was a lengthy psychotherapeutic process which  helped me come to terms with my history and its impact which finally got me  functioning again.

 

Therapy guided my process of integration and I am now well and no longer  subsumed in my trauma. For the first time, I can not only live in the present
but embrace my future.  Acknowledging and  appropriately addressing my complex trauma caused by childhood abuse 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.

 

I am  one of more than 2 million Australian adults who suffered some form of  childhood trauma and I am lucky.  I had the  resources and the support to recover. Research  tells us that 1 in 5 women and 1 in 7 men are affected.

 

A seminal study the  Adverse Childhood Experiences (ACE) study by Kaiser Permanente in 1998, which  is still ongoing, looked at the impacts of all forms of abuse and neglect as  well as that of family dysfunction i.e. living with parent with mental illness,  substance abuse, who is incarcerated. It

showed that
adverse childhood experiences are vastly more common than recognized and that  they have a powerful relation to adult health and social outcomes. It found a
highly significant relationship between adverse childhood experiences and  depression, suicide attempts, alcoholism, drug abuse, sexual promiscuity,
domestic violence, cigarette smoking, obesity, physical inactivity, and  sexually transmitted diseases. The more adverse childhood experiences reported,
the more likely a person was to develop heart disease, cancer, stroke,  diabetes, skeletal fractures, and liver disease, as an adult.

 

Experiences of interpersonal  trauma are appallingly prevalent in our society. One off events such as a  physical or sexual assault, perpetrated by a stranger produce discrete  behavioural and biological responses to reminders of the trauma as are  characterised by PTSD – hyperarousal,  numbing and intrusive re-enactments of the trauma such as flashbacks or  nightmares. These are devastating enough but the repercussions of childhood  trauma tend to be more global. Let me tell you why.

 

Childhood trauma is usually  intentional, generally  perpetrated by someone the child knows and trusts, often the person charged  with the child’s care, and it disrupts the earliest of attachments. Without  a safe, stable attachment, abused children focus on simply surviving, shifting  resources normally earmarked for learning and development. Thirdly the traumatic acts are  generally repeated, prolonged and extreme.  This  combination of ongoing trauma exposure and the developmental impact of such  exposure typifies complex trauma.

 

During childhood the brain grows and develops rapidly, especially  in the first 3 to 5 years, with further rapid development during puberty and it  continues to grow and develop until a person is in their twenties. During this  entire period trauma can and does impact fundamental neuro-chemical processes,  and these in turn can affect the growth, structure, and functioning of the  brain and the mind. Chronic  trauma interferes with the capacity to integrate sensory, emotional and  cognitive input into a cohesive whole. Neural development and social  interaction are inextricably intertwined.

 

A child’s capacity  to regulate their emotions and behaviour is a reflection of their caregivers’  responses to them. Children internalise the affective and cognitive characteristics  of their relationships with their primary care-givers and form internal working  models for their feelings, thoughts and reactions. Early patterns of attachment  determine how effectively individuals will process information from then on.  Infants who feel safe, secure and understood learn to trust what they feel.  They also come to make sense of and the world around them. They come to rely on  their emotions and thoughts and this informs their reactions to any situation. They  become confident about their feelings and can express them. They learn to feel  good about themselves, to value themselves and feel confident that they can make  good things happen. They also are reassured that if they don’t know how to deal  with a difficult situation that someone else around them will. They are able to  develop strategies for responding purposefully to a range of situations rather  than reacting to them.

 

When a child experiences trauma, the parent or caregiver of a child,  whose environment is secure, can help restore a sense of safety and control. In
this way a child’s distress can be ameliorated and their fear dissipates. A  parent or caregiver’s capacity to mitigate a child’s terror reflects the
capacity of the parent or caregiver to respond to the threat.

 

If the parent is unable to manage their own reactions, and 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 does not learn how to modulate their  emotional arousal. As a result the child is unable to process and attribute  meaning to what is happening.

 

The child does not  learn to self-regulate and might dissociate or stay agitated as a result. Spaced  out and hyperaroused children learn to ignore their emotions and/or what their  thoughts. They can’t connect the dots and make meaning of what they are  experiencing and so do not learn to respond appropriately to a range of  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.

 

With childhood  trauma, the acts are often repeated and the child often becomes hyper-vigilant,  anxiously anticipating the next episode. When children are unable to feel safe,  secure and in control they feel helpless. 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 (fearful) stimulus to (fight/flight/freeze)  response without being able to learn from the experience.

 

These children are  easily triggered by any reminder of the trauma – sensations, physiological states, images, sounds, situations. These reminders 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 respond in a punitive rather than a supportive way.

 

The fundamental betrayal the child experiences establishes lifetime patterns of fear and mistrust.

 

Traumatized children struggle to modulate their aggression and impulse control. They also have difficulty negotiating relationships with caregivers, peers, and,
subsequently, intimate partners. They also experience a host of other challenges: substance abuse, borderline and antisocial personality, as well as
eating, dissociative, affective, somatoform, cardiovascular, metabolic, immunological, and sexual disorders. They are also prone to re-victimisation –
repeated interpersonal trauma – community and domestic violence, physical and sexual assaults.

 

The medical model works on the principle that something is wrong with a person rather than highlighting that something wrong was done to or happened to
a person. Trauma survivors are frequently pathologised with a range of diagnoses over a long period of time. Anyone interacting with trauma survivors must understand the impact traumatic life events have on the development of individuals.

 

I am a medical practitioner by training. The Hippocratic Oath states: “First do no harm”. However harm is done to trauma survivors when their experience goes unacknowledged and when their particular vulnerabilities and sensitivities are dsregarded, disrespected and misunderstood. Harm is done when survivors are labelled; when they are negated as human beings; and when the traumatic experience at the very core of their being is disaffirmed.

 

The impacts are far more pervasive than those characterised by PTSD alone. In fact the majority of traumatized children do not meet the diagnostic criteria
for PTSD.  The current psychiatric diagnostic classification system does not capture the lived experiences of these children. The narrow PTSD diagnosis is often used and other labels are also applied with so called co-morbid pathology – Depression, Attention Deficit Hyperactivity Disorder (ADHD),Oppositional Defiant Disorder (ODD), Conduct Disorder, Generalized Anxiety Disorder, Separation Anxiety Disorder, and Reactive Attachment Disorder.

 

Each of these diagnoses cherry-picks an aspect of the child’s experience rather than looking holistically in the context of their trauma and their attempts to manage their traumatic stress. Such diagnoses and treatment responses often focus on particular behaviours or symptom complexes rather than
on the core impacts of the trauma on the child.

 

Diagnosis does not capture the complex disruptions of affect regulation, disturbed attachment patterns, rapid behavioural regressions and shifts in emotional states,  loss of autonomous strivings, the aggressive behaviour against self and others, failure to achieve developmental competencies; loss of bodily regulation in the areas of sleep, food and self-care;  altered schemas of the world; anticipatory behaviour and traumatic expectations; multiple somatic problems,
from gastrointestinal distress to headaches; apparent lack of awareness of danger and resulting self endangering behaviours; the self-hatred and self-blame
and the chronic feelings of ineffectiveness.

 

Many areas of functioning can be affected and let’s examine them in a little more detail.

 

  1. Affects are often intense and include rage, terror, shame and self-blame, betrayal. Traumatised children exhibit intense reactions to stimuli which secure children would find  trivial. They struggle to regulate their emotions and reactive behaviours and settle them back down.

 

  1. They work to feel in control in the face of perceived threats and to ward off unwanted emotions. They tend to either re-enact prior traumas as perpetrators, acting aggressively or sexually acting out with other children or alternatively employ frozen avoidance reactions. They show little insight into the origins of their reactions.

 

  1. They are prone to somatic symptoms such as headaches or stomachaches, an expression of their physiological dysregulation, a response to fearful and helpless emotions.

 

  1. Their view of the world incorporates their betrayal and hurt. Children who have been traumatised are continually anticipating that they will be hurt again. Their response to stress varies from hyper-vigilance and being constantly on guard, frightened and over-reactive to feelings of helplessness, defeat and freeze responses.  They readily become confused or dissociate in the presence of stressful stimuli.

 

  1. Anticipating further trauma permeates these children’s relationships with themselves and others. They do not believe that anyone will look after them and keep them safe and continually anticipate that they will be victimised or abandoned.

 

These reactions and behaviours will show up across the board in educational, familial, peer relationships, problems with the legal system, and problems in holding down jobs.

 

Obviously therapeutic/counselling support is crucial but often other support is needed first or concurrently.  Support in dealing with the powers that be i.e. the “red tape” in health or social welfare bureaucracies so they receive the services of funds they need, providing advocacy support in a judicial hearing, , or working with school personnel to keep them in the education system. It may include filling out forms, writing letters, making phone calls, or completing reports.

 

In addition the adolescent trauma survivor may need support in the most basic and important ways –  food, shelter, financial support, social integration, and physical/social protection. All of these basic needs may need to be addressed before attention to psychological issues can be made.

 

Does the client have a place to stay tonight? When did he or she last eat? When did he or she last get a medical examination? Is he or she engaged in unsafe sex, IV drug abuse, or other risky behaviours? Does he or she report self-injurious behaviour? Is there evidence of a severe eating disorder?

Therapeutic approaches for traumatized youth has four main aims:
(1) establishing safety in their environment, including home, school, and community, (2) developing skills in emotional regulation and interpersonal functioning, (3) making meaning about past traumatic events and finding more positive, constructive views of themselves with hope for the
future (4) enhancing resiliency and integration into social network.

 

Almost all traumatized youth live in a continually traumatizing environment. They either need to learn how to live in that environment or find a
new environment. Creating a system of care and safety in which a child and the family can begin to heal often means working with child protection, the police
and courts to develop a safer living environment, engaging the family and the school, and other primary support figures, in order to create a network to develop safety within the living environment. It is impossible for any child to take in new information when he or she is fighting for survival. Building a network of support for the child and their family is vital.

 

Development of basic skills which have been lost or never acquired such as managing feelings and forming healthy relationships can occur within a therapeutic context.  Caretakers and family and community agencies need to be engaged so new skills can be reinforced at home and then incorporated into the day-to-day world.

 

A phased approach is recommended to avoid “information overload” which affects the capacity to learn. Lessons learned in the first phase serve
as a building block for other phases. The process is not linear and it is often necessary to revisit earlier phases of treatment time and again.  Before any therapeutic work can begin, the safety of the child and family must be addressed.

 

Therapists/counsellors need to work closely with child protection, schools, and family support networks to develop safety and a treatment plan that addresses the needs of the child, as well as the family. The focus is on building trust and a positive working relationship. The emotion regulation skills of the second stage help clients review their traumatic experiences. Once children possess improved methods for coping and an increased capacity for emotion regulation, they are better able to communicate and process traumatic memories.

 

They will then experience less distress about their history and react less to triggers. As they learn to regulate their emotions and develop better social skills they will start to see themselves differently. This will make them feel better about themselves and more confident that change is possible.

 

Instilling the principles of resiliency in youth means they can continue to develop in positive, healthy, and functional ways and avoid future
victimization and/or aggressive behaviours. Involving the youth in creative projects or youth programs, identifying expectations and responsibilities,
working with families and communities to maximize safety will encourage youth to achieve and develop their unique talents. The traumatic experience can then move from being the central aspect of their lives to being a part of their history. All of these phases can take place within community mental health
settings, hospitals, schools, and families with support services.

 

 

Often complex trauma is compounded by socioeconomic deprivation or social marginalization. The adolescent abused at home, assaulted as a result of community violence or gang activity, and who lives with poverty, poor nutrition, inadequate schools, social discrimination, is often struggling not only with a trauma history and social deprivation, but also the likelihood of additional trauma in the future.

 

Although the youth may appear to be “acting out,” “self-destructive,” “borderline,” or “conduct-disordered,” these behavioural patterns reflect strategies to cope with or the effects of, prior victimization – suicidal behavior, self harm, substance abuse, eating disorders, dysfunctional sexual behavior, excessive risk-taking, and involvement in physical altercations. These activities help the adolescent to distract, soothe, avoid, or otherwise reduce ongoing or triggered trauma-related dysphoria.

 

We need to speak a little about risk because although many of the effects of trauma are chronic, others are more severe, and may endanger a youth’s immediate wellbeing, or in fact threaten his or her life. His or her environment may still be exposing him or her to risk and ongoing victimization. He or she may be suicidal, abusing major substances, or involved in various forms of risky behaviour.

 

It is very important to evaluate current safety. Is the client in imminent danger or at risk of hurting others? In cases of ongoing interpersonal violence, is the client in danger of victimization from others in immediate future? Is the client acutely suicidal? Is the client’s immediate psychosocial environment unsafe?

 

Although a number of specific trauma therapies help it is the development of a positive therapeutic relationship that is crucial to progress. This is probably especially true for adolescents who have been repeatedly traumatised, whose life experiences have taught them to mistrust authority and to anticipate being maltreated.

 

The adolescent will often test the therapist and in fact anyone trying to support him/her. He/she will continue to practice behaviours which they have utilised in the past, coping mechanisms such as feigning disinterest despite being desperate for connection and validation. It is important for the therapist not to react and become angry, punitive or rejecting as that will reinforce the youth’s beliefs from the past. Showing empathy, understanding, respect and a non-shaming non-blaming approach will ultimately lead to trust and a collaborative relationship of care.

 

The therapeutic
relationship and process will undoubtedly trigger memories, feelings, and
thoughts associated with prior relational traumas. In the midst of a positive
therapeutic relationship the youth will experience reactivated rejection,
abandonment fears, misperception of danger, or authority issues but also respect, caring, and empathy.
The positive relational feelings will gradually win over and such intrusions will
lose their generalizability.

 

In dealing with youth with trauma
histories it is important to be developmentally sensitive and to work with traumatized
youth as is appropriate to their psychological ages. Similarly
some traumas are more common in one sex than the other, and that sex-role
socialization often affects how such injuries are experienced and expressed.

 

Research indicates that girls and women are more at risk for victimization in close relationships than are boys and men, and are especially more likely to be sexually victimized, whereas boys and men are at greater risk than girls of physical abuse and assault. In addition to trauma exposure differences, young men and women tend to experience, communicate, and process the distress associated with traumatic events in somewhat different ways. Cultural differences also need to be taken into account as do different views of the world and experiences.

 

The process also needs to keep the client’s level of affect regulation, i.e., his or her relative capacity to tolerate and internally reduce painful emotional states in mind. Adolescents with limited affect regulation abilities are more likely to be overwhelmed and destabilized by current negative events and those triggered by painful memories. Those with less ability to internally regulate painful states are more likely to become highly distressed, if not emotionally overwhelmed, during treatment, and may respond with increased avoidance, including “resistance” and/or dissociation

 

In supporting youth with impaired affect regulation capacities any therapeutic work should proceed carefully, so that traumatic memories are activated and processed in small increments – “working within the therapeutic window”. That way the trauma processing will not exceed the capacities of the survivor to tolerate that level of distress.

 

The therapist’s ability to communicate and demonstrate safety is a central component to relationship building. The adolescent is more likely to “let down his/her guard” and open himself or herself to a relationship if, repeatedly over time, the therapeutic process is safe with little evidence of any danger. Nonintrusiveness; Visible positive regard; Reliability and stability; Transparency; Demarking the limits of confidentialit are important.

 

Trauma also makes one feel very alone, isolated from others, and, at the core, unknowable. Being able to  interact regularly with a person who is attuned, who listens and hears, and who seems to understand, can be a powerfully positive experience and helps build the therapeutic alliance, and so a new form of attachment between client and therapist.

 

Despite the prevalence of short-term interventions for traumatised youth most therapy for complex trauma proceeds slowly. As the therapist counsels patience and remains constant and invested in the therapeutic process, he or she has the opportunity to communicate acceptance of the client and trust in the therapeutic relationship. This process requires the therapist to model patience as well.

 

Suicidal thoughts and behaviors are relatively common among abused or traumatized individuals perhaps especially in the context of ongoing adversity. In some cases, suicidal behaviors are passive, wherein the client engages in high risk activities and/or fails to protect him/herself in dangerous situations. In other cases, there may be repeated suicide attempts. Anyone interacting with traumatised adolescents must be vigilant to the possibility of suicidal behavior. And when there is imminent risk institute a crisis plan and seek a psychiatric consultation, medication, or hospitalization.

 

I’m now going to speak more generally about trauma informed care and practice, which effectively has been the basis of everything I’ve said to date
but perhaps not named so specifically. Many in the mental health sector have long advocated the necessity of a new approach to service delivery for people
with mental illness and co-existing problems who frequently have a history of trauma. This approach must move away from prioritising the search for diagnoses to recognising the person’s traumatic life experience within a holistic framework.

 

“Trauma-Informed Care and Practice is a strengths-based framework grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment.”

 

A large percentage of those seeking help at a diversity of health and welfare settings have trauma histories which are severely affecting their health and wellbeing. Australia’s mental health system has, generally speaking, a poor record in recognising the relationship between trauma and the development of mental health problems. There is a lack of policy focus as to how this knowledge can be incorporated into service delivery.

The substantive core issue of what happened to that person to impact them so profoundly is often relegated to ‘interest value’ only.
This characterisation makes little sense given that recognition and integration of experienced trauma is fundamental to the recovery process.

People can be impacted by trauma through a diversity of experiences which know no boundaries with regards to age, race, ethnicity, social or economic status, gender, disability; geography or sexual orientation. Trauma affects us all, directly or indirectly and can be devastating and debilitating.

Contexting a particular diagnosis as a means to access services is stigmatising and discriminatory. Only a wide range of flexible services holistically delivered with an understanding of the behaviours which characterise presentations in terms of traumatic stress, disrupted attachment, personal invalidation and adaptive coping strategies can meet the needs of these consumers.

A trauma informed approach to care and practice moves away from prioritising the search for a diagnosis to recognition of the person’s traumatic life experience and that it is the consumer’s lived experience which may have resulted in an individual’s contact with mental health services through adoption of extreme coping strategies. We propose that a shift to a trauma informed care and practice approach are not limited to mental health but apply to multiple systems requiring an integrated approach which has survivors at the centre of a model of recovery.

A  trauma informed approach to care must also be supported by trauma specific  services, providing specific interventions designed to address the consequences  of trauma in the individual and facilitate recovery.

However,  whilst conversations and program delivery around TIC are occurring in small  service pockets this does not amount to a broad based systemic change across  the mental health service system. Such TIC programs and services that do exist  clearly acknowledge ‘that no one  understands the challenges of the recovery journey from trauma better than the  person living it’.  The underpinning philosophy is informed by an understanding of the particular vulnerabilities  and ‘triggers’ that trauma survivors experience, with services delivering  better outcomes; minimising re-victimisation and ensuring self and community  wellness and connectedness can be promoted. It is a paradigm shift in service  delivery culture.

 

Trauma informed care is grounded in and directed by a thorough  understanding of the neurological, biological, psychological and social effects
of trauma and violence and the prevalence of these experiences in persons who  receive mental health services.

 

A trauma informed approach primarily views the individual as having been  harmed by something or someone:  thus  connecting the personal and the socio-political environments, (Bloom, 1997, p.  71).

 

This framework expects individuals to  learn about the nature of their injuries and to take responsibility in their  own recovery (Bloom, 2000). [i]

 

The key principles are as follows:

  • Integrate
    philosophies of quality care that guide assessment and all clinical
    interventions

 

  • Is  based on current literature

 

  • Is informed  by research and evidence of effective practices and philosophies

 

Trauma informed care and practice

 

 

  • Involves not  only changing assumptions about how we organise and provide services, but  creates organisational cultures that are personal, holistic, creative,  open, and therapeutic

 

It is a practice  that can be utilised to support service providers in moving from a caretaker to  a collaborator role using a model of recovery-orientated approach

 

 

Trauma-informed programs and services internationally represent the ‘new  generation’ of transformed mental health and allied human services  organisations and programs which serve people with histories of violence and  trauma.[ii]

 

When a human service program seeks to become trauma-informed, every part  of its organisation, management, and service delivery system is assessed and  modified to ensure a basic understanding of how trauma impacts the life of an  individual who is seeking services.

 

Organisations, programs, and services are based on an understanding of  the particular vulnerabilities and/or triggers that trauma survivors experience  (that traditional service delivery approaches may exacerbate), so that these   and programs can be more supportive, effective and avoid  re-traumatisation.[iii]

 

So how different  might service systems look if the Trauma Informed?

 

  1. Key Features of Trauma Informed  Care & Practice Systems

 

Examples

 

Systems
without Trauma Sensitivity
Trauma
Informed Care Systems
Consumers
are labelled & pathologised as manipulative, needy, attention-seeking
Are
inclusive of the survivor’s perspective
Misuse
or overuse of displays of power – keys, security, demeanour
Recognise
that coercive interventions cause traumatization / re-traumatization – and
are to be avoided
Culture
of secrecy – no advocates, poor monitoring of staff
Recognise
high rates of PTSD and other psychiatric disorders related to trauma exposure
in children and adults
Staff
believe key role are as rule enforcers
Provide
early and thoughtful diagnostic evaluation with focused consideration of
trauma in people with complicated, treatment-resistant illness
Little
use of least restrictive alternatives other than medication
Recognise
that mental health treatment environments are often traumatizing, both
overtly and covertly
Institutions
that emphasize “compliance” rather than collaboration
Recognise
that the majority of mental health staff are uninformed about trauma, do not
recognize it and do not treat it

 

 

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. Trauma-informed
care facilitates recovery, minimises re-victimisation and promotes self and
community wellness and connectedness.

 

 

 

 



[i]
Bloom, S. 1997: 2000. Creating Sanctuary: Toward the evolution of sane
societies. New York: Routledge

[ii] Corinne Henderson
& Jenna Bateman. 2010. A National
Strategy for Trauma Informed Care.
Mental Health Coordinating Council.

[iii] Corinne Henderson
& Jenna Bateman. 2010. A National
Strategy for Trauma Informed Care.
Mental Health Coordinating Council.

Kezelman C (2011) Trauma informed Care and Practice – youth mental health

 

TheMHS Conference 6-9 September 2011 – Trauma informed Care and Practice – using a wide-angled lens

The following presentation was co-presented with Corinne henderson, Senior Policy Officer MHCC at TheMHS conference 2011

THEMHS Conference 6-9 September 2011

Trauma Informed Care & Practice – Using a wide
angle lens

 

Dr Cathy Kezelman trained as a medical practitioner and
practiced as a GP for 20 years. She is a director of Adults Surviving Child
Abuse (ASCA) and a board member of the MHCC (Mental Health Coordinating Council
).

 

In 2010 Cathy published her own memoir, Innocence Revisited – a tale in parts, chronicling her own battle with depression and suicidal ideation, at the core of which was unresolved childhood trauma.

 

Corinne Henderson is Senior Policy Officer, MHCC. Her role is
primarily to advocate for legislative and systemic reform in mental health. She
is a trained psychotherapist and sits on the NSW Mental Health Review Tribunal.
Publications include Reframing Responses 1 & 11 (2010) and the NSW Mental
Health Rights Manual (2011).

 

 

Mental health in Australia

 

The MHCC and ASCA have collaborated over
a number of years lobbying for the needs of adult survivors of childhood trauma
with complex needs. We have also been working together with our other partners for
18 months developing and advocating for a national agenda around trauma
informed care and practice.

 

We are encouraged that the political environment
now has a much greater focus on mental health. Minister Mark Butler the first
federal minister for health recently announced a number of new initiatives and
funding opportunities.

 

However planning and funding for
consumers impacted by trauma histories falls perilously short of what’s needed.
Whilst trauma is core to the difficulties of many consumers and awareness of it
pivotal to their sustained recovery, in services, trauma per se is seldom
identified or addressed, leaving many consumers struggling with their daily
functioning.

 

Trauma

It is rare to travel through life
without experiencing trauma and the spectrum is vast.

 

Any traumatic experience has the potential to
invoke fear, helplessness, and horror, and overwhelm a person’s resources for
coping. However today I would like to talk about trauma which can be
characterised as complex trauma.

 

Defining
Complex trauma

Complex trauma refers to traumatic stressors that are interpersonal
– premeditated, planned, and perpetrated by one human being on another. These
actions can be both violating and exploitative of another person.[i]

 

Childhood
trauma

Individuals’ and society’s responses to trauma
vary enormously but reactions to complex trauma tend to be more severe with diverse
impacts which persist long after the trauma has ended.

 

Experiences of interpersonal trauma
are appallingly prevalent in our society. They can be a once off event such as
a physical or sexual assault, perpetrated by a stranger (rarely) occurring
without warning. However the trauma of child abuse – physical, sexual, and emotional
abuse in all its forms including chronic neglect as well as  witnessing and experiencing domestic violence,
perpetrated by someone the child knows and trusts, (often those charged with
the child’s care), are generally repeated, prolonged and extreme.

 

Most commonly child abuse is perpetrated
within the family or by other adults in positions of trust and in regular
contact through school, church, sports or other community activities.

 

Childhood trauma generally characterizes a
series of traumatic events starting at a young age which disrupt the earliest
of attachments.  Its effects are all the
more pervasive because children are young, vulnerable and developmentally
immature.

 

As it is usually intentional, these experiences differ from the
trauma of natural disasters and separation, death and loss. Because the acts
are often repeated the child victim is often becomes hyper-vigilant, anxiously
anticipating further harm – in fight, flight or freeze mode.

 

Trauma in childhood can and does
affect the rapid growth, structure, and functioning of the brain.

 

Impacts of childhood trauma

Without a safe, stable attachment, abused
children focus on simply surviving, shifting resources normally earmarked for
learning and development. This combination of ongoing trauma exposure and the
developmental impact of such exposure typifies complex
trauma
, which features a multitude of traumatic stress challenges.

 

Such abuse involves a
fundamental betrayal of key relationships establishing lifetime patterns of
fear and mistrust, impacting an individual’s sense of self, self-worth, and relationships
with others and with the world in general, emotional
regulation, self-soothing and stress management. Consequences are commonly more
global than those caused by abuse perpetrated in adulthood.

 

Coping
strategies

Many adults who have suffered childhood trauma
have adopted extreme coping strategies which can persist into adult life (as an
attempt to manage overwhelming traumatic stress). They include suicidality,
substance abuse and addictions, self-harming behaviours such as cutting and
burning, dissociation, and re-enactments such as abusive relationships. Whilst
challenging, in the
context of trauma these behaviours make perfect sense.

 

Trauma frequently leads to a diversity
of mental health as well as other types of co-existing problems such as poor
physical health, substance abuse, eating disorders, relationship and
self-esteem issues and contact with the criminal justice system.

 

 

Prevalence

I am one of more than 2 million
Australian adults who suffered some form of childhood trauma. Research tells us that 1 in 5 women and 1 in 7 men
are affected. On this basis in every room of 25 people at least 4 will have
experienced childhood abuse in some form or other.

 

Challenges of supporting consumers
with history of childhood trauma

Consumers with a history of childhood
trauma are a vulnerable group. Many are disadvantaged, not only by their trauma
but also by the accompanying socio-economic disadvantage. Survivors often
experience deep feelings of insecurity, low self-esteem, poor frustration
tolerance, difficulties with trust and interpersonal relationships, and sensitivity
to criticism, and well as all risk-taking and life threatening behaviours which
compound the challenges.

 

Complex trauma -aetiology

Complex trauma is compounded and
cumulative and not limited to that of child abuse. When it occurs later in life
it can compound that from childhood. It can include all forms of violence
experienced within the community – civil unrest, war trauma, genocide, cultural
dislocation, sexual exploitation, incarceration as well as the impacts
homelessness, poverty and chronic disadvantage and mental, physical health
issues and disability, grief and loss.

 

Service responses

The criteria of a diagnosis of PTSD
were developed to capture the impacts of war trauma. It features a triad – of
intrusive re-experiencing of traumatic memories, emotional numbing and
avoidance of reminders of the trauma, including memory loss, and hyper-arousal.
The characterization of the impacts of childhood trauma in terms of PTSD fail
to capture the often pervasive impacts of childhood trauma and service
responses based solely on the diagnosis most generally fall short.

 

Working through the compounded impacts
of complex trauma can be slow process involving a number of phases including
establishing safety, stability, building a therapeutic relationship, education
and skill building, processing and integration. The failure of practitioners,
systems and governments to appreciate these complexities means that many
survivors of complex trauma do not find the care and support they need to
reclaim their health and wellbeing.

 

Many of us working in the mental
health sector have long advocated the necessity of a new approach to service
delivery for people with mental illness and co-existing problems who frequently
have a history of trauma. This approach must move away from prioritising the
search for diagnoses to recognising the person’s traumatic life experience
within a holistic framework.

 

Australia’s
mental health system has, generally speaking, a poor record in recognising the
relationship between trauma and the development of mental health problems.
There is a lack of policy focus as to how this knowledge can be incorporated
into service delivery.

The substantive
core issue of what happened to that person to impact them so profoundly is
often relegated to ‘interest value’ only. This characterisation makes little
sense given that recognition and integration of experienced trauma is
fundamental to the recovery process.

 

ASCA &
MHCC emphasise a broader focus on the spectrum of complex mental health and
psychosocial problems resulting from unaddressed and often unacknowledged
trauma histories and services responding to the diversity of complex need.

People can be
impacted by trauma through a diversity of experiences which
know no boundaries with regards to age, race, ethnicity, social or economic
status, gender, disability; geography or sexual orientation. Trauma affects us
all, directly or indirectly and can be devastating and debilitating.

We propose that to
context a particular diagnosis as a means to access services is stigmatising
and discriminatory. Only a wide range of flexible services holistically
delivered with an understanding of the behaviours
which characterise presentations in terms of traumatic stress, disrupted
attachment, personal invalidation and adaptive coping strategies can meet the needs
of these consumers.

We strenuously
advocate a trauma informed approach to
care and practice
which moves away from prioritising the search for a
diagnosis to recognition of the person’s traumatic life experience and that it
is the consumer’s lived experience which may have resulted in an individual’s
contact with mental health services through adoption of extreme coping
strategies. We propose that a shift to a trauma
informed care and practice approach are not limited to mental health but apply
to multiple systems requiring an integrated approach which has survivors at the
centre of a model of recovery.

A trauma informed approach to care must also
be supported by trauma specific services, providing specific interventions
designed to address the consequences of trauma in the individual and facilitate
recovery.

So what is TIC?

 

It is grounded in and directed by a
thorough understanding of the neurological, biological, psychological and
social effects of trauma and violence and the prevalence of these experiences
in persons who receive mental health services.

 

Trauma-Informed Care and
Practice is a strengths-based framework grounded in an understanding of and
responsiveness to the impact of trauma, that emphasizes physical,
psychological, and emotional safety for both providers and survivors, and that
creates opportunities for survivors to rebuild a sense of control and
empowerment.

 

What is a Trauma-Based Approach?

 

It
primarily views the individual as having been harmed by something or
someone:  thus connecting the personal
and the socio-political environments, (Bloom, 1997, p. 71).

 

This
framework expects individuals to learn about the nature of their injuries and to
take responsibility in their own recovery (Bloom, 2000). [ii]

 

What are the Key Principles?

 

  • Integrate philosophies of quality care
    that guide assessment and all clinical interventions

 

  • Is based on current literature

 

  • Is informed by research and evidence of
    effective practices and philosophies

 

Trauma Informed Care & Practice

 

Involves not only changing assumptions about how we organise and
provide services, but creates organisational cultures that are personal,
holistic, creative, open, and therapeutic

 

It is a practice that can be utilised to support service providers
in moving from a caretaker to a collaborator role using a model of
recovery-orientated approach

 

 

 

A Cultural Shift

 

Trauma-informed programs and services internationally represent
the ‘new generation’ of transformed mental health and allied human services
organisations and programs which serve people with histories of violence and
trauma.[iii]

 

Systemic Transformation occurs

 

When a human service program seeks to become trauma-informed,
every part of its organisation, management, and service delivery system is
assessed and modified to ensure a basic understanding of how trauma impacts the
life of an individual who is seeking services.

 

Transformational Outcomes can happen
when

 

Organisations,
programs, and services are based on an understanding of the particular
vulnerabilities and/or triggers that trauma survivors experience (that
traditional service delivery approaches may exacerbate), so that these services
and programs can be more supportive, effective and avoid re-traumatisation.[iv]

 

 

Medical
model

The
medical model is the basis of our primary care system. It works on the principle that something is wrong with a person
rather than highlighting that something wrong was done to or happened to a
person. Trauma
survivors are frequently pathologised with a range of
diagnoses over a long period of time. Anyone interacting with trauma survivors must understand the impact
traumatic life events have on the development of individuals.

 

 

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. Trauma-informed
care facilitates recovery, minimises re-victimisation and promotes self and
community wellness and connectedness.

 

Services often mirror the power and control experienced in past
abusive relationships. The composite failures in service
provision and expertise, as well as in access and equity exacerbate mental
health issues for consumers and escalate the risk of suicide. Responsive and effective crisis management must be matched
by affordable, accessible, ongoing care

 

Trauma survivors often experience services as unsafe, disempowering and/or invalidating and frequently
after searching for a service which
understands them, their behaviours and reactions in the context of their trauma
history they often give up in despair.

 

Current services

Trauma
survivors characteristically seek help from a diversity of public, private and
community services over a long period of time. Mainstream services cannot
adequately address their needs – being
crisis-driven, or meeting short term needs only. Care is often fragmented with
little to no co-ordination between services and poor referral and follow-up
pathways.

 

Many trauma survivors have not connected their current problems
and behaviours with their past traumatic experiences and nor have their health
workers. The cost of
inadequate service responses individually and in health, welfare and economic terms is immense.

 

Co-morbidity

Trauma survivors with complex needs often
experience a range of co-existing mental health, substance abuse problems and other
life burdens. However they are not co-morbid at all, but rather a range of
‘normal’ human responses to horrendous experiences. Most clients presenting to mental health AOD services have trauma histories yet care is often fragmented and fails to respond to their multiple needs
which can include unemployment, welfare dependency, homelessness and social
exclusion.

 

 

Embracing model of trauma informed care and
practice 

We propose the integration of a model of Trauma-Informed Care and
Practice across all health, mental health and human services. This necessitates
the development of evidence based models and practice programs building
capacity through supporting workforce education and training; data collection,
research, outcome measurement and evaluation.

 

This must include strategies
to increase community awareness around the relationship between trauma and mental
health while working to eradicate stigma and discrimination, and facilitate
access and equity.

 

Successful model

Successful treatment programs need to recognise a survivor’s need
to be respected, informed, connected, and hopeful regarding recovery. Providers
must move from a caretaker to a collaborator role, empowering survivors in
recovery orientated model. Trauma-informed care changes assumptions about
service design and provision, creating organisational cultures that are
personal, holistic, creative, open, and therapeutic. There must be an emphasis
on collaboration, partnership and cooperation, promoting linkages between
services.

 

A trauma informed
system

The new system we envisage will be characterized by safety from
physical harm and re-traumatization; an understanding of survivors and their
symptoms in the context of their history, culture, sexual orientation,
ethnicity and gender and community; open and genuine collaboration between
workers and those seeking help at all phases of service delivery; an emphasis
on building on strengths and acquiring skills rather than on managing symptoms;
an understanding that symptoms represent attempts to cope, regardless of how
extreme they may seem; a perception that childhood trauma was a defining
experience/s  that an individual’s core  identity.

 

Improved outcomes

Studies have shown that programs that utilize a
trauma-informed model, report a decrease in psychiatric symptoms, substance use
and trauma symptoms, an improvement in consumers’ daily functioning, decreases
in the use of intensive services such as 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. A trauma-informed
care and practice approach provides renewed hope of recovery to consumers with
complex trauma histories who experience severe, and persistent mental health
AOD problems.

 

 

We need to address the systemic failure of the
existing mental health system to provide appropriate trauma-informed services
to the majority of Australians needing them.

 

While recent budget announcements with
increased funding for mental health are welcomed the changes fail to
acknowledge the prevalence of trauma, its dynamics and/or the needs of trauma
clients. However we are truly encouraged by the groundswell of interest in
moving this agenda forward, with conversations clearing starting to occur in government
circles as well.

Our recent
conference highlighted how an international movement to change the way service
systems respond to trauma can substantially improve the lives of those affected
by complex trauma.

Our combined vision
is to increase awareness and knowledge about TICP and drive an important policy
and systemic change – promoting a cultural shift that embraces the concept
across both the government and non-government sectors in all health and
community services.

This has the
potential to create an environment that is more supportive, comprehensively
integrated, empowering and therapeutic for a diversity of trauma survivors.

Following from the
conference we have identified a number of starting point for discussion to move
the National TICP agenda forward further which include the need to:

  • Investigate current
    trauma informed care and practice evident in Australia and New Zealand – a mini
    audit of service delivery and evaluation processes

 

  • Investigate existing
    gaps ( such as in inpatient services)

 

  • provide an overview
    of evidence-based literature from international
    and Australian sources

 

  • define TIC in
    practice and determine what is transferable across sectors, and

 

  • develop principles,
    standards and guidelines that will assist us in developing an assessment tool
    for organisations working in the community, public and private sectors

In all of our
discussions we emphasise the importance of community services that enable people to remain connected
to their communities and families, remain in work, and recover and reintegrate
with the community, such as: adult education programs, psycho-social
rehabilitation, home-based outreach, peer support, supported accommodation and
job placement and support services. Such services enable trauma survivors to
stay living in the community, in their own homes, limiting hospitalizations and
crisis presentations s. With the right care and support, trauma survivors can
ultimately live well.

So to conclude – MHCC
has now developed a microsite devoted to TICP

  • Key
    conference presentations are available in full plus a range of research papers
    and news and information on TICP

 

  • MHCC, ASCA
    and collaborating partners have established a TICP Network currently comprising
    over 200 people which will enable us to keep those interested up to date and in
    communication with interested others.

We encourage you to
visit the website, join our network and make use of the resources.

Moreover we ask you
to share your knowledge and expertise with us by sending us your comments and
feedback.



[i] Christine A. Courtois .Understanding Complex Trauma,
Complex Reactions, and Treatment Approaches

Available: http://www.giftfromwithin.org/pdf/Understanding-CPTSD.pdf

[ii]
Bloom, S. 1997: 2000. Creating Sanctuary: Toward the evolution of sane
societies. New York: Routledge

[iii] Corinne Henderson
& Jenna Bateman. 2010. A National
Strategy for Trauma Informed Care.
Mental Health Coordinating Council.

[iv] Corinne Henderson
& Jenna Bateman. 2010. A National
Strategy for Trauma Informed Care.
Mental Health Coordinating Council.

 

 

Creating a Culture of Prevention and Wellbeing – Trauma informed Care and Practice

This paper was presented at Youth Mental Health Day Sept 2011 in ACT at a professional development seminar.

Trauma-informed Care and practice (Youth  Mental Health Day)

 I plan to speak with you today about trauma and especially trauma in childhood and its impact on youth mental health. I would like to highlight how
awareness of trauma and its impact, and responsiveness to it can make a significant difference to the lives of young Australians. We are living in a
changing political environment and one which has a greater focus on mental health than ever before. This focus is long overdue. However responses to mental
health issues still are not on par with those to physical illnesses. However inroads are being made all the time.

Mark Butler the first ever federal minister for mental health recently announced a number of new initiatives and funding opportunities and they were most
welcome. However trauma and its impacts did not receive a Guernsey within those announcements. Planning and funding for individuals impacted by trauma
histories continues to fall perilously short of what’s needed. Whilst trauma is core to the difficulties of many Australians and awareness of it pivotal to
their sustained recovery, in services, trauma per se is seldom identified or addressed. This leaves many individuals struggling and without the right help
they will continue to struggle with their daily functioning from childhood through adolescence to adulthood and right into old age.

It is rare to travel through life without experiencing trauma and the spectrum of trauma that can impact the human condition is vast. Any traumatic experience has the potential to invoke fear, helplessness, and horror, and overwhelm a person’s resources for coping. However today I would like to talk about trauma of childhood abuse, which can be characterised as complex trauma.

Complex trauma refers to trauma which is compounded and cumulative. It is most often interpersonal i.e. perpetrated by one human being on another, intentional and of early life onset.   So the individual experiences multiple, chronic, and/or extreme developmentally adverse traumatic events (e.g., sexual, emotional or physical abuse, witnessing and experiencing domestic violence, neglect, community violence), often within the child’s care-giving system.

Other stressors occur in childhood, for example traumatic medical and surgical procedures, accidents, war trauma and civil unrest. However most trauma begins at home with up to 80% of child maltreatment perpetrated by a child’s parents. Child abuse is of course not only perpetrated within the immediate family but within the extended family and by other adults in positions of trust and in regular contact through school, church, sporting groups or other community activities.

While health practitioners and workers happily ask about developmental milestones and the family’s medical history obtaining information about childhood trauma, abuse, neglect and other exposures to violence has not been routine. Perhaps this reluctance parallels the social taboos and stigma which have further prevented those who have lived with childhood trauma from receiving the help and support they need to live healthy engaged lives.

Adverse childhood experiences

Traumatic childhood experiences are not only extremely common but they also have a profound impact on diverse areas of functioning. Children with alcoholic parents, parents with a mental illness, who are abused or neglected in some way or who live in a family violence situation struggle to feel safe and secure.

The impacts of their trauma are often pervasive and multifaceted, and can include depression and a range of mental health impacts, various medical illnesses, as well as a variety of impulsive and self-destructive behaviours. All of the presentations need to be considered in the context of the lived experience of their trauma, regardless of their age. This is the basis of a trauma-informed approach to care which I’ll talk about later.

To date our health system generally has failed in this regard. Rather than approaching individuals holistically services and practitioners have approached people in a piecemeal way. All workers and professionals need to remain cognisant of the possible impacts of traumatic stress and the systemic internal disorganization it often causes.

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, the impact of which I have
grappled with for 13 years. My story of recovery and beyond has been chronicled in a memoir entitled Innocence Revisited – a tale in parts.

As a medical practitioner, one would assume that I was informed about trauma, its effects on mental health and how to address the impact. Nothing was
further from the truth! I was a GP in Sydney for twenty years. I worked hard juggling the demands of practice with being married with 4 children and a foster child. Back then I could, do most things relatively easily.

In April 1998 when I was in my mid 40’s my niece was killed in a car accident. I grieved for her, as one would expect and grieving takes as long as it takes. As other members of my family started to come to terms with their loss I was becoming more distressed. I started to feel anxious and then had my first panic attack. I thought I was going to die! The panic attacks became more frequent, the anxiety generalized and I grew depressed. Then came the nightmares and flashbacks as the trauma stored in my subconscious unlocked.

Soon I could barely function. I was forced to leave work setting myself a 4 month sabbatical – that was 13 years ago. After that my world collapsed.

I spent most of the next 2 years in bed, completely immobilized, battling a relentless blackness of mood. I struggled with suicidal thoughts and then gestures. The antidepressants the psychiatrist prescribed helped take the edge off my mood at times, but it was a lengthy psychotherapeutic process which
helped me come to terms with my history and its impact which finally got me functioning again.

Therapy guided my process of integration and I am now well and no longer subsumed in my trauma. For the first time, I can not only live in the present
but embrace my future.  Acknowledging and appropriately addressing my complex trauma caused by childhood abuse 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.

Prevalence

I am one of more than 2 million Australian adults who suffered some form of childhood trauma and I am lucky.  I had the resources and the support to recover.
Research tells us that 1 in 5 women and 1 in 7 men are affected.

A seminal study the Adverse Childhood Experiences (ACE) study by Kaiser Permanente in 1998, which is still ongoing, looked at the impacts of all forms of abuse and neglect as well as that of family dysfunction i.e. living with parent with mental illness, substance abuse, who is incarcerated. It  showed that
adverse childhood experiences are vastly more common than recognized and that they have a powerful relation to adult health and social outcomes. It found a
highly significant relationship between adverse childhood experiences and depression, suicide attempts, alcoholism, drug abuse, sexual promiscuity,
domestic violence, cigarette smoking, obesity, physical inactivity, and sexually transmitted diseases. The more adverse childhood experiences reported,
the more likely a person was to develop heart disease, cancer, stroke, diabetes, skeletal fractures, and liver disease, as an adult.

Childhood trauma

Experiences of interpersonal trauma are appallingly prevalent in our society. One off events such as a physical or sexual assault, perpetrated by a stranger produce discrete behavioural and biological responses to reminders of the trauma as are characterised by PTSD – hyperarousal, numbing and intrusive re-enactments of the trauma such as flashbacks or nightmares. These are devastating enough but the repercussions of childhood trauma tend to be more global. Let me tell you why.

Childhood trauma is usually intentional, generally perpetrated by someone the child knows and trusts, often the person charged with the child’s care, and it disrupts the earliest of attachments. Without a safe, stable attachment, abused children focus on simply surviving, shifting resources normally earmarked for learning and development. Thirdly the traumatic acts are generally repeated, prolonged and extreme.  This combination of ongoing trauma exposure and the developmental impact of such exposure typifies complex trauma.

 Impacts on brain and mind 

During childhood the brain grows and develops rapidly, especially in the first 3 to 5 years, with further rapid development during puberty and it continues to grow and develop until a person is in their twenties. During this entire period trauma can and does impact fundamental neuro-chemical processes,
and these in turn can affect the growth, structure, and functioning of the brain and the mind. Chronic trauma interferes with the capacity to integrate sensory, emotional and cognitive input into a cohesive whole. Neural development and social interaction are inextricably intertwined.

Attachment

A child’s capacity to regulate their emotions and behaviour is a reflection of their caregivers’ responses to them. Children internalise the affective and cognitive
characteristics of their relationships with their primary care-givers and form internal working models for their feelings, thoughts and reactions. Early
patterns of attachment determine how effectively individuals will process information from then on. Infants who feel safe, secure and understood learn to
trust what they feel. They also come to make sense of and the world around them. They come to rely on their emotions and thoughts and this informs their
reactions to any situation. They become confident about their feelings and can express them. They learn to feel good about themselves, to value themselves and
feel confident that they can make good things happen. They also are reassured that if they don’t know how to deal with a difficult situation that someone
else around them will. They are able to develop strategies for responding purposefully to a range of situations rather than reacting to them.

When a child experiences trauma, the parent or caregiver of a child, whose environment is secure, can help restore a sense of safety and control. In
this way a child’s distress can be ameliorated and their fear dissipates. A parent or caregiver’s capacity to mitigate a child’s terror reflects the capacity of the parent or caregiver to respond to the threat.

If the parent is unable to manage their own reactions, and 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 does not learn how to modulate their emotional arousal. As a result the child is unable to process and attribute meaning to what is happening.

The child does not learn to self-regulate and might dissociate or stay agitated as a result. Spaced out and hyperaroused children learn to ignore their emotions and/or what their thoughts. They can’t connect the dots and make meaning of what they are experiencing and so do not learn to respond appropriately to a range of 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.

With childhood trauma, the acts are often repeated and the child often becomes hyper-vigilant, anxiously anticipating the next episode. When children are unable to feel safe, secure and in control they feel helpless. 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 (fearful) stimulus to (fight/flight/freeze) response without being able to learn from the experience.

These children are easily triggered by any reminder of the trauma  – sensations, physiological states, images, sounds, situations. These reminders 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 respond in a punitive rather than a supportive way.

The fundamental betrayal the child experiences establishes lifetime patterns of fear and mistrust. Traumatized children struggle to modulate their aggression and impulse control. They also have difficulty negotiating relationships with caregivers, peers, and, subsequently, intimate partners. They also experience a host of other challenges: substance abuse, borderline and antisocial personality, as well as eating, dissociative, affective, somatoform, cardiovascular, metabolic, immunological, and sexual disorders. They are also prone to re-victimisation – repeated interpersonal trauma – community and domestic violence, physical and sexual assaults.

The medical model works on the principle that something is wrong with a person rather than highlighting that something wrong was done to or happened to
a person. Trauma survivors are frequently pathologised with a range of diagnoses over a long period of time. Anyone interacting with trauma survivors must understand the impact traumatic life events have on the development of individuals.

I am a medical practitioner by training. The Hippocratic Oath states: “First do no harm”. However harm is done to trauma survivors when their experience goes unacknowledged and when their particular vulnerabilities and sensitivities are disregarded, disrespected and misunderstood. Harm is done when survivors are labelled; when they are negated as human beings; and when the traumatic experience at the very core of their being is disaffirmed.

The impacts are far more pervasive than those characterised by PTSD alone. In fact the majority of traumatized children do not meet the diagnostic criteria
for PTSD.  The current psychiatric diagnostic classification system does not capture the lived experiences of these children. The narrow PTSD diagnosis is often used and other labels are also applied with so called co-morbid pathology – Depression, Attention Deficit Hyperactivity Disorder (ADHD),Oppositional Defiant Disorder (ODD), Conduct Disorder, Generalized Anxiety Disorder, Separation Anxiety Disorder, and Reactive Attachment Disorder.

Each of these diagnoses cherry-picks an aspect of the child’s experience rather than looking holistically in the context of their trauma and their attempts to manage their traumatic stress. Such diagnoses and treatment responses often focus on particular behaviours or symptom complexes rather than on the core impacts of the trauma on the child.

Diagnosis does not capture the complex disruptions of affect regulation, disturbed attachment patterns, rapid behavioural regressions and shifts in emotional states,  loss of autonomous strivings, the aggressive behaviour against self and others, failure to achieve developmental competencies; loss of bodily regulation in the areas of sleep, food and self-care;  altered schemas of the world; anticipatory behaviour and traumatic expectations; multiple somatic problems,
from gastrointestinal distress to headaches; apparent lack of awareness of danger and resulting self endangering behaviours; the self-hatred and self-blame
and the chronic feelings of ineffectiveness.

Many areas of functioning can be affected and let’s examine them in a little more detail.
1. Affects are often intense and include rage, terror, shame and self-blame, betrayal. Traumatised children exhibit intense reactions to stimuli which secure children would find  trivial. They struggle to regulate their emotions and reactive behaviours and settle them back down.
They work to feel in control in the face of perceived threats and to ward off unwanted emotions. They tend to either re-enact prior traumas as perpetrators,
acting aggressively or sexually acting out with other children or alternatively employ frozen avoidance reactions. They show little insight into the origins of
their reactions.

They are prone to somatic symptoms such as headaches or stomachaches, an expression of their physiological dysregulation, a response to fearful and helpless emotions.

Their view of the world incorporates their betrayal and hurt. Children who have been traumatised are continually anticipating that they will be hurt again. Their response to stress varies from hyper-vigilance and being constantly on guard, frightened and over-reactive to feelings of helplessness, defeat and freeze
responses.  They readily become confused or dissociate in the presence of stressful stimuli.
Anticipating further trauma permeates these children’s relationships with themselves and others. They do not believe that anyone will look after them and keep them safe and continually anticipate that they will be victimised or abandoned.

These reactions and behaviours will show up across the board in educational, familial, peer relationships, problems with the legal system, and problems in holding down jobs.

Obviously therapeutic/counselling support is crucial but often other support is needed first or concurrently.  Support in dealing with the powers that be i.e. the “red tape” in health or social welfare bureaucracies so they receive the services of funds they need, providing advocacy support in a judicial hearing, , or working with school personnel to keep them in the education system. It may include filling out forms, writing letters, making phone calls, or completing reports.

In addition the adolescent trauma survivor may need support in the most basic and important ways –  food, shelter, financial support, social integration, and physical/social protection. All of these basic needs may need to be addressed before attention to psychological issues can be made.

Does the client have a place to stay tonight? When did he or she last eat? When did he or she last get a medical examination? Is he or she engaged in unsafe sex, IV drug abuse, or other risky behaviours? Does he or she report self-injurious behaviour? Is there evidence of a severe eating disorder?

Therapeutic approaches for traumatized youth has four main aims:
(1) establishing safety in their environment, including home, school, and community, (2) developing skills in emotional regulation and interpersonal functioning, (3) making meaning about past traumatic events and finding more positive, constructive views of themselves with hope for the
future (4) enhancing resiliency and integration into social network.

 Almost all traumatized youth live in a continually traumatizing environment. They either need to learn how to live in that environment or find a new environment. Creating a system of care and safety in which a child and the family can begin to heal often means working with child protection, the police
and courts to develop a safer living environment, engaging the family and the school, and other primary support figures, in order to create a network to develop safety within the living environment. It is impossible for any child to take in new information when he or she is fighting for survival. Building a network of support for the child and their family is vital.

Development of basic skills which have been lost or never acquired such as managing feelings and forming healthy relationships can occur within a therapeutic context.  Caretakers and family and community agencies need to be engaged so new skills can be reinforced at home and then incorporated into the day-to-day world.

A phased approach is recommended to avoid “information overload” which affects the capacity to learn. Lessons learned in the first phase serve as a building block for other phases. The process is not linear and it is often necessary to revisit earlier phases of treatment time and again.  Before any therapeutic work can begin, the safety of the child and family must be addressed.

Therapists/counsellors need to work closely with child protection, schools, and family support networks to develop safety and a treatment plan that addresses the needs of the child, as well as the family. The focus is on building trust and a positive working relationship. The emotion regulation skils of the second stage help clients review their traumatic experiences. nce children possess improved methods for coping and an increased capacity for
emotion regulation, they are better able to communicate and process traumatic memories.

They will then experience less distress about their history and react less to triggers. As they learn to regulate their emotions and develop better social skills

they will start to see themselves differently. This will make  them feel better about themselves and more confident that change is possible.

 Instilling the principles of resiliency in youth means they can  continue to develop in positive, healthy, and functional ways and avoid future
victimization and/or aggressive behaviours. Involving the youth in creative  projects or youth programs, identifying expectations and responsibilities,
working with families and communities to maximize safety will encourage youth  to achieve and develop their unique talents. The traumatic experience can then  move from being the central aspect of their lives to being a part of their  history. All of these phases can take place within community mental health
settings, hospitals, schools, and families with support services.

Often complex trauma is compounded  by socioeconomic deprivation or social marginalization. The adolescent abused  at home, assaulted as a result of community violence or gang activity, and who  lives with poverty, poor nutrition, inadequate schools, social discrimination, is often struggling not only with a trauma history and social deprivation, but  also the likelihood of additional trauma in the future.

Although the youth may appear to  be “acting out,” “self-destructive,” “borderline,” or “conduct-disordered,” these  behavioural patterns reflect strategies to cope with or the effects of, prior  victimization – suicidal behavior, self harm, substance abuse, eating  disorders, dysfunctional sexual behavior, excessive risk-taking, and  involvement in physical altercations. These  activities help the adolescent to distract, soothe, avoid, or otherwise reduce  ongoing or triggered trauma-related dysphoria.

We need to speak a little about  risk because although many of the effects of trauma are chronic, others are  more severe, and may endanger a youth’s  immediate wellbeing, or in fact  threaten his or her life. His or her environment may still be exposing him or  her to risk and ongoing victimization. He or she may be suicidal, abusing major  substances, or involved in various forms of risky behaviour.

 It is very important  to evaluate current safety. Is the client in imminent danger or at risk of  hurting others? In cases of ongoing interpersonal violence, is the client in  danger of victimization from others in immediate future? Is the client acutely  suicidal? Is the client’s immediate psychosocial environment unsafe?

 Although a number of specific trauma  therapies help it is the development of a positive therapeutic relationship that is crucial to progress. This is probably especially true for adolescents  who have been repeatedly traumatised, whose life experiences have taught them  to mistrust authority and to anticipate being maltreated.

The adolescent will often test  the therapist and in fact anyone trying to support him/her. He/she will  continue to practice behaviours which they have utilised in the past, coping  mechanisms such as feigning disinterest despite being desperate for connection  and validation. It is important for the therapist not to react and become angry,  punitive or rejecting as that will reinforce the youth’s beliefs from the past.  Showing empathy, understanding, respect and a non-shaming non-blaming approach  will ultimately lead to trust and a collaborative relationship of care.

 The therapeutic  relationship and process will undoubtedly trigger memories, feelings, and  thoughts associated with prior relational traumas. In the midst of a positive  therapeutic relationship the youth will experience reactivated rejection,  abandonment fears, misperception of danger, or authority issues but also respect, caring, and empathy.  The positive relational feelings will gradually win over and such intrusions will  lose their generalizability.

 In dealing with youth with trauma  histories it is important to be developmentally sensitive and to work with traumatized  youth as is appropriate to their psychological ages. Similarly  some traumas are more common in one sex than the other, and that sex-role  socialization often affects how such injuries are experienced and expressed.

 Research indicates  that girls and women are more at risk for victimization in close relationships  than are boys and men, and are especially more likely to be sexually  victimized, whereas boys and men are at greater risk than girls of physical  abuse and assault. In addition to  trauma exposure differences, young men and women tend to experience,  communicate, and process the distress associated with traumatic events in  somewhat different ways. Cultural differences also need to be taken into  account as do different views of the world and experiences.

 The process also needs to keep  the client’s level of affect regulation, i.e., his or her relative capacity to  tolerate and internally reduce painful emotional states in mind. Adolescents  with limited affect regulation abilities are more likely to be overwhelmed and  destabilized by current negative events and those triggered by painful  memories. Those with less ability to internally regulate painful states are  more likely to become highly distressed, if not emotionally overwhelmed, during  treatment, and may respond with increased avoidance, including “resistance”  and/or dissociation

In supporting youth with impaired  affect regulation capacities any therapeutic work should proceed carefully, so  that traumatic memories are activated and processed in small increments –  “working within the therapeutic window”. That way the trauma processing will  not exceed the capacities of the survivor to tolerate that level of distress.

The therapist’s  ability to communicate and demonstrate safety is a central component to  relationship building. The adolescent is more likely to “let down his/her  guard” and open himself or herself to a relationship if, repeatedly over time, the  therapeutic process is safe with little evidence of any danger. NonintrusivenessVisible positive regard; Reliability and stability; Transparency; Demarking the limits of confidentialit are important.

Trauma also makes one  feel very alone, isolated from others, and, at the core, unknowable. Being able  to interact regularly with a person who is attuned, who listens and hears, and  who seems to understand, can be a powerfully positive experience and helps  build the therapeutic alliance, and so a new form of attachment between client  and therapist.

Despite the  prevalence of short-term interventions for traumatised youth most therapy for  complex trauma proceeds slowly. As the therapist counsels patience and remains  constant and invested in the therapeutic process, he or she has the opportunity  to communicate acceptance of the client and trust in the therapeutic  relationship. This process requires the therapist to model patience as well.

Suicidal thoughts and behaviors  are relatively common among abused or traumatized individuals perhaps  especially in the context of ongoing adversity. In some cases, suicidal behaviors are passive, wherein the client engages in high risk activities  and/or fails to protect him/herself in dangerous situations. In other cases,  there may be repeated suicide attempts. Anyone interacting with traumatised adolescents must be vigilant to the possibility of suicidal behavior. And when  there is imminent risk institute a crisis plan and seek a psychiatric consultation, medication, or hospitalization.

I’m now going to speak more generally about trauma informed care and practice, which effectively has been the basis of everything I’ve said to date
but perhaps not named so specifically. Many in the mental health sector have long advocated the necessity of a new approach to service delivery for people
with mental illness and co-existing problems who frequently have a history of  trauma. This approach must move away from prioritising the search for diagnoses to recognising the person’s traumatic life experience within a holistic  framework.

“Trauma-Informed Care and Practice is a strengths-based framework grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and  empowerment.”

A large percentage of those seeking help at a diversity of health and welfare settings have trauma histories which are severely affecting their health and wellbeing. Australia’s mental health system has, generally speaking, a poor record in recognising the relationship between trauma and the development of mental health problems. There is a lack of policy focus as to how this knowledge can be incorporated into service delivery.

The substantive core issue of what happened to that person to impact them so profoundly is often relegated to ‘interest value’ only. This characterisation makes little sense given that recognition and integration of experienced trauma is fundamental to the recovery process. People can be impacted by trauma through a diversity of experiences which know no boundaries with  regards to age, race, ethnicity, social or economic status, gender, disability;
geography or sexual orientation. Trauma affects us all, directly or indirectly and can be devastating and debilitating.

Contexting a particular diagnosis as a means to access services is stigmatising and discriminatory. Only a wide range of flexible services holistically delivered with an understanding of the behaviours which characterise presentations in terms of traumatic stress, disrupted attachment, personal invalidation and adaptive coping  strategies can meet the needs of these consumers.

A trauma informed approach to care and practice moves away from prioritising the search for a diagnosis to recognition of the person’s traumatic life experience and that it is the consumer’s lived experience which may have resulted in an individual’s contact with mental health services through adoption of extreme coping strategies. We propose that a shift to a trauma informed care and practice approach are not limited to mental health but apply to multiple systems requiring an integrated approach which has survivors at the centre of a model of recovery.

A trauma informed approach to care must also be supported by trauma specific services, providing specific interventions designed to address the consequences
of trauma in the individual and facilitate recovery.

However, whilst conversations and program delivery around TIC are occurring in small service pockets this does not amount to a broad based systemic change across the mental health service system. Such TIC programs and services that do exist clearly acknowledge ‘that no one  understands the challenges of the recovery journey from trauma better than the person living it’.  The underpinning philosophy is informed by an understanding of the particular vulnerabilities and ‘triggers’ that trauma survivors experience, with services delivering better outcomes; minimising re-victimisation and ensuring self and community wellness and connectedness can be promoted. It is a paradigm shift in service delivery culture.

Trauma informed care is grounded in and directed by a thorough understanding of the neurological, biological, psychological and social effects
of trauma and violence and the prevalence of these experiences in persons who receive mental health services.

 What is a Trauma-Based Approach?

 

It primarily views the individual as having been harmed by something or someone:  thus connecting the personal and the socio-political environments, (Bloom, 1997, p. 71).

 

This framework expects individuals to learn about the nature of their injuries and to take responsibility in their  own recovery (Bloom, 2000). [i]

 

  1. What are the Key Principles?

 Integrate philosophies of quality care that guide assessment and all clinical interventions

 

  • Is based on current literature

 

  • Is informed by research and evidence of effective practices and philosophies

 

  1. Trauma Informed Care & Practice

 

  • Involves not only changing assumptions about how we organise and provide services, but  creates organisational cultures that are personal, holistic, creative, open, and therapeutic

 

It is a practice  that can be utilised to support service providers in moving from a caretaker to a collaborator role using a model of recovery-orientated approach  

Trauma-informed programs and services internationally represent the ‘new generation’ of transformed mental health and allied human services  organisations and programs which serve people with histories of violence and  trauma.[ii]

 

Systemic Transformation occurs when a human service program seeks to become trauma-informed, every part  of its organisation, management, and service delivery system is assessed and  modified to ensure a basic understanding of how trauma impacts the life of an
individual who is seeking services.

 

Organisations, programs, and services are based on an understanding of the particular vulnerabilities and/or triggers that trauma survivors experience  (that traditional service delivery approaches may exacerbate), so that these  services and programs can be more supportive, effective and avoid  re-traumatisation.[iii]

 

So how different  might service systems look if the Trauma Informed?

 

  1. Key Features of Trauma Informed Care & Practice Systems

 

Examples

 

Systems
without Trauma Sensitivity
Trauma
Informed Care Systems
Consumers are labelled &
pathologised as manipulative, needy, attention-seeking
Are inclusive of the survivor’s
perspective
Misuse
or overuse of displays of power – keys, security, demeanour
Recognise
that coercive interventions cause traumatization / re-traumatization – and
are to be avoided
Culture
of secrecy – no advocates, poor monitoring of staff
Recognise
high rates of PTSD and other psychiatric disorders related to trauma exposure
in children and adults
Staff
believe key role are as rule enforcers
Provide
early and thoughtful diagnostic evaluation with focused consideration of
trauma in people with complicated, treatment-resistant illness
Little use of least restrictive alternatives
other than medication
Recognise that mental health
treatment environments are often traumatizing, both overtly and covertly
Institutions that emphasize
“compliance” rather than collaboration
Recognise that the majority of mental
health staff are uninformed about trauma, do not recognize it and do not
treat it

 

 

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. Trauma-informed
care facilitates recovery, minimises re-victimisation and promotes self and
community wellness and connectedness.

 


[i]
Bloom, S. 1997: 2000. Creating Sanctuary: Toward the evolution of sane
societies. New York: Routledge

[ii] Corinne Henderson
& Jenna Bateman. 2010. A National
Strategy for Trauma Informed Care.
Mental Health Coordinating Council.

[iii] Corinne Henderson
& Jenna Bateman. 2010. A National
Strategy for Trauma Informed Care.
Mental Health Coordinating Council.

 

 

 

Trauma-informed care and practice – changing the lives of Australian adult survivors of childhood trauma

The following paper was delivered at the MHCC Trauma informed Care and Practice Conference – Meeting the Challenge

Failure of policy, systems and services

As a group, adult survivors of childhood trauma in Australia have repeatedly been ignored in mental health policy reform and have continually fallen through the cracks in service systems. The reasons for this are many and varied. Factors include the stigma and taboo which exist around abuse, in general, and the legacy of abuse, in particular, as well as a collective denial about the scale of the issue and the long-term complex needs experienced by many survivors. Sometimes, the failure to acknowledge the issues is pure ignorance. Adults traumatised by interpersonal violence in childhood often have severe and persistent mental health, health, behavioural, social and/or substance abuse problems. The international and national research evidence around these impacts is copious and yet has failed to influence policy reform and planning. There remains a prevailing attitude that, as adults, people should be able to put their abusive childhoods behind them – on their own.

The good news is that people are resilient and with the right help and psychosocial supports, adult survivors can find their road to recovery. The sad reality however is that this resilience is repeatedly tested by the current appalling lack of investment in a trauma-informed approach to care and support Australia-wide.

Trauma-informed Care

Let’s define trauma-informed care and practice and put it in context in relation to adult survivors of childhood trauma. “Trauma-Informed Care and Practice is a strengths-based framework grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment.”

The majority of survivors cannot access and/or afford to sustain the holistic support they need to make sense of their histories and work towards recovery.  What’s more, few service systems or workers have the insight and awareness needed to appropriately acknowledge and support survivors’ fundamental needs. These collective failures repeatedly compound the multiple challenges that survivors of childhood trauma, their families and communities experience.

Trauma

All trauma has the potential to invoke fear, helplessness, and horror, and overwhelm a person’s resources for coping. The trauma on which I’m focusing can be caused by all forms of abuse – sexual, physical and emotional including neglect and witnessing or experiencing violence in the home or neighborhood. Often victims of abuse experience several forms of trauma concurrently. While individuals’ and society’s reactions to trauma vary enormously the trauma of childhood abuse can be especially damaging. There is a multitude of reasons for this.

Childhood trauma

During childhood the brain grows and develops rapidly, especially in the first 3 to 5 years, with further rapid development during puberty and it continues to grow and develop until a person is in their twenties. During this entire period trauma can and does impact fundamental neuro-chemical processes, and these in turn can affect the growth, structure, and functioning of the brain. If experiences occur when an infant is pre-verbal the impacts can be particularly complex since memory may locate them in inexplicable somatic expression only.

The trauma of child abuse is rarely an isolated incident. Childhood trauma is commonly repeated, prolonged and extreme, characterized by a series of traumatic events starting at a young age and disrupting the earliest of attachments.  Its effects are all the more pervasive because children are young, vulnerable and developmentally immature.

Childhood trauma is interpersonal i.e. perpetrated by one human being on another,  is most commonly perpetrated by adults on whom the child depends and trusts, the very adults charged with the child’s care. The trauma perpetrated is also generally intentional, differentiating it from the trauma of natural disasters and separation, death and loss. For all these reasons childhood trauma is more prone to cause global consequences than trauma which is experienced in adulthood.

Complex trauma

The criteria of a diagnosis of PTSD were developed to capture the impacts of war trauma featuring the triad of intrusive re-experiencing of traumatic memories, emotional numbing and avoidance of reminders of the trauma, including memory loss, and hyperarousal. The characterization of the impacts of childhood trauma in terms of PTSD alone and service responses based solely on the diagnosis fail to capture the often pervasive impacts of childhood trauma.

Without the security of a safe, stable attachment, children who are abused focus on simply surviving and so shift resources normally earmarked for learning and development. This combination of ongoing trauma exposure and the developmental impact of such exposure typifies complex trauma, which features an additional array of traumatic stress challenges. Sadly the concept of Complex PTSD was rejected for inclusion in the DSM v.

Child abuse effects

Secure attachment relationships with attuned, consistent caregivers enable children to internalize key self-regulatory functions and develop a sense of safety and basic trust in the world. The fundamental betrayal and relational damage a child suffers when that child is repeatedly abused and neglected, sets up lifetime patterns of fear and mistrust, impacting personal identity and self-worth, relationships with others and with the world, emotional regulation, self-soothing and stress management. Adult survivors often additionally struggle with somatic symptoms and chronic feelings of hopelessness.

Coping strategies

Many adults who have suffered childhood trauma have developed extreme coping strategies as ways of managing the impacts of overwhelming traumatic stress. Many of these strategies are adopted in childhood but persist into adult life. They include suicidality, substance abuse and addictions, self-harming behaviours such as cutting and burning, dissociation, and re-enactments such as abusive relationships. These behaviours are often challenging not only for the survivor but for those seeking to support them. However in the context of trauma they make perfect sense.

Challenges of meeting needs of adult survivors

Meeting the needs of adult survivors can be challenging for all of the reasons I’ve outlined (the deep feelings of insecurity, sensitivity of criticism, low self-esteem, difficulties with trust and interpersonal relationships, substance abuse, self-harming, suicidal and risk-taking behaviours with which many survivors struggle).

Challenges for survivors seeking help

When a child is abused the child takes on an inappropriate sense of shame and self-blame and these feelings often continue into adult life. Even though survivors may want to talk about their feelings, their own shame as well as fear of how others will respond can stop them from doing so. Child abuse, at its core, is about being and feeling unsafe and survivors try to protect themselves from being hurt again. Hence survivors will tend to withdraw, isolate themselves and not seek help. Strategies such as these combined with the symptoms of hyper-arousal or avoidance that accompany PTSD, can make it particularly hard for survivors to seek help and engage in and sustain treatment.

Recovery from Childhood trauma

Fortunately survivors can and do recover and can live successful and fulfilling lives. They can learn how to trust, to feel safe and relate to others, how to self-regulate. Neuroscience tells us that neural pathways can repair themselves but survivors need support, empathy, understanding and respect. Our current systems of care often fail to respond ignoring the underlying trauma, at the core of survivors’ issues, failing to address it. Frequently the possibility of underlying trauma is not on a health professionals’ radar at all or if known about, is not viewed as pivotal. In fact it can all too readily be invalidated, negated or dismissed. Such responses come at a huge cost, not just to individuals but to families and communities. ASCA witnesses that cost every day in its work.

Every day ASCA receives calls from child abuse survivors who cannot find or afford the care and support they need. They report having experienced a health care professional who has been disempowering, re-victimising or otherwise unhelpful; a GP who was uninformed, who didn’t inquire about trauma despite symptoms which were highly suggestive. A worker who didn’t know how to respond to a disclosure, a counsellor, psychologist or psychiatrist they felt had minimized or dismissed their feelings and experiences rather than listening empathically and validating them.

It is staggering how often survivors are told by those in health care environments things like “It happened such a long-time ago; there’s no value in talking about it. What does it matter? Stop whingeing about it.” These attitudes parallel the survivor’s experience of being told to keep quiet about their abuse or, on disclosure, being ignored or vilified. Some workers believe that talking about past traumas is irrelevant and self-pitying or imply that the trauma was the person’s fault, that he/she is carrying on about nothing, making things up, exaggerating, or has a personality disorder.

Medical model

The medical model is designed to diagnose i.e. to apply a label to a disease, a pathology or group of symptoms. Physical diseases fit into symptom profiles and can have labels applied and these labels enable medical practitioners to apply the treatment responses they have learnt to those symptom profiles and diseases. However the repercussions of trauma do not fit neatly into a single diagnosis or even a number of diagnoses. A vast spectrum of disorders can be attributable to prior trauma and survivors may carry any psychiatric diagnosis, and frequently carry a range of diagnoses over time. This is in and of itself is a major issue.

As a survivor of childhood trauma myself, I can attest to the fact that whilst in the midst of dealing with my childhood trauma I could easily have ticked many categories in the DSM IV. Anxiety disorder, depression, suicidality, Chronic PTSD, Dissociative Disorders but none of these diagnoses captured the essence of my struggle. Thankfully I had a therapist who didn’t pathologise me.

The premise of the medical model is the principle that something is wrong with a person rather than highlighting that something wrong was done to or happened to a person. I developed a range of mental health challenges because of what had happened to me. And as one of my medical colleagues at the time so delicately put it: You’re not becoming one of those mental health patients are you? Well maybe I was but then maybe I needed to be understood rather than being judged and ostracised.

Common to all survivors what I needed was empathy, compassion and understanding. My mental health challenges were ‘normal’ reactions to extremely ‘abnormal’ circumstances and appreciating this is fundamental to the movement to embrace a trauma-informed approach. Rather than articulating a diagnosis it is critical that anyone interacting with survivors understands the effects traumatic life events have on the development of individuals. For me,  finding a therapist who validated my experience, who bore witness to what had happened to me, who I learnt to trust, who gave me unconditional support, who listened empathically and who could contain my angst and help me feel and be safe, was crucial to my recovery.

Borderline personality disorder

One of the most pathologising diagnoses if that of Borderline Personality Disorder. Many of the repercussions of complex trauma parallel the symptom profile of the diagnosis of Borderline personality disorder – impulsivity, self-harm, emotional lability, relational instability and instability of sense of self. This diagnosis has carried enormous stigma implying hopelessness, manipulation and resistance to treatment. However understanding the behaviours which characterise it in terms of traumatic stress, disrupted attachment, personal invalidation and adaptive coping strategies help workers understand and empathise with those who they are seeking to support.

Responding to complex needs

In recent years, cognitive-behaviour therapy, exposure and cognitive restructuring have been used extensively as evidence-based responses to PTSD. However the application of such techniques to those who have experienced complex trauma especially prior to the establishment of safety can be fraught. Working through the compounded impacts of complex trauma can take a long time and involves a number of stages including establishing safety, stabilisation, establishing a therapeutic relationship, education and skill building, processing and integration. The failure of practitioners, systems and governments to appreciate these complexities means that many survivors of childhood trauma do not find the care and support they need to reclaim their health and wellbeing.

Services

Sadly, in Australia adult survivors with complex needs struggle to find services in which workers are adequately trained around trauma. Systems are overstretched and services tend to focus on crisis and risk management delivering short term rather than the longer-term interventions needed for sustained recovery. In many cities and towns it is hard to access expert long term and affordable counselling/therapy and/or skilled groups and workshops. In rural and regional areas services are virtually non-existent.

Current systems commonly label and pathologise survivors and their presentations. An inherent lack of understanding and awareness around potential triggers leaves survivors open to retraumatisation. This means survivors often experience services as being unsafe, disempowering and/or invalidating. Characteristically survivors shop around, presenting to a large number and range of services over a long period of time including government, non-government, public, private and community-managed services. Survivors continually search for a service which will understand them and their behaviours and reactions in the context of their trauma. Often times they are left not knowing where to turn and effectively give up. Of course there are exceptions and some specialist services are sensitive to survivors needs but they are few and far between. Often they depend on an individual rather than a service culture and when the individual leaves, so does the possibility that survivors presenting there will receive the ongoing care and support they need towards recovery.

Co-morbidity and life burdens

Trauma survivors with complex needs often experience co-morbid mental health and substance abuse problems and a range of life burdens. These findings are supported by extensive research evidence. That is – the majority of clients presenting to mental health and AOD services have trauma histories integrally intertwined with their substance abuse and/or mental health challenges. Yet despite it being patently obvious that all three issues should be addressed in an integrated way, this rarely happens. Care for survivors with co-morbidity is often fragmented and fails to respond to their multiple needs which can include unemployment, welfare dependency, homelessness and social exclusion. A holistic approach to care and support is needed and yet to date we see little to no co-ordination between services along with poor referral and follow-up pathways.

Service Delivery

What do adult survivors of childhood trauma need?

I am a medical practitioner by training. The Hippocratic oath states: “First do no harm” .However harm is often done to trauma survivors when their trauma goes unacknowledged and when their particular vulnerabilities and sensitivities are disrespected and misunderstood. Harm is done when survivors are labelled and they are negated as human beings and as individuals disaffirming their traumatic experiences at the very core of their being.

At the most basic level, trauma informed care involves the provision of services that do no harm – e.g., that do not re-traumatise victims or blame victims for their efforts to manage their traumatic reactions.

Supporting survivors

Workers need to recognise the adaptive function of “symptoms;” and work in a collaborative and empowering way. Understanding a symptom as an adaptation reduces guilt and shame, increases self-esteem, and provides a pathway for developing new skills and better adaptations. Validating resilience is important even when past adaptations and ways of coping are causing problems in the present. Survivors need to feel understood, have their experiences heard and validated and find a sense of belonging.

Survivors generally also benefit from making connections between their past experiences and their current situation as part of an integrated recovery journey, enabling them to ultimately view their abuse as part rather than all of them and acknowledge their other social roles and strengths.

Relationships

However none of this can occur in isolation. Relationships are crucial to the process of recovery but it is the nature of those relationships that is vital. As the relationships which caused the original trauma were disempowering and controlling, relationships of care and support must challenge the beliefs created by the original trauma. They must be safe, consistent and constructive, non-violent, non-blaming and non-shaming, and feature persuasion and not coercion, ideas and not force, and mutuality rather than authoritarian control.

Predictable environments with clear boundaries and well defined roles allow survivors to feel empowered and re-build a sense of self-efficacy and personal control – factors which are essential to recovering from the overwhelming fear and helplessness that is the legacy of victimisation. Approaches should be collaborative and mutually respectful with the survivor setting the pace. This allows survivors to build on their strengths, and resiliency, and to further develop their coping skills while embracing hope and working towards a positive future.

Trauma-informed system of care

I support the belief that what we need to see is a cultural & philosophical shift to a system that embraces trauma-informed care and practice across the board. This will require sustained commitment and investment in services and programs. Systems will need to integrate awareness and understanding around trauma and traumatic stress in their work and approach people from a trauma informed perspective – that is, to consider the possibility of undisclosed or  unaddressed childhood trauma at the root of presentrations. Being cogniscent of the possibility can make an enormous difference to the way a survivor reacts, copes going forward and recovers.

Characteristics of systems change

In a trauma informed  system, survivors’ conditions and behaviours are viewed differently, staff respond differently, and the day-to-day delivery of services is conducted differently. As survivors’ needs cross service systems these proposed changes are not limited to mental health but apply to multiple systems. Such change will require collaboration between services and networks of health and allied care professionals i.e. an integrated approach which has survivors at the core in a model of recovery.

Trauma informed system

The new system will be characterized by safety from physical harm and re-traumatization; an understanding of survivors and their symptoms in the context of their history, culture, sexual orientation, ethnicity and gender and community; open and genuine collaboration between workers and those seeking help at all phases of service delivery; an emphasis on building on strengths and acquiring skills rather than on managing symptoms; an understanding that symptoms represent attempts to cope, regardless of how extreme they may seem; a perception that childhood trauma was a defining experience/set of experiences that forms the core of an individual’s identity rather than a single discrete event; and by a focus on what happened to a person i.e. the wrong which was done to the person rather than what is wrong with the person.

For example, agencies should routinely consider the possibility of trauma even when it hasn’t been disclosed, and focus on creating safety and increasing access to trauma specific services when supporting people who have disclosed.

Improved outcomes for survivors

A trauma-informed care and practice approach with emerging best practice models provides renewed hope of recovery to clients with complex, severe, and persistent mental health and AOD issues.

A variety of studies and pilot programs, that utilize a trauma-informed model, report a decrease in psychiatric symptoms, substance use and trauma symptoms, as well as an improvement in consumers’ daily functioning. Some studies have found decreases in the use of intensive services such as hospitalization and crisis intervention following the implementation of trauma-informed care.

Trauma-informed integrated services do not cost more than standard services and have improved outcomes. Services report greater collaboration with consumers, enhanced skills, and a greater sense of self-efficacy among consumers, as well as more support from their agencies. Supervisors report more collaboration within and outside their agencies, improved staff morale, fewer negative events, and more effective services.

ASCA – Adults Surviving Child Abuse

ASCA is a small organisation which advocates for the needs of Australian adult survivors to be better met by means of a trauma-informed approach to care. Callers to ASCA’s 1300 line are listened to and heard and their feelings are validated. Establishing safety and maintaining confidentiality is a priority. Some callers to our line are speaking about their abuse for the very first time. The way that disclosure is handled can make all the difference to that person’s progress. ASCA has also developed a database of ASCA-endorsed therapists – practitioners and agencies which have met ASCA’s minimum criteria of training, skills, qualifications and experience.

Over the last few years ASCA has also developed a set of evidence-based psycho-educational workshops for adult survivors based on national and international best practice. These workshops help survivors and their supporters understand the impacts of abuse, facilitating insight into current and past behaviours and feelings while providing the tools for positive change. ASCA’s education and training for community workers and health care professionals is helping to develop a trauma-informed workforce better trained and better informed to support the complex needs of adult survivors of childhood trauma.

ASCA quote

“Please, please educate counsellors, psychologists-anyone who comes into contact with survivors of child abuse that it can have life-long effects. We cannot move on until we have dealt with our baggage and it takes a long time and endless patience and support. We don’t want to wallow, however we need to deal with and express our pain and anger and go through the stages of grief and loss for our lost childhood. Counsellors etc need to understand the stages of childhood development and realise the impact of not experiencing these important developmental stages. I don’t believe there are any quick fixes. We need to be listened to, have our experiences validated. Counsellors with little experience, despite the best of intentions can do more harm than good. Inappropriate ‘help’ kept me in denial and isolation for many years.’

Asking the question: What happened to you?

 

The following is an interview I and a fellow speaker, Janey Kelf were involved  on April 30th as part of a 24 hour talk-athon “breaking the silence”

Asking the Question: “What Happened to You?”

by TAALK

in HealthAirdate: Sat, Apr 30, 2011 follow

Understand how the standard medical model of diagnosis often fails to heal patients by focusing on the obvious symptoms rather than the underlying cause. You’ll receive an introduction to the idea of trauma-informed care and practice across service systems. Join our host, Diane Cranley, as she talks with Dr. Cathy Kezelman – medical practitioner, CEO of ASCA Australian national charity, Director of MHCC (Mental Health Coordinating Council NSW); Janey Kelf – Counselor with an interest in the creative arts and the politics of childhood abuse survival.

http://www.blogtalkradio.com/taalk/2011/04/30/asking-the-question-what-happened-to-you

Trauma-informed care

The following is the presentation I gave at a forum I was involved in convening around establishing a National Strategy for Trauma-informed Care

Planning and funding for mental health in Australia fall perilously short of what’s needed to address needs. Its deficiencies are no more marked than in its responses to those impacted by trauma. Although  trauma is core to the difficulties of a substantial percentage of consumers, and awareness of it pivotal to these consumers’ sustained recovery, in current services, trauma per se is seldom identified or addressed.  Without addressing the core issues of their trauma, these consumers will continue to struggle with their daily functioning.

I am here wearing several hats. I am a medical practitioner by training, Chairperson of ASCA (adults Surviving Child Abuse) and a director of the MHCC. I am also a mental health consumer; I underwent a protracted psychotherapeutic process within the private system to reclaim my mental health, my mental health issues having arisen as a result of my childhood trauma. Acknowledging and appropriately addressing my underlying trauma was core to my recovery. Anything less would have, at worst, seen me lost to suicide, or barely functioning in my daily life at best

One might have assumed that my medical training and practice would have given me some insight into the impacts of childhood trauma. They didn’t. One might also have assumed that my medical colleagues would have offered care and support, or at least an appropriate referral. Not so. When I fell off my perch, my medical colleagues bolted faster than anyone.

I was fortunate to find a health care practitioner who could contain my angst and guide my process of recovery. Few can. In fact in cities such practitioners and services are few and far between while in rural and regional areas, they are non-existent.

I was also fortunate to have had the resources to afford ongoing therapy. Few do. The current provisions under the MBS for the needs of many trauma clients are patently inadequate.  The 12 sessions available annually, on referral and 18, when in critical need fall way short of the mark.

I was also fortunate to have had the social and community supports needed to connect back with family and friends and ultimately with my community. I was also privileged to have a home, an education, and the training required to ultimately find a job. As a result of their trauma, for many those crucial skills to daily living are sadly lacking as are the supports to acquire them.

Research shows that adult survivors of all forms of childhood trauma manifest high rates of mental illness including PTSD, complex PTSD, dissociative disorders, depressive and anxiety symptoms/disorders and suicidality, self-harm with comorbid substance abuse issues being an all too common accompaniment.

ASCA recently completed a research study exploring the intersection between childhood abuse, alcohol and drug use and mental health. The study, the first of its kind identified a lack of capacity to identify and treat abuse-related trauma in both the mental health or AOD sector, with workers from both sectors failing to address the complex and multiple needs of clients.

By conservative estimates there are more than 2 million Australian adults who experienced abuse in some form and or neglect in childhood. Research tells us that 1 in 5 women and 1 in 7 men are affected. On this basis in every room of 25 people at least 4 will have experienced childhood abuse in some form or other.

The high prevalence of childhood abuse in the community demonstrates how crucial it is when assessing a patient/client presenting with mental health issues with or without comorbid substance abuse/ eating disorders to approach the presentation from a Trauma Informed perspective – that is, to consider the possibility of undisclosed or  unaddressed childhood trauma. Given that childhood abuse can underpin these conditions and in fact be their root cause, remaining aware to the possibility can be crucial to long-term outcomes. In cases in which childhood trauma is a feature of a client’s history, guiding the client in how best to acknowledge, understand, process and integrate the impact of their childhood trauma can be a necessary part of dealing with the PTSD, depression, anxiety suicidality and substance abuse.

Consumers with a history of childhood trauma are a vulnerable group of which many are disadvantaged, by their trauma in the first instance but also by accompanying socio-economic disadvantage. They often experience deep feelings of insecurity, low self-esteem, poor frustration tolerance, difficulties with trust and interpersonal relationships, sensitivity to criticism , substance abuse and self-harming, suicidal and risk-taking behaviours and these factors compound the challenges of adequately meeting their needs.

Child abuse extracts a terrible price not just on children but without the right support, throughout their adult lives. Aspirations for our children are for them to be: healthy and safe, to be enjoying and achieving, making a positive contribution, and ultimately achieve economic well-being. Adults abused as children often miss out in all areas of life. The supports of family and community, so vital in determining resilience and connectedness, are often exploded in abusive families through isolation, secrecy, trauma and neglect. Trust needs to be re-established along with self-esteem, a sense of self, identity and culture. Survivors need to belong, to be understood and validated and to deal with their abuse issues before they can begin to form healthy relationships and participate in community and/or the life of a new family.

In our current mental health system the complex and persistent mental health needs and/or substance abuse problems of Australian adult survivors of childhood trauma abuse are chronically unmet or poorly addressed.  They are frequently the highest users of the inpatient, crisis, residential and support services. Many have not connected their current problems and behaviours with their prior trauma but then nor have their mental health workers.

Mental health consumers with a history of childhood trauma currently present to a wide range of services. Mainstream services are often unable to adequately address their needs – some approaches are crisis-driven, some re-victimising and others meet short term needs only. Trauma survivors characteristically present to multiple services over a long period of time, seeking help from a diversity of government, non-government and private services. Care is often fragmented with little to no co-ordination between services and poor referral and follow-up pathways.

Failure to provide effective care means continuation of support at a crisis level with no real long-term benefit. Often numerous services are involved in responding to one crisis. There have been a few notable specialist services. While there are more services available for women than men, there are insufficient for either, with poor affordability and failures in access and equity. Women with disabilities, from CALD and ATSI populations face particular challenges in terms of accessing appropriate care.

Most specialist services, including those with established efficacy have been unable to sustain ongoing funding. Those which continue have characteristically long waiting periods. While the NGO sector arguably provides the majority of skilled services in this sector, securing funding

There is a lack of expert long-term affordable counselling/therapy and/or appropriate groups/workshops. What is available is rarely affordable. In fact there are deficiencies in workforce capacity across the board, with a particular lack of rural, regional and outreach services.

The personal cost of childhood trauma to the individual, families, and communities, and of not adequately meeting the needs of consumers with a history of childhood trauma, in health, welfare and economic terms is immense. This group is persistently over-represented in community, health and criminal justice systems as a result.

Every day ASCA receives calls from child abuse survivors who feel they have been failed by the system and don’t know where to turn. From friends and family who don’t know how to support their friends or loved ones. From health care practitioners who don’t know how to help their clients or find appropriate support for themselves while supporting their clients.

Every day consumers call recounting how they have been let down by one arm of the health system or another, by an agency, a worker or a practitioner. By a GP who was uninformed, who didn’t inquire about trauma, despite symptoms which were highly suggestive. By a worker who didn’t know how to respond to a disclosure, a counselor, psychologist or psychiatrist they felt had minimized or dismissed their feelings and experiences rather than listening empathically and validating them.

ASCA is one of the few organizations delivering evidence-based services to adult survivors of childhood trauma. Yet despite the proven success of its programs ASCA receives no ongoing or core government funding. The complex needs of our clientele cross departmental boundaries and therein lies the problem. It means that no department, State or Federal needs to hold the portfolio for adult survivors of childhood trauma. And so none does. Despite the wealth of evidence linking childhood trauma with adult mental health outcomes DoHA has repeatedly told us that the needs of our clients do not come under their jurisdiction. We cannot even secure a meeting with the Minister to present our case. Similarly despite repeated submissions to NSW Health we remain an unfunded NGO.

The sporadic funding ASCA, a small NGO with a large brief, receives reflects the challenges of the broader system. The lack of identifiable and sustainable income streams prevents planning and sabotages any capacity for delivering a comprehensive model of care to our client base.

In the existing mental health system there is a systemic failure to provide appropriate trauma-informed services to the majority of Australians needing them. Similarly the proposed mental health system fails to consider the dynamics of trauma and the needs of trauma clients. Mental health issues represent 13% of the health burden but attract only 6% of the health budget. Despite the small amounts of additional funding proposed The National Health and Hospital Reform Agenda indicates a return to the medical model with the focus federally being on funding mental health beds while failing to invest in enhancing community-based services. This is not the direction needed to deliver recovery oriented, consumer directed services, of which trauma-informed care is an integral part.

Community services are a critical component of this of a trauma-informed model of care. Appropriate service enable people to remain connected to their communities and families, remain in work, and recover and reintegrate with the community. Community-based services include clinical services in the first instance. However an integral part of these services are community mental health support and recovery services. These include adult education programs, psycho-social rehabilitation, home-based outreach, peer support, supported accommodation and job placement and support services. Such services enable trauma survivors to stay living in the community, in their own homes, limiting hospitalizations and crisis presentations to a range of services. With the right care and support, trauma survivors can ultimately live well.

The proposed roll-out of GP superclinics will perpetuate the focus on primary care and potentially dilute the contribution of community mental health services. While primary mental health care and specialist mental health services are crucial elements of service delivery so also are community mental health services. To best serve the needs of community members, community mental health services need to be located in the community. Existing models of collaboration between primary mental health care and specialist mental health services need to be expanded to include community mental health services and all need to operate from a trauma-informed perspective.

In traditional services, healing and recovery for trauma victims can be difficult with a significant risk of re-traumatisation. Survivors frequently encounter services that mirror the power and control experienced in the abusive relationships that caused the past trauma. The composite failures in service provision and expertise, as well as in access and equity exacerbate the mental health issues, of consumers and in particular, escalate the risk of suicide. Responsive and effective crisis management must be matched by affordable accessible ongoing care so that the core issues of childhood abuse are adequately addressed.

Successful treatment programs need to recognise a survivor’s need to be respected, informed, connected, and hopeful regarding their own recovery. The relationship between trauma and the related symptoms and the need to work collaboratively with survivors and their carers family and friends and with other human services agencies to empower survivors as consumers, is key to positive outcomes.

Trauma-informed programs and services clearly acknowledge ‘that no one understands the challenges of the recovery journey from trauma better than the person living it’. They are based on an understanding of the particular vulnerabilities and/or triggers that trauma survivors experience, making these services more supportive and effective. By facilitating recovery through trauma-informed care, re-victimisation can be minimised and self and community wellness and connectedness can be promoted. It is a shift in service delivery culture.

It is proposed that Australia embrace a model of Trauma-Informed Care to improve mental health service delivery and health outcomes. Part of this process would involve a strategy to increase community awareness around the relationship of trauma to mental health issues while working to eradicate stigma and discrimination, and facilitate access and equity. An understanding that trauma underpins the presentation of many people to public, private and community based services necessitates the development of evidence based models and practice programs building capacity through supporting workforce education and training; data collection, research, outcome measurement and evaluation.

Such a model would support providers in moving from a caretaker to a collaborator role by empowering the survivor in a model of recovery orientated practice. Trauma-informed care involves not only changing assumptions about how we organise and provide services, but creates organisational cultures that are personal, holistic, creative, open, and therapeutic. This model of care needs to be integrated into any proposed mental health system. It needs to empasise collaboration, partnership and cooperation, promoting linkages between services, while embracing a systemic trauma-informed approach.

The incorporation of a model of trauma-informed Care within mental health service delivery across the board coupled with an investment in community mental health services will undoubtedly significantly improve outcomes for consumers with a history of trauma, while reducing the pressure on already stretched hospital services. It will enable a system of mental health care with is client-focussed, based on need rather than funds, and recovery-oriented.

Planning and funding for mental health in Australia fall perilously short of what’s needed to address needs. Its deficiencies are no more marked than in its responses to those impacted by trauma. Although  trauma is core to the difficulties of a substantial percentage of consumers, and awareness of it pivotal to these consumers’ sustained recovery, in current services, trauma per se is seldom identified or addressed.  Without addressing the core issues of their trauma, these consumers will continue to struggle with their daily functioning.

I am here wearing several hats. I am a medical practitioner by training, Chairperson of ASCA (adults Surviving Child Abuse) and a director of the MHCC. I am also a mental health consumer; I underwent a protracted psychotherapeutic process within the private system to reclaim my mental health, my mental health issues having arisen as a result of my childhood trauma. Acknowledging and appropriately addressing my underlying trauma was core to my recovery. Anything less would have, at worst, seen me lost to suicide, or barely functioning in my daily life at best

One might have assumed that my medical training and practice would have given me some insight into the impacts of childhood trauma. They didn’t. One might also have assumed that my medical colleagues would have offered care and support, or at least an appropriate referral. Not so. When I fell off my perch, my medical colleagues bolted faster than anyone.

I was fortunate to find a health care practitioner who could contain my angst and guide my process of recovery. Few can. In fact in cities such practitioners and services are few and far between while in rural and regional areas, they are non-existent.

I was also fortunate to have had the resources to afford ongoing therapy. Few do. The current provisions under the MBS for the needs of many trauma clients are patently inadequate.  The 12 sessions available annually, on referral and 18, when in critical need fall way short of the mark.

I was also fortunate to have had the social and community supports needed to connect back with family and friends and ultimately with my community. I was also privileged to have a home, an education, and the training required to ultimately find a job. As a result of their trauma, for many those crucial skills to daily living are sadly lacking as are the supports to acquire them.

Research shows that adult survivors of all forms of childhood trauma manifest high rates of mental illness including PTSD, complex PTSD, dissociative disorders, depressive and anxiety symptoms/disorders and suicidality, self-harm with comorbid substance abuse issues being an all too common accompaniment.

ASCA recently completed a research study exploring the intersection between childhood abuse, alcohol and drug use and mental health. The study, the first of its kind identified a lack of capacity to identify and treat abuse-related trauma in both the mental health or AOD sector, with workers from both sectors failing to address the complex and multiple needs of clients.

By conservative estimates there are more than 2 million Australian adults who experienced abuse in some form and or neglect in childhood. Research tells us that 1 in 5 women and 1 in 7 men are affected. On this basis in every room of 25 people at least 4 will have experienced childhood abuse in some form or other.

The high prevalence of childhood abuse in the community demonstrates how crucial it is when assessing a patient/client presenting with mental health issues with or without comorbid substance abuse/ eating disorders to approach the presentation from a Trauma Informed perspective – that is, to consider the possibility of undisclosed or  unaddressed childhood trauma. Given that childhood abuse can underpin these conditions and in fact be their root cause, remaining aware to the possibility can be crucial to long-term outcomes. In cases in which childhood trauma is a feature of a client’s history, guiding the client in how best to acknowledge, understand, process and integrate the impact of their childhood trauma can be a necessary part of dealing with the PTSD, depression, anxiety suicidality and substance abuse.

Consumers with a history of childhood trauma are a vulnerable group of which many are disadvantaged, by their trauma in the first instance but also by accompanying socio-economic disadvantage. They often experience deep feelings of insecurity, low self-esteem, poor frustration tolerance, difficulties with trust and interpersonal relationships, sensitivity to criticism , substance abuse and self-harming, suicidal and risk-taking behaviours and these factors compound the challenges of adequately meeting their needs.

Child abuse extracts a terrible price not just on children but without the right support, throughout their adult lives. Aspirations for our children are for them to be: healthy and safe, to be enjoying and achieving, making a positive contribution, and ultimately achieve economic well-being. Adults abused as children often miss out in all areas of life. The supports of family and community, so vital in determining resilience and connectedness, are often exploded in abusive families through isolation, secrecy, trauma and neglect. Trust needs to be re-established along with self-esteem, a sense of self, identity and culture. Survivors need to belong, to be understood and validated and to deal with their abuse issues before they can begin to form healthy relationships and participate in community and/or the life of a new family.

In our current mental health system the complex and persistent mental health needs and/or substance abuse problems of Australian adult survivors of childhood trauma abuse are chronically unmet or poorly addressed.  They are frequently the highest users of the inpatient, crisis, residential and support services. Many have not connected their current problems and behaviours with their prior trauma but then nor have their mental health workers.

Mental health consumers with a history of childhood trauma currently present to a wide range of services. Mainstream services are often unable to adequately address their needs – some approaches are crisis-driven, some re-victimising and others meet short term needs only. Trauma survivors characteristically present to multiple services over a long period of time, seeking help from a diversity of government, non-government and private services. Care is often fragmented with little to no co-ordination between services and poor referral and follow-up pathways.

Failure to provide effective care means continuation of support at a crisis level with no real long-term benefit. Often numerous services are involved in responding to one crisis. There have been a few notable specialist services. While there are more services available for women than men, there are insufficient for either, with poor affordability and failures in access and equity. Women with disabilities, from CALD and ATSI populations face particular challenges in terms of accessing appropriate care.

Most specialist services, including those with established efficacy have been unable to sustain ongoing funding. Those which continue have characteristically long waiting periods. While the NGO sector arguably provides the majority of skilled services in this sector, securing funding

There is a lack of expert long-term affordable counselling/therapy and/or appropriate groups/workshops. What is available is rarely affordable. In fact there are deficiencies in workforce capacity across the board, with a particular lack of rural, regional and outreach services.

The personal cost of childhood trauma to the individual, families, and communities, and of not adequately meeting the needs of consumers with a history of childhood trauma, in health, welfare and economic terms is immense. This group is persistently over-represented in community, health and criminal justice systems as a result.

Every day ASCA receives calls from child abuse survivors who feel they have been failed by the system and don’t know where to turn. From friends and family who don’t know how to support their friends or loved ones. From health care practitioners who don’t know how to help their clients or find appropriate support for themselves while supporting their clients.

Every day consumers call recounting how they have been let down by one arm of the health system or another, by an agency, a worker or a practitioner. By a GP who was uninformed, who didn’t inquire about trauma, despite symptoms which were highly suggestive. By a worker who didn’t know how to respond to a disclosure, a counselor, psychologist or psychiatrist they felt had minimized or dismissed their feelings and experiences rather than listening empathically and validating them.

ASCA is one of the few organizations delivering evidence-based services to adult survivors of childhood trauma. Yet despite the proven success of its programs ASCA receives no ongoing or core government funding. The complex needs of our clientele cross departmental boundaries and therein lies the problem. It means that no department, State or Federal needs to hold the portfolio for adult survivors of childhood trauma. And so none does. Despite the wealth of evidence linking childhood trauma with adult mental health outcomes DoHA has repeatedly told us that the needs of our clients do not come under their jurisdiction. We cannot even secure a meeting with the Minister to present our case. Similarly despite repeated submissions to NSW Health we remain an unfunded NGO.

The sporadic funding ASCA, a small NGO with a large brief, receives reflects the challenges of the broader system. The lack of identifiable and sustainable income streams prevents planning and sabotages any capacity for delivering a comprehensive model of care to our client base.

In the existing mental health system there is a systemic failure to provide appropriate trauma-informed services to the majority of Australians needing them. Similarly the proposed mental health system fails to consider the dynamics of trauma and the needs of trauma clients. Mental health issues represent 13% of the health burden but attract only 6% of the health budget. Despite the small amounts of additional funding proposed The National Health and Hospital Reform Agenda indicates a return to the medical model with the focus federally being on funding mental health beds while failing to invest in enhancing community-based services. This is not the direction needed to deliver recovery oriented, consumer directed services, of which trauma-informed care is an integral part.

Community services are a critical component of this of a trauma-informed model of care. Appropriate service enable people to remain connected to their communities and families, remain in work, and recover and reintegrate with the community. Community-based services include clinical services in the first instance. However an integral part of these services are community mental health support and recovery services. These include adult education programs, psycho-social rehabilitation, home-based outreach, peer support, supported accommodation and job placement and support services. Such services enable trauma survivors to stay living in the community, in their own homes, limiting hospitalizations and crisis presentations to a range of services. With the right care and support, trauma survivors can ultimately live well.

The proposed roll-out of GP superclinics will perpetuate the focus on primary care and potentially dilute the contribution of community mental health services. While primary mental health care and specialist mental health services are crucial elements of service delivery so also are community mental health services. To best serve the needs of community members, community mental health services need to be located in the community. Existing models of collaboration between primary mental health care and specialist mental health services need to be expanded to include community mental health services and all need to operate from a trauma-informed perspective.

In traditional services, healing and recovery for trauma victims can be difficult with a significant risk of re-traumatisation. Survivors frequently encounter services that mirror the power and control experienced in the abusive relationships that caused the past trauma. The composite failures in service provision and expertise, as well as in access and equity exacerbate the mental health issues, of consumers and in particular, escalate the risk of suicide. Responsive and effective crisis management must be matched by affordable accessible ongoing care so that the core issues of childhood abuse are adequately addressed.

Successful treatment programs need to recognise a survivor’s need to be respected, informed, connected, and hopeful regarding their own recovery. The relationship between trauma and the related symptoms and the need to work collaboratively with survivors and their carers family and friends and with other human services agencies to empower survivors as consumers, is key to positive outcomes.

Trauma-informed programs and services clearly acknowledge ‘that no one understands the challenges of the recovery journey from trauma better than the person living it’. They are based on an understanding of the particular vulnerabilities and/or triggers that trauma survivors experience, making these services more supportive and effective. By facilitating recovery through trauma-informed care, re-victimisation can be minimised and self and community wellness and connectedness can be promoted. It is a shift in service delivery culture.

It is proposed that Australia embrace a model of Trauma-Informed Care to improve mental health service delivery and health outcomes. Part of this process would involve a strategy to increase community awareness around the relationship of trauma to mental health issues while working to eradicate stigma and discrimination, and facilitate access and equity. An understanding that trauma underpins the presentation of many people to public, private and community based services necessitates the development of evidence based models and practice programs building capacity through supporting workforce education and training; data collection, research, outcome measurement and evaluation.

Such a model would support providers in moving from a caretaker to a collaborator role by empowering the survivor in a model of recovery orientated practice. Trauma-informed care involves not only changing assumptions about how we organise and provide services, but creates organisational cultures that are personal, holistic, creative, open, and therapeutic. This model of care needs to be integrated into any proposed mental health system. It needs to empasise collaboration, partnership and cooperation, promoting linkages between services, while embracing a systemic trauma-informed approach.

The incorporation of a model of trauma-informed Care within mental health service delivery across the board coupled with an investment in community mental health services will undoubtedly significantly improve outcomes for consumers with a history of trauma, while reducing the pressure on already stretched hospital services. It will enable a system of mental health care with is client-focussed, based on need rather than funds, and recovery-oriented.

Planning and funding for mental health in Australia fall perilously short of what’s needed to address needs. Its deficiencies are no more marked than in its responses to those impacted by trauma. Although  trauma is core to the difficulties of a substantial percentage of consumers, and awareness of it pivotal to these consumers’ sustained recovery, in current services, trauma per se is seldom identified or addressed.  Without addressing the core issues of their trauma, these consumers will continue to struggle with their daily functioning.

I am here wearing several hats. I am a medical practitioner by training, Chairperson of ASCA (adults Surviving Child Abuse) and a director of the MHCC. I am also a mental health consumer; I underwent a protracted psychotherapeutic process within the private system to reclaim my mental health, my mental health issues having arisen as a result of my childhood trauma. Acknowledging and appropriately addressing my underlying trauma was core to my recovery. Anything less would have, at worst, seen me lost to suicide, or barely functioning in my daily life at best

One might have assumed that my medical training and practice would have given me some insight into the impacts of childhood trauma. They didn’t. One might also have assumed that my medical colleagues would have offered care and support, or at least an appropriate referral. Not so. When I fell off my perch, my medical colleagues bolted faster than anyone.

I was fortunate to find a health care practitioner who could contain my angst and guide my process of recovery. Few can. In fact in cities such practitioners and services are few and far between while in rural and regional areas, they are non-existent.

I was also fortunate to have had the resources to afford ongoing therapy. Few do. The current provisions under the MBS for the needs of many trauma clients are patently inadequate.  The 12 sessions available annually, on referral and 18, when in critical need fall way short of the mark.

I was also fortunate to have had the social and community supports needed to connect back with family and friends and ultimately with my community. I was also privileged to have a home, an education, and the training required to ultimately find a job. As a result of their trauma, for many those crucial skills to daily living are sadly lacking as are the supports to acquire them.

Research shows that adult survivors of all forms of childhood trauma manifest high rates of mental illness including PTSD, complex PTSD, dissociative disorders, depressive and anxiety symptoms/disorders and suicidality, self-harm with comorbid substance abuse issues being an all too common accompaniment.

ASCA recently completed a research study exploring the intersection between childhood abuse, alcohol and drug use and mental health. The study, the first of its kind identified a lack of capacity to identify and treat abuse-related trauma in both the mental health or AOD sector, with workers from both sectors failing to address the complex and multiple needs of clients.

By conservative estimates there are more than 2 million Australian adults who experienced abuse in some form and or neglect in childhood. Research tells us that 1 in 5 women and 1 in 7 men are affected. On this basis in every room of 25 people at least 4 will have experienced childhood abuse in some form or other.

The high prevalence of childhood abuse in the community demonstrates how crucial it is when assessing a patient/client presenting with mental health issues with or without comorbid substance abuse/ eating disorders to approach the presentation from a Trauma Informed perspective – that is, to consider the possibility of undisclosed or  unaddressed childhood trauma. Given that childhood abuse can underpin these conditions and in fact be their root cause, remaining aware to the possibility can be crucial to long-term outcomes. In cases in which childhood trauma is a feature of a client’s history, guiding the client in how best to acknowledge, understand, process and integrate the impact of their childhood trauma can be a necessary part of dealing with the PTSD, depression, anxiety suicidality and substance abuse.

Consumers with a history of childhood trauma are a vulnerable group of which many are disadvantaged, by their trauma in the first instance but also by accompanying socio-economic disadvantage. They often experience deep feelings of insecurity, low self-esteem, poor frustration tolerance, difficulties with trust and interpersonal relationships, sensitivity to criticism , substance abuse and self-harming, suicidal and risk-taking behaviours and these factors compound the challenges of adequately meeting their needs.

Child abuse extracts a terrible price not just on children but without the right support, throughout their adult lives. Aspirations for our children are for them to be: healthy and safe, to be enjoying and achieving, making a positive contribution, and ultimately achieve economic well-being. Adults abused as children often miss out in all areas of life. The supports of family and community, so vital in determining resilience and connectedness, are often exploded in abusive families through isolation, secrecy, trauma and neglect. Trust needs to be re-established along with self-esteem, a sense of self, identity and culture. Survivors need to belong, to be understood and validated and to deal with their abuse issues before they can begin to form healthy relationships and participate in community and/or the life of a new family.

In our current mental health system the complex and persistent mental health needs and/or substance abuse problems of Australian adult survivors of childhood trauma abuse are chronically unmet or poorly addressed.  They are frequently the highest users of the inpatient, crisis, residential and support services. Many have not connected their current problems and behaviours with their prior trauma but then nor have their mental health workers.

Mental health consumers with a history of childhood trauma currently present to a wide range of services. Mainstream services are often unable to adequately address their needs – some approaches are crisis-driven, some re-victimising and others meet short term needs only. Trauma survivors characteristically present to multiple services over a long period of time, seeking help from a diversity of government, non-government and private services. Care is often fragmented with little to no co-ordination between services and poor referral and follow-up pathways.

Failure to provide effective care means continuation of support at a crisis level with no real long-term benefit. Often numerous services are involved in responding to one crisis. There have been a few notable specialist services. While there are more services available for women than men, there are insufficient for either, with poor affordability and failures in access and equity. Women with disabilities, from CALD and ATSI populations face particular challenges in terms of accessing appropriate care.

Most specialist services, including those with established efficacy have been unable to sustain ongoing funding. Those which continue have characteristically long waiting periods. While the NGO sector arguably provides the majority of skilled services in this sector, securing funding

There is a lack of expert long-term affordable counselling/therapy and/or appropriate groups/workshops. What is available is rarely affordable. In fact there are deficiencies in workforce capacity across the board, with a particular lack of rural, regional and outreach services.

The personal cost of childhood trauma to the individual, families, and communities, and of not adequately meeting the needs of consumers with a history of childhood trauma, in health, welfare and economic terms is immense. This group is persistently over-represented in community, health and criminal justice systems as a result.

Every day ASCA receives calls from child abuse survivors who feel they have been failed by the system and don’t know where to turn. From friends and family who don’t know how to support their friends or loved ones. From health care practitioners who don’t know how to help their clients or find appropriate support for themselves while supporting their clients.

Every day consumers call recounting how they have been let down by one arm of the health system or another, by an agency, a worker or a practitioner. By a GP who was uninformed, who didn’t inquire about trauma, despite symptoms which were highly suggestive. By a worker who didn’t know how to respond to a disclosure, a counselor, psychologist or psychiatrist they felt had minimized or dismissed their feelings and experiences rather than listening empathically and validating them.

ASCA is one of the few organizations delivering evidence-based services to adult survivors of childhood trauma. Yet despite the proven success of its programs ASCA receives no ongoing or core government funding. The complex needs of our clientele cross departmental boundaries and therein lies the problem. It means that no department, State or Federal needs to hold the portfolio for adult survivors of childhood trauma. And so none does. Despite the wealth of evidence linking childhood trauma with adult mental health outcomes DoHA has repeatedly told us that the needs of our clients do not come under their jurisdiction. We cannot even secure a meeting with the Minister to present our case. Similarly despite repeated submissions to NSW Health we remain an unfunded NGO.

The sporadic funding ASCA, a small NGO with a large brief, receives reflects the challenges of the broader system. The lack of identifiable and sustainable income streams prevents planning and sabotages any capacity for delivering a comprehensive model of care to our client base.

In the existing mental health system there is a systemic failure to provide appropriate trauma-informed services to the majority of Australians needing them. Similarly the proposed mental health system fails to consider the dynamics of trauma and the needs of trauma clients. Mental health issues represent 13% of the health burden but attract only 6% of the health budget. Despite the small amounts of additional funding proposed The National Health and Hospital Reform Agenda indicates a return to the medical model with the focus federally being on funding mental health beds while failing to invest in enhancing community-based services. This is not the direction needed to deliver recovery oriented, consumer directed services, of which trauma-informed care is an integral part.

Community services are a critical component of this of a trauma-informed model of care. Appropriate service enable people to remain connected to their communities and families, remain in work, and recover and reintegrate with the community. Community-based services include clinical services in the first instance. However an integral part of these services are community mental health support and recovery services. These include adult education programs, psycho-social rehabilitation, home-based outreach, peer support, supported accommodation and job placement and support services. Such services enable trauma survivors to stay living in the community, in their own homes, limiting hospitalizations and crisis presentations to a range of services. With the right care and support, trauma survivors can ultimately live well.

The proposed roll-out of GP superclinics will perpetuate the focus on primary care and potentially dilute the contribution of community mental health services. While primary mental health care and specialist mental health services are crucial elements of service delivery so also are community mental health services. To best serve the needs of community members, community mental health services need to be located in the community. Existing models of collaboration between primary mental health care and specialist mental health services need to be expanded to include community mental health services and all need to operate from a trauma-informed perspective.

In traditional services, healing and recovery for trauma victims can be difficult with a significant risk of re-traumatisation. Survivors frequently encounter services that mirror the power and control experienced in the abusive relationships that caused the past trauma. The composite failures in service provision and expertise, as well as in access and equity exacerbate the mental health issues, of consumers and in particular, escalate the risk of suicide. Responsive and effective crisis management must be matched by affordable accessible ongoing care so that the core issues of childhood abuse are adequately addressed.

Successful treatment programs need to recognise a survivor’s need to be respected, informed, connected, and hopeful regarding their own recovery. The relationship between trauma and the related symptoms and the need to work collaboratively with survivors and their carers family and friends and with other human services agencies to empower survivors as consumers, is key to positive outcomes.

Trauma-informed programs and services clearly acknowledge ‘that no one understands the challenges of the recovery journey from trauma better than the person living it’. They are based on an understanding of the particular vulnerabilities and/or triggers that trauma survivors experience, making these services more supportive and effective. By facilitating recovery through trauma-informed care, re-victimisation can be minimised and self and community wellness and connectedness can be promoted. It is a shift in service delivery culture.

It is proposed that Australia embrace a model of Trauma-Informed Care to improve mental health service delivery and health outcomes. Part of this process would involve a strategy to increase community awareness around the relationship of trauma to mental health issues while working to eradicate stigma and discrimination, and facilitate access and equity. An understanding that trauma underpins the presentation of many people to public, private and community based services necessitates the development of evidence based models and practice programs building capacity through supporting workforce education and training; data collection, research, outcome measurement and evaluation.

Such a model would support providers in moving from a caretaker to a collaborator role by empowering the survivor in a model of recovery orientated practice. Trauma-informed care involves not only changing assumptions about how we organise and provide services, but creates organisational cultures that are personal, holistic, creative, open, and therapeutic. This model of care needs to be integrated into any proposed mental health system. It needs to empasise collaboration, partnership and cooperation, promoting linkages between services, while embracing a systemic trauma-informed approach.

The incorporation of a model of trauma-informed Care within mental health service delivery across the board coupled with an investment in community mental health services will undoubtedly significantly improve outcomes for consumers with a history of trauma, while reducing the pressure on already stretched hospital services. It will enable a system of mental health care with is client-focussed, based on need rather than funds, and recovery-oriented.