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.

Vatican shows systemic lack of accountability

Vatican shows systemic lack of accountability

OVER recent decades, tens of thousands of victims of abuse by Catholic clergy have suffered at the hands of the Catholic Church’s policies. These policies have perennially sacrificed the victim in favour of the institution and the perpetrating clergy. Pope Benedict has held senior doctrinal roles overseeing these policies for nearly three decades. Over that time it is the victims who have borne the cross of abuse and the betrayal by the Church through inaction.

The Australian has uncovered yet another shameful story, this time of the unrepentant Peter Chalk, the former Catholic priest safely ensconced in Japan as allegations of child sex abuse against him mount up, and of the alleged cover-up by the hierarchy of the Missionaries of the Sacred Heart (“After 20 years, an abuser is revealed”, 18-19/9).

Chalk’s statements, as reported, display a complete lack of remorse. He is quoted: “There certainly seems to be some kind of desire, especially in English-speaking countries, to make a big issue out of these things. What the exact motivation of people is I don’t know.” Might I suggest that the desire and motivation for victims is to find justice, support, help and redress?

And, no, children of 14 should not be “considered as adults”. Children are children and being abused is never a child’s fault or responsibility. There is no “maximum amount of fun in these so-called crude areas”. Such appalling ignorance and pernicious minimisation of the crimes of child sexual assault only serve to compound the harm caused to victims.

It is the systemic lack of accountability from the church which has enabled the rape and abuse of countless more innocent children and left countless victims struggling day-to-day to find a life worth living. Surely addressing the damage to the victims is the priority here?

Consider the underlying trauma

The following is a paper I presented at the 11th International Mental Health Conference in Gold Coast August 2010. The conference focussed on depression and anxiety and my point was to highlight the need to consider, acknolwedge and address any underlying trauma.

To read the paper go to Underlying trauma