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