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

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

THEMHS Conference 6-9 September 2011

Trauma Informed Care & Practice – Using a wide
angle lens

 

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

 

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

 

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

 

 

Mental health in Australia

 

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

 

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

 

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

 

Trauma

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

 

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

 

Defining
Complex trauma

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

 

Childhood
trauma

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

 

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

 

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

 

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

 

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

 

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

 

Impacts of childhood trauma

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

 

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

 

Coping
strategies

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

 

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

 

 

Prevalence

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

 

Challenges of supporting consumers
with history of childhood trauma

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

 

Complex trauma -aetiology

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

 

Service responses

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

 

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

 

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

 

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

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

 

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

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

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

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

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

So what is TIC?

 

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

 

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

 

What is a Trauma-Based Approach?

 

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

 

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

 

What are the Key Principles?

 

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

 

  • Is based on current literature

 

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

 

Trauma Informed Care & Practice

 

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

 

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

 

 

 

A Cultural Shift

 

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

 

Systemic Transformation occurs

 

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

 

Transformational Outcomes can happen
when

 

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

 

 

Medical
model

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

 

 

Trauma informed care involves the provision of
services that do no harm – e.g., that do not re-traumatise or blame victims for
their efforts to manage their traumatic reactions. Trauma-informed
care facilitates recovery, minimises re-victimisation and promotes self and
community wellness and connectedness.

 

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

 

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

 

Current services

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

 

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

 

Co-morbidity

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

 

 

Embracing model of trauma informed care and
practice 

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

 

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

 

Successful model

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

 

A trauma informed
system

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

 

Improved outcomes

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

 

Trauma-informed services do not cost more than
standard services and report more successful collaboration with all
stakeholders, enhanced skills, and a greater sense of self-efficacy among
consumers, improved staff morale, fewer negative events, and more effective
services and positive outcomes. A trauma-informed
care and practice approach provides renewed hope of recovery to consumers with
complex trauma histories who experience severe, and persistent mental health
AOD problems.

 

 

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

 

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

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

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

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

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

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

 

  • Investigate existing
    gaps ( such as in inpatient services)

 

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

 

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

 

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

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

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

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

 

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

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

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



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

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

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

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

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