1. Trauma Informed Care & Practice:
using a wide angle lens
TheMHS Conference 2011
Resilience in Change
Presenters:
Dr Cathy Kezelman, ASCA
Corinne Henderson, MHCC
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2. Mental Health in Australia
Poor funding for trauma, especially complex 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.
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3. Trauma
Invokes
– Fear
– Helplessness
– Horror
– Lack of control
Overwhelms
– Coping mechanisms
Childhood trauma is often especially damaging
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4. Defining complex trauma
Complex trauma generally refers to
traumatic stressors that are interpersonal –
that is, they are premeditated, planned,
and caused by other humans, such as
violating and/or exploitation of another
person
Christine A. Courtois. Understanding Complex Trauma, Complex Reactions, and Treatment
Approaches. Available: http://www.giftfromwithin.org/pdf/Understanding-CPTSD.pdf
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5. Childhood trauma
• Rarely an isolated incident
• Interpersonal
• Intentional
• Prolonged
• Extreme
• Repeated
• Affects developing brain
- Disrupts attachment
- Affects template for development
- Impacts fundamental neuro-chemical processes
- Affects growth, structure and function of brain
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6. Impacts of childhood trauma
Sustained trauma exposure in childhood often has global and pervasive
consequences
• Lifetime patterns of fear and lack of trust
• Long-term difficulties with emotional regulation and stress
management
• Chronic feelings of helplessness
• Somatic symptoms
Child abuse impacts
• Sense of self
• Interpersonal relationships
• Behaviours
• Cognitions
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7. Coping strategies
Extreme coping strategies are adopted in childhood to
manage overwhelming traumatic stress
Many persist in adult life:
– Suicidality
– Self-harm
– Substance abuse
– Dissociation
– Re-enactments of abusive relationships
Behaviours are challenging but in context of trauma make
sense
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8. Repercussions
Include
• diversity of mental health
• poor physical health
• substance abuse
• eating disorders
• relationship and self-esteem issues
• contact with the criminal justice system
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9. Prevalence – child abuse
• More than 2 million Australian adults have been abused
as children (conservative estimate)
• Research tells us that 1 in 5 women and 1 in 7 men are
affected
• In every room of 25 people at least 4 will have
experienced childhood abuse in some form or other.
Draper, B., Pfaff, J., Pirkis, J., Snowdon, J., Lautenschlager, N., Wilson, I., et al. (2007). Long-Term
Effects of Childhood Abuse on the Quality of Life and Health of Older People: Results from the
Depression and early prevention of Suicide in General Practice Project. JAGS
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10. Challenges of working
with survivors of childhood trauma
• deep feelings of insecurity
• low self-esteem
• poor frustration tolerance
• difficulties with trust and interpersonal relationships
• sensitivity to criticism
• substance abuse
• self-harming, suicidal and risk-taking behaviours
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11. Complex trauma - aetiology
Often compounded and cumulative
Includes all forms of violence experienced
within the community – civil unrest, war
trauma, genocide, cultural dislocation,
sexual exploitation, incarceration as well as
the impacts of homelessness, poverty and
chronic disadvantage and mental, physical
health issues and disability, grief and loss
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12. Service responses
• Diagnosis of PTSD alone misses additional challenges
of traumatic stress resulting from childhood trauma
• Phased lengthy process - establishing
safety, stabilisation, establishing a therapeutic
relationship, education and skill building, processing
and integration.
• Many survivors of complex trauma do not find the care
and support they need
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13. Trauma Informed Care & Practice
A new generation of service delivery
An approach that moves away from
prioritising diagnoses to recognising a
person‟s traumatic life experience
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14. Key References
• Bessel van der Kolk, Alexander McFarlane & Lars Weisaeth.
2007. Traumatic Stress: The Effects of Overwhelming
Experience on the Mind, Body and Society
• Babette Rothchild. 2000. The Body Remembers: The
Psychophysiology of Trauma and Trauma Treatment
• Judith Herman. 1992. Trauma & Recovery: From Domestic
Abuse to Political Terror
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15. Possible reasons for a lack of policy
focus
• a mental health system based on a „diagnose and treat‟
that fails to acknowledge the possible underlying causes
of the presenting problems
• differing perspectives on the scientific validation of the
lived experience of people presenting with trauma
related symptoms
• a medicalised response for people impacted by
trauma, that is often less than therapeutic
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16. Reframing Responses Supporting
Women Survivors of Child Abuse:
Information Resource Guide and
Workbook for Community Managed
Organisations
Available: MHCC website
http://www.mhcc.org.au/projects-and-research/reframing-
responses-resource-guide.aspx
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17. Towards recovery: Mental health
services in Australia 2008
Following the Senate Inquiry & report
recommendations, the government focussed
on people with a diagnosis of BPD who
characteristically have a history of childhood
abuse
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18. Borderline Personality Disorder
• is but one of the possible impacts of childhood
abuse
• represents a most pathologising diagnosis
• carries enormous stigma implying
hopelessness, manipulation and resistance to
treatment
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19. MHCC / ASCA Collaboration
Learning & Development Unit
Long term impacts of Childhood Abuse:
An Introduction
Two day workshop for the community mental health workforce
MHCC/ ASCA co-facilitation
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20. Trauma Informed Programs
A paradigm shift in service delivery culture:
acknowledging „that no one understands the challenges of
the recovery journey from trauma better than the person
living it’
Informed by an understanding of the particular
vulnerabilities and „triggers‟ that trauma survivors
experience minimising re-victimisation
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21. TICP - A joint initiative
MHCC , ASCA, Education Centre Against Violence
(ECAV) and the Private Mental Health Consumer
Carer Network Australia (PMHCCN)
Sept 2010 – an inaugural forum to discuss a
national strategy and agenda for promoting
Trauma Informed Care across all human service
systems
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22. Trauma Informed Care & Practice
Meeting the Challenge Conference 2011
Part of a broader initiative towards a national
agenda
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23. 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 people who receive mental
health services
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24. So what is Trauma Informed
Practice?
• a strengths-based framework grounded in an
understanding of and responsiveness to the
impact of trauma
• emphasizes physical, psychological, and
emotional safety for both providers and survivors
• creates opportunities for survivors to rebuild a
sense of control and empowerment
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25. What is a Trauma-Based Approach?
Primarily views the individual as having
been harmed by something or someone:
thus connecting the personal and the socio-
political environments (Bloom:1997)
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26. 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
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27. 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
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28. 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
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29. 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
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30. 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 and avoid re-traumatisation
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31. Service Systems
So how different might service systems
look if they are Trauma Informed ?
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32. Systems without Trauma Sensitivity
• Consumers are labelled & pathologised as manipulative, needy, attention-seeking
• Misuse or overuse of displays of power - keys, security, demeanour
• Culture of secrecy - no advocates, poor monitoring of staff
• Staff believe key role are as rule enforcers
• Little use of least restrictive alternatives other than medication
• Institutions that emphasize “compliance” rather than collaboration
• Institutions that disempower and devalue staff who then “pass on” that disrespect to service recipients.
• High rates of staff and recipient assault and injury
• Lower treatment adherence
• High rates of adult, child/family complaints
• Higher rates of staff turnover and low morale
• Longer lengths of stay/increase in recidivism
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33. Trauma Informed Systems
• Are inclusive of the survivor's perspective
• Recognise that coercive interventions cause traumatization / re-traumatization – and are to be avoided
• Recognise high rates of psychiatric disorders related to trauma exposure in children and adults
• Provide early and thoughtful diagnostic evaluation with focused consideration of trauma in people with complicated, treatment-
resistant illness
• Recognise that mental health treatment environments are often traumatizing, both overtly and covertly
• Value consumers in all aspects of care
• Use neutral, objective and supportive language
• Offer individually flexible plans approaches
• Avoid all shaming / humiliation
• Provide awareness/training on re-traumatizing practices
• Are institutions that are open to outside parties: advocacy and clinical consultants
• Provide training and supervision in assessment and treatment of people with trauma histories
• Focusing on what happened to the client rather than what is „wrong with you‟ (i.e. your diagnosis)
• Ask questions about current abuse
• Presume that every person in a treatment setting may have been exposed to abuse, violence, neglect or other traumatic
experiences
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34. Medical model
• Labels a disease
• Pathologises
• Studies symptoms rather than people
• Works on premise that something is wrong with a person rather than
something happened to the person
Mental health challenges are “normal” reactions to extremely
“abnormal circumstances”
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35. Current services
• Mainstream services are not trauma-informed
• Systems are overstretched
• Few specialist trauma-specific services
• Services are often crisis-driven and revictimising
• Focus is on short term interventions and outcomes
• Often experienced as disempowering, invalidating
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36. Co-morbidity?
Not co-morbidity – all are impacts of trauma
• The majority of clients presenting to mental health and AOD
services have trauma histories
• Care is often fragmented and fails to respond to multiple
needs
• Unemployment, welfare dependency, homelessness and
social exclusion
• A holistic approach is needed
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37. Embracing a model of
Trauma Informed Care and Practice
• increase community awareness around the relationship
of trauma to mental health
• work to eradicate stigma and discrimination, and
facilitate access and equity
• develop evidence based models and practice programs
• build capacity through supporting workforce education
and training; data collection, research, outcome
measurement and evaluation
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38. Successful model
• Collaborative
• Respectful
• Hopeful
• Informative
• Holistic
• Integrated
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39. Trauma informed system
• Safety from physical harm and re-traumatization
• Understand survivors and “symptoms” in context
• Open collaboration between workers and those seeking help
• Build on strengths and acquire skills
• Understanding symptoms as attempts to cope
• Perceive childhood trauma as a defining experience/set of
experiences that forms the core of an individual‟s identity
• focus on what happened to a person rather than what is
wrong with the person.
Harris, M., & Fallot, R. (2001). Using trauma theory to design service systems. New Directions for Mental
Health Services, 89. Jossey Bass.
Saakvitne, K., Gamble, S., Pearlman, S., & Tabor Lev, B. (2000). Risking connection: A training curriculum for
working with survivors of childhood abuse. Sidran Institute.
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40. Improved outcomes
USA reports of a Trauma informed approach
have included decrease in:
– Psychiatric symptoms
– Substance use
– Trauma symptoms
– Hospitalisation and crisis care
 Improvement in consumers‟ daily functioning
 Cost effective
Cited :Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings The Open
Health Services and Policy Journal, 2010, 3, 80-100 . Elizabeth, Hopper, Ellen, Bassuk & Olivet
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41. TICP National Agenda
• Investigate current TICP evident in Australia and New Zealand –
a mini audit of service delivery and evaluation processes
• Investigate existing gaps
• provide an overview of evidence-based literature
• define TIC in practice and determine what is transferable across
sectors
• develop principles, standards and guidelines
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42. Importance of CMOs
CMOs enable trauma survivors to stay living in the
community, in their own homes, limiting hospitalizations
and crisis presentations
• people to remain connected to their communities and
families
• remain in work
• recover and reintegrate with the community
With the right care and support, trauma survivors can
ultimately live well
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43. The Trauma Informed Care & Practice
Network MHCC are pleased to announce the
launch of a TICP microsite hosted at
www.mhcc.org.au
Visit the microsite for more
information on:
• Joining the National TICP Network
• TICP News & Events
• Find resources
• View some great presentations
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45. Thank you
Contact details
Dr Cathy Kezelman E:ckezelman@asca.org.au
Corinne Henderson E:corinne@mhcc.org.au
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