Trauma-informed care andpractice - changing the lives of Australian adult survivors of childhood trauma Dr. Cathy Kezelman CEO: Adults Surviving Child Abuse www.asca.org.au
Failure of policy, systems and servicesExists as a result of many factors including Collective denial about - scale of the issue i.e. number of people affected - severity of issue i.e. long-term complex needs Stigma and taboo around legacy of abuse Lack of investment in trauma informed approach
Trauma-informed Care“Trauma-Informed Care is a strengths-based framework that is 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.”• Hopper, E.K., Bassuk, E. L., & Olivey, J. (2010). Shelter from the storm: trauma-informed care in homelessness services settings, The Open Health Services and Policy Journal , 3, 80-100.
TraumaInvokes fear Helplessness Horror Lack of controlOverwhelms Coping mechanismsChildhood trauma is often especially damaging
Childhood traumaRarely an isolated incidentInterpersonalIntentionalProlongedExtremeRepeatedAffects developing brain - Disrupts attachment - Affects template for development - Impacts fundamental neuro-chemical processes - Affects growth, structure and function of brain
Complex traumaSustained trauma exposure• Causes complex trauma and often complex needs – more than PTSD• Often has global and pervasive consequencesPTSD - re-experiencing of traumatic memories, emotional numbing/avoidance and hyperarousal• Diagnosis of PTSD alone misses additional challenges of traumatic stress resulting from childhood trauma
Child abuse - effects• Lifetime patterns of fear and lack of trust• Long-term difficulties with emotional regulation and stress management• Chronic feelings of helplessness• Somatic symptomsChild abuse impacts• Sense of self• Interpersonal relationships• Behaviours• Cognitions
Coping strategiesExtreme 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 relationshipsBehaviours are challenging but in context of trauma make sense
Challenges of meeting needs of adult survivors• Deep feelings of insecurity• Sensitivity to criticism• Low self-esteem• Difficulties with trust and interpersonal relationships• Substance abuse, self-harming, suicidal and risk-taking behaviours
Challenges for survivors to seek help• Shame• Self-blame• Fear about being unsafe• Isolation and withdrawal• Symptoms of PTSD – avoidance and hyper-arousal
Recovery from childhood traumaSurvivors can learn how to trust, feel safe, relate and self- regulateNeural pathways can repair themselvesHowever -• Current systems of care often fail to acknowledge or address underlying trauma• Survivors often feel their issues are minimised, dismissed or invalidated
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 personMental health challenges are “normal” reactions to extremely “abnormal circumstances”We need to ask the question: What happened to you?
Borderline Personality DisorderPathologising diagnosisWe need to understand behaviours in terms of• traumatic stress• personal invalidation• disrupted attachment• coping strategies
Responding to complex needsWorking through compounded impacts of complex trauma can take a long time and go through a number of stages e.g.• Establishing safety• Stabilisation• Establishing therapeutic relationship• Education and skill building• Processing and integrationAdapted Christine Curtois http://drchriscourtois.com/default.aspx
ServicesMainstream services are not trauma-informedSystems are overstretchedFew specialist trauma-specific servicesServices are often crisis-driven and revictimisingFocus is on short term interventions and outcomesOften experienced as disempowering, invalidating
Co-morbidity and life burdensTrauma survivors with complex needs often experience co- morbid mental health and substance abuse problems and a range of life burdens.Currently there is little to no co-ordination between services along with poor referral and follow-up pathways.
Service delivery - What do adult survivors of childhood trauma need?Services where trauma is acknowledged particular vulnerabilities and sensitivities are respected an understood victims are not blamed or retraumatised
Supporting survivorsUnderstand symptoms as adaptations Work collaborativelyEmpowerValidate resilienceEnable understanding of the relationship between past abuse andcurrent feelings and behavioursEstablish trust and safetyEnable choiceEstablish clear boundariesAcknowledge strengthsHelp survivors to embrace hope
Relationships Crucial to recovery Constructive Persuasion and not coercion Ideas and not force Mutuality and not authoritarian controlThese new relationships need to challenge the beliefs created by the original trauma
Trauma-informed System of Care• Sustained commitment and investment in trauma- specific services and programs• Philosophical and cultural shift• Integrate awareness and understanding around trauma and traumatic stress into work• Always consider possibility of undisclosed or unaddressed trauma• Not limited to mental health but applies to all systems
Systems change•Survivors conditions and behaviours are vieweddifferently•Staff respond differently•Day-to-day delivery of services is conducted differently•System understands the connection between pasttrauma and current behaviours•System develops strategies for responding to complextrauma
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.
Improved outcomes for survivorsUSA 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 effectiveCited in Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings The Open Health Services and Policy Journal, 2010, 3, 80-100 Elizabeth K. Hopper, Ellen L. Bassuk, and Jeffrey Olivet
ASCA – Adults Surviving Child AbuseTrauma informed approach to care 1300 line – empathy, validation, safety, handling disclosure and appropriate referral Creating New Possibilities – psycho-educational workshops for survivors Education and training for health professionals and community workers Australian national day - Forget-me-knot Day for all Australians to unite in support of adult survivors of childhood trauma
ASCA quote – from workshop attendee“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.’
Adults Surviving Child Abuse For more information go to www.asca.org.auContact: Dr. Cathy Kezelman, CEO ASCA firstname.lastname@example.orgAuthor of Innocence Revisited – a tale in parts www.jojopublishing.com