MHCC & ASCA co-presentation THEMHS 2011. Trauma Informed Care & Practice: Using a wide angle

Trauma Informed Care & Practice:using a wide angle lens TheMHS Conference 2011 Resilience in ChangePresenters:Dr Cathy Kezelman, ASCACorinne Henderson, MHCC1

Mental Health in AustraliaPoor 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.2

TraumaInvokes – Fear – Helplessness – Horror – Lack of controlOverwhelms – Coping mechanismsChildhood trauma is often especially damaging3

Defining complex traumaComplex trauma generally refers totraumatic stressors that are interpersonal –that is, they are premeditated, planned,and caused by other humans, such asviolating and/or exploitation of anotherpersonChristine A. Courtois. Understanding Complex Trauma, Complex Reactions, and TreatmentApproaches. Available: http://www.giftfromwithin.org/pdf/Understanding-CPTSD.pdf4

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 brain5

Impacts of childhood traumaSustained 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 symptomsChild abuse impacts• Sense of self• Interpersonal relationships• Behaviours• Cognitions6

Coping strategiesExtreme coping strategies are adopted in childhood tomanage overwhelming traumatic stressMany persist in adult life: – Suicidality – Self-harm – Substance abuse – Dissociation – Re-enactments of abusive relationshipsBehaviours are challenging but in context of trauma makesense7

RepercussionsInclude • diversity of mental health • poor physical health • substance abuse • eating disorders • relationship and self-esteem issues • contact with the criminal justice system8

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-TermEffects of Childhood Abuse on the Quality of Life and Health of Older People: Results from theDepression and early prevention of Suicide in General Practice Project. JAGS9

Challenges of workingwith 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 behaviours10

Complex trauma - aetiologyOften compounded and cumulativeIncludes all forms of violence experiencedwithin the community – civil unrest, wartrauma, genocide, cultural dislocation,sexual exploitation, incarceration as well asthe impacts of homelessness, poverty andchronic disadvantage and mental, physicalhealth issues and disability, grief and loss11

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 need12

Trauma Informed Care & PracticeA new generation of service deliveryAn approach that moves away fromprioritising diagnoses to recognising aperson‟s traumatic life experience13

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 Terror14

Possible reasons for a lack of policyfocus• 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 therapeutic15

Reframing Responses SupportingWomen Survivors of Child Abuse:Information Resource Guide andWorkbook for Community ManagedOrganisationsAvailable: MHCC websitehttp://www.mhcc.org.au/projects-and-research/reframing-responses-resource-guide.aspx16

Towards recovery: Mental healthservices in Australia 2008Following the Senate Inquiry & reportrecommendations, the government focussedon people with a diagnosis of BPD whocharacteristically have a history of childhoodabuse17

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 treatment18

MHCC / ASCA CollaborationLearning & Development UnitLong term impacts of Childhood Abuse:An IntroductionTwo day workshop for the community mental health workforce MHCC/ ASCA co-facilitation19

Trauma Informed ProgramsA paradigm shift in service delivery culture:acknowledging „that no one understands the challenges ofthe recovery journey from trauma better than the personliving it’Informed by an understanding of the particularvulnerabilities and „triggers‟ that trauma survivorsexperience minimising re-victimisation20

TICP - A joint initiativeMHCC , ASCA, Education Centre Against Violence(ECAV) and the Private Mental Health ConsumerCarer Network Australia (PMHCCN)Sept 2010 – an inaugural forum to discuss anational strategy and agenda for promotingTrauma Informed Care across all human servicesystems21

Trauma Informed Care & PracticeMeeting the Challenge Conference 2011Part of a broader initiative towards a nationalagenda22

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 services23

So what is Trauma InformedPractice?• 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 empowerment24

What is a Trauma-Based Approach?Primarily views the individual as havingbeen harmed by something or someone:thus connecting the personal and the socio-political environments (Bloom:1997)25

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 philosophies26

Trauma Informed Care & PracticeInvolves not only changing assumptions about howwe organise and provide services, but createsorganisational cultures that arepersonal, holistic, creative, open, and therapeutic27

A cultural shiftTrauma-informed programs and servicesinternationally represent the „newgeneration‟ of transformed mental healthand allied human services organisationsand programs which serve people withhistories of violence and trauma28

Systemic transformation occursWhen a human service program seeks to becometrauma-informed, every part of its organisation,management, and service delivery system isassessed and modified to ensure a basicunderstanding of how trauma impacts the life of anindividual who is seeking services29

Transformational Outcomes canhappen when…………….Organisations, programs, and services are basedon an understanding of the particularvulnerabilities and/or triggers that trauma survivorsexperience and avoid re-traumatisation30

Service SystemsSo how different might service systemslook if they are Trauma Informed ?31

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 recidivism32

Trauma Informed Systems• Are inclusive of the survivors 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 experiences33

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”34

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, invalidating35

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 needed36

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 evaluation37

Successful model • Collaborative • Respectful • Hopeful • Informative • Holistic • Integrated38

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.39

Improved outcomesUSA reports of a Trauma informed approachhave included decrease in: – Psychiatric symptoms – Substance use – Trauma symptoms – Hospitalisation and crisis care  Improvement in consumers‟ daily functioning  Cost effectiveCited :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 & Olivet40

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 guidelines41

Importance of CMOsCMOs enable trauma survivors to stay living in thecommunity, in their own homes, limiting hospitalizationsand crisis presentations• people to remain connected to their communities and families• remain in work• recover and reintegrate with the communityWith the right care and support, trauma survivors canultimately live well42

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 presentations43

Thank you Contact details Dr Cathy Kezelman E:ckezelman@asca.org.au Corinne Henderson E:corinne@mhcc.org.au45

MHCC & ASCA co-presentation THEMHS 2011. Trauma Informed Care & Practice: Using a wide angle

by mhcc on Sep 18, 2011

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MHCC & ASCA co-presentation THEMHS 2011. Trauma Informed Care & Practice: Using a wide angle — Presentation Transcript