Trauma Informed Care & Practice:using a wide angle lens<br />TheMHS Conference 2011<br />    Resilience in Change <br />Pr...
        Mental Health in Australia<br />Poor funding for trauma, especially complex trauma<br />Although  trauma is core t...
                       Trauma<br />Invokes<br />Fear<br />Helplessness<br />Horror<br />Lack of control<br />Overwhelms<br...
         Defining complex trauma<br />Complex trauma generally refers to <br />traumatic stressors that are interpersonal–...
               Childhood trauma<br />Rarely an isolated incident<br />Interpersonal<br />Intentional<br />Prolonged<br />E...
         Impacts of childhood trauma<br />Sustained trauma exposure in childhood often has global and pervasive consequenc...
             Coping strategies<br />Extreme coping strategies are adopted in childhood to <br />manage overwhelming trauma...
                   Repercussions<br />Include<br /><ul><li>diversity of mental health
poor physical health
substance abuse
eating disorders
 relationship and self-esteem issues
contact with the criminal justice system </li></li></ul><li>           Prevalence – child abuse<br />More than 2 million A...
               Challenges  of working with survivors of childhood trauma<br />deep feelings of insecurity<br />low self-es...
          Complex trauma - aetiology<br />Often compounded and cumulative<br />Includes all forms of violence experienced ...
             Service responses<br />Diagnosis of PTSD alone misses additional challenges of traumatic stress resulting fro...
Trauma Informed Care & Practice<br />A new generation of service delivery <br />An approach that moves away from prioritis...
Key References<br />Bessel  van der Kolk, Alexander McFarlane & Lars  Weisaeth. 2007. Traumatic Stress: The Effects of Ove...
Possible reasons for a lack of policy focus<br />a mental health system based on a ‘diagnose and treat’ that fails to ackn...
Reframing Responses Supporting Women Survivors of Child Abuse:<br />Information Resource Guide and Workbook for Community ...
Towards recovery: Mental health services in Australia 2008<br />Following the Senate Inquiry  & report recommendations, th...
Borderline Personality Disorder<br />is but one of the possible impacts of childhood abuse<br />represents a most patholog...
MHCC / ASCA CollaborationLearning & Development Unit<br />Long term impacts of Childhood Abuse: An Introduction<br />Two d...
Trauma Informed Programs <br />A paradigm shift in service delivery culture:<br />acknowledging ‘that no one understands t...
TICP - A joint initiative<br />MHCC , ASCA, Education Centre Against Violence (ECAV) and the Private Mental Health Consume...
Trauma Informed Care & Practice<br />Meeting the Challenge Conference 2011<br />Part of a broader initiative towards a nat...
 Trauma-Informed Care<br />is grounded in and directed by a thorough<br />understanding of the neurological, biological,<b...
So what is Trauma Informed Practice?<br />a strengths-based framework grounded in an understanding of and responsiveness t...
What is a Trauma-Based Approach?<br />Primarily views the individual as having been harmed by something or someone:  thus ...
    What are the Key Principles?<br />Integrate philosophies of quality care that guide assessment and all clinical interv...
Trauma Informed Care & Practice<br />Involves not only changing assumptions about how we organise and provide services, bu...
                 A cultural shift<br />Trauma-informed programs and services <br />internationally represent the ‘new <br ...
Systemic transformation occurs<br />When a human service program seeks to become<br />trauma-informed, every part of its o...
Transformational Outcomes can happen when…………….<br />Organisations, programs, and services are based <br />on an understan...
              Service Systems<br />So how different might service systems<br />look if they are Trauma Informed ?<br />
Systems without Trauma Sensitivity<br />Consumers are labelled & pathologised as manipulative, needy, attention-seeking <b...
    Trauma Informed Systems<br />Are inclusive of the survivor's perspective<br /> <br />Recognise that coercive intervent...
                Medical model<br />Labels a disease<br />Pathologises<br />Studies symptoms rather than  people<br />Works...
              Current services<br />Mainstream services are not trauma-informed<br />Systems are overstretched<br />Few sp...
                 Co-morbidity?<br />Not co-morbidity – all are impacts of trauma<br />The majority of clients presenting t...
Embracing a model of Trauma Informed Care and Practice <br />increase community awareness around the relationship of traum...
           Successful model<br /><ul><li>Collaborative
Respectful
Hopeful
Informative
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MHCC & ASCA co-presentation THEMHS 2011. Trauma Informed Care & Practice: Using a wide angle lens

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  1. 1. Trauma Informed Care & Practice:using a wide angle lens<br />TheMHS Conference 2011<br /> Resilience in Change <br />Presenters: <br />Dr Cathy Kezelman, ASCA <br />Corinne Henderson, MHCC<br />
  2. 2. Mental Health in Australia<br />Poor funding for trauma, especially complex trauma<br />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. <br />Without addressing the core issues of their trauma, these consumers will continue to struggle with their daily functioning.<br /> <br />
  3. 3. Trauma<br />Invokes<br />Fear<br />Helplessness<br />Horror<br />Lack of control<br />Overwhelms<br />Coping mechanisms<br />Childhood trauma is often especially damaging<br />
  4. 4. Defining complex trauma<br />Complex trauma generally refers to <br />traumatic stressors that are interpersonal–<br />that is, they are premeditated, planned,<br />and caused by other humans, such as<br />violating and/or exploitation of another <br />person<br />Christine A. Courtois. Understanding Complex Trauma, Complex Reactions, and Treatment <br />Approaches. Available: http://www.giftfromwithin.org/pdf/Understanding-CPTSD.pdf<br />
  5. 5. Childhood trauma<br />Rarely an isolated incident<br />Interpersonal<br />Intentional<br />Prolonged<br />Extreme<br />Repeated<br />Affects developing brain<br /> - Disrupts attachment<br /> - Affects template for development<br /> - Impacts fundamental neuro-chemical processes <br /> - Affects growth, structure and function of brain<br />
  6. 6. Impacts of childhood trauma<br />Sustained trauma exposure in childhood often has global and pervasive consequences<br />Lifetime patterns of fear and lack of trust<br />Long-term difficulties with emotional regulation and stress management<br />Chronic feelings of helplessness<br />Somatic symptoms<br />Child abuse impacts <br />Sense of self<br />Interpersonal relationships<br />Behaviours<br />Cognitions<br />
  7. 7. Coping strategies<br />Extreme coping strategies are adopted in childhood to <br />manage overwhelming traumatic stress <br />Many persist in adult life:<br />Suicidality<br />Self-harm<br />Substance abuse<br />Dissociation<br />Re-enactments of abusive relationships<br />Behaviours are challenging but in context of trauma make<br />sense<br />
  8. 8. Repercussions<br />Include<br /><ul><li>diversity of mental health
  9. 9. poor physical health
  10. 10. substance abuse
  11. 11. eating disorders
  12. 12. relationship and self-esteem issues
  13. 13. contact with the criminal justice system </li></li></ul><li> Prevalence – child abuse<br />More than 2 million Australian adults have been abused as children (conservative estimate)<br /> Research tells us that 1 in 5 women and 1 in 7 men are affected<br />In every room of 25 people at least 4 will have experienced childhood abuse in some form or other.<br />Draper, B., Pfaff, J., Pirkis, J., Snowdon, J., Lautenschlager, N., Wilson, I., et al. (2007). Long-Term<br />Effects of Childhood Abuse on the Quality of Life and Health of Older People: Results from the <br />Depression and early prevention of Suicide in General Practice Project. JAGS<br />
  14. 14. Challenges of working with survivors of childhood trauma<br />deep feelings of insecurity<br />low self-esteem<br />poor frustration tolerance<br />difficulties with trust and interpersonal relationships<br />sensitivity to criticism <br />substance abuse <br /> self-harming, suicidal and risk-taking behaviours <br />
  15. 15. Complex trauma - aetiology<br />Often compounded and cumulative<br />Includes all forms of violence experienced <br />within the community – civil unrest, war <br />trauma, genocide, cultural dislocation, <br />sexual exploitation, incarceration as well as <br />the impacts of homelessness, poverty and <br />chronic disadvantage and mental, physical <br />health issues and disability, grief and loss<br />
  16. 16. Service responses<br />Diagnosis of PTSD alone misses additional challenges of traumatic stress resulting from childhood trauma<br />Phased lengthy process - establishing safety, stabilisation, establishing a therapeutic relationship, education and skill building, processing and integration. <br />Many survivors of complex trauma do not find the care and support they need<br />
  17. 17. Trauma Informed Care & Practice<br />A new generation of service delivery <br />An approach that moves away from prioritising diagnoses to recognising a person’s traumatic life experience<br />
  18. 18. Key References<br />Bessel van der Kolk, Alexander McFarlane & Lars Weisaeth. 2007. Traumatic Stress: The Effects of Overwhelming Experience on the Mind, Body and Society<br />Babette Rothchild. 2000. The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment<br />Judith Herman. 1992. Trauma & Recovery: From Domestic Abuse to Political Terror<br />
  19. 19. Possible reasons for a lack of policy focus<br />a mental health system based on a ‘diagnose and treat’ that fails to acknowledge the possible underlying causes of the presenting problems <br />differing perspectives on the scientific validation of the lived experience of people presenting with trauma related symptoms <br />a medicalised response for people impacted by trauma, that is often less than therapeutic <br />
  20. 20. Reframing Responses Supporting Women Survivors of Child Abuse:<br />Information Resource Guide and Workbook for Community Managed Organisations<br />Available: MHCC website<br />http://www.mhcc.org.au/projects-and-research/reframing-responses-resource-guide.aspx<br />
  21. 21. Towards recovery: Mental health services in Australia 2008<br />Following the Senate Inquiry & report recommendations, the government focussed on people with a diagnosis of BPD who characteristically have a history of childhood abuse <br />
  22. 22. Borderline Personality Disorder<br />is but one of the possible impacts of childhood abuse<br />represents a most pathologisingdiagnosis<br />carries enormous stigma implying hopelessness, manipulation and resistance to treatment<br />
  23. 23. MHCC / ASCA CollaborationLearning & Development Unit<br />Long term impacts of Childhood Abuse: An Introduction<br />Two day workshop for the community mental health workforce<br /> MHCC/ ASCA co-facilitation<br />
  24. 24. Trauma Informed Programs <br />A paradigm shift in service delivery culture:<br />acknowledging ‘that no one understands the challenges of the recovery journey from trauma better than the person living it’<br />Informed by an understanding of the particular vulnerabilities and ‘triggers’ that trauma survivors experience minimising re-victimisation<br />
  25. 25. TICP - A joint initiative<br />MHCC , ASCA, Education Centre Against Violence (ECAV) and the Private Mental Health Consumer Carer Network Australia (PMHCCN) <br />Sept 2010 – an inaugural forum to discuss a national strategy and agenda for promoting Trauma Informed Care across all human service systems <br />
  26. 26. Trauma Informed Care & Practice<br />Meeting the Challenge Conference 2011<br />Part of a broader initiative towards a national agenda<br />
  27. 27. Trauma-Informed Care<br />is grounded in and directed by a thorough<br />understanding of the neurological, biological,<br />psychological and social effects of trauma <br />and violence and the prevalence of these<br />experiences in people who receive mental<br />health services<br />
  28. 28. So what is Trauma Informed Practice?<br />a strengths-based framework grounded in an understanding of and responsiveness to the impact of trauma<br />emphasizes physical, psychological, and emotional safety for both providers and survivors<br />creates opportunities for survivors to rebuild a sense of control and empowerment<br />
  29. 29. What is a Trauma-Based Approach?<br />Primarily views the individual as having been harmed by something or someone: thus connecting the personal and the socio-political environments (Bloom:1997) <br />
  30. 30. What are the Key Principles?<br />Integrate philosophies of quality care that guide assessment and all clinical interventions<br />Is based on current literature<br />Is informed by research and evidence of effective practices and philosophies<br />
  31. 31. Trauma Informed Care & Practice<br />Involves not only changing assumptions about how we organise and provide services, but creates organisational cultures that are personal, holistic, creative, open, and therapeutic<br />
  32. 32. A cultural shift<br />Trauma-informed programs and services <br />internationally represent the ‘new <br />generation’ of transformed mental health<br />and allied human services organisations <br />and programs which serve people with<br />histories of violence and trauma<br />
  33. 33. Systemic transformation occurs<br />When a human service program seeks to become<br />trauma-informed, every part of its organisation, <br />management, and service delivery system is <br />assessed and modified to ensure a basic <br />understanding of how trauma impacts the life of an<br />individual who is seeking services <br />
  34. 34. Transformational Outcomes can happen when…………….<br />Organisations, programs, and services are based <br />on an understanding of the particular <br />vulnerabilities and/or triggers that trauma survivors<br />experience and avoid re-traumatisation<br />
  35. 35. Service Systems<br />So how different might service systems<br />look if they are Trauma Informed ?<br />
  36. 36. Systems without Trauma Sensitivity<br />Consumers are labelled & pathologised as manipulative, needy, attention-seeking <br /> <br />Misuse or overuse of displays of power - keys, security, demeanour <br /> <br />Culture of secrecy - no advocates, poor monitoring of staff <br /> <br />Staff believe key role are as rule enforcers <br /> <br />Little use of least restrictive alternatives other than medication <br /> <br />Institutions that emphasize “compliance” rather than collaboration <br /> <br />Institutions that disempower and devalue staff who then “pass on” that disrespect to service recipients.<br />High rates of staff and recipient assault and injury<br /> <br />Lower treatment adherence<br /> <br />High rates of adult, child/family complaints <br /> <br />Higher rates of staff turnover and low morale <br /> <br />Longer lengths of stay/increase in recidivism <br /> <br />
  37. 37. Trauma Informed Systems<br />Are inclusive of the survivor's perspective<br /> <br />Recognise that coercive interventions cause traumatization / re-traumatization – and are to be avoided<br />Recognise high rates of psychiatric disorders related to trauma exposure in children and adults <br />Provide early and thoughtful diagnostic evaluation with focused consideration of trauma in people with complicated, treatment-resistant illness<br />Recognise that mental health treatment environments are often traumatizing, both overtly and covertly<br />Value consumers in all aspects of care<br /> <br />Use neutral, objective and supportive language<br /> <br />Offer individually flexible plans approaches<br /> <br />Avoid all shaming / humiliation<br /> <br />Provide awareness/training on re-traumatizing practices<br /> <br />Are institutions that are open to outside parties: advocacy and clinical consultants<br /> <br />Provide training and supervision in assessment and treatment of people with trauma histories<br /> <br />Focusing on what happened to the client rather than what is ‘wrong with you’ (i.e. your diagnosis)<br /> <br />Ask questions about current abuse <br /> <br />Presume that every person in a treatment setting may have been exposed to abuse, violence, neglect or other traumatic experiences<br />
  38. 38. Medical model<br />Labels a disease<br />Pathologises<br />Studies symptoms rather than people<br />Works on premise that something is wrong with a person rather than something happened to the person<br />Mental health challenges are “normal” reactions to extremely <br />“abnormal circumstances”<br />
  39. 39. Current services<br />Mainstream services are not trauma-informed<br />Systems are overstretched<br />Few specialist trauma-specific services<br />Services are often crisis-driven and revictimising<br />Focus is on short term interventions and outcomes<br />Often experienced as disempowering, invalidating<br />
  40. 40. Co-morbidity?<br />Not co-morbidity – all are impacts of trauma<br />The majority of clients presenting to mental health and AOD services have trauma histories<br />Care is often fragmented and fails to respond to multiple needs<br />Unemployment, welfare dependency, homelessness and social exclusion<br /> A holistic approach is needed <br />
  41. 41. Embracing a model of Trauma Informed Care and Practice <br />increase community awareness around the relationship of trauma to mental health<br />work to eradicate stigma and discrimination, and facilitate access and equity<br />develop evidence based models and practice programs<br />build capacity through supporting workforce education and training; data collection, research, outcome measurement and evaluation<br />
  42. 42. Successful model<br /><ul><li>Collaborative
  43. 43. Respectful
  44. 44. Hopeful
  45. 45. Informative
  46. 46. Holistic
  47. 47. Integrated </li></li></ul><li> Trauma informed system<br />Safety from physical harm and re-traumatization<br />Understand survivors and “symptoms” in context<br />Open collaboration between workers and those seeking help<br />Build on strengths and acquire skills<br />Understanding symptoms as attempts to cope<br />Perceive childhood trauma as a defining experience/set of experiences that forms the core of an individual’s identity <br />focus on what happened to a person rather than what is wrong with the person. <br />Harris, M., & Fallot, R. (2001). Using trauma theory to design service systems. New Directions for Mental Health Services, 89. Jossey Bass.<br />Saakvitne, K., Gamble, S., Pearlman, S., & Tabor Lev, B. (2000). Risking connection: A training curriculum for working with survivors of childhood abuse. Sidran Institute.<br />
  48. 48. Improved outcomes<br />USA reports of a Trauma informed approach <br />have included decrease in:<br />Psychiatric symptoms <br />Substance use<br />Trauma symptoms<br />Hospitalisation and crisis care<br /><ul><li>Improvement in consumers’ daily functioning
  49. 49. Cost effective </li></ul>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 <br />
  50. 50. TICP National Agenda<br />Investigate current TICP evident in Australia and New Zealand – a mini audit of service delivery and evaluation processes<br />Investigate existing gaps<br />provide an overview of evidence-based literature<br />define TIC in practice and determine what is transferable across sectors<br />develop principles, standards and guidelines<br />
  51. 51. Importance of CMOs<br />CMOs enable trauma survivors to stay living in the community, in their own homes, limiting hospitalizations and crisis presentations <br />people to remain connected to their communities and families<br />remain in work<br />recover and reintegrate with the community<br />With the right care and support, trauma survivors can ultimately live well<br />
  52. 52. The Trauma Informed Care & Practice Network<br />MHCC are pleased to announce the launch of a TICP microsite hosted at www.mhcc.org.au<br />Visit the microsite for more information on:<br />Joining the National TICP Network<br />TICP News & Events <br />Find resources <br />View some great presentations <br />
  53. 53.
  54. 54. Thank you<br />Contact details <br />Dr Cathy KezelmanE:ckezelman@asca.org.au<br />Corinne Henderson E:corinne@mhcc.org.au<br />

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