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Is trauma informed care really possible in mental health services?

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Is trauma informed care really possible in mental health services?

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Keynote talk delivered at the 2018 Summer TheMHS Forum, in Sydney, Australia. Talk by our Human Rights Advisor, Indigo Daya.

While we know that trauma is a critical issue for most mental health consumers, we are also concerned that changes intending to implement trauma-informed practice are not always addressing the need. We highlight major issues to be resolved when considering the implementation of trauma-informed practice. This is too important to get it wrong.

Keynote talk delivered at the 2018 Summer TheMHS Forum, in Sydney, Australia. Talk by our Human Rights Advisor, Indigo Daya.

While we know that trauma is a critical issue for most mental health consumers, we are also concerned that changes intending to implement trauma-informed practice are not always addressing the need. We highlight major issues to be resolved when considering the implementation of trauma-informed practice. This is too important to get it wrong.

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Is trauma informed care really possible in mental health services?

  1. 1. www.vmiac.org.au Is trauma-informed practice really possible? Indigo Daya Human Rights Advisor, VMIAC Adjunct Research Fellow, Swinburne University TheMHS Summer Forum 2018
  2. 2. www.vmiac.org.au VMIAC envisions a world where all mental health consumers stand proud, live a life with choices honoured, rights upheld, and these principles are embedded in all aspects of society
  3. 3. Is trauma the elephant in the room of mental health? Does trauma-informed practice feel huge & overwhelming?
  4. 4. Perhaps we can sit with the discomfort of major change… And even very different perspectives…
  5. 5. A bit of my story
  6. 6. Peeling back layers of an onion* * Concept by Ron Coleman, Working to Recovery, Scotland Our madness experiences often have many layers. We can’t know what lies beneath without working beyond the superficial. The deeper layers are where the trauma is.
  7. 7. ‘Psychotic’, ‘Borderline personality disorder’ ‘At risk, lacking insight’ (hearing voices, suicidality) Terrified, despairing Shame Memories, triggers, overwhelm Self-judgement & self-blame Self-loathing Devalued core identity ‘I am evil’ ‘Mentally ill’ medicalemotionaltrauma
  8. 8. Containment Observation Diagnostic labels Force Pills Humiliation Seclusion Disability Poverty ‘Chemical imbalance’ myth Injections Punishment Shock treatment Memory loss Obesity Sedation Fear, mistrust, despair Compassion Comfort People like me Practical help Coping skills Respect Choice Empathic listening Courage Acknowledgment of trauma Therapeutic exploration Making sense of experience Finding myself innocent Safety, trust, hope Human rights
  9. 9. Is trauma informed practice possible?
  10. 10. Not in public mental health services. Well, not yet, anyway. Andersen, Hans Christian. Fairy Tales by Hans Andersen. Arthur Rackham, illustrator. London: George G. Harrap, 1932.
  11. 11. Why Trauma-Informed Practice isn’t possible (yet) 1. Trauma-informed practice is already being co-opted 2. The scale of change needed is huge 3. There are many contra- indications to trauma- informed practiceAndersen, Hans Christian. Fairy Tales by Hans Andersen. Arthur Rackham, illustrator. London: George G. Harrap, 1932.
  12. 12. (1) Ways that services are getting trauma-informed practice wrong… co-opting • ‘It’s just about not causing trauma’ • ‘It’s about new trauma screening tools’ • ‘It’s about screening for trauma, referring on to specialist services for that, then business as usual for us’ • ‘It’s about diagnosing comorbid trauma disorders, like PTSD’ • Not addressing conflicting interests & risks in family inclusive practice
  13. 13. (2) The scale of change A trauma informed approach 1… • Realizes the widespread impact of trauma and understands potential paths for recovery; • Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; • Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and • Seeks to actively resist re-traumatization. 1 Substance Abuse and Mental Health Services Administration (SAMHSA). (2015). Trauma-Informed Approach and Trauma-Specific Interventions. Retrieved from: https://www.samhsa.gov/nctic/trauma-interventions
  14. 14. … yet this requires genuine reform To support this approach, we would need… • Recovery orientation – yet this has largely failed in the clinical sector • Substantially more face-to-face time in a pressured system • Fundamental changes to practice by all staff: this is not an ‘add-on’, it’s a game changer • Shifting away from existing diagnostic frameworks • Substantial increases in knowledge & skill, including a diversified workforce • Revisiting mental health legislation and built environments
  15. 15. (3) Contraindications to trauma- informed practice Much of what happens in clinical mental health services is contraindicated in the context of trauma: • Human rights breaches • Double-binds • Incompatibilities with principles of trauma- informed practice
  16. 16. Human Rights (Victorian Charter of Human Rights, 2006) Right to recognition & equality before the law Protection from torture & cruel, inhuman or degrading treatment Right to life Freedom from forced work Freedom of movement Freedom of thought, conscience, religion & belief Privacy & reputation Freedom of expression Peaceful assembly and freedom of association Protection of families and children Humane treatment when deprived of liberty Taking part in public life Cultural rights Property rights Right to liberty & security of person Rights of children in the criminal process Rights in criminal proceedings Right to a fair hearing Right not to be tried or punished more than once Retrospective criminal laws
  17. 17. Human rights breaches that happen in mental health services Right to recognition & equality before the law Protection from torture & cruel, inhuman or degrading treatment Right to life Freedom from forced work Freedom of movement Freedom of thought, conscience, religion & belief Privacy & reputation Freedom of expression Peaceful assembly and freedom of association Protection of families and children Humane treatment when deprived of liberty Taking part in public life Cultural rights Property rights Right to liberty & security of person Rights of children in the criminal process Rights in criminal proceedings Right to a fair hearing Right not to be tried or punished more than once Retrospective criminal laws
  18. 18. The double bind faced by consumers Submit To treatment I don’t want, that doesn’t help, that harms me Fight back Defend my rights and risk worse coercion and harms
  19. 19. The double-bind created by mental health services often replicates our original traumas
  20. 20. Principles of Trauma-Informed Practice* • Safety • Trustworthiness & transparency • Peer support • Collaboration & mutuality • Empowerment, voice & choice • Cultural, Historical, and Gender Issues 1 Substance Abuse and Mental Health Services Administration (SAMHSA). (2015). Trauma-Informed Approach and Trauma-Specific Interventions. Retrieved from: https://www.samhsa.gov/nctic/trauma-interventions
  21. 21. Trauma Informed Practice …what’s in the way Principles of trauma- informed practice (SAMHSA) Common contraindications in public mental health services Safety Seclusion, restraint, sexual assault, psychological injury Trustworthiness & transparency Privacy breaches, coercion, punitive measures, unlawful practice Peer support Some positive change, but…? Collaboration & mutuality Substitute decision making, extreme boundaries Empowerment, voice & choice Compulsion, a lot that’s done about us without us, rules & controls Cultural, Historical, and Gender Issues Some positive change, but…?
  22. 22. “Do the best you can until you know better. Then when you know better, do better.” MAYA ANGELOU
  23. 23. Moving towards trauma- informed practice 1. Practice listening, validation & non- judgement 2. Call out any co-opting of trauma informed practice 3. Provide information about trauma 4. Develop therapeutic skills 5. Learn about trauma, & emotion 6. Be an ally and challenge harmful practice & rights breaches 7. Introduce new support & recovery options
  24. 24. www.vmiac.org.au Indigo Daya Human Rights Advisor Contact p 9380 3900 e indigo.daya@vmiac.org.au Indigo Daya @IndigoDaya Indigo Daya BLOG www.indigodaya.com
  25. 25. Further reading ‘The time is always right to do what is right’ Martin Luther King
  26. 26. Be an ally & challenge harmful practice • Learn about & respect consumer history & perspectives • Invite us to work with you • Don’t misuse your privilege • Respect our experiences, beliefs, choices & rights • When you see injustice or harm, stand with us & take action • Support us to make complaints, use advocates and legal services (that’s not ‘being litigious’, it’s promoting rights and empowerment) • Do no harm
  27. 27. Learn about our movement
  28. 28. Read the work of consumer / survivor leaders, writers & thinkers Eleanor Longden Tina Minkowitz Shery Mead Rachel Waddingham Jacqui Dillon Rufus May Will Hall Ron Coleman Oryx Cohen Judi Chamberlin Patricia Deegan Daniel Fisher Mary O’Hagan • Merinda Epstein • Cath Roper • Vrinda Edan • Wanda Bennetts • Flick Grey • Amanda Waegli • Louise Byrne • Fay Jackson • Neil Turton-Lane • Stephanie Ewert • Tim Heffernan • Maybe me!
  29. 29. Read the work of critical professional voices (allies with consumer movement) Organisations: • Mad in America (US) • Critical Psychiatry Network (UK) • Drop the Disorder (UK) • Intervoice / International Hearing Voices Movement • Schizophrenia does not exist (Netherlands) • International Institute for Psychiatric Drug Withdrawal • ImROC (UK) • Joanna Moncrieff • Peter Breggin • Lucy Johnstone • John Read • Pat Bracken • Richard Bentall • Jay Watts • Sam Timimi • Jeffrey Lacasse • Bruce Levine • Daniel Mackler • David Cohen, UCLA • Jo Watson • Noel Hunter • Dirk Corstens • Judith Herman • Mike Slade
  30. 30. Learn about genuinely trauma-informed support, recovery & healing options • Hearing Voices Approach ― Making sense of voices, listening to voices, dialoguing with voices, profiling voices (Maastricht interview) • Alternatives to Suicide (Western Mass) • Intentional Peer Support (Shery Mead) • Narrative therapy • eCPR (Daniel Fisher)
  31. 31. https://youtu.be/0nUjbFGOKNg WorkSafe Victoria video https://youtu.be/fMPr9rs2ooQ ConsumerSafe video Try to see it as we do…

Editor's Notes

  • I am wondering how many people feel like that trauma elephant is just a bit like this? Huge, overwhelming, threatening?

    I hope not, but I know that big change can feel this way, so I wanted to acknowledge that.
  • This is a hopeful elephant, hanging out with a dog. It’s here to remind us that it’s possible to sit alongside something big, and different, and tricky, and to be ok with that.

    It’s even possible for people with really different experiences and views – like clinicians and consumers – to sit alongside each other and begin to listen.

    I hope we can do that today… even if I do feel a bit like an enormous scary elephant.
  • This is an onion. Ron Coleman, a man I count as a mentor and a friend, and a leader in the international hearing voices movement, talks about making sense of madness and trauma as being like peeling back the layers of an onion.

    You work on the layer you can see, and when you peel it back, more than likely there will be another layer underneath. This was a really helpful concept for me.
  • These were the layers of ‘my onion’. The 3 layers on top were all that psychiatric services seemed to see or address. Every now and then, a clinician would see the top layer of emotions, but that was a rare thing.

    And so, it was with my peers, and eventually with a sexual assault counsellor, that I was able to unpeel the remaining layers.

    What I found was that all of the layers on the surface – the ‘illness’ – were actually just a profoundly painful reaction to shame from childhood abuse. And these were all things that I could heal from, with the right time, support and knowledge.

    It we are to be trauma-informed, we need to understand that so much of our trauma is just sitting there, hidden beneath layers of psychiatric labelling and supposed risk.
  • Think about those things that I was experiencing, and then have a look at what I actually got from clinical services (on the left).

    On the right are the things I eventually got, and that contributed to really healing – but I had to go and find these on my own, in different places. I had to lie to my psychiatrist and services as well.

    What does this tell us about trauma-informed practice? How much work do we have to do?
  • Image from the old fairy tale, ‘The Emperor's New Clothes’.

    I’ve seen lots of services who are trying to implement trauma informed practice, both here and overseas. And I’m afraid that it really reminds me of this old fairy tale. It feels like everyone is saying how wonderful this new policy is, and yet it’s not actually authentic in any way, kind of like the emperor’s clothes. So, as a consumer/survivor, I feel like that little girl in the crowd, the one who called out ‘but the emperor’s wearing no clothes’! This is often our role, as consumers, to say the uncomfortable truth that no-one else seems able or willing to say. To speak truth to power, if you like. But gosh, it would be really great if more people could join in.

    Right now, I have yet to see a single clinical mental health service do anything that is even close to authentic trauma informed practice.
  • These are, I think, three big reasons why trauma informed practice is not yet possible in clinical mental health services. Each of them has some complexity, so let’s explore them. The next set of slides talks through each of these issues.
  • Services around Australia and overseas are ‘having a go’ at TIP. To date, I’ve not seen a single clinical service that’s gotten it right. Each of them is ‘co-opting’ or seriously misinterpreting, what this new kind of practice is supposed to be about. These are some of the most common ways that I have seen services getting it wrong:

    Not causing trauma: Yes…’but’. People often think that TIP is about reducing restrictive practices. But you should never cause trauma anyway. You’re a health service, and your patients have a right to be safe. There’s also that Charter of healthcare rights, and international conventions, and that Hippocratic oath thing, that somehow seems to be less relevant in mental health. Not hurting people is not being trauma-informed. It’s called providing safe services, and it’s what every service should do regardless of trauma-informed practice. So while trauma informed practice will include an element to ensure this doesn’t happen – if this is all you do, then you have failed before you’ve begun.

    New screening tools: If you just screen people with tools and forms, you have missed the point, and risk causing harm. Trauma is too complex and individual to leave to a form. Many people’s experience won’t fit on a form any way. And most of the relevant information about the trauma will come from understanding how it fits into the person’s life – past and present. Trauma disclosure should be supported through interpersonal sessions, following the establishment of rapport and trust. And, really, has ANY problem in health services ever been addressed with a new form??

    Referrals then business as usual: If you do not have trauma expertise then you absolutely should refer to specialist services. However the experience of trauma should also influence all of your thinking about assessment, diagnosis and treatment. If it doesn’t change all of these things in a major way, then you haven’t got it. Trauma can be associated with almost any ‘mental health diagnosis’. Many people associate trauma with hearing voices, having unusual beliefs, with depression, anxiety, borderline personality disorder and mania – in fact, all of the common experiences that services might be working with. This must mean that we can’t continue ‘as usual’. For many people, it will mean that the primary treatment and support should come from a different service, and is likely to involve peer support and/or talking therapies.

    Diagnosing comorbid PTSD: Using a trauma history to give us more labels and more treatments is missing the point very badly. It also means that you are most likely ignoring the way that trauma can be linked to any type of mental or emotional experience. Trauma is not an ‘add on’ experience – it’s at the heart of most of our experiences. Further, PTSD does not fit with everyone’s experience, it’s just one way of responding to trauma – but there are many ways.

    Conflicts with family inclusive practice: Family inclusive practice matters, although family sensitive practice is probably more aligned with consumer perspectives. However, approaches to including families seem to exclude critical considerations for trauma informed practice. This is a major risk for the many consumers who have experienced trauma within a family, whether it’s partner violence or child abuse, and sometimes abuse into adulthood. Of course sometimes family are the best supporters we could possibly have, but sometimes they can also be the people who hurt us the most, and even at the root of our trauma. We can’t return to the old days of the ‘schizophrenogenic mother’, we have to be better than that, but it seems to have become not OK anymore to speak about uncomfortable realities – sometimes carers and family members are harmful to us, and so sometimes they are the last people who should be involved. What does it mean if an abusive husband can attend a case conference about the wife he beats up? What does it mean if a past perpetrator of child abuse is still having a say about our mental health treatment? And I know that of the many women I have sat with over the years who were sexually abused by their father, that the part of the experience that sent them over the edge was not that original abuse, but having told their mother and not being believed. And sometimes, that mother was the person’s carer. So if you’re thinking that you’re doing trauma-informed practice, and you haven’t thought about this, you have a problem.
  • Another barrier to trauma-informed practice is that it require some of the most substantial reforms we’ve ever seen in mental health. This is not a small thing. It is not something we can do with a framework document and a two-day course and a poster.

    Think about these elements of a trauma informed approach. I include these because so often people only talk about the principles of trauma informed care. They’re really important, of course, but if you don’t know anything about trauma that they can seem a little vague and fluffy. The approach, on the other hand, is clearer about what should actually DO, rather than HOW we should do it.

    Stop and really think about what it would mean to do all these things in mental health services, all the time.

  • The trauma informed approach from the previous slide requires lots of reform to become a reality. The things on this slide are necessary - and much more.

    We’ve already seen the concept of ‘recovery’ get co-opted by the clinical sector. Almost everyone says that they are recovery oriented, but this is superficial at best. There are five core processes that underpin recovery: connectedness, hope, identity, meaning and empowerment. How do clinical services support these processes? In reality services are still just as focused on symptom remission as they have always been.

    Shifting away from the DSM is massive – and we know that there is no other approach sitting there ready to replace it. Although, the Power Threat Meaning Framework, by the British Psychological Society, starts to open up this conversation.

    But any one of these actions would require commitment by a brave government, willing to risk upsetting the status quo of power, to face public criticism, industrial unrest and many political problems. But genuine, deep reform, comes once a generation if we’re lucky, and I’m not sure we’ve ever seen it in mental health. Sure, there was deinstitutionalisation, but as Ron Coleman reminds us, all that really happened was that we got institutionalised in CTOs and poverty instead of big old buildings.

    I don’t know how we make this happen, but I know it’s a huge ask.
  • Mental health consumers/survivors lose the right to bodily integrity, but that’s just one of many breaches of human rights.

    There is much that happens in mental health services that is just the complete opposite of what a genuinely trauma-informed system would do.

    Right now, we know that services are very often the cause of trauma – and so that’s can’t possible be trauma-informed.
  • Human rights breaches are common for mental health consumers. So, when we say our rights are breached, which rights do we mean?

    These are from Victoria, but they are based on the International Covenant of Civil and Political Rights, which Australia has ratified – so they apply to everyone in this country, even if our laws have been slow to catch up.
  • Depending on our experience, around half of our rights can be breached.

    Some of the most common ways that rights are breached include compulsory detention and compulsory treatment (which currently affects almost 60% of consumers) but there are many other practices that breach rights.

    When we think about trauma-informed practice, we need to remember that inherent in most interpersonal trauma experiences (but not all), is a severe violation of human rights. This is part of why choice is a central principle of trauma informed practice. So how can we possibly be trauma informed when we breach so many basic human rights? We are not even in the situation yet where clinicians fully appreciate which rights they breach, and how.

    We often hear clinicians and government say that these rights violations are justified by the right to health: yet this is a serious misuse of that right. The right to health, according to the United Nations, includes the right to informed consent. So forced treatment is not upholding the right to health – it’s breaching it. The right to health puts an obligation on governments to provide a healthy environment, society, and health services… but it is supposed to be up to the people whether or not they avail themselves of those services. The right to health is not a right to be healthy.
  • So often, for consumers with a trauma history, we are faced with an impossible choice:
    We can submit to a service that is based in medical models of treatment, and which feels largely, even wholly, unsuited to help us, or
    We can fight back

    If we submit, we know that this will make us worse. We become more disempowered, we take on board disabling medication effects, like cognitive impairment that we may not be able to escape from. We lose our dignity and self-respect. But if we fight back, (or be ‘non-compliant’), we know that we’ll face restrictions and force that will be traumatising and make us worse.

    These are impossible situations. The only way out is to escape and get free of services, which some of us do by faking compliance and lying our way to freedom. Is this trauma-informed? Is it possible that this kind of double-bind replicates the kind of ‘mad-making’ experiences of trauma?
  • So often, for consumers with a trauma history, we are faced with an impossible choice:
    We can submit to a service that is based in medical models of treatment, and which feels largely, even wholly, unsuited to help us, or
    We can fight back

    If we submit, we know that this will make us worse. We become more disempowered, we take on board disabling medication effects, like cognitive impairment that we may not be able to escape from. We lose our dignity and self-respect. But if we fight back, (or be ‘non-compliant’), we know that we’ll face restrictions and force that will be traumatising and make us worse.

    These are impossible situations. The only way out is to escape and get free of services, which some of us do by faking compliance and lying our way to freedom. Is this trauma-informed? Is it possible that this kind of double-bind replicates the kind of ‘mad-making’ experiences of trauma?
  • The principles of trauma informed practice are generally well accepted, but with slight variations. I show two versions here, and I prefer the one by SAMSHA because it includes peer support. Without peer support, I may well still be on the pension and heavily medicated and hating myself.
  • And these are the common contraindications to the principles that we see frequently in clinical mental health services. I cannot see a way that it is possible to embed these principles authentically until we eliminate all the contraindications in the right hand column.
  • I know this might feel confronting for you all to hear.

    I know that you chose to become a mental health clinician in order to help people.

    And what I’m saying may not sound very helpful at all.

    I am not speaking today with the aim of making you feel bad. Don’t do that. Instead I am speaking with the aim of motivating you:

    I have worked with too many clinicians not to know that for the vast majority of you, your intentions are good.
    Like Maya Angelou said, do the best you can, until you know better.

    So this is what I ask: Work with us, help us to have our say, so that, together, we can know better, and eventually, we can do better.
  • There are a whole lot of prerequisites before the clinical mental health sector can do trauma-informed practice. I am not sure if these prerequisites are even possible… many days I would much rather just see us create a trauma system to replace most of the mental health system. It would be entirely different: voluntary, in the community not health settings, the workforce would be entirely different, the services and assumptions and concepts would be different too.

    But we also have to work with what we have today.

    The things on this list are not a complete list. And doing them won’t bring us trauma-informed practice, but they will move us closer towards it. Closer to be being more helpful and less harmful. I have selected things that you can each do as individuals, rather than dramatic big things that governments must do. Because we also need to address discriminatory and harmful legislation, funding, workforce issues and much more.

    If the only thing you can do is step 1, it could make an enormous positive impact on people’s lives
    If you see the kinds of examples of co-opting that I shared today, or new ones, call it out. This is too important to get it wrong.
    Providing information is one of the simplest changes you could make. Because so many of us have never even disclosed our history of trauma, there is a lot we don’t know about how trauma can impact us. I was 40 before I learned about grooming, and suddenly so much of my experience made sense. Think about how you can make information available to people, even if it’s just a brochure stand.
    The lack of therapeutic skills is one of our biggest issues in the mental health workforce. We’ve become so medicalised it’s almost like we’ve forgotten why we're here. How can a clinical mental health service have less therapeutic skills than someone I can see in my community? We have to change this across the system – but you can also change this for yourself. Take a course, read up, get good supervision.
    Learn everything you can about trauma and about emotions. These are the reasons most of us are at your services, so you should know this stuff.
    Stand with consumers by being a genuine ally. Stand against harmful practice in your service, and model positive change.
    Psychiatry might have a lack of ‘evidence-based’ approaches for trauma informed practice, but we survivors actually know quite a lot. So do some of those trauma specialists who work with us in different settings. We don’t have to start from scratch. Learn about approaches that people find helpful outside of your services, and think about ways to incorporate them.

    But the bottom line is this: if you use compulsion or think you are acting in our best interests, then you have already hurt us. If consumers are not safe, both psychologically as well as physically, then you are not trauma informed.

    There is more information about some of these ideas in the additional reading section.

  • Thank you for sitting with my challenges, and for welcoming me into this space. I hope we get many more opportunities to speak again.
  • If you worked in women’s health you would probably take a course in women’s studies or gender studies. If you worked in LGBTIQ health you would want to study queer theory. Yet almost no one in mental health even knows about Mad Studies, or takes time to understand the consumer movement. If you want to be helpful to us, then please, take time to get to know us. Out of your services, take time to read and enquire and learn. Most importantly, have conversations with us. The consumer movement is not going away.

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