1. Trauma Informed Care & Practice:using a wide angle lens TheMHS Conference 2011 Resilience in Change Presenters: Dr Cathy Kezelman, ASCA Corinne Henderson, MHCC

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.

3. Trauma Invokes Fear Helplessness Horror Lack of control Overwhelms Coping mechanisms Childhood trauma is often especially damaging

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

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

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

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

9. poor physical health

10. substance abuse

11. eating disorders

12. relationship and self-esteem issues

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. Borderline Personality Disorder is but one of the possible impacts of childhood abuse represents a most pathologisingdiagnosis carries enormous stigma implying hopelessness, manipulation and resistance to treatment

23. MHCC / ASCA CollaborationLearning & Development Unit Long term impacts of Childhood Abuse: An Introduction Two day workshop for the community mental health workforce MHCC/ ASCA co-facilitation

24. 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

25. 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

26. Trauma Informed Care & Practice Meeting the Challenge Conference 2011 Part of a broader initiative towards a national agenda

27. 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

28. 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

29. 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)

30. 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

31. 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

32. 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

33. 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

34. 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

35. Service Systems So how different might service systems look if they are Trauma Informed ?

36. 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

37. 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

38. 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”

39. 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

40. 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

41. 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

43. Respectful

44. Hopeful

45. Informative

46. Holistic

49. 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

50. 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

51. 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

52. 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

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