Match: Trauma-informed Service Integration for Trauma Recovery. Mental Health Services - Sexual Assault, Domestic Violence, Diverse traumas: Knowledge, resource sharing, interdisciplinary activity – the way forward for trauma recovery
Hosted by Blue Knot Foundation
This article includes the discussions and presentations of participants in this event but does not necessarily reflect the views or policies of the Mental Health Commission of NSW.
From Childhood Trauma to Recovery
By Susan Hely
Childhood trauma is all around us. It is the theme of this year’s Oscar-winning movie Moonlight, about a gay boy abused by his mother and gangs at school. It lives on in the experiences told by refugees arriving from war torn countries. It is a focus of the Australian Royal Commission into Institutional Responses to Child Sexual Abuse and it was also the focus of a two-day ‘match’ gathering held in February 2017 as part of the International Initiative for Mental Health Leadership.
Despite its visibility there is a stigma about talking publicly and privately about childhood traumas. Many people have never spoken about their personal trauma. But remaining silent and struggling on alone isn’t good for survivors. “We know that people who have not received the support they need to recover are often left struggling with their health and wellbeing,” explains Dr Cathy Kezelman AM, president of the Blue Knot Foundation, The Foundation, which hosted the match for mental health leaders from Australia, New Zealand and Sweden.
The Blue Knot Foundation is a national organisation that looks after the needs of adult Australians who have experienced trauma and abuse in childhood. Its research estimates that one in four Australian adults have experienced some sort of childhood trauma through neglect, domestic and family violence, war and civil unrest, other adverse childhood experiences as well as child sexual and other forms of abuse. Evidence about the serious psychological and physical toll that childhood trauma takes on adults is mounting. The landmark, long-ranging Dunedin Study tracks the lives of around 1000 babies born in the early 1970s, following up at regular intervals. It strongly indicates that early-life psychosocial stress such as child abuse and the interaction between ‘nature’ (genetic makeup) and ‘nurture’ children as well as the ways genetic expression can be affected by a person’s environment and leads to poor health and accelerated ageing. The findings revealed that there are early signs that young people with abuse histories might be at risk of sliding into psychosis without early intervention to prevent this from occurring.
Creating services that are `trauma-informed’, and building public knowledge about the impacts and how to support adult survivors was a key theme of the match. “We are all in this together and how do we all work it out?” Dr Pam Stavropoulos, head of research with the Blue Knot Foundation challenged the gathering.
Participants at the match discussed how the word ‘trauma’ is not necessarily the best one to explain the immense impact of abuse on people’s lives but coming up with a better term isn’t straightforward.
The match discussed what is trauma? “Trauma is overwhelming stress,” explains Dr Kezelman. “It overwhelms the coping mechanisms.” The Blue Knot Foundation focuses on cumulative, underlying trauma.
Certainly the awareness of being trauma informed is changing, according to participants. People who did speak out about their abuse in the past typically found that they weren’t believed, were often punished and re-traumatised, explains Dr Kezelman. “Typically they suffered from a massive failure of our systems of care,” she says.
“When we are able to acknowledge trauma and respond appropriately, we will no longer have a society that silences trauma survivors, ignores their trauma, fails to respond appropriately and makes the trauma so much worse,” says Dr Kezelman.
“Trauma robs people of their self,” says Dr Stavropoulos. “Many struggle day to day with their self-esteem and relationships as well as their mental and physical health.”
Many people who access the mental health and community service sectors have complex trauma histories.
Certainly trauma is a society-wide public health challenge and its financial, personal and societal costs are enormous according to the Blue Knot Foundation’s Economic paper, The Cost of Unresolved Childhood Trauma and Abuse in Adults in Australia.
The Blue Knot Foundation, formerly Adults Surviving Child Abuse (ASCA), trains professionals working in the health and legal sectors to better support survivors.
The Blue Knot Helpline on 1300 657 380 offers professional phone trauma counselling and support to around 5,000 callers every year. “We have people in their seventies and eighties calling for the first time,” explains Dr Stavropoulos.
Blue Knot also provides a referral database and runs workshops to help survivors and their friends and families live better lives.
The earlier trauma is addressed; the sooner people can work through it and stem trauma’s psychological and physiological damage.
Often those working with people who are trauma survivors are traumatised by what they hear. This is known as secondary or `vicarious’ trauma, explained Kersten Evelius, a match participant from the special advisory ministry of Health and Social Welfare in Stockholm. She explained that Sweden is grappling with an influx of refugees displaced by the war in Syria as well as parts of Africa, many of whom have had horrific experiences.
Measures to help protect children have been targeted not only at institutions but also at home life. Barbara Disley, the chief executive of Emerge Aotearoa, in New Zealand spoke about how the government has put a legal ban on parents hitting their children with force under the Anti-Smacking Bill that was introduced in 2009 in New Zealand.
Janet Peters, psychologist from New Zealand and IIMHL contractor, talked about a recent documentary film, `Resilience’, about adverse childhood experience and the biology of stress reveals there is a sharply higher incidence of heart attacks and depression among trauma survivors. It reported that lifespan could be reduced by 20 years.
Dr Stavropoulos discussed the recent program on dissociation on ABC radio’s All In The Mind. In it Professor Warwick Middleton, the director of the Trauma and Dissociation Unit at Belmont Hospital, talked about how a lot of child abuse occurs within the family. He stressed that the biggest institution in our society is one that isn’t being investigated by a Royal Commission and it is the family: “It is in many cases closed and fairly hierarchical, and it’s very, very hard for the average abuse survivor to speak out about what happened in the family,” explains Professor Middleton.
Recovery from Trauma
While the match discussed many challenges for services working with trauma survivors, particularly around receiving adequate support from the government and having enough skilled clinicians to help people recover from trauma, there are encouraging developments.
“Research has established that people who have experienced severe early trauma can recover. And when parents have actively worked through their own trauma, their children do better too. It intercepts transmission of trauma to the next generation,” explains Dr Kezelman.
Neuroscientific research establishes that the structure and function of the brain can change throughout life. Clinical findings show that even severe early life trauma can be resolved.
“The brain is neuroplastic and not hard-wired or fixed as previously thought. It can change in structure and function with new input and experiences,” explains Dr Kezelman.
Every interpersonal interaction has the potential to assist the integration of neural networks that can help a person’s wellbeing.
“This means paying attention to the way we engage with other people, as well as what we do. It also means thinking about what may have happened to someone rather than judging what is wrong with them,” she says.
There are many ways of helping trauma survivors recover such as counselling, psychotherapy and self-administered soothing and stabilising strategies.
Despite the advances in understanding trauma histories are often not taken. This often means that only superficial symptoms, such as depression and anxiety are treated and the real cause of the problem, the underlying trauma, can remain unrecognised. The core issues of the trauma need to be understood and appropriately treated for people to begin to recover. Misdiagnosis and medication-only treatment only does not deal with the trauma directly, says Dr Kezelman, although it can assist with symptoms.
Subject to being `trauma informed’, a range of psychotherapy and counselling approaches can be helpful. Community-based and other supports are also important. The traumatised person cannot `go it alone’ and expect the best outcomes, particularly where isolation has compounded the initial trauma.
The ACE Survey
One vital tool for identifying complex childhood trauma is the Adverse Childhood Experiences (ACE) survey. It is a ground-breaking way to identify different childhood traumas and can prompt appropriate follow up.
It was developed as part of a study, which started in 1998, and which found that childhood trauma was very common, including within the study’s cohort of university educated, middle class people. It found that people commonly experience different sorts of trauma, and the larger the range of trauma, the greater the risk of health, social and emotional problems. Also it found a strong link between childhood trauma and chronic diseases such as lung cancer, heart disease, diabetes, depression, autoimmune diseases, violence and suicide.
How does the ACE study work? It measures 10 types of childhood trauma. Five are directly interpersonal — physical abuse, verbal abuse, sexual abuse, physical neglect, and emotional neglect. Five are related to other family members: a parent who’s an alcoholic, a mother who’s a victim of domestic violence, a family member in jail, a family member diagnosed with a mental illness, and the disappearance of a parent through divorce, death or abandonment. Each type of trauma counts as a score of one. So a person who has been physically abused, with one alcoholic parent, and a mother who was beaten up has an ACE score of three. The study of 17,000 people found that 64% had an ACE score of at least one, 40% had 2 or more and 12% had an ACE score of 4 or more different types of adversity.
There are other types of childhood trauma such as losing a caregiver (grandmother, mother, grandfather, etc.), homelessness, surviving and recovering from a severe accident. However, the ACE Study limits itself to the most common.
One of the topics of the conference was how organisations put the ACE assessments and subsequent interventions into practice.
The Value of Lived Experience
One group of people who intimately understand the challenge of coping with trauma and the possibility of recovery and healing are people with a lived experience.
It’s important to remember that the person who has experienced trauma is the expert of their experience. Despite the chaos, each survivor has within them the strength to work though the confusion with good supports along the way.
Within metal health services, people with a lived experience are employed as lived experience workers often known as peer workers
“Peer workers can share the skills, leanings and stores from their journey to support others in their recovery,” explains event participant Jane Ellis, a carer consultant with the office of the chief psychiatrist, SA Health.
Often people with trauma are distressed and unable to coherently articulate what has happened to them and how they feel. Lived experience workers can translate between individuals, families and support people to assist understanding and compassion of the impacts of trauma.
Lived experience can develop a good rapport with trauma survivors and assist them to connect with services and community supports.
In many instances people with trauma and staff prefer to work with people with a lived experience. Some countries have a mandated quota of peer workers. They can also help break down the stigma experienced by people with trauma and hopefully break down discrimination. But there is still a lack of awareness about the value of lived experience workers.
People with lived experience in Australia can train by completing a certificate IV in mental health peer work.
A growing number of people with lived experience from the community work with clinicians, government, researchers and educators. They advocate to help improve and change the mental health system so that it is relevant and meaningful.
How to speak about trauma
Having a supportive conversation with someone who experienced childhood trauma can be life changing. Dr Kezelman says individuals, services, and social institutions can become trauma-informed and interact in a positive way, using sensitive language with survivors.
The Blue Knot Foundation’s publication Talking About Trauma is a practical guide for people to talk about trauma. Dr Kezelman says that it is vital to look for ways to bring safety, trust, choice, collaboration and empowerment into all interactions and conversations.
The gathering agreed that changing the conversation about trauma is important for everyone as we are all likely find ourselves in situations of needing to support survivors. It is better not to tell survivors to ‘move on” or ‘snap out of it’ or ‘focus on the positive’, as these phrases can have the effect of discounting their distress and increase their sense of isolation.
Because what is good for trauma recovery is also good for general wellbeing, being informed about trauma is a winning strategy for everyone in society.
One of the important developments is Blue Knot Foundation’s guide for everyday conversations with people who you know or suspect have actually experienced trauma.
Six Books on Trauma
The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma
By Bessel van der Kolk (2014)
Rebuilding Shattered Lives: Treating Complex PTSD and Dissociative Disorders
By James A. Chu (2011)
The Mindful Brain: Reflection and Attunement in the Cultivation of Well-Being
By Daniel J. Siegel (2007)
Building the Bonds of Attachment: Awakening Love in Deeply Troubled Children
By Daniel A. Hughes (2004)
The Child Survivor: Healing Developmental Trauma and Dissociation
By Joyanna L. Silberg (2013)
On the Web
Still Face Experiment: Dr Edward Tronick