Treatment of Complex Trauma and Trauma
Informed Care and Service Delivery
Perinatal Mental Health Seminar
Dr. Cathy Kezelman
©ASCA 2014
“Failure to acknowledge the reality of trauma and abuse in
the lives of children, and the long-term impact this can have
in the lives of adults, is one of the most significant clinical
and moral deficits of current mental health approaches.
Trauma survivors still experience stigma and discrimination
and un-empathic systems of care. Clinicians and mental
health workers need to be well informed about the current
understanding of trauma and trauma-informed
interventions” Professor Louise Newman
The Last Frontier: Practice Guidelines
for Treatment of Complex Trauma &
Trauma Informed Care and Service
Delivery
• Launched by Federal Minister for
Mental Health (October 2012)
• Endorsed by national and
international experts
• Download or purchase at
www.asca.org.au/guidelines
Single: Unexpected event - natural
disaster, traumatic accident, terrorist
attack or single episode of assault,
abuse or witnessing of it = PTSD
Complex:
• Interpersonal
• Inescapable
• Repeated
• Cumulative
Emotional Neglect
Recurrent
physical abuse
Physical Neglect
Recurrent
emotional
abuse
Mother treated
violently
One or no parents
Contact sexual abuse
Family
Community
Incarcerated
household
member
An alcohol
and/or drug
abuser in the
household
Family member
chronically
depressed,
mentally ill,
institutionalized,
or suicidal
Intergenerational
Ten Categories are from the Adverse Childhood Experiences (ACE) Study
Individual
ACE Study: Childhood trauma powerfully impacts mental
and physical health ‘a half-century’ later (Felitti, Anda et al, 1998)
Initially protective (and often creative) strategies to deal
with childhood adversity lose protective function
over time and threaten emotional AND
physical health in adulthood (Felitti, Anda et al, 1998)
Controlling
Avoidance
People pleasing
Numbing
Self harming
The ACE Score and a Lifetime History of
Depression
Percent depressed (%)
70
Women
Men
60
50
40
30
20
10
0
0
1
2
ACE Score
3
>=4
Percent attempted (%)
The ACE Score and the Prevalence of
Attempted Suicide
20
15
10
5
0
0
1
2
ACE Score
3
>=4
ACE Score and Drug
Abuse
Percent With Health Problem (%)
14
ACE Score
12
0
1
2
3
4
>=5
10
8
6
4
2
0
Ever had a
drug problem
Ever addicted
to drugs
Ever injected
drugs
(1) has negative effects across the life-cycle for those who
directly experience it
(1) intergenerational impacts on the children of parents
whose trauma histories are unresolved (Hesse, Main et al, in
Solomon & Siegel, 2003)
‘Emotional abuse, loss of caregivers, inconsistency, chronic
misattunement principal contributors to psychiatric
problems’ (Dozier, Stovall, & Albus, 1999; Pianta, Egeland, & Adam, 1996; van der Kolk, ibid)
• Impairs wide range of functioning
• Erodes health and wellbeing
• Disrupts neural integration
• Coping mechanisms affect quality of life
• High alert - easily triggered -> cannot `move on’
• deep feelings of insecurity; low self-esteem
• poor frustration tolerance; sensitivity to criticism
• hyper (physical or psychological agitation) or hypoaroused (shut down – emotionally numb)
• substance abuse, self-harming, suicidal, risk-taking
behaviours
• Anxiety; depression; health problems (emotional and
physical); disconnection and shame; isolation; confusion;
being `spaced out’; fear of intimacy and new experiences
Lifetime patterns of fear and lack of trust; long-term
difficulties with emotional regulation/ stress; chronic
feelings of helplessness; affects relationships with self,
others, the world
Conditions conducive to development of selfregulation (beginning with a sense of safety) are
crucial to adult survivors of childhood trauma
In contrast to the traumatized person who has
experienced a sense of safety and well-being prior to
onset of the (single-incident) trauma, the survivor of
complex trauma does not start with this advantage
(Shapiro, 2010)
The possibility of underlying trauma (ie even not
disclosed) requires immediate attunement to:
• attachment issues
• the possibility of dissociation
`Contact itself is the feared element because it brings
a promise of love, safety & comfort that cannot be
fulfilled & that reminds [the client] of the abrupt
breaches of infancy’ (Hedges, 1997:114; ibid).
People often show a `mix’ of `hyper’ (visibly agitated) and
`hypo’ (emotionally `shut down’) responses rather than
being `either-or’
KEY POINTS:
• Both HYPER & HYPO arousal responses can be traumarelated
• Failure to understand this leads to inappropriate
responses by health professionals
• Don’t underestimate capacity of positive
interactions to be soothing and validating
• Positive relational experiences promote wellbeing
- actively assist healing
• Prior experience of person is difficult – not person
This applies to us all - especially important for people
with trauma histories
New Paradigm
ahead
• Minimises re-traumatisation
• Recognises many conditions
are trauma-related
• Current systems inadequate
• Applicable to full spectrum of
human services delivery
(Perry, 2008; Ross and Halpern, 2009)
• Awareness of impacts
• ‘Do no harm’ approach
• Cultural safety
• Staff training
Safety
Trustworthiness
Collaboration
Empowerment
Choice
• Commits to and acts upon the core principles
• Requires evaluation of all components of the system
• Design service systems that ‘accommodate the
vulnerabilities of trauma survivors’ (Fallot and Harris, 2009:3)
• Delivered in a way that will ‘avoid inadvertent retraumatisation and...facilitate client participation in the
services which affect them’ (Fallot and Harris, 2009:3)
• Trauma as a defining and organising experience that
forms the core of an individual’s identity rather than a
single discrete event (Jennings, 2004; Fallot and Harris, 2009)
• Understanding client behaviours as adaptive attempts to
cope
• ‘What happened to the person rather’ than ‘what is
wrong with the person’
(Bloom, 2011; FallotandHarris, 2009)
• Emphasis on skill building
• Stress experienced by staff negatively impacts clients
• Staff sensitivities can be ignited in interactions with
clients, particularly if staff themselves have unresolved
trauma histories
• Vicarious trauma (VT) is the `negative transformation in
the helper’ from exposure to traumatic material in the
context of a helping relationship (Pearlman & Caringi, 2009)
Stress breeds stress and attentiveness to wellbeing is the
antidote
• Professional support line 1300 657 380
Operates 9am-5pm Monday - Sunday EST
• Education and training workshops
• Resources
Factsheets, guidelines, newsletters
• Advocacy and health promotion
www.asca.org.au
Contact:
Dr. Cathy Kezelman
ckezelman@asca.org.au 0425 812 197