Putting trauma into perspective Dr Cathy Kezelman, President Adults Surviving Child Abuse (ASCA)
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Putting trauma into perspective Dr Cathy Kezelman, President Adults Surviving Child Abuse (ASCA)
Why am I interested in trauma? • Lived experience of trauma - sexually and emotionally abused as a child • Mental health consumer • Medical practitioner • President ASCA (Adults Surviving Child Abuse) • Director MHCC (Mental Health Coordinating Council) • Member NSW Mental Health Community Advisory Council • Member NTICP AWG (National Trauma Informed Care and Practice Advisory Working Group) 4
What happened to me? • Previously ‘successful’ GP, mother, 4 children – fiercely independent, emotionally detached, judgmental • Breakdown – anxiety, panic attacks, nightmares, flashbacks, depression, suicidal, fragmentation, body/sensations, emotions out of control • Terror, horror, confusion, chaos, shame, self-blame, self- loathing, hopeless, helpless, worthless • Isolated, alone, disconnected 5
What did I need to help me?
• To learn to feel safe, to trust
• To develop a healthy relationship - empathy, validation,
listening, hearing -> attachment
• To have someone bear witness to what had happened to
me
• To have support of family, friends, community
6What helped me recover? • Growing trust, safety -> regulate my emotions, find inner strengths and build on them -> greater empathy, patience, tolerance • Sharing of power/collaboration -> make choices ->more in touch with feelings, thoughts, beliefs, desires • Developing healthy relationship -> more connected, deeper relationships with therapist, friends, family • Integrating my mind, body, thoughts -> sense of self, self-esteem, overcoming shame • Making sense of what happened -> capacity to reflect 7
What could have happened to me? • Pathologised with multiple co-morbidities, misdiagnosed • Excess medication, damaging side-effects • Multiple admissions to multiple services, coercive treatments • Labelled, ostracised, stigmatised -> isolated, withdrawal lost to follow up, piecemeal treatment • Suicide, self-harm, substance abuse 8
What is trauma? • Experience of real or perceived threat • Invokes fear, helplessness, confusion, pain, loss of control • State of high arousal -> overwhelms normal coping mechanisms -`fight‐flight’ response -> `freeze’ response when threat cannot be escaped If trauma is not resolved, the person remains on `high alert’, is easily triggered by seemingly minor stress, and cannot `move on’ 9
What is complex trauma? • Interpersonal: more prevalent, premeditated, often repeated, extreme, prolonged, inescapable • Often developmental, compounded -> impacts cumulative • Trauma from childhood -> especially damaging because it compromises core neural networks • Survivors especially susceptible to re- traumatisation from triggers/ systems that reflect aspects of prior trauma (secrets, betrayal, ‘power over’) 10
Why is understanding trauma important? It’s common • Highly prevalent across all Australian communities and in services • Majority of people in mental health/human services sector - many overwhelming life experiences, interpersonal violence and adversity (Bloom, 2011; Jennings, 2004:6). • Trauma - expectation rather than exception Current organisation of mental health, health and human services does not reflect this reality and is inadequate to cope with it 11
Why is understanding trauma important? It’s destructive Unresolved trauma: • has negative effects across the life-cycle for those who directly experience it • has intergenerational impacts on the children of parents whose trauma histories are unresolved Parents do not need to be actively abusive for their children to be adversely affected. An unresolved trauma history will negatively impact infants via disrupted attachment styles 12
How can complex trauma affect people? • Lifetime patterns of fear • Lack of trust • Long-term difficulties with emotional regulation • Sensitivity to stress • Chronic feelings of helplessness • Affects relationships with self, others, the world • Disconnection and shame • Isolation • Confusion • Being `spaced out’ • Fear of intimacy and new experiences 13
How do people attempt to cope? Adopt extreme coping strategies in childhood to try to manage overwhelming traumatic stress Many persist in adult life ….. • Suicidality; Self-harm; Substance abuse; smoking ; physical inactivity; overeating • Dissociation ; tendency to repeat patterns of abusive relationships Behaviours can be challenging but in context of trauma make sense 14
What are possible impacts? • Diversity of mental health issues • Poor physical health • Substance abuse; eating disorders • On education, jobs, housing, relationships • Contact with the criminal justice system 15
What does trauma research tell us? (1) Adverse Childhood Experiences Study - US study of over 17,000 -> many public health problems may be long-term result of responses to abuse e.g. eating, drinking, smoking, gambling etc Felitti, Anda et al, 1998 • 10 ACE’s : 36% no score, 26% score 1, 16% score 2, 10% score 3, 12% score 6 or more • Higher ACE -> higher incidence of depression and antidepressant medication: 54% of current depression and 58% of suicide attempts in women attributable to ACEs • ASCA score of 4 -> 20% risk of attempted suicide 16
What does trauma research tell us? (2) • ACE score smoking, alcohol, drugs Many health risks associated with smoking, alcohol, drug use, obesity • Boys with ACE score of 6 or more -> 46 times more likely than those with a score of 0 to be IV drug users • ACE scores directly linked to: liver disease; chronic lung disease; coronary artery disease; autoimmune disease, obesity, diabetes, cancer, skeletal fractures 17
How might survivors present? • Easily frustrated, sensitive to criticism, insecure, low self- esteem • Hyper (physical or psychological agitation) or hypo-aroused (shut down – emotionally numb) • Self-harming or risk taking behaviours ‘Maybe most difficult part of having been traumatized is dealing with triggers that reside inside. The trauma is a thing of the past, but your body keeps reacting as if you are still in imminent danger’ (van der Kolk, 2011:xxi). 18
How does current system respond? • Often solely bio-medical approach – focus on symptoms not people: diagnosis, co-morbidity; pathologising, stigmatising, re-traumatising • Often fails to acknowledge possible underlying causes of presentations. Many trauma survivors have not connected current issues with past traumatic experiences; nor have their workers. • Systems and services need to understand prevalence, impacts, stakes of trauma to adequately support those with lived experience, families and communities 19
What happened to you - current system? “I suffered ill-treatment with medical professionals who did not recognise or did not know how to effectively handle trauma. I suffered 5 years of misdiagnosis, maltreatment and forced hospitalisation, in which re-traumatisation was prevalent.” Anonymous - survivor 20
It doesn’t have to be like this – evidence `A large body of knowledge about the impact of traumatic experience...on a wide variety of psychological, physical & social problems...is by now well established, yet there is still relatively little application of this science to standard practice’ (Bloom, 2011:82). 21
Presenting the evidence `The Last Frontier: Practice Guidelines for Treatment of Complex Trauma & Trauma Informed Care & Service Delivery’ Dr Cathy Kezelman and Dr Pam Stavropoulos; Adults Surviving Child Abuse (‘ASCA’) 2012 “These guidelines tackle the last frontier of mental health and medical services, namely, the recognition of the major role of trauma in the development of emotional disorders and medical illnesses and its unacceptably high individual, familial, and social/economic cost” Christine A. Courtois, PhD, ABPP Guidelines fill gap for whole system – practitioners, workers, organisations, systems and policy makers 22
Using evidence – changing practice • Evidence base to translate research into practice • Framework to respond to public health challenge of trauma Set the standards in each of the following domains: 1. `Practice Guidelines for Treatment of Complex Trauma’ - for clinical context; reflect role of trauma in mental illness and new possibilities for clinical treatment. 2. ` Practice Guidelines for Trauma-Informed Care and Service Delivery’ for services with which people with trauma histories come into contact 23
When we don’t use evidence `[M]any survivors have been retraumatized by [health professionals] who had inadequate understanding & skills to treat complex trauma-related problems...’ (van der Hart et al, 2006:224) Re-traumatisation by and within services and systems is highly prevalent . Trauma has often occurred in the service context itself’ (Jennings, 2004:6; Bloom & Farragher, 2011; Davidson, 1997) 24
When we don’t use evidence Every day ASCA receives calls from survivors to 1300 line: • health professional was disempowering, re-victimising or otherwise unhelpful • GP was uninformed - didn’t inquire about trauma despite highly suggestive symptoms. • worker didn’t know how to respond to disclosure • counsellor, psychologist or psychiatrist minimized or dismissed their feelings and experiences. “It happened such a long-time ago; there’s no value in talking about it. What does it matter? Stop whingeing about it.” 25
When we do use evidence
• Research shows that even severe early trauma can be
resolved, and its negative intergenerational effects can
be intercepted.
•
• People can recover and their children can do well.
• Time for hope and optimism to build on strengths and
resilience to facilitate recovery
Mental health and human service delivery need to
reflect the current research insights. Siegel, citing Roisman et al,
2002; Phelps, Belskg & Cmic, 1998, `An Interpersonal Neurobiology of Psychotherapy’
26ASCA Contact Details Support • Professional Support Line: 1300 657 380 • Counsellor: counsellors@asca.org.au • www.asca.org.au Professional Development and Training Inquiries events@asca.org.au ; 02 8920 3611 Guidelines www.asca.org.au/guidelines Dr. Cathy Kezelman; ckezelman@asca.org.au ; 0425 812 197 27
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