The ongoing controversy about the scope of the Australia royal commission that is investigating child sex abuse -- that it is focusing only on the nation's institutional and organizational settings and not including families, and that it is not investigating other forms of abuse -- overshadows a remarkable event that occurred late last year and is now playing out across the country. Australia's Minister for Mental Health Mark Butler announced new national guidelines for trauma-informed care and practice. The Last Frontier: Practice Guidelines for Treatment of Complex Trauma and Trauma-Informed Care and Service Delivery were developed for individual practitioners and human service organizations, including hospitals, mental health clinics, prisons, schools, child welfare services, law enforcement, employment, housing, and legal services.
The Federal Department of Health and Ageing funded the development of the guidelines, which were produced by two people from Adults Surviving Child Abuse (ASCA) -- Dr. Cathy Kezelman, ASCA president, and Dr. Pam Stavropoulos, its consultant in clinical research (both are members of ACEsConnection). The announcement was held at the country's Parliament House in Canberra on October 29, Blue Knot Day, Australia’s national day of awareness about child abuse.
The national guidelines are a first step toward developing a national policy for trauma-informed practice for complex trauma, says Kezelman, a physician and president of ASCA. “They acknowledge the prevalence of unresolved complex trauma in mental health and general health and social services, and are a call for systemic change, both clinically and organizationally.”
The guidelines distill the last 20 years of research related to complex trauma. Most trauma treatments focus on event-driven trauma, such as natural disasters or car crashes. But more people have complex trauma, which is two or more types of severe and chronic trauma usually experienced in childhood. Australia is the first country in the world to issue national guidelines for complex trauma and trauma-informed care and practice, combined into one document. It is now a step ahead of the United States in elevating the issue of complex trauma and its long-term health, social, and economic consequences into the national conversation.
The following is a Q-and-A I did with Kezelman via email and Skype.
Why did Australia develop the guidelines?
Identifying and appropriately addressing the needs of people who have experienced trauma is a major public health challenge, not just in Australia, but globally.
• Complex trauma and its effects are often unrecognised, misdiagnosed and unaddressed. Human service systems – medical, mental health, education, social services, criminal justice systems -- do not routinely screen for complex trauma.
• People with complex trauma usually have a decades-long “revolving door” relationship with medical, mental health and social services. Their care is fragmented with poor referral and follow-up, and the systems they engage with often, and often unintentionally, re-traumatize them.
• This situation is psychologically, financially and systemically costly. In 2007 alone, the cost of child abuse to the Australian community is conservatively estimated to be at least $10.7 billion, and is almost certainly far higher.
Up until now, changes have been isolated and sporadic. Some forward-thinking mental health organizations in Australia have instituted trauma-informed practices for responding to people with complex trauma, some organizations have developed trauma-informed training for their staff, and a few parts of the criminal justice system are instituting changes. But this does not constitute broad-based practice and systemic change.
How should Australia address these issues?
In Australia, an entire systems change must be undertaken. Mental health and other human services need to screen for complex trauma, and identify, acknowledge and appropriately address the condition and its consequences. Colleges and universities need to provide courses in complex trauma and trauma-informed practices in social work, physical or mental health, criminal justice or education. All health services and systems – not just a few -- in all sectors of human service need to adopt a trauma-informed approach.
Professor Louise Newman, a psychiatrist and director of the Centre for Developmental Psychiatry and Psychology at Monash University in Melbourne says, “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.”
Research shows that the impacts of even severe early trauma can be resolved and its negative intergenerational effects can be intercepted. People can and do recover and their children can do well. For this to occur, mental health and human service delivery systems need to reflect the current research insights.
The guidelines establish a framework that responds to the national health challenge presented by people who have experienced complex trauma and set the standards for clinical treatment and trauma-informed care and service delivery.
The Last Frontier: Practice Guidelines for Treatment of Complex Trauma and Trauma-Informed Care and Service Delivery fills the long overdue gap between the overwhelming evidence about the effects of complex trauma on individuals and the possibilities, treatment and services that enable sustained recovery.
Why don’t treatment practices for regular PTSD work?
Trauma is often characterized as a single event, such as a car crash or natural disaster. Yet repeated extreme interpersonal trauma resulting from adverse childhood events is not only more common, but far more prevalent than currently acknowledged, even by the mental health sector.
Established guidelines for the treatment of trauma relate to post-traumatic stress disorder (PTSD). They are inadequate to address the many dimensions of complex trauma.
Research shows that most people who seek treatment for trauma-related problems have histories of complex trauma. It also shows that those who experience complex trauma may react adversely to current, standard PTSD treatments. There is thus a clear and urgent need for clinical guidelines that are directed to treatment of complex trauma.
The differences between complex trauma and `single-incident’ trauma are significant. For example, complex trauma includes repercussions of affect-dysregulation (difficulty regulating emotions and impulse control), structural dissociation (fragmentation and compartmentalisation of the personality), somatic dysregulation (challenges regulating bodily responses), and impaired self-development and disorganized attachment (challenges in formation of basic models of healthy relationships. These are not included or addressed in the diagnostic criteria for PTSD. But they are the foundation for clinicians working with survivors of complex trauma, regardless of the specific diagnosis or assessment and treatment methodologies applied.
What research are the guidelines based on?
The national guidelines are based on the research and recommendations of key clinicians and theorists of complex trauma, such as Christine Courtois and Julian Ford, authors of Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide; Bessel van der Kolk, founder and medical director of The Trauma Center at the Justice Resource Institute; Babette Rothschild, author of The Body Remembers; Vincent Felliti and Robert Anda, co-principal investigators of the ACE study, and others. These guidelines are the first to present the collective wisdom of the now substantial research knowledge that has been accumulated over the last 20 years to enable us to address complex trauma effectively using a number of core principles.
Numerous trauma-informed and trauma-specific models exist. Most were developed in the United States. The foundational principles for effective treatment of complex trauma are now solid, and best practices continue to evolve as our understanding of complex trauma deepens.
The core principles of trauma-informed care are safety, trustworthiness, choice, collaboration, and empowerment. These principles underpin the national guidelines, and, if comprehensively implemented, would result in a major shift in the way human services currently function.
What organizations should use these trauma-informed care and service delivery guidelines?
National and international research shows that the majority of people who use mental health services have experienced complex trauma. This is also true of people who use other parts of the human service sector, including hospitals, physicians, social services, law enforcement and prisons.
The current organization of human services does not reflect this reality, is manifestly inadequate to address it, and is in urgent need of reconfiguration. It is for this reason that an ever-increasing number of people and organizations are calling for a new paradigm of trauma-informed care and practice, in physical health and mental health specifically, and across the full spectrum of human service delivery.
Current research suggests that creating a trauma-informed culture can benefit staff and clients. Staff can benefit from greater job satisfaction and reduced risk of vicarious traumatization and burnout; clients, from reducing the risk of retraumatization and enabling recovery. To the extent that the large numbers of people who experience trauma-related problems access a range of diverse services, it’s critical that all aspects of human services incorporate trauma-informed practices. These include:
• Mental health and human service sectors, including drug and alcohol, sexual assault, child protection, housing, supported accommodation, and refugee services; disability, advocacy, and aged-care services; and services for indigenous, CALD (culturally and linguistically diverse), and GBLTQI (gay, bisexual, lesbian, transgender, questioning and intersex) people;
• Private-practice counselling, psychotherapy, psychology and psychiatry;
• Primary and allied health care services – general practice;
• Public and private hospitals;
• Criminal justice, child protection, emergency services, legal services, policing, education, employment and housing.
How many people in Australia have experienced some form of adverse childhood experience that can affect them later in life?
Five million Australians, out of a total population of 22.6 million, have experienced complex trauma. This number is drawn from studies that were conducted between 1992 and 2010, with the majority of the research dating from 2005-2010.
Child physical and sexual abuse
In 2007 an Australian University study of more than 21,000 older Australians, the largest of its kind to date, found that over 13% reported sexual or physical abuse in childhood. These figures did not include those emotionally abused or neglected or forced to live with family violence.
In a 2005 study by the Australian Bureau of Statistics, 18% of people over 18 reported having experienced physical or sexual abuse before the age of 15. Emotional abuse, neglect and being forced to live with family violence were excluded.
Up to one-quarter of young people aged 12-20 years old in Australia have witnessed an incident of physical domestic violence against their mother or stepmother. Witnessing male to female parental violence ranged from 14 per cent for those living with both biological parents to 41 per cent for those living with their mother and her partner.
Children also experience domestic violence when intervening to protect their mother. A Western Australian study found that one-third of children were hit by their father while trying to defend their mother or stop the violence.
In addition to exposure to domestic violence, it is estimated that in 30% to 60% of families where domestic violence is a factor, child abuse is also occurring.
Living with a parent with a mental illness
A detailed analysis in 2005 concluded that just over a million Australian children in 2005 under the age of 18 live with at least one parent who has a mental health issue.
Parent who abuses substances
It has been estimated that roughly 13% of Australian children live in a home with at least one adult who misuses alcohol.
A recent analysis of the 2007 National Drug Strategy Household Survey suggested that this figure is between 17 - 34%.
Parent in prison
On any given day in Australia, approximately 38,000 children have a parent in prison. About two-thirds of the women in prison are the mothers of dependent children.
Around one in four people aged 18-34 years in 2006-07 reported experiencing the divorce or permanent separation of their parents during their childhood. In contrast, less than one in ten people aged 65 years and over had experienced parental divorce or permanent separation before they were 18 years old.
Nearly one in five people aged 75 years and older reported having experienced the death of a parent when they were children. This compares with about one in ten people aged 55-64 years and about one in twenty aged 18-24 years.
Given the results of the ACE Study, do you think that 5 million people is a low estimate?
These are conservative estimates and were left conservative due to the difficulty in accessing reliable comprehensive data. Notably while these figures incorporate statistics from a number of categories of adverse childhood experiences, they do not include statistics from all of the categories included within the ACE Study. Notably, they do not include figures for the number of adults who have experienced emotional abuse and neglect as children.
The ACE Study indicated that 64% of people have experienced one or more adverse childhood experiences and hence the figure quoted of 5 million Australian adults could well be low.
The figure of 5 million has been quoted extensively to media and also to members of Parliament and is consistently met with disbelief. It would be important for Australia to conduct its own ACE research to secure accurate prevalence figures to inform policy reform.
How will the guidelines be applied?
The national guidelines are currently being disseminated through state and federal governments and government agencies as well as federal and state-based mental health bodies, umbrella practitioner organizations, nongovernmental organizations and to consumers, workers and practitioners.
The guidelines have been well received -- they have been downloaded more than 3,500 times since their release -- but it is now time to translate the research presented in the guidelines into practice. With funding from the government and a philanthropic body, ASCA has started to develop trauma-informed training for mental health and community sectors.
ASCA has also submitted a proposal to develop education and training workshops and online learning programs for primary care physicians and mental health practitioners from different disciplines. ASCA is also talking with the government about introducing broad-based trauma screening using Internet-based questionnaires, based on the pioneering work of the ACE Study.
What are the next steps?
We’ll be watching the level of take-up or practice informed by the national guidelines, and ASCA will continue to advocate for its broad-based introduction and build its networks both nationally and internationally to enable collaboration.
We hope the guidelines will lead to policy changes. ASCA and a number of other mental health organizations are driving a national agenda around trauma-informed care and practice. ASCA was involved in hosting a national forum in 2010 and a national conference around trauma-informed care and practice in 2011. The advisory working group, of which ASCA is a member, is currently developing a discussion paper to present to the National Mental Health Commission, whose role it is to advise mental health policy to government federally.
How have the national guidelines been received?
The national guidelines have been welcomed by practitioners, workers, consumers, and organizations inside and outside Australia. They are regarded as a long overdue and much needed accessible resource.
Prior to their release, 16 Australian organizations endorsed the guidelines, including the Australian Society of Psychological Medicine and the Centre for Developmental Psychiatry and Psychology; 40 individuals, including psychiatrists, psychologists, physicians, and nurses have endorsed it.
Outside institutions endorsing the guidelines include the Clinic for Dissociative Studies in London, England and the National Center on Family Homelessness in the United States. Prior to their release, 27 individuals in nine countries endorsed the guidelines, including Dr. Robert Anda, co-founder of the CDC’s ACE Study, Dr. Steven Frankel, psychiatrist and associate clinical professor at University of California-San Francisco Medical School; and Dr. Catherine Classen, director of the Women’s Mental Heath Research Program and associate professor of the Department of Psychiatry at the University of Toronto in Canada.
Is this a significant development, i.e., do you expect a significant shift in understanding about childhood adversity and its short- and long-term consequences?
This is a highly significant development. The guidelines have been described as `ground breaking’, and the level of national and international support they have received attests to the momentous point at which things currently stand. They have established the substantive research base behind the repercussions of childhood adversity.
We have been observing a gradual shift over time with progressive erosion of the stigma and taboo around child abuse and breaking of the secrecy and silence in some systems, including but not limited to religious institutions, particularly the Catholic Church, state-based institutions, organizations including the Boy Scouts and sporting organizations. The formation of the Royal Commission into institutional child sexual abuse in Australia is a crucial step toward child protection, justice, and accountability, and better meeting survivors' needs.
As a result we are now starting to see greater awareness around the reality of child abuse and neglect, although little awareness until recently about the long-term impacts of the broad diversity of complex trauma and its cost to individuals, communities and society in economic, health and welfare terms. There’s little acknowledgement of the abuse that occurs in the home and family. Minimization and denial are still at play, and overcoming society’s desire ‘not to know’ is challenging.
We believe the shift will come slowly. The recent announcement by the federal government of a Royal Commission to investigate institutional child sexual abuse will be a broad-based inquiry. ASCA is in regular contact with Australian governmental officials as the Royal Commission takes shape and it is expected that the guidelines will inform its operation. When the evidence is irrefutable, and when the government of the day starts to shift its understanding and provides support for change, greater acknowledgement and acceptance must surely follow.
There is also a substantial economic argument for change, in terms of the burden of disease, loss of productivity and associated community impacts. In its conversations with the Federal Government, ASCA has raised the proven savings of trauma screening as evidenced by the findings of medical evaluation incorporating such screening introduced in the US, based on the ACE Study. Conversations are ongoing. Evidence of the efficacy of informed practice with improved outcomes for individuals, communities, and the next generation provides the impetus for further conversations that will generate the significant shift we need to see.
When was Adults Surviving Child Abuse founded?
ASCA was founded in 1995 by a small number of passionate survivors who found there was nowhere to go for help to deal with the effects of their abuse. It is Australia's largest, most influential organization representing the interests of those who have survived childhood trauma in all forms -- complex trauma, interpersonally generated, rather than trauma caused by a single event. Based on the CDC’s ACE Study, ASCA expanded last year to include all survivors of complex trauma experienced during childhood. It has 5,000 members and associates.
Its advisory panel comprises 16 experts from all of Australia’s states and territories, and from a diversity of disciplines. They include psychiatrists, psychologists, counsellors, psychotherapists, general practitioners, mental health nurses, researchers and academics with affiliations to universities, colleges and institutes.