New Practice Guidelines for Treatment of Complex Trauma & Trauma-Informed Service Delivery were launched in the Australian Federal Parliament on October 29. They were produced by the Sydney-based organization `Adults Surviving Child Abuse' (ASCA) which is the peak body in Australia representing the interests of adult survivors of child abuse in all its forms. The Guidelines are being described as `ground breaking', and we have been overwhelmed by the national and international endorsements they have received.
Prior to their release, trauma guidelines have focused on `single incident' trauma (PTSD). This is in contrast to cumulative, interpersonally generated (`complex') trauma which research shows to be both more prevalent and more pervasive in its effects. The Guidelines actually comprise two sets - clinical and organizational. The first are designed for health professionals, doctors and clinicians who treat those who experience the multiple effects of complex trauma. The second are for service providers with whom people with complex trauma histories come into contact.
As we know from the ACE Study, suboptimal childhood experiences are alarmingly common. And the coping mechanisms they generate become the symptoms of adult physical and emotional ill health (key finding of current research - neuroplasticity means that resolution of early life trauma is possible!) It is also the case that millions of people who experience complex trauma, and who would potentially benefit from psychotherapy (which neuroscientific research now shows to be effective) will not be able to access it. Hence the urgent need for service settings which are accessed to operate with basic trauma awareness (and thus the capacity to avoid client re-traumatization). People with unresolved childhood trauma are in contact with diverse social institutions and services, from community agencies to the criminal justice system. We're not all clinicians, but we can all become `trauma-informed'. Neuroscientific insights into the effects of overwhelming stress on the brain would also seem to require this.
Like many projects, construction of the Guidelines has a back story. Initially the intention was to arrive at clinical guidelines alone. But as the research proceeded, it became clear that a second set of organizational guidelines was not only complementary, but at least as important. Neuroscientific research establishes that experiences shape both the structure and function of the brain, and that positive relational experiences assist neural integration. This also has implications for experience of services. As a society, we need to maximize positive relational impacts across the full range of human service delivery - from formal policies to informal worker;client interactions. Research shows that both direct clinical treatment and the way in which diverse services are provided (ie organizationally) needs to be `bottom up' as well as `top down'.
Given what we now know about the prevalence of unresolved childhood trauma, we are talking about millions of people who would benefit from our social institutions (including but beyond the health sector) becoming `trauma-informed'. As Sandra Bloom also highlights, the staggering prevalence of unresolved childhood trauma means that rigid distinction between those who give care and those who receive care is itself problematic. This is not a scenario of `us' and `them'. And while the delivery of health services is the obvious place to begin, there are many more human service settings that need to become trauma-informed.
That the powerful epidemiological data of the ACE Study is not yet widely operationalized remains a glaring anomaly. It is also an increasingly untenable anomaly. This is because ACE findings are now complemented by others from what Dan Siegel and colleagues call the new `consilience' - ie convergence of research findings independently arrived at from disciplines as diverse as psychology and affective neuroscience, and which coincide in a shared reading of the centrality of relational experiences to functioning of the mind, brain and body.
Much of this research comes from your country. So at first we were mystified (as well as delighted!) by the strength of the international affirmation we, in Australia, are receiving for the Guidelines. Hadn't we just collated and distilled diverse bodies of research and core elements to derive from them? But as invitation to present the guidelines at the recent Annual Conference of the ISSTD in Long Beach made clear (fulfilment of which afforded the coveted opportunity to meet Vincent in San Diego afterwards!) it was our own `integration' of this research which was being welcomed. That and the two sets of guidelines (both trauma-specific and trauma-informed) in combination with the intellectual and epidemiological credibility of the ACE Study.
In retrospect, and with the calibre of such research on our side, how could the Guidelines informed by it not be widely endorsed? The time is right for the alliance-building which is critical to operationalization of the now compelling evidence base. It is fitting that Vincent's first speciality was infectious diseases. Because Bloom has likened what we now know about the effects of adverse experience on the brain to discovery of the relationship between microbes and infectious diseases two hundred years ago (`the psychological equivalent of the germ theory!') Next step (beside which accumulation of the research may pale in comparison in terms of degree of difficulty!) is implementation of this knowledge....
The Last Frontier: Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery can be downloaded free of charge at www.asca.org.au/guidelines
A Q & A with ASCA President Dr Cathy Kezelman will soon be made available.
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