by J Bateman · 2013 — The NTICP AWG was formed by a partnership established in 2011 by the Mental Health. Coordinating Council (MHCC), Adults Surviving Child Abuse (ASCA), NSW Health.

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ii Please cite this paper as follows: Ment al Health Coordinating Council (MHCC) 201 3 , Trauma – Informed Care and Practice: T owards a cultural shift in policy reform across mental health and human services in Australia , A N ational S trategic D irection , Position Paper and Recommendations of the National Trauma – Informed Care and Practice Advisory Working Group, Authors : Bateman , J & Henderson , C (MHCC) Kezelman, C (Adults Surviving Child Abuse , ASCA) © Mental Health Coordinating Council 201 3 Authors: Jenna Bateman , Corinne Henderson and D r Cathy Kezelman For any further information please contact: Jenna Bateman Chief Executive Officer , MHCC E: T: (02) 9555 8388 # 102 Corinne Henderson Senior Policy Advisor , MHCC E: T: (02) 9555 8388 # 101 Dr Cathy Kezelman President , Adults Surviving Child Abuse (ASCA) Board member MHCC E: T: (02) 8920 3611 Mental Health Coordinating Council Building 125, Corner of Church & Glover Streets Lilyfield NSW 2040 PO Box 668 Rozelle NSW 2039 Website:

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iii Contents Trauma – Informed Care and Practice: towards a cultural shift in policy reform in mental health and h uman services in Australia P urpose .. .. .. 2 P osition Paper Recommendations : A National Strategic Direction .. 3 Section 1 .. .. .. .. 4 Executive Summary .. .. .. .. 4 Trauma – Informed Care and Practice .. .. 4 Evolution of the national agenda in Australia .. .. . 5 National Trauma – Informed Care and Practice Advisory Working Group (NTICP AWG) .. .. .. 7 Section 2 .. .. .. .. 8 Language Understanding T rauma .. .. .. .. 8 Definitions .. .. .. .. .. 8 Principles of Trauma – Informed Care & Pract ice .. . 10 Section 3 .. .. .. .. . 14 International Evidence: The L iterature .. .. . 14 a. Defining trauma .. .. .. .. 14 b. Prevalence .. .. .. .. 14 c. Re – victimis ation .. .. .. 15 d. Populations at risk .. .. .. . 15 e. Presentation .. .. .. 17 f. Mental health impacts .. .. .. .. 18 g. Other health impacts .. .. .. 19 i. Resilience .. .. .. .. 20 j. Economic cost .. .. .. 23 Section 4 .. .. .. .. . 24 Systems .. .. .. .. 24 .. .. .. 24 2. Re – traumatisation in services .. .. 25 3. System failures .. .. .. . 27 4. Requisites for implementing Trauma – Informed Care and Practice across service settings .. .. .. .. 27 5. Benefits of introducing TICP International Evidence .. .. 28 6. Rationale for embedding TICP into Australian service systems .. . 29 7. A Trauma – Informed Recovery – Oriented approach .. .. 30 8. Why we need to change cultures and systems: .. . 31

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iv Section 5 .. .. .. .. . 33 T ICP in Australia A National Strategic Direction .. .. .. 3 3 Scope of reform .. .. .. .. .. 34 a) Mental health in Australia: current policy and workforce challenges . 34 b) Costs of retaining the status quo: health utilisation, burden of cost to individuals and communities .. .. .. .. 35 c) Systems for change broader implementation .. .. 38 d) Current developments in Australian TICP refor m .. . 42 Innovation .. .. .. .. . 44 a) Policy .. .. .. .. 44 b) Policy and Practice .. .. .. 44 c) Practice/Practice Guidelines .. .. . 45 Translation .. .. .. .. 46 a) Workforce development and training .. .. .. 46 b) Workforce capacity building .. .. .. 46 c) Research into practice .. .. .. 48 Dissemination .. .. .. .. 53 TICP in Australia a national strategic direction .. .. 53 Implementation .. .. .. 55 a. Role of the National TICP Advisory Working Group .. 55 b. MHCC and ASCA activities supporting and promoting TICP nationally .. 56 c. NTICP AWG ongoing activities .. .. 56 d. Priority activities for the NTICP AWG .. .. . 56 Section 6 .. .. .. .. . 57 Measurable Cultural Change .. .. .. . 57 Position Paper Recommendations .. .. 57 Consultation .. .. .. 58 Appendicies .. .. .. .. . 59 Appendix 1 NTICP AWG Terms of Reference .. .. .. 60 Appendix 2 MHCC Policy Template: General Integration of a TICP Approach .. 63 Appendix 3 ASCA Practice Guidelines Endorsement Listing .. 73 Appendix 4 TICP Activities 2006 – 2013 .. .. 78 Appendix 5 Trauma – Informed Care and Practice Organisational Toolkit (TICPOT) 84 Appendix 6 Bibliography .. .. .. . 87 Appendix 7 Endnotes .. .. .. 97

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Mental Health Coordinating Council September 2013 1 Trauma – Informed Care and Practice: towards a cultural shift in policy reform in mental health and human services in Australia National Trauma – Informed Care and Practice Advisory Working Group Position Paper and Recommendations – oriented, trauma – informed treatment program a little more than four years ago, where I felt safe and respected, that I could begin to What happened to you? instead of What s wron g with you? Tonier Cain , s urvivor 1 If the origins of so much dysfunction are to be found in the adverse experiences of childhood then what exactly is the role of the mental health professional, the substance abuse counsellor, the domestic violence advocate? What should social service institutions focus their efforts upon? Can we stay comfortably settled in our offices or is advocacy for fundamental change a moral necessity? Bloom , S & Farragher , B 2011 , Destroying Sanctuary: The Crisis in Human Service D elivery System , New York: Oxford University Press 2 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 in the early childhood shapes brain and psychological deve lopment, sets up vulnerability to stress and to the range of mental health problems. 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 curren t understanding of trauma and trauma – informed in terventions Professor Louise Newman, Psychiatrist and Director Centre for Developmental Psychiatry and Psychology, Monash University 3

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2 Trauma – Informed Care and Practice: A National Strategic Direction Th is position paper and recommendations are informed by the work of many international experts in the field, and their work underpins the recommendations outlined in the position paper. 4 Purpose Trauma – Informed Care and Practice (TICP) : a national strategic direction This paper provides the research evidence for Trauma – Informed Care and Practice and the rationale for cultural and systemic reform in Australia and also presents recommendations for a strategic framework for implementation at both service and system levels. It additionally identifies the steps needed to embed trauma – informed principles into policy and the integration of evidence – based research into practice. The p osition paper: encapsulate s the principles of Trauma – Informed C are and P ractice, and promote s the need for and benefits of their integration into mental health and human services practice and policy reform; delineate s the contexts in which the implement ation of t rauma – i nformed c are into practice would improve outcomes for consumers with trauma histories ; establish es the breadth and depth of reform needed for the incorporation of t rauma – i nformed care and practice across and within a diversity of human service sectors, cultures, systems, professional frameworks and models of service delivery ; explores implementation integration of Trauma – informed Care and Principles (TICP Principles) into practice at the systems and service levels ; and identifies the range of agencies and sectors to be engaged in establishing the TICP agenda including: State and Commonwealth Governments, policy makers, Mental Health Commissions , health and human service sectors as well as the broader community .

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4 Trauma – Informed Care and Practice: A National Strategic Direction Section 1 Executive Summary The experience of trauma and its impacts on individuals, communities and society as a whole are substantial . This paper recognises the prevalence of interpersonal trauma in our society ; it acknowledges that a large percentage of those seeking help across a diversity of health and human service settings have trauma histories severely affecting their mental and physical health and wellbeing . T he impacts of trauma characteristically persist lon g after the trauma has ended. Although exact prevalence estimates vary, there is a broad consensus that m any consumers who engage with public , private and community managed mental health and human services are trauma survivors and that their trauma experiences shape their responses to service providers . 5 This paper presents the position of the N ational Trauma – Informed Care and Practice Advisory Working Group ( N TICP AWG) on developing a national approach to trauma – informed care and practice. Inherent in this is a n understanding of the relationship between trauma, mental illness , co – existing conditions and complex psychosocial difficulties , particularly important in the context of dynamic changes to the service system environment in Australia including the introduction of the National Disability Insurance Scheme (NDIS) and Partners in Recovery . It incorporates the recommendations that the N TICP AWG present as necessary to facilitate a strategic approach towards a cultural shift in policy reform in mental health and human services in Australia . The paper is informed by extensive international and national evidence , and provide s a platform from which the NTICP AWG will advocate for broad – based policy reform to embed t rauma – i nformed principles of practice within and across jurisdictions and sectors. Trauma – I nformed Care and Practice We can now connect the psychobiology of trauma to the social determinants of health. Never before have we had an integrative framework that allows extensive and specialised bodies of knowledge to be connected to each other within a human rights context as well as a public health challenge. Bloom , S & Fa rragher , B 2013 , Restoring Sanctuary: A new operating system for trauma informed systems of care , Oxford University Press Australia s mental health and human service systems have, generally speaking, a poor record in recognising the relationship between trauma and the development of mental health conditions, co – existing difficulties and complex psychosocial problems, and responding appropriately to them. The lack of policy focus is reflected by a lack of awareness and education around trauma – informed app roaches within practice and service settings. 6 This position paper presents an approach described as Trauma – Informed Care and Practice (TICP) to address these factors. TICP exemplifies a new generation of transformed mental health and human service organisations and programs that serve people with histories of trauma.

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Mental Health Coordinating Council September 2013 5 Responding appropriately to trauma and its effects requires knowledge and understanding of trauma , workforce education and training, and collaboration between consumers and carers, policy makers, and service providers and crosses service systems. It involves not only changing assumptions about how we organise and provide services, build workforce capacity and supervise workers, but creates organisational cultures that are personal, holistic, creative, open, safe and therapeutic. TICP is a practice that can be utilised to support service providers in moving from a caretaker to a collaborator role . 7 When a human service program seeks to become trauma – informed, every part of its organisation, management, and service delivery system is assessed and modified to ensure a basic understanding of how trauma impacts the life of an individual who is seeking services. 8 By facilitating recovery through trauma – informed care, re – victimisation can be minimised and self and community wellness and connectedness can be promoted. Transformational outcomes can happen when organisations, programs and services are based o n an understanding of the particular vulnerabilities and/or triggers that trauma survivors experience (that traditional service – delivery approaches may exacerbate) so that services and programs can be more supportive, effective and avoid re – traumatisatio n. Trauma – Informed services understand that until an individual is safe physically and emotionally from violence and abuse, recovery is not possible (Herman, 1992). 9 Evolution of the national agenda in Australia In 2007, the Senate Standing Committee on Community Affairs conducted an Inquiry into Mental Health in Australia. The final report: Towards recovery: Mental health services in Australia , was tabled in September 2008. In response to numerous statements (inc luding representations and submissions from the Mental Health Coordinating Council ( MHCC ) and Adults Surviving Child Abuse ( ASCA) particularly identifying the link between poor mental and physical health, complex need and a history of trauma ; the Senate Committee called for Government recognition of adult survivors of childhood abuse, specifically emphasising the necessity for a nation – wide initiative for people with a diagnosis of Borderline Personality Disorder (BPD). MHCC and ASCA were amo ng those who strongly advocated for broad – based mental health and psychosocial supports for trauma survivors , contesting that (in the context of childhood trauma) BPD is but one of the possible impacts, and that using a particular diagnosis as a means to a ccess services is not only using a too – narrow lens but is also stigmatising and discriminatory. Then, as now, we advocate for the availability of a wide range of flexible, holistic, trauma – informed recovery – oriented services as well as funding for trauma – s pecific services. Our efforts led to collaboration with other organisations shar ing similar goals. In September 2010, MHCC, ASCA , NSW Health Education Centre Against Violence (ECAV) and the Private Mental Health Consumer Carer Network Australia (PMHCCN) he ld a forum, the purpose of which was to discuss the development of a national agenda for promoting Trauma – Informed Care and Practice (TICP) across public, private and community – based mental health and human service systems. The all – day forum brought togeth er individuals from several Australian states , including consumers and carers, federal politicians, the President of the NSW Mental Health Review Tribunal (at the time) , senior clinicians, health

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6 Trauma – Informed Care and Practice: A National Strategic Direction professionals and academics with expertise in mental health, disability and trauma across service sectors . It also included senior executives from a range of community – managed peak bodies and service providers experienced in working with the psychological impacts of trauma. The focus of the day was to identify exis ting research evidence about trauma and share experiences in practice. The forum discussions established the need for development of a service – delivery culture embracing a TICP approach, as well as the need to advocate for trauma – specific services. A spec ific outcome in the report of the day s proceedings was the call to host a national conference on trauma. This would form part of an ongoing broader initiative towards a national agenda promoting that the principles of trauma – informed care be integrated ac ross service systems throughout Australia. The landmark Trauma Informed Care & Practice: Meeting the Challenge Conference 2011 delivered by MHCC in collaboration with ASCA, ECAV and PMHCCN was held in Sydney in June 2011, funded by the NSW Health M ental Health Drug & Alcohol Office (MH DAO ) . The Hon Mark Butler MP, then Minister for Mental Health and Ageing, Minister for Social Inclusion , opened the event with a video welcome. Over 240 people from every state in Australia and New Zealand attended on both d ays. The conference included a specially made video presentation from Kathleen Guarino, a high – profile professional working in the trauma field for the Substance Abuse and Mental Health Services Administration ( SAMHSA ) in the USA. The event was targeted a t consumers, carers and people working in the mental health and human services sectors including public, private and community – managed agencies such as : drug and alcohol ; primary and allied health ; counselling ; refugee ; therapeutic and social support servi ces ; sexual assault and child protection, sexual health; disability ; Aboriginal, culturally, linguistically and ethnically diverse organisations ; as well as legal, advocacy education and research bodies. Subsequently in October 2011, MHCC launched a micro site (hosted from its website) devoted to TICP . As well as widely promoting the microsite across member organisations and collaborating partners networks we also encouraged people who had attended the original forum and the conference to join a TICP network. People were advised to visit the microsite for information about the work of the national TICP advisory working group (led by MHCC and ASCA) to : keep connected and share information ; read about TICP news and events; seek training opportunities; find resources ; and access research papers , video presentations and PowerP oint presentations including those of key speakers from the TICP conference in 2011. The TICP n e twork continues to grow and now comprises some 210 people/ organisations. Following these events, interest in trauma and trauma – informed care and practice have become topics high on the policy reform and workforce development agend a across service sectors. MHCC and ASCA along with other training providers facilitate numerous courses and professional – development opportunities targeted at different professional and practice groups across Australia . ECAV continue to provide consultation and training to clinici ans employed within NSW Health inpatient and community – based treatment services across metropolitan, rural and remote areas.

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Mental Health Coordinating Council September 2013 7 MHCC ha s been inundated with enquir i es about the provision of policy and organisational tools . There has been a marked increase in requests for specifically targeted professional development for the public, private and community – services workforce across numerous disciplines . O ther groups across service sectors and government have offer ed a range of trauma – related conferences, forums, seminars and ongoing training opportunities for a diversity of human service and health sectors including the criminal justice system. The N ational Trauma – Informed Care and Practice Advisory Working Group (NT ICP AWG ) is encouraged by the groundswell of interest and energy around its national agenda. National Trauma – Informed Care and Practice Advisory Working Group (NTICP AWG) The NTICP AWG was formed by a partnership established in 2011 by the Mental Health Coordina ting Council (MHCC) , Adults Surviving Child Abuse (ASCA), NSW Health Education Centre Against Violence (ECAV) and the Private Mental Health Consumer Carer Network Australia (PMHCCN). The partnership has facilitated opportunities for public, private and the community – managed mental health sectors to understand and embrace the principles of trauma – informed care and practice thereby adopt ing a shift in organisational culture and service delivery for people engaging with mental health and other human services w ho are victims/survivors of interpersonal trauma. Members of the National Trauma – Informed Care and Practice Advisory Working Group: Jenna Bateman, M e ntal Health Coordinating Council , NSW Dr Richard Benjamin, Eastern M ental Health Services, Rosny , TAS * Jo Campbell, Education Centre Against Violence ECAV, NSW *** Dr Sabin Fernbacher, Northern Area Mental Health Service, VIC* Corinne Henderson, Mental Health Coordinating Council , NSW Dr Cathy Kezelman, A dults Surviving Child Abuse A SCA, National Janne McMa hon, Private Mental Health Consumer Carer Network Australia, SA ** Jan Roberts, NSW Official Visitor, NSW * Alan Woodward, Lifeline Foundation for Suicide Prevention , National Dragan Wright, Creating Differently, p rivate practitioner, trainer ** (* Public sector; ** private sector; *** public education; others listed are CMOs) Advisors to the NTIC P AWG are: Professors Louise Newman, Beverley Raphael and Warwick Middleton ; Karen Willis (Rape Crisis) . The NTCIP AWG thank s Chris McCabe, ECAV for her participation and support on the AWG from 2010 to 2012 .

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