The second day of the forum was opened by Dr Cathy Kezelman, a medical practitioner, mental health consumer advocate and president of ASCA. Dr Kezelman spoke with us about the importance of trauma-informed practice within healthcare services.
Dr Kezelman began by defining recovery and wellbeing. Recovery involves moving towards a positive and meaningful sense of identity separate from a condition or disability. Wellbeing involves how a person feels about themselves and their life. Dr Kezelman spoke about the need for hope within healthcare services and the promise of moving towards recovery-oriented approaches.
Dr Kezelman explained that between 4 and 5 million Australian adults are affected by trauma and many health practitioners have their own trauma histories. Dr Kezelman highlighted that trauma also often also occurs inadvertently through people’s contact with healthcare services and unfortunately, mental health services currently don’t adequately reflect the impact of trauma. Dr Kezelman said that we need to become trauma-informed within healthcare services and, promisingly, research shows that people can recover from trauma through interventions that focus on strengths and resilience.
Dr Kezelman explained that becoming trauma-informed involves a strengths-based focus on safety and security. According to Dr Kezelman, the core principles of trauma-informed practice are: trustworthiness, collaboration, choice (autonomy, empowerment), clear roles and boundaries, and doing no harm. Ultimately, trauma-informed practice involves a focus on what has happened to the person rather than what’s "wrong" with the person.
Dr Kezelman said that in order to become trauma-informed, practitioners need to reflect on their beliefs and current practices, reassess roles, recognize issues of power and hierarchy, respectfully negotiate boundaries (to avoid harm and humiliation), and tolerate their own discomfort. She explained that practitioners need to understand consumers’ presentations in the context of their lived experiences and must also have a working knowledge of traumatic stress and its impacts. Further, practitioners must understand that opportunities for healing rest in the context of relationships. They must also be aware that trauma survivors are often sensitive to situations reminiscent of trauma and strong emotional reactions may be triggered by sensory input. Practitioners should understand that such responses are likely to make perfect sense in the context of that person’s experiences of trauma, and recognize that many apparently unhealthy behaviours are in fact adaptive responses to past trauma.
Dr Kezelman spoke of specific strategies for trauma-informed practice. Firstly, she explained that recovery from trauma occurs within the context of relationships and research shows that this is neurologically-based. Specifically, positive relational experiences assist neural integration and create new pathways of learning within the brain. Given that secure and supportive relationships are crucial to trauma-recovery, these positive experiences of connection must take place in healthcare services. People who have experienced trauma may experience the world as unsafe and believe people can’t be trusted. It is therefore difficult for people to seek help and trust help providers. Therefore, practitioners need to ensure both the physical and emotional safety of the consumer through being responsive to each individual’s needs and creating a space of security and safety.
Consumers with trauma histories need a welcoming supportive environment to facilitate reflecting and responding rather than reacting. Healthcare workers can should also practice open and respectful communication involving active listening and acceptance. They should avoid negative, pejorative labels and use person-focused language to ensure that the consumer feels listened to and validated.
In a related vein, Dr Kezelman said that ensuring consumers’ privacy and confidentiality creates an environment of consistency and predictability. People with trauma have experienced violation of personal boundaries and need to feel secure about their privacy and dignity in seeking help. Uncertainty and confusion can trigger intense trauma response and providing information can enhance consumers’ sense of safety and control. According to Dr Kezelman, when behaviours become challenging, practitioners’ immediate reactions are often to become more punitive and rigid. It is important in such situations to take time to find out what they need and work with them to deescalate.
Dr Kezelman also highlighted the importance of considering how culture impacts how trauma is experienced, how survivors manage, express experiences, and which supports are most effective. It is also important for workers to be aware of their own cultural attitudes and beliefs and how this impacts the way they view their work with clients. Dr Kezelman also said that involving consumers in peer support is an important endeavour, as this process counters shame, counters power imbalances, promotes understanding of dynamics of differences and creates shared decision making.
Dr Kezelman spoke of the importance of staff training in building a trauma-informed healthcare workforce. All staff in healthcare settings need to be informed that people can recover from trauma, there is hope, and we need to honour the person’s resiliency. Dr Kezelman also explained that staff wellbeing is an important consideration as staff sensitivities can be ignited by interactions with clients, especially if they themselves have an unresolved trauma history. Dr Kezelman stated that practitioners need to: 1) be aware of their own needs and limits; 2) establish a balance between work, leisure and rest; 3) foster connections with others and something greater e.g. spirituality. She also spoke of the need to promote collegial support, model warmth and respect within the workplace, and create opportunities for peer support and debriefing.
Dr Kezelman concluded with the benefits that implenting trauma-informed care practices have been demonstrated to bring to both consumers and staff in mental health and human services settings. These include improvements in clinical outcomes and consumer satisfaction with quality of care, as well as improved staff morale, collaboration with consumers and development of a mentally healthier workforce. Further information on training in trauma-informed care principles and practice is available from ACSA.
About Trauma-Informed Care and Practice
Trauma-Informed Care and Practice: a national strategic direction
Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery