Trauma Informed Peer Work - Resource Booklet

Acknowledgements © 2018 Mental Health Coordinating
Council. Apart from any use permitted

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custodians of the land. be reproduced by any process without
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The Mental Health Coordinating Council Requests and enquiries concerning
(MHCC) acknowledges and greatly reproduction and rights should be
appreciates the funding provided by NSW addressed to:
Health (Mental Health Drug and Alcohol Mental Health Coordinating Council
Office) to establish training and other Attention: Learning and Development Unit
workforce-development initiatives for PO Box 668
community-managed organisations Rozelle, NSW 2039
working for mental health in NSW. Phone: +61 2 9555 8388, extension 106
Email: training@mhcc.org.au
MHCC acknowledges the work of co-
authors Michelle Everett (OVP), Corinne
Henderson (MHCC), Yvette Segal
(MHCC), Lorna Downes (previously from
MHCC) and Dr Cathy Kezelman (Blue
Knot Foundation) and the invaluable
contribution people with lived experience
and the project reference group made to
the development of this training both
originally and subsequently when involved
in reviewing material for updates.
MHCC thanks everyone else involved in

the development of this book.
National Training
CHC
Package
Version number: 1.2.0
Original release: April 2016
Last revised: December 2018
Release for use: February 2019
Published and distributed by: Mental

Health Coordinating Council © 2018
Cartoons by Merinda Epstein reproduced
with permission.
Disclaimer
The Mental Health Coordinating Council
does not give a warranty nor accept any
liability in relation to the content of this
work.
Resource Book v1.2.0 1 © MHCC 2018

Cert IV MHPW-Trauma Informed Peer Work
Acknowledgements
MHCC acknowledges the traditional custodians of the land.
The Mental Health Coordinating Council (MHCC) acknowledges and greatly appreciates the
funding provided by NSW Health (Mental Health Drug and Alcohol Office) to establish
training and other workforce-development initiatives for community-managed organisations
working for mental health in NSW.
MHCC acknowledges the work of co-authors Michelle Everett (OVP), Corinne Henderson
(MHCC), Yvette Segal (MHCC), Lorna Downes (previously from MHCC) and Dr Cathy
Kezelman (Blue Knot Foundation) and the invaluable contribution people with lived
experience and the project reference group made to the development of this training both
originally and subsequently when involved in reviewing material for updates.
MHCC thanks everyone else involved in the development of this resource book.
National Training Package N/A
Version number: 1.2.0
Original release: January 2016
Last revised: January 2019
Release for use: January 2019
Published and distributed by: Mental Health Coordinating Council © 2018

Cartoons by Merinda Epstein reproduced with permission.
Disclaimer
The Mental Health Coordinating Council does not give a warranty nor accept any liability in
relation to the content of this work.
© 2018 Mental Health Coordinating Council. Apart from any use permitted under the
Copyright Act 1968, no part may be reproduced by any process without prior written
permission from the MHCC. Requests and enquiries concerning reproduction and rights
should be addressed to:
Mental Health Coordinating Council
Attention: Learning and Development
PO Box 668
Rozelle, NSW 2039
Phone: +61 2 9555 8388, extension 106

Contents
Overview of workshop ................................................................................................ 5
Aims of the workshop ....................................................................................................... 5
Learning outcomes ........................................................................................................... 5
Language and definitions ........................................................................................... 6
Preferred language ........................................................................................................... 6
Person-first language ....................................................................................................... 7
Safety in the learning environment ................................................................................... 8
Introduction ................................................................................................................ 9
Principles of a trauma-informed care and practice approach ..................................... 9
Trauma-informed recovery-oriented services and practice ...................................... 11
The Policy Context ......................................................................................................... 11
Understanding the nature and impact of trauma ...................................................... 13
What is trauma? ............................................................................................................. 13
Why are some people more affected than others? ......................................................... 17
Common beliefs about trauma—what do you believe? ................................................... 19
Coping with the impact of trauma ................................................................................... 20
Suicide ........................................................................................................................... 27
Understanding the stress response ................................................................................ 29
Trauma-informed care and practice — recognition of safety .................................... 42
Attachment relationships ................................................................................................ 43
Safety in service environments ....................................................................................... 49
Re-traumatisation of consumers and carers within services ........................................... 51
Using an understanding of trauma to support safety and recovery ................................. 53
Families and communities – ripples of trauma ......................................................... 58
The experience of Aboriginal and Torres Strait Islander Peoples.................................... 58
Ripples of healing ........................................................................................................... 62
Culture, gender and privilege.......................................................................................... 64
The importance of safe and healing relationships .................................................... 66
Peer worker characteristics and contribution to the relationship...................................... 68
Boundaries and relationships ......................................................................................... 69
Impact on workers .................................................................................................... 77
Trauma-informed responses to heightened distress ................................................ 83
Strengths-based practice ................................................................................................ 84
Collaborative and strengths-based ways of responding to distress ................................. 85

Contributing to organisation and system change ..................................................... 86
Appendix A: A short history of interpersonal trauma and its relationship to mental
health ....................................................................................................................... 92
Appendix B: Prevalence of interpersonal violence in Australia ................................. 97
Appendix C: Grounding strategies ......................................................................... 103
References ............................................................................................................. 106
Glossary of terms ........................................................................................................... 114

Overview of workshop
This course is specifically designed for consumer and carer peer workers who work in the
mental health sector.
This course focuses primarily on interpersonal trauma, that is, trauma that occurs in the
context of human relationships. Interpersonal trauma is highly prevalent in the community as
a whole, and particularly evident among those who seek and receive services. However, the
principles and the knowledge that underpins this course are relevant to any kind of trauma,
and a trauma-informed approach should apply whether lived experience of trauma is known
or not.
Aims of the workshop

To enable community service workers and mental health workers to:
• understand contemporary thinking about trauma-informed care and practice and

apply this approach to the workplace
• feel confident to respond to and support people who have experienced trauma.
Learning outcomes
On completion of the course participants will be better able to:
• understand the relationship between recovery-orientation and a trauma-informed

care and practice approach
• understand the principles of a trauma-informed care and practice approach and apply
them to the workplace
• understand stress responses to trauma in the body and the brain
• understand the responses to trauma and the impact on the individual, the family and
communities
• understand the potential psychosocial outcomes of the lived experience of trauma
• understand the importance of safety including in the body, environments and
relationships
• develop trauma-informed relationships that foster support and healing
• appropriately respond to disclosures, triggers and flashbacks
• appropriately respond to distress through a strengths-based approach
• exercise self-care and understand the impact of vicarious trauma.
Important information
This course will not prepare participants to provide trauma-specific treatments or
therapies that are typically provided by psychologists, psychotherapists, psychiatrists and
other mental health professionals. However, participants may acquire a better
understanding of the diversity of alternatives available in order to support people to
access them when needed and want them.
This resource book covers and greatly supplements the materials discussed over the two
days of this training.

Language through a recovery lens: a national perspective
The Commonwealth Government (Australian Health Ministers’ Advisory Council) makes the
following point regarding language.
Words and language are critically important in the mental health field where stigma and
discrimination, disempowerment and loss of self-esteem can cause people to battle with self-
stigma. Consistent with the language of recovery, the following ‘people-first’ language
descriptors are used wherever possible:
‘person’, ‘people with lived experience’, ‘lived expertise’ and ‘experts by experience’
rather than ‘clients’, ‘service users’ or ‘patients’
‘family and support people’, which includes family members, partners, friends or
anyone whose primary relationship with the person concerned is a personal,
supportive and caring one (Commonwealth of Australia, 2013, p. 5).
‘mental health condition’, ‘mental health issues’, ‘mental health difficulties’, ‘challenges’
and ‘emotional distress’ are used where possible in place of diagnoses, ‘mental
health problems’, and at times, alongside the term ‘mental illness’
Official Australian legal and policy documents tend to use the terms ‘consumers’ and
‘carers’; however, not every person chooses to use these terms to refer to themselves.
Language and definitions

As discussed in Foundations of Mental Health Peer Work 1, language can be alienating,
controlling, dismissive, incomprehensible and even offensive. However, language can also
convey respect and understanding and particular word choices to describe people and their
experiences can be empowering. Two principles guide our choice of language in this course
and in working respectfully in mental health. They are the principles of preferred language
and person-first language.
Refer to the Resource Book Foundations of Mental Health Peer Work 1 for more information
on these principles and a list of key terms and abbreviations.
Preferred language
The language chosen for use in this course may not be the best fit for every person you work
with, or for every worker. Workers should actively seek to use and understand the preferred
language of individuals with respect to how they describe and define themselves, their
experience of trauma and their distress. Preferences may have a cultural basis (including
consumer-activism culture), or a personal, political or philosophical values base, and all of
these considerations should be taken into account in how you use preferred language.
The language (and conceptual) preferences of people using

community and/or mental health services should be integrated by
workers into all forms of communication including procedures and
documentation wherever possible.
Preferences in the use of language may also reflect the person’s degree of comfort in talking
about what has happened to them (e.g. the ‘attack’ rather than the ‘rape’), their identity
(‘survivor’ rather than ‘victim’, or vice versa) or reveal their own perspective of those events
(‘rage’ rather than ‘violence’). This language may change over time and may (or may not) be
meaningful with respect to how the person understands the impact of trauma.

The guiding principles are self-determination, choice and respect, and workers are
encouraged to be guided by the preferred language of the person with whom they are
working.
Person-first language
Person-first language is language that always identifies a person before describing any
attribute. In mental health services, person-first language can be overlooked in favour of
professional language, which can have the effect of characterising people as if the person is
the ‘diagnosis’ or is the ‘symptom’.
It reminds us to not lose sight of the person, and to avoid making the mistake of thinking that
all that is relevant to know is that the person has a particular diagnosis of mental illness or
has experienced a particular trauma. Person-first language emphasises that a person is
much more than their mental, social or emotional distress. They are a mother, cousin, uncle,
friend, lover, worker, neighbour, artist, musician, poet, pet owner, elder or advocate; they
have other identities as people and as members of their communities.
Note: There is a glossary of terms on page 114 of this book.

Safety in the learning environment
Understanding the importance of safety will be a recurrent theme in this course, and includes
safety for the learner. The facilitators will work to ensure that people feel safe enough to
listen and learn. We encourage people to talk to the facilitators if they feel their response will
interfere with their ability to take part in the course.
We recognise that:
• A high proportion of people have a lived experience of trauma, so the likelihood is

that participants in this course may have their own personal experiences with trauma
• Many participants are likely to be close to someone in their lives who has
experienced trauma
• Even without a personal lived experience, the subject matter around the topic of
trauma is difficult and often painful to hear.
Some of the ways in which this course will utilise the principles of trauma-informed care in its
delivery will include the following:
• We encourage participants in the course to do what they need to do in order to keep

themselves safe, e.g. leaving the room for a short time or organising to talk to a
person they trust
• You will not be required to do anything that feels unsafe to you – we will always do
our best to negotiate different ways of learning and working together around this topic
• Throughout the course we will learn about and practice different coping and
grounding skills. You can read more about grounding strategies in Appendix C
• All participants are asked to respect the confidentiality of others and what is shared in
the group
• All participants are asked to show respect for each other’s experiences and feelings
• No participant will be expected to discuss his or her own traumatic experiences
• If you do refer to your own personal experience or the stories of others, we ask that
you do this in general terms only. Sometimes the specific nature of one person’s
experience can inadvertently distress others
• The course is conducted in a collaborative manner, which means that you will have
many opportunities to contribute to how the days of this course are run.
Notes: Group agreement/ self-care agreement

Introduction
Many people who have accessed or are receiving support for their mental health have
experienced trauma in their childhood, in their family, in their community, at schools or within
other institutions including mental health services. The experience of mental distress itself
can also be traumatic, and lead to traumatic losses and other experiences such as
homelessness. Trauma affects the way people relate to others and the way they access a
whole range of services. Unless services understand and respond effectively to the impacts
of trauma we risk adding to the effects of trauma and creating further harm.
The objective of trauma-informed care is that service delivery is informed by an

understanding of the impact of trauma. Trauma-informed care has been defined in the
following way:
Trauma-informed care is a strengths-based framework that is grounded in an

understanding of and responsiveness to the impact of trauma, that emphasizes
physical, psychological, and emotional safety for both providers and survivors,
and that creates opportunities for survivors to rebuild a sense of control and
empowerment. (Hopper, Bassuk & Olivet 2010)
The following set of principles provides a framework for understanding and implementing
trauma-informed care. This course will introduce and explore the principles of trauma-
informed care listed below; it will provide participants with an opportunity to consider how
these principles can be applied in their work and in their service or organisation.
Principles of a trauma-informed care and practice

approach
Broadly speaking, trauma-informed care and practice principles are:
• based on current literature
• informed by research and evidence of effective practices and philosophies
• led by consumers/survivors
• culturally safe and inclusive.

The eight foundational principles that represent the core values of trauma-informed
care and practice are:
Principle 1 - Understanding trauma and its impact - A trauma-informed approach

recognises the prevalence of trauma and understands the impact of trauma on the
emotional, psychological and social wellbeing of individuals and communities
Principle 2 - Promoting safety - A trauma-informed approach promotes safety -

Establishing a safe physical, psychological and emotional environment where basic
needs are met, which recognises the social, interpersonal, personal and environmental
dimensions of safety and where safety measures are in place, and provider responses
are consistent, predictable, and respectful
Principle 3 - Supporting consumer control, choice and autonomy - A trauma-

informed approach values and respects the individual, their choices and autonomy, their
culture and their values
Principle 4 - Ensuring cultural competence - A trauma-informed care and practice

approach understands how cultural context influences perception of responses to
traumatic events and the recovery process; respects diversity; and uses interventions
respectful of and specific to cultural backgrounds
Principle 5 – Safe and healing relationships - A trauma-informed care and practice

approach fosters healing relationships where disclosures of trauma are possible and are
responded to appropriately. It also promotes collaborative, strengths-based practice that
values the person’s expertise and judgement
Principle 6 - Sharing power and governance – A trauma-informed care and practice

approach recognises the impact of power and ensures that power is shared
Principle 7 - Recovery is possible - Understanding that recovery is possible for

everyone regardless of how vulnerable they may appear; instilling hope by providing
opportunities for consumer involvement at all levels of the system; facilitating peer
support; focusing on strength and resiliency; and establishing future-oriented goals
Principle 8 - Integrating care - Maintaining a holistic view of consumers and their

recovery process; and facilitating communication within and among service providers and
systems.
Adapted from: Fallot, RD & Harris, M 2009, Creating Cultures of Trauma-Informed Care (CCTIC): A
Self- Assessment and Planning Protocol, Community Connections, Washington, DC. (MHCC, 2018)
Trauma-informed services have benefits for all who participate in a service including staff
(Cocozza et al. 2005; Finklestein et al. 2005; Bloom 2010). Trauma-informed services
recognise that staff who work in those services may also have experienced significant
trauma in their own lives (Bloom 2010).
In a trauma-informed service, every person has a responsibility to practise in ways that are
trauma-informed, including managers, administrators and supervisors.
To provide trauma-informed services, all staff of an organization, from the receptionist to

the direct care workers, to the board of directors, must understand how violence impacts
the lives of the people being served, so that every interaction is consistent with the
recovery process and reduces the possibility of re-traumatisation. (Elliot et al. 2005, p. 462)

Trauma-informed recovery-oriented services and practice
The Policy Context
All Australian mental health services (government and community managed) have a clear
mandate to offer services that are recovery-oriented. Recovery orientation has been widely
adopted as an overarching philosophy of practice, guiding mental health service delivery. It
is embedded into policy and practice standards in Australia and is widely accepted
internationally and nationally across mental health and psychosocial support services. The
principles of TICP and recovery-oriented practice are aligned, and contemporary best
practice is a trauma-informed recovery-oriented approach.
In this context, recovery is a process that is consumer driven, defined and directed.
Recovery is a journey that is facilitated by the person’s own decisions, actions and choices.
Recovery-oriented services place a high value on recognising a person’s rights, capacity and
lived-experience expertise to determine the nature of the care and support they receive.
Recovery-oriented services recognise the whole of the person in the context of their life
experience, culture and community, their values and priorities.
The Australian government recognises the importance of trauma informed care services in:
o Fifth National Mental Health and Suicide Prevention Plan
o Trauma-informed services and trauma-specific care for Indigenous Australian
children.
o Roadmap for national mental health reform 2012-2022, COAG
o Australian Health Ministers’ Advisory Council 2013, The National framework for
recovery oriented mental health services: Policy & Theory.
The National Mental Health Commission has also recognised the importance of a TICP
approach in:
• National Mental Health Commission 2015, Contributing lives, thriving communities:
Report of the National Review of Mental Health Programmes and Services, Volume 1
Strategic Directions, Practical Solutions 1–2 years.
In 2013/14 the NSW Mental Health Commission emphasised the importance of incorporating
and understanding trauma and its effects in mental health service provision as evidenced in
the following documents:
• Living Well - A Strategic Plan for Mental Health in NSW 2014-2024.
• Yarning Honestly About Aboriginal Mental Health in NSW 2013.
The NSW Ministry of Health has recognised the significance of responding to trauma and its
effects in mental health service provision. This is evidenced in the following New South Wales
Health Policy Directives, Guidelines and Plans including: Aboriginal Mental Health and Well
Being Policy 2006-2010; Aggression, Seclusion & Restraint in Mental Health Facilities -
Guideline Focused Upon Older People; Aggression, Seclusion & Restraint in Mental Health
Facilities; Building Strong Foundations (BSF) Program Service Standards; Clinical Care of
People Who May Be Suicidal; Drug and Alcohol Psychosocial Interventions Professional
Practice Guidelines; Sexual Safety - Responsibilities and Minimum Requirements for Mental
Health Services; Sexual Safety of Mental Health Consumers Guidelines.
The NSW Strategic Mental Health Plan 2014-2024 identifies trauma-informed care as a key
workforce training priority for mental health (in development).

Recent research has established that the majority of people accessing mental health
services have experienced one or more significant traumas in their lifetime, and many are at
increased risk of further trauma. These experiences of trauma continue to impact on the
distress experienced by the person, their relationships with others and their interaction with
services. It can be argued that in order to be recovery-oriented, services need to
acknowledge this significant aspect of the lives of consumers.
A trauma-informed care and practice approach is a critical development within services that
are recovery-oriented. It is not an additional service, but a set of values, knowledge and
principles that enhance the capacity of a service to support recovery.
Becoming trauma-informed may also require a cultural shift in services and for workers,
because trauma has typically been overlooked or minimised in its relevance. Services and
workers are in a position to acknowledge the impact of trauma, the ways in which the person
has coped with this trauma and to engage in practices that do not compound or add to this
trauma.
Recovery-oriented practice and trauma-informed care: the common factors

A trauma-informed recovery-oriented practice approach demonstrates values and principles
that include:
• Establishing safety
• Strengths-based practice
• Valuing a person’s lived experience
• Avoidance of pathologising and labelling
• Working in ways that support autonomy and self-determination
• Recognising and addressing power imbalance
• Intentionally building hope and optimism
• Building trust and mutual respect.
The approach also reframes ‘symptoms’ as adaptations to life events, and as solvable
emotional difficulties. There is also a recognition of the limitations to what practitioners can
offer and the resilience of people to self-direct their own recovery and determine the type of
support they would like to access. There is no magic solution to human distress therefore
humility on the part of professionals helps ‘keep it real’. It also avoids any pretence that if
only people were less ‘treatment resistant’ they would rapidly recover.
This course has been written to be consistent with recovery-oriented practice within mental
health support services, but can equally be utilised by those working in any service that has
contact with mental health consumers.
Key messages
• Trauma-informed care is not trauma therapy.
• Trauma-informed care can be practiced and its principles embedded
across a wide range of service settings.
• It has benefits for all involved in and with the organisation.

Understanding the nature and impact of trauma
Principle 1 - Understanding trauma and its impact

A trauma-informed care and practice approach recognises the prevalence of trauma and
understands the impact of trauma on the emotional, psychological and social wellbeing of
individuals and communities.
Services and workers that are trauma-informed recognise that many survivor’s behaviours
and responses represent adaptive responses to past traumatic experiences
What is trauma?
In this context, trauma refers to a person’s enduring emotional, psychological and physical
response to events that are experienced as a threat to their life, their physical integrity or
their ability to comprehend and cope with the event or circumstances. Trauma can also
result from witnessing these threats to others.
Trauma does not refer to the event alone but to a person’s responses to that event or
circumstances. The same event or circumstances can lead to trauma for some people and
not others. A person’s response will partly depend upon the resources (both personal and
external) that they have access to at the time of and subsequent to the event(s).
Many aspects of trauma are best understood by understanding the nature of our normal
responses to threat, and the ways that we try to achieve safety from further threat.
Threats to our survival are not only physical but can be threats to our social survival, such as
humiliation, exclusion or abandonment.
Events that lead to trauma include:
• physical assault
• accidents
• sexual assault
• natural disasters
• witnessing death or injury to others
• neglect and abandonment in childhood
• abuse in childhood including emotional abuse and neglect
• war
• captivity
• torture
• extremes of deprivation and poverty
• experiences in care and treatment

Activity 1
What are some other events that people find difficult to cope with? Would we regard these
as traumatic events? What makes them traumatic?
Post-traumatic stress disorder (PTSD)

PTSD became a formal diagnosis in the 3rd edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-III). This was largely as a result of research regarding the impact
of soldiers’ combat experiences and lobbying by groups representing their interests, as well
as those working with domestic violence and child abuse (van der Kolk et al. 1996). The
DSM is now in its fifth edition (DSM V).
Post-traumatic stress disorder is a pattern of responses to a ‘traumatic stressor’ that persists

over time.
The DSM V defines a ‘traumatic stressor’ as follows:
The person was exposed to: death, threatened death, actual or threatened serious
injury, or actual or threatened sexual violence, as follows: (one required)
• Direct exposure
• Witnessing, in person
• Indirectly, by learning that a close relative or close friend was exposed to
trauma. If the event involved actual or threatened death, it must have been
violent or accidental
• Repeated or extreme indirect exposure to aversive details of the event(s),
usually in the course of professional duties (e.g., first responders, collecting
body parts; professionals repeatedly exposed to details of child abuse). This
does not include indirect non-professional exposure through electronic media,
television, movies, or pictures.
Diagnostic criteria for PTSD include a history of exposure to a traumatic stressor and
symptoms from each of four symptom clusters: intrusion, avoidance, negative alterations in
cognitions and mood, and alterations in arousal and reactivity:
• ‘Intrusion symptoms’ - The traumatic event is persistently re-experienced in the

following way:
o Recurrent, involuntary, and intrusive memories
o Traumatic nightmares
o Dissociative reactions (e.g., flashbacks) which may occur on a continuum
from brief episodes to complete loss of consciousness
o Intense or prolonged distress after exposure to traumatic reminders
o Marked physiologic reactivity after exposure to trauma-related stimuli.
• ‘Avoidance symptoms’ - Persistent deliberate avoidance of distressing trauma-

related stimuli after the event:

o Trauma-related thoughts or feelings
o Trauma-related external reminders (e.g., people, places, conversations,
activities, objects, or situations).
• Negative alterations in thoughts and mood that began or worsened after the
traumatic event:
o Inability to recall key features of the traumatic event
o Persistent (and often distorted) negative beliefs and expectations about
oneself or the world (e.g., ’I am bad’; ’The world is completely dangerous’)
o Persistent distorted blame of self or others for causing the traumatic event or
for the resulting consequences
o Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or
shame)
o Significantly decreased interest in activities that were previously important or
enjoyable
o Feeling alienated from others (e.g., detachment or estrangement)
o Persistent inability to experience positive emotions.
• Alterations in ‘arousal and reactivity’ that began or worsened after the traumatic
event:
o Irritable or aggressive behaviour
o Self-destructive or reckless behaviour
o Hypervigilance
o Exaggerated startle response (hyperarousal)
o Problems in concentration
o Sleep disturbance.
For PTSD to be diagnosed, these symptoms must be present for at least one month, but
they may not commence until many months or years after the actual event.
The symptoms must also cause ‘significant symptom-related distress or functional

impairment’ and not be caused by medication, substance use, or other illness.
It is estimated that in any year, 6.4 per cent of Australians meet the criteria for PTSD, many
of whom are not receiving treatment.
‘PTSD’ is usually generated by ‘one off’ events, which may vary considerably. They include
experience or witnessing accidents and emergencies, natural disasters, and single episodes
of assault, physical or sexual. Such events can be deeply traumatic. Nevertheless, ‘there is
more to trauma than PTSD’ (Shapiro 2010, p.11), Complex trauma includes far more than
the defining features of single-incident PTSD (Blue Knot Foundation 2018). See Complex
Trauma below.
Complex trauma
Complex trauma occurs as a result of traumatic stressors that are interpersonal –
premeditated, planned and perpetrated by one human being on another. It is particularly
damaging if it occurs in childhood. These actions can be both violating and exploitative of
another person.

Complex, interpersonally generated trauma is severely disruptive of a person’s capacity to
manage internal states. Complex trauma contrasts with ‘single-incident’ trauma (which
relates to an unexpected and ‘out of the blue’ event such as a natural disaster, traumatic
accident, terrorist attack or single episode of assault, abuse or witnessing of such an event).
It is cumulative and repetitive (ASCA, 2012).
This is not to minimise the impact of single-incident trauma, or encourage a hierarchy of

trauma in which one form of trauma is perceived as being more worthy of attention than
another. A trauma-informed approach is always indicated regardless. However complex
trauma is complex by its very nature and so demands different service and practice
responses. Both the traumatic event(s) and circumstances and the impacts of the events are
said to be complex because they have ongoing, multidimensional consequences.
Complex Trauma survivors are likely to have histories of physical and/or sexual abuse as
well as chronic neglect and/or protracted emotional abuse, witnessing domestic violence,
and/or have been victims of interpersonal violence as a consequence of wars, genocide, civil
unrest, refugee and combatant trauma. Such trauma frequently leads to a diversity of mental
health conditions and of co-occurring problems such as poor physical health, substance
misuse, eating disorders, relationship and self-esteem issues, suicidality and contact with
the criminal justice system.
Such trauma is not well accounted for by current diagnoses in mental health. Despite the
changes to PTSD diagnostic criteria, the diagnosis still fails to accurately reflect the
experiences of survivors of these forms of trauma.
Judith Herman (1992b) argued in relationship to the diagnosis of borderline personality

disorder that if the traumatic events cannot be recalled (fully) or were so pervasive that they
could not be distinguished easily as separate events, then PTSD would not be apparent.
She also noted that complex trauma has a profound impact on the development of identity
and sense of self of the survivor. Emanating from Herman’s work the term ‘complex trauma’
and ‘complex PTSD’ have persisted in the literature regarding trauma, and have been
considered as possible new diagnoses, but at this time are not formal diagnoses utilised in
the field of psychiatry.
“Complex post-traumatic stress disorder, leads to alterations in a number of important

domains: affects regulation, consciousness, self-perception, perception of the perpetrator,
relations with others, and systems of meaning” (Herman, 1992).
Interpersonal trauma
Interpersonal violence has been defined by the World Health Organisation (WHO) as the
intentional use of physical force, or power, threatened or actual, against oneself, another
person, or against a group or community that either results in, or has a likelihood of resulting
in, injury, death, psychological harm, mal-development or deprivation. This definition
includes victimisation perpetrated against intimate partners, parents, siblings, children, other
relatives, friends, acquaintances, colleagues and strangers (Krug et al. 2002). It should be
noted that interpersonal violence is often gendered, with marginalised groups being at
greater risk, including but not limited to LGBTQI people and Aboriginal and Torres Strait
Islander people.
Events and circumstances perpetrated by other people are more likely to lead to long-term
mental health consequences (Courtois 2009; Davidson et al. 2004; Kelley et al. 2009). This
is referred to as interpersonal trauma and typically involves the use or abuse of power or
betrayal by one person (or group of people) over another person (or group of people).
Trauma that occurs at the hands of another person (or group of people) has the potential to

impact on the way the person understands and forms other relationships throughout their
life, including relationships with services.
Interpersonal trauma involves a betrayal of trust, which can generalise to a loss of trust in all
other relationships with people. Given that protective factors and healing can be found in
relationships, this leaves the survivor in a particularly difficult position in forming and
maintaining further relationships. A consequence of this is that often there is a generalised
mistrust in practitioners, and therefore a disinclination to engage with the very services and
supports that might assist a person’s recovery.
Many survivors of interpersonal trauma (such as abuse in childhood, domestic violence, etc.)
meet the criteria for PTSD, however many do not, and it has been found that the response to
interpersonal trauma, particularly that which occurs in childhood, is more complex (Cloister
et al. 2009).
Why are some people more affected than others?

It is useful to understand an individual’s experience of trauma by considering:
• the particular event or circumstances
• how the person experienced the event
what support they received during and afterwards
Influences on the impact of traumatic events
Culture &
Age meaning
Supportive or
harmful
Vulnerabilities: relationships
personal & Person
socioeconomic
Prior trauma
Resources & or loss
resilience: personal & After effects
socioeconomic Secret or Losses as a
Single or shared result
multiple
traumatic Believed or Supported or
events dismissed blamed
Help to get Access to

safe justice
Adapted from Daya, 2014
Factors that affect the degree to which a person will be affected by the events include:
• age (the younger a person is the less resources they will have for coping with
extreme stressors)
• vulnerability (other stressors and demands on the individual or their environment)
• relationships with others (are their relationships supportive, neutral or harmful)

• the negative or blaming responses of others
• if the threat has been ongoing or occurred over a long time
• losses that occurred as a result of the trauma
• prior experiences of trauma and loss.
The impact of trauma is cumulative in that a person may survive and cope with one or more
traumatic events with sufficient time and support, however if trauma is repeated the person’s
resources are depleted and they are more vulnerable to further impacts (Cloitre et al. 2009).
Resilience
Resilience refers to the capacity of human beings of any age to survive and thrive in the face
of adversity. Research has demonstrated the crucial importance of a parent’s focus on a
child’s subjective experience for the development of the child’s wellbeing. One of the
strongest predictors of a child’s subsequent recovery relates to maternal and family
dynamics.
In this context resilience helps us understand how it is that some people appear less
impacted by trauma than others (Agaibi & Wilson 2005).
Research concerning people who have endured trauma and appear to be coping well
reveals both individual and social factors that influence resilience. These factors may be
present prior to, during, or after the experience of trauma, such as:
• self-esteem and self-confidence
• parenting or care-giving that models and supports effective coping
• secure attachment with a primary caregiver
• problem-focused coping, rather than emotion-focused coping
• disclosure of the abuse or trauma to others
• receiving a protective and validating response from others
• an opportunity and an ability to make meaning of the trauma (make sense of what
happened and how it affected me)
• relative absence of guilt regarding the trauma
• connection to and identification with other survivors.
(Agaibi & Wilson 2005)
However, there is no recipe for complete personal resilience in the face of trauma.
Resilience is a complex interaction between the characteristics of the individual, features of
the trauma experienced and the social context of the survivor. Recognising the resilience in
all survivors of trauma is consistent with a strengths-based approach. It is important to
remember that:
• The impact of trauma is highly individual and depends on multiple factors including
supportive relationships
• All people who have experienced trauma exhibit some resilience and have drawn on
a variety of means of coping.

Common beliefs about trauma—what do you believe?
We will each bring our own beliefs about trauma to our work as we attempt to understand
the impact of trauma on others. Some of these beliefs will be based upon our own personal
and cultural values. Some beliefs may also be based upon our personal experiences of
trauma and healing.
Self-reflection and exploring our own beliefs and values is an important step in taking care
not to impose these on others, but to understand and respect the beliefs and values held by
a survivor.
Self-reflection: Beliefs and values

These are statements that you may have heard expressed by others. Do you agree or
disagree? Can you identify how you developed this belief? What impact could these
beliefs have on a survivor of trauma if significant others strongly held (or disagreed with)
this belief?
• The best way to recover from trauma is to focus on the future and move forward
• Best not dredge up the past—talking about the past will only make things worse
• Being preoccupied with the past is a sign that the person is not ready to move on
• Strong people can forget and move on
• Forgiveness is an essential part of healing
• If it’s normal where he/she comes from then it’s not as traumatic
• If they haven’t brought it up before now, it probably isn’t that important to them
• If someone was being that frightened, surely they would have said something at
the time
• Women need to talk about these things, but men are better left to deal with it
themselves
• Physical and emotional abuse are not as bad as sexual abuse.
To clarify our assumptions and beliefs, it is useful to recognise changes in our understanding
of the relationship between interpersonal trauma and mental health over time. It’s also
useful to be acquainted with the research evidence about the incidence (how often it occurs
over a period of time) and prevalence (how many people are affected) of trauma. Some
information can be found in Appendix A and Appendix B.
Key messages
• The impact of trauma is highly individual and depends on multiple
factors including supportive relationships.
• All people who have experienced trauma exhibit some resilience and
have drawn on a variety of means of coping.

Coping with the impact of trauma
In order to understand how trauma has affected a person, we must also consider how they
coped at the time; and how these coping strategies were effective or meaningful for them.
Coping strategies are:

“all the cognitive and behavioural efforts made to control, reduce, or tolerate the
internal or external requirements that threaten or overwhelm the individual’s
response capacity, i.e. the regulation of emotional distress (internal) and problem
management (internal or external)”. (Brousse et al. 2011, p. 127)
In other words, they are the ways a person thinks or acts in order to survive the traumatic
event/events, and to avoid becoming overwhelmed.
Coping strategies that we all use in the face of difficulty fall into three broad categories:
• problem-focused coping (obtaining information, taking direct action, devising plans etc.)
• socially-focused coping (telling others, seeking support from others)
• emotion-focused coping (attempts to manage the intensity of the emotion).
We have all developed preferences for particular coping strategies that we use in various
contexts. Ideally we will assess how the coping strategies we use are working and adjust
them when they are less effective.
Steven Onken wrote that the behavioural, emotional (and practical) adaptations that abused
adults and children make in order to survive are brilliant, creative solutions and are
personally costly (2012).
In response to trauma, particularly trauma that is inescapable or is occurring in the context of

a person’s primary social group or social supports, emotion-focused coping strategies may
be the most commonly used and are associated with greater long-term difficulties (Brousse
et al. 2011).
The coping strategies used at a time of trauma may continue to be used even when the trauma
has passed, and they may or may not be working as effectively for the person in adulthood.
Some strategies that worked well at one time may also bring additional problems for the person.
The Adverse Child Experiences (ACE) Study has established that, in the USA, adverse
childhood experiences are major risk factors for disease and early death as well as poor
quality of life. The greater the number of adverse experiences, the higher the prevalence of
negative outcomes, with the coping mechanisms adopted in childhood and persisting into
adulthood becoming risk factors for later disease and disability.
Characteristically, survivors of childhood abuse exhibit early onset of mental health

difficulties and a tendency towards chronicity, lowered self-esteem and sense of
hopelessness (Romans et al. 1992). Many traumatised people adopt extreme coping
strategies in order to manage anxiety and overwhelming emotional distress including:
suicidality, substance abuse and addictions, self-harming behaviours such as cutting and
burning, and dissociation. Many coping strategies become risk factors for later physical
health issues.
However, it is important to recognise that even for behaviours and attitudes that might
appear problematic for the person, the use of the strategies can be understood as attempts
to cope and survive and demonstrate resilience.

Activity 2a: You will be assigned a scenario on one of the following pages.
Learner alert: These scenarios describe traumatic events and impacts and may be
distressing for some people to read, however they are similar to the types of real
experiences that you may hear in your work role.
Please use strategies to keep yourself safe when reading and considering these
scenarios.
1. What events or circumstances could be traumatic for this person? Highlight or

underline these in one colour.
2. Why might these events or circumstances be traumatic?
3. How did the person cope? Where do you see evidence of strength and resilience?
Highlight or underline these in a different colour.
Amanda is 37 and works part time as a childcare assistant. Amanda has a community
treatment plan and her case manager has referred her to your service for additional
support.
Amanda rents her own flat, where she is not supposed to have pets but she keeps her
cats Rosy and Cocoa there.
Amanda was 13 when she saw her little sister Agnes being sexually abused by their
cousin Colin, who was then aged 18. She had tried to keep Agnes safe by watching over
her. Amanda told her mother that she had seen Colin touching Agnes. Amanda’s mother
made her tell her aunt (Colin’s mother) what she had seen. Her aunt asked Agnes and
Colin about the abuse, but Colin denied it and Agnes would not speak about it. Amanda’s
mother made her apologise to her aunt and to Colin.
When she was 14, Amanda started hanging out with some older friends and didn’t go to
school as much. One night when she was 16 her drink was spiked and her boyfriend and
his mates raped her. They told her she was “up for it” and a whole lot of fun. She has
never told anyone.
You meet Amanda at her home. You notice that she is fidgety, crying a lot and having
trouble concentrating. Amanda describes a number of occasions when she feels
disconnected from the world and those close to her. She also tells you when you ask
about her physical health that she dreads visiting doctors. She keeps apologising and
asking you: “Do you think I’m crazy”?
Greg’s Dad played professional football for Australia. Greg also played football but tells
you he felt pressured to perform well. He stopped playing after he dropped the ball in a
game and his father slapped him and called him “useless” in front of his friends. He
started avoiding social situations.
Greg began to spend time locked in his room to avoid his father’s temper. He would turn
his music up loud and smoke his Mum’s cigarettes. At the age of 15 he began to smoke
pot. Greg felt that he deserved to be hit by his Dad, but he did not like it when his Dad hit
his Mum.
One night he came out of his room to protect his Mum and threatened his Dad with a
knife. A week later, he stabbed a student who was bullying him at school and was put in

juvenile detention. When he got out, he moved interstate. He started smoking heavily
again but cut down when he met his girlfriend Jo. They both want to work and have their
own place.
Greg tells you how angry he has been getting with Jo. He doesn’t trust her and believes
she may be sneaking behind his back to see someone else. He tells you that he threw
things around their flat last night and broke the TV.
Amina came from Afghanistan to Australia by boat when she was six. Her brother died on
the journey and her sister Alice was born in an immigration detention centre. After 18
months, the family were found to be refugees and were released to live in the community.
Her Mum died a few years later and Amina took responsibility for caring for her Dad and
Alice. Her Dad went through long periods of depression and had serious health problems.
Amina was popular and academically successful at school, but began self-harming at 14
years old. When she was 16, her Dad found out that she had begun a romantic
relationship with a friend, Sophia. Amina’s Dad was very distressed by this. Amina moved
out of home and has been “couch surfing’ with friends.
A friend recently took Amina to hospital after she self-harmed and was admitted to a
Mental Health Facility. She has been referred to your service for support. She says she
can’t remember why she cut herself and that “it was probably nothing”.
Carol mother experienced post-natal depression and struggled to cope after Carol was
born. She tried to drown Carol when she was three. After this, Carol lived with her Dad
and step mother, who constantly told her that she was “useless”. She would visit her
mother in the school holidays but always felt anxious and sick before seeing her.
At the age of 10, Carol started to binge eat and rapidly put on weight. Kids at school
called her “fat” and “ugly”. Her father made “fat jokes” and stuck notes on the fridge telling
her to lose weight. Carol wore baggy clothes and kept to herself.
She went to hospital after taking an overdose at the age of 17 and has lost count of how
many times she has taken an overdose since then. A friend suggested your service might
help her manage her ongoing eating disorder and distress.
She has started an online blog, where she anonymously writes about her feelings and
experiences.
Ray’s Mum was too sick to look after him when he was young, so he lived with his
grandmother. His grandmother got married and her new husband became violent and
aggressive. His grandmother thought it better for Ray to live elsewhere, so at the age of 9
he returned to living with his Mum. Ray would regularly run away from home so that he
could go and keep his grandmother safe. Each time he did this, his grandmother sent him
back to his Mum and he would be punished.
In his teens, Ray often felt depressed and anxious. He found it difficult to trust people. He
left school at the age of 15 and did odd jobs where he could find work. As soon as he
could afford a car, Ray began travelling all over Australia and now travels with his dog,
Penny, who he considers his best friend.

He sometime loses hope and becomes severely depressed and spends time in a Mental
Health Unit. He has not been in one for the past 5 years with the support of your service.
Trisha and her younger brothers spent much of their childhood living between their
divorced parents’ homes. When she was 13, during one of the many parties at her Dad’s
house, she was sexually assaulted by her father’s friend.
Trisha told her friend about it, and her friend reported it to the police. Trisha’s Mum said
that they would not be visiting their Dad anymore. Her brothers were angry about this and
blamed Trisha.
Trisha stopped talking to her friend and her brothers and isolated herself. She began
hearing voices. The voices stop if she takes medication, but she doesn’t always do this
because sometimes she finds them a comfort.
She is now studying part time at university to become a nurse, with the help of various
learning support services. She tried moving out of home when she started studying but
moved back because she missed her Mum. She is engaging better with your service and
her care plan.
Miranda is 37 years old and works as a childcare assistant. She loves her job and is very
close to the children she looks after. She often arrives at the centre early to lay out craft
activities and prepare for the day before the children start to arrive.
Miranda often talks to the children about what is happening for them during the week and
sometimes hears stories from children about scary, frightening or stressful things. Miranda
has had to complete a few mandatory reports in the past based on admissions from
children. Miranda recently heard a very detailed and worrying story from a child and had to
make a report in conjunction with her manager because of concerns of safety for the child.
Since hearing this report Miranda has not been able to forget the story and often finds
herself upset by this when at home. She has started sleeping badly and no longer has the
energy to get to work early to set up the day, arriving late on quite a few occasions. Her
patience is shorter with the other staff and she often snaps at them over small mishaps.
She has started worrying that all the children around her are in danger.
Miranda lives at home alone with her two cats Rosy and Cocoa and often sits with them
when she is feeling overwhelmed but can’t sleep. She hasn’t felt as creative as she used
too but is still managing to do a small amount of journaling.
Miranda’s manager is worried about the changes in her behaviour and recommends she
contact the Employee Assistance Programme (EAP) available through their employer.
When Miranda starts to talk to a counsellor assigned through the EAP about what has
been happening she keeps apologising and asking you: “Do you think I’m crazy”?

Activity 2b: How might these be perceived by, and responded to, by others?
Coping strategy Benefit to the Others’ Others’ response

person perception
e.g. minimising Less overwhelmed; It’s not been an Trauma not

significance of family can decide when to issue for them; it acknowledged.
violence address it; can’t have been that No response;
preserves bad dismissed as part of
relationships delusional beliefs
e.g. drinking to dull Respite from Substance abuse;

memories physical tension and not motivated to quit
intrusive images
e.g. self-injury
e.g. trying to please

others
e.g. finding ways to

‘numb’ feelings
e.g. risky sexual

behaviours
e.g. finding excuses

for the perpetrator

What is self-injury
People who have survived trauma in childhood are more likely to engage in intentional self-
injury (Muehlenkamp et al. 2010; Maniglio 2011), however not all people who self-injure
report that they have experienced abuse or trauma.
Types of intentional self-injury include hitting oneself, cutting, burning, bruising, head-
banging, picking at the skin, scalding, biting, or swallowing and inserting objects into the
body (Fliege, 2009). It may also include problematic eating and elimination, risky sexual
behaviour, substance abuse and misuse, neglect of medical health needs, reckless handling
of weapons, reckless driving or provoking aggression from others (Deiter, Nicholls &
Pearlman 2000). It does not include accepted cultural practises such as body piercing or
religious rituals and rites of passage.
Why do people self-injure?
The range of reasons that people give for engaging in self-injury are as broad as any other
human behaviour.
Research on self-injury shows a strong relationship between difficulties in emotional

regulation and dissociative experiences, and the use of self-harm as a strategy to cope.
Many people who experience acute distress and agitation report achieving relief by engaging
in deliberate acts of self-injury (Klonsky 2007). For some people this distress and the self-
injury are also associated with thoughts of suicide, while for others self-injury is a means of
resisting suicide and feeling more present (i.e. less dissociative) (Klonsky 2007).
There are also biological aspects to the development of

self-injury as a coping mechanism. When we endure any
sudden injury including a cut to the skin, our bodies
produce substances that provide temporary pain relief.
These are called endogenous opiates, and their
production can biologically reinforce the behaviour that
brought them about (Klonsky, 2007; Klonsky &
Muehlenkamp, 2007). However, whilst providing
temporary pain and distress relief, a compulsive loop or
pattern can develop (Nock 2009).
Attitudes and responses towards people who self-injure

Farber (2000) recognises that mental health services often find it difficult to acknowledge
intentional self-harm.
Our tardiness in acknowledging the prevalence of self-harm is tied to our tardiness in

coming to acknowledge the prevalence of violent trauma in our culture and the
tendency toward violence in ourselves .. For many abused and traumatised people
who have plenty to scream and cry about, self-harm is what happens when screams
are not listened to. (Farber 2000, p. 107)
Bosman and Van Meijel (2008) completed a literature review which identified that consumers
perceived that workers responded to self-injury in the following ways:
• Pathologised their behaviour
• Focused on ceasing the behaviour as opposed to understanding it

Themes emerging from reports of what people who have self-injured would like from workers
are:
• Being approached with understanding and respect

• Being able to participate in problem solving
• To be provided with treatment choices; and interactions that nurture hope, self-
confidence and self-esteem.
Many people do want to stop engaging in self-injury, but they need to be understood and
supported so they can explore alternatives that meet their needs.
As workers, our own attitudes to self-injury can either assist or be a barrier to the person
seeking and receiving support. It may not be a part of your role to directly address or discuss
this behaviour, but your acceptance and understanding, compassion and respect will at least
‘do no harm’.
Communication
Communicating with people who have experienced trauma requires workers to understand
that the individual may not feel safe enough to engage in interpersonal interactions
(Cozolino, 2002). Workers need to reflect on how they help or hinder safe communication
and utilise the principles of TICP to assist individuals (Isobel, Delgado & Kitto, 2016).
Helpful responses when relating to people who self-injure include:
• showing that you see the person in pain behind the self-injury and care about them
• showing concern for the injuries themselves; support access to medical care or first
aid if needed
• conveying your respect for the person’s efforts to manage or cope
• making it clear that it is OK to talk about it and assist the person to decide who to talk to
• acknowledging how frightening it may be to think of living without self-injury
• supporting the person to express feeling in other ways
• helping the person to break down isolation and shame and to build support networks.
Do not ignore, minimise or dismiss the self-injury. Refer to your organisational policy
guidelines regarding expectations of workers’ response when self-injury has been disclosed.
Alternatives to self-injury
Sometimes people who self-injure can find much less harmful or painful alternatives. These
alternatives can be explored with a counsellor or mental health professional. A qualified
counsellor or mental health professional will help the person explore how they feel prior to
enacting self-injury and how they feel afterwards. More information can be found on the
website below.
For more information

The Lifeline website has useful information for both consumers who self-harm and people
who support someone who self-harms https://www.lifeline.org.au/get-help/topics/self-
harm.

Suicide
The following notes are general in nature and are not expected to prepare you to work
effectively with someone who is currently experiencing suicidal thoughts.
You must be aware of your organisation’s policies and processes around suicide for the
appropriate response for you in your work role. Additional training in understanding and
responding to suicide is offered by MHCC (see MHCC’s Respond to Risk of Suicide
course).
You should not hold information about a consumer’s suicidality on your own - always
consult with a senior colleague, manager or supervisor.
Risk of suicide is an uncomfortable and often painful conversation for most people. Many
people will have some personal exposure to suicidality or the consequences of suicide
during their life.
Discussing suicide can also evoke anxiety in workers that the consumer’s wellbeing may be
compromised. Concerns about ways to respond appropriately and responsibly, may lead
workers’ to question their own skills and practice approach.
Knowing and reflecting on our own values and attitudes toward suicidality is a critical aspect
of developing a sensitive and emphatic trauma-informed response to disclosure (or
detection) of suicidal thoughts or behaviour.
Conversations about suicide present dilemmas for the person in distress as well as the
worker, as these quotes show:
What will happen if I talk about this?

You can need help, and be afraid to ask for it.
I lie to protect myself. If I tell them that I’m not in control and not safe, are they going
to lock me up? This is worse, because it is all the freedom you have.
You can be completely disempowered if you say you are going to kill yourself. There is
unilateral decision making. Things are done to you. Decisions are made about you. You
have no choice about anything. Sometimes all you really need is someone to talk with.
(Jennings 1997)
Understanding that there may be a range of underlying emotions, experiences, fears and
beliefs—some of which may be related to past trauma and current fear—extends your ability
to respond to suicidality in trauma-informed ways.
Working together to find a way to be safe requires remaining connected in your relationship
with the consumer and those who support them. This will require more than risk assessment
alone.
When relationships are entirely built on assessment of risk they are by nature
controlling and disempowering ... It is crucial that support people maintain a rigorous
self-awareness of their own need to ‘fix’, ‘do it right’ or unilaterally determine the
outcome. (Mead & Hilton 2003, p. 90)

Personal reflection
What helps and hinders safe communication?
• How do your feelings and attitudes toward suicidality impact on the people you
support?
• How can you convey respect and understanding in ways that might assist the
person to be more open to receiving help?
Key messages
• People who experienced trauma have drawn on a variety of means to survive
and cope
• Self-injury may be connected to trauma—experiencing judgement and
shaming responses is a source of further trauma for survivors.
• Past trauma and current fear can result in overwhelming distress and
suicidality.
• A trauma-informed approach recognises these links and takes care not to
retraumatise people with the response to acute distress.

Understanding the stress response
In order to understand how we respond to trauma it is helpful to understand what happens in
our brain and our bodies whenever we experience threats or extremes of stress. When any
threat is perceived, our brains register this and prepare our bodies to respond before we can
consciously process what is happening.
The involuntary responses that occur in the brain and our bodies are known collectively as
the stress response. Understanding the usual and adaptive processes that occur in
response to threats and stress can also be an important part of healing for survivors of
trauma.
The stress response enables us to have the best chance of surviving the moment by
providing the body with the resources it needs to fight or run away. This was first described
as a flight or fight response in the early 20th century by Walter Cannon, but now is also
referred to as fight/flight/freeze, with the recognition that remaining still or passive is also a
part of this survival mechanism.
For all mammals, and humans in particular, relationships with others are intrinsically linked
with our stress response, as it is through these relationships that we learn to regulate and
manage this automatic response. Relationships are also our source of comfort, protection
and safety.
We will discuss the normal functioning of the stress response on:

• the brain
• the body and
• relationships.
(The body and the brain are not separate entities, but we will discuss the stress response
from each of these perspectives in the interest of simplicity.)
We will also briefly discuss the impact of trauma on childhood development in order to better
understand the long-term impact of trauma on survivors of childhood trauma.
The stress response and the brain

Our brains are biased toward perceiving threats, even when there is none, and this is
reflected in the adage that it is:
“Better to be safe than sorry”

For instance, the person that assumes a movement in the grass is a predator and moves
away is more likely to survive (and pass on their genes) than the person who assumes the
movement is only the wind. Threat is perceived very quickly and automatically, before we
have a chance to consciously ‘think’ about what is happening. This ability to register threat is
shared among most living creatures, enabling us to have immediate responses whenever
survival is threatened.
The parts of the brain that register threat (the sensory thalamus and the basal ganglia) are
very primitive and closely linked to the brain stem which deals with autonomic and non-
conscious processes throughout the body.
The message that threat has been perceived through our senses goes to the amygdala,
triggering the experience of fear and the fight/flight/freeze response. The amygdala plays a
central role in the learning of fear and the processing of other basic emotional responses. It
allows us to pair any stimulus with remembered danger so that we react quickly. This pairing

of stimulus and danger is not conscious, and we may not be aware of having ‘learned’ this.
However, learning through fear is remarkably powerful and difficult to ‘unlearn’.
The hippocampus assists with conscious and autobiographical memory and it also receives
and processes information about the threat (Cozolino 2006, p. 57). It works together with the
amygdala to store information about situational cues present at the time of an emotionally
charged event, such as where we were and what we were doing (that is, the ‘context’). In
other words the hippocampus plays a critical role in the formation, organisation and storage
of new memories and connects certain sensations and emotions to these memories.
The Neurobiology of Stress – Brain regions involved in stress response

https://evolutionofalabrat.wordpress.com/2014/08/24/stress-its-all-in-your-head/
Only after our fight/flight/freeze response has been triggered do we have an opportunity to
consciously assess and process the threat. This is when the pre-frontal cortex processes the
information. The pre-frontal cortex is involved with working memory (memory that we actively
hold in our minds to assist us as we do tasks and solve problems). It also impacts our
reasoning about the relationships between objects and events, as well as some decision-
making. This area helps us to rationally assess threats, manage emotion, plan responses
and control impulses and moderate social behaviour. We are then more able to ‘process’ the
incident, and have some opportunity for decision-making.
If we then assess the situation to be safe (because we have fought, escaped or

misinterpreted the threat) the pre-frontal cortex can switch off the fight/flight/freeze response
(Wilson, Hansen & Li 2011, p. 89).

An easy way to understand how to make sense of how the brain works:
Dr Daniel Siegel presenting a Hand Model of the Brain -

https://www.youtube.com/watch?v=gm9CIJ74Oxw or animated link
https://www.youtube.com/watch?v=5CpRY9-MIHA
• Brain Stem: Basic survival response, states of arousal; automatic
• Limbic System: Emotion (fear), evaluation, unconscious
• Cerebral Cortex: thinking, concepts, reflection, conscious
Activity 3: Understanding fight or flight

Think of a time when you experienced a fight or flight response when you were actually or
ultimately safe and unharmed. Perhaps you can recall when there were a few moments
when you lost your child in a crowd or a car didn’t stop at a crossing or someone came up
behind you very quickly. Do not choose a time when you were actually harmed or still
feel intense fear when you recall it.
Discuss the incident with the person next to you and try and recall:
• what was happening in your body?
• what did you do next?
• how long did it take to settle down?

The stress response and the body
Figure 2: The sympathetic nervous system

http://pixgood.com/fight-or-flight-diagram.html
Any demand on our resources can provoke a stress response (i.e. even something which is
not necessarily an interpersonal threat or traumatic event) and can trigger the activation of
the sympathetic nervous system. Having a responsive sympathetic nervous system enables
us to respond to a multitude of demands throughout every day. When a threat has been
perceived or the demand is sudden or significant, the sympathetic nervous system prepares
the body to respond immediately via the fight/flight/freeze responses.
There are a range of hormonal responses and changes in the body in this process, regulated
by three structures that direct the release of these hormones known as the HPA Axis
(Hypothalamus-Pituitary-Adrenal axis). The HPA Axis translates the brain messages to the
body (Cozolino 2006 p. 57). The HPA axis also co-ordinates the release of hormones that
help to settle the stress response (Wilson, Hansen & Li 2011, p. 89).
Some of the effects of sympathetic nervous system arousal include:
• increased blood flow to major muscle groups, including to the heart and lungs
• increased respiratory rate and heart rate
• reduced blood flow to the extremities (hands and feet)
• muscle tension across the shoulders
• energy reserves (fat and sugar) are mobilised
• digestion slows down as blood flow is restricted to the lining of the gut
• pupils dilate, vision focuses on details.

If our bodies are equipped with the resources needed to fight or flee and we achieve safety
and the threat passes, then we can recuperate and our stress response settles. The
parasympathetic nervous system responds to the signal that the threat has passed and
switches off the fight or flight response.
The parasympathetic nervous system response can be thought of as operating as a brake

for the sympathetic nervous system (McCrory, de Brito & Viding 2010), whereas the
sympathetic nervous system operates as an accelerator. The freeze response is thought to
occur when both the sympathetic nervous system and the parasympathetic nervous system
are activated: like a brake and an accelerator both at the same time. ‘Freeze’ is more likely
to occur when neither fight nor flight are possible or the best options for survival. This will be
explored further when we look at responses to extreme stressors and trauma.
The impact of trauma on the body and the stress response

The stress response of the body is described as ‘efficient’ as it switches on when needed,
fires up quickly and switches off when no longer required. For some survivors of extremes of
stress and trauma their stress response is less efficient or ‘dysregulated’; (McCrory, de Brito
& Viding 2010) due to:
• being very easily switched on

• being hard to switch on (also known as hypoarousal)
• being hard to switch off or to calm down (also known as hyperarousal)
• releasing less cortisol in response to stress (e.g. Carpenter et al. 2011).
The way that people may experience this change in the function of the stress response
includes:
• being easily startled, jumpy or ‘on edge’

• feeling shut down or cut off or numb
• finding it hard to calm down after becoming upset
• finding it difficult to ‘get moving’ even when they want to be able to.
The impact of trauma on brain development

As our brains develop in childhood they grow and organise themselves literally from the
‘bottom up’; that is, from the functions that are most essential for survival to increasingly
sophisticated functions such as impulse control and planning. Under conditions of stress, our
‘lower’ brain stem responses become dominant (‘bottom up’) and we are less able to be
calm, reflect and respond flexibly. We are born with a well-functioning brainstem which
controls basic survival functions such as heart rate, breathing, sleep and hunger.
We are also born with a functioning ‘threat detection’ system. The amygdala develops in the
foetus and is able to register a fear response at eight months gestation, that is, prior to birth
(Cozolino 2006 p. 57). We can learn and therefore have ‘memory’ of fear prior to us being
able to use language or understand any context for that fear. These ‘memories’ are recalled
in physical and emotional reactions.
The hippocampus begins to develop in the foetus and develops further as we interact with
the world around us, and well into adulthood (Cozolino 2006 p. 57). Prior to the development
of the hippocampus we do not have the capacity for ‘autobiographical’ memories of our lives.
The prefrontal cortex is one of the last parts of our brain to reach maturity (in our mid-
twenties) and is associated with higher order thinking and skills such as planning. The
prefrontal cortex has the capacity to inhibit or ‘switch off’ the stress response.

Findings in brain regions Associated functional difficulties
Reduced activity in Broca’s area Difficulty using language to talk about or describe
(necessary for speech production) the trauma (Hull 2002)
when recalling trauma (Hull 2002)
Reduced volume and complexity of Difficulties with attention, learning and memory
the hippocampus, which is necessary (Hedges & Woon 2011; Pechtel & Pizzagalli 2011)
for learning and memory (Wilson,
Difficulty establishing context when
Hansen & Li 2011; McCrory, de Brito
experiencing fear (Ali et al. 2011) therefore
& Viding 2010)
responding with fear when there is no danger
Reduced volume of the corpus Difficulty with ‘sensory integration’ leading to
callosum, the nerve bundle connecting heightened emotions (Wilson, Hansen & Li
the left and right hemispheres of the 2011 p. 90) if the brain can’t co-ordinate all of the
brain, and needed for co-ordinating information available to it
regions of the brain in responses
(Wilson, Hansen & Li 2011)
Changes in the functioning of the Increased attention and sensitivity to cues for
amygdala which is central to the fear threat, for example angry faces (McCrory, de
response (Wilson, Hansen & Li 2011; Brito & Viding 2010; Pechtel & Pizzagalli 2011),
Pechtel & Pizzagalli 2011) therefore responding with fear to small signals of
threat like a person being annoyed or frustrated
Lower activity in some areas of the Difficulty interpreting and regulating emotion
frontal lobes (McCrory, de Brito & (Wilson, Hansen & Li 2011 p. 90) therefore
Viding 2010) that might otherwise be annoyance can become rage, and disappointment
able to inhibit the fear response could become despair quite quickly
Changes in ‘reward pathways’ of the Less reward is anticipated from activity, which
brain that are associated with can appear as low motivation (Pechtel &
anticipation of pleasure and the power Pizzagalli 2011) because less pleasure is
of reinforcement (Pechtel & Pizzagalli expected
2011)
Changes to the automatic detection Greater attention to non-verbal ‘negative’
and processing of emotions (Pechtel information (Pechtel & Pizzagalli 2011) like body
& Pizzagalli 2011; Weber et al. 2009). language and facial expressions
Table 1 - trauma and brain development
Table 1 summarises some of the changes in brain development that have been noted for the
survivors of trauma and the implications for the way the person might function as a result
Some regions of the brain have periods of rapid growth and development at particular ages.
These are known as ‘critical periods’ where positive experiences are required for optimal
development, and negative experiences or neglect can adversely impact development of
that part of the brain and its associated functions (Wilson, Hansen & Li 2011 p. 90).
If a child’s physical and emotional environment is chronically stressful, or the child is

exposed to overwhelming stress, normal brain development will be affected, particularly
those areas that are developing at the time of the trauma (Gunnar & Quevedo 2007; Pechtel
& Pizzagalli 2011).

Some of these changes could be regarded as adaptive responses to threat in the
environment of the developing child (McCrory, de Brito & Viding 2010). It is in non-
threatening environments that these changes are less helpful or adaptive for the person.
Additionally, frequent activation of the stress response during development has an impact on
other developing systems for growth and learning (Gunnar & Quevedo 2007).
Whilst a person’s brain may be affected, people can and do recover. People who have
experienced extremes of stress and trauma may have some changes in the way their brains
have developed and continue to function, but have good reason to remain optimistic about
change to these functions over time (Hedges & Woon 2011).
Briere (2002) writes that the impacts of abuse and/or neglect differ enormously depending
on a complex interplay of factors including but not limited to the following variables:
disposition; resilience; bio-psychological factors; family environment and other supports;
peers; security; positive parent/child attachment; and previous history of support or abuse,
including duration, frequency and nature of abuse. However, recovery is possible and many
people go on to lead fulfilling lives.
Until recently it was thought that neurons (nerve cells), including those in the brain, could not
regrow or repair once they were damaged (Doidge 2007, p. 250). However, it has now been
established that at least some areas of the brain can grow new cells (neurogenesis) and
have the ability to modify their connections or re-wire themselves especially in response to
learning or positive experiences (neuroplasticity). The hippocampus in particular is capable
of repair and new cell growth.
Improved living conditions, enriched environments, and corrective emotional

experiences can reverse the adverse consequences of early adversity. (Gunnar &
Quevedo 2007, p. 21)
Some factors that have been shown to influence repair and recovery of the brain include:
• environments rich in stimulation and interest

• the intense concentration involved when learning new things
• relationships that are safe and offer support
• oxytocin, the hormone we release when we are in loving relationships and in the
process of childbirth and nursing.
Freeze, appease and dissociation

We’ve just explored what occurs in the body and the brain when we are threatened and
experience a fight or flight response, and all being well, this response enables us to achieve
safety and turn the fight or flight response off.
However, in response to interpersonal threats where neither fight nor flight are possible, or
are not enough to ensure our safety in the moment, we have other responses that assist in
surviving the threat.
If the brain perceives we can fight we will do so, if it perceives that we can’t fight we will flee,
if it perceives that we can’t do either of those, we will freeze. Children are typically unable to
fight or flee from those who are the source of threat and fear; therefore the younger the child
is, the more likely they will freeze, appease or dissociate in response to trauma. However,
adults are also capable of these responses when they are unable to fight or flee.
During a freeze response the body is experiencing many of the same changes as in fight or
flight, but the person experiences a subjective sense of being unable to move, or to speak

(Bados, Toribio & Garcia-Grau 2008). It is believed that the sympathetic nervous system
(‘accelerator’) and the parasympathetic nervous system (‘brake’) are activated
simultaneously, resulting in the person feeling ‘paralysed’.
Siegel (2010) reiterates that the state of fight or flight is reactive, and can leave us isolated
with feelings and sensations of fear.
"When we see things as threatening, we have left the open state of receptive
presence and entered the reactive state of fight, flight or freeze." (p. 22)
"Instead of being present with mindfulness, we become removed, alone and
paralysed.” (p. 23)
Sometimes the person may also experience a limited ability to move or speak, but only to do
exactly what a person with more power asks of them, or only what is necessary to ‘appease’
the source of threat. This is one way we can understand the behaviour of children who try to
please, to ‘be good’ for the person who is abusive or frightens them.
Dissociation occurs when one or more aspects of the experience, and consequently the
memory of that experience are separated from other aspects of awareness. This is a
complex phenomenon and occurs along a continuum from everyday ‘spacing out’ to whole
aspects of awareness or memory being absent.
We will all experience some degree of dissociation at different times in our lives, from some
‘vagueing out’ during automatic processes like driving, to some disruption of awareness and
memory due to fear (as above). More extensive and disruptive experiences of dissociation are
not uncommon for survivors of trauma, particularly when that trauma occurs during childhood.
The more extensive experiences of dissociation present as poor memory for whole aspects
or time periods of childhood. Adults who experience dissociation can also describe:
• not being able to feel parts of their body
• feeling separate from the environment, as if watching from somewhere else
• being ‘cut off’ from emotion
• arriving or leaving places without being able to recall the circumstances.
At its most extreme, dissociation results in ‘parts’ of the person having awareness and
memory that is not shared with other ‘parts’.
All of these responses may be the most helpful in ensuring the person survives the moment.
Any of these responses can also be problematic for the person in the long term.
Understanding these powerful responses to overwhelming or chronic stress is important in

providing trauma-informed care as they equip workers with a means of understanding behaviour
that could otherwise be misunderstood as ‘challenging behaviour’ (Greenwald et al. 2008).
Understanding these responses also equips workers with a greater ability to support the
person experiencing distress related to past trauma. This knowledge will also remind both
worker and survivor of the function of these complex stress responses in ensuring the
greatest chance of survival.

Activity 4: Understanding dissociation
1. Take a few moments to observe what thoughts, sensations and emotions you are
aware of right now and write them in column 1.
2. Now recall the event you discussed in activity 3. What can you recall about all of
these aspects of your experience? Write your responses in column 2.
3. What do you notice about what stands out? Are there pieces missing? Are some
aspects more prominent than others?
1. Here and now 2. When affected by fear
What I can see
What I can
hear
What I feel in
my body
What emotions
I am feeling
What I am
thinking
What I know is
happening
You may note that these aspects of your awareness in the here and now are connected and
‘make sense’ in that they are associated.
In moments of extreme stress or fear, these associations in awareness can be disrupted. If

we experience ‘dissociation’ in awareness, memories will also be dissociated to some extent
and can be recalled in ‘pieces’.
Understanding triggers and flashbacks

Fear-based learning is very difficult to ‘unlearn’. Once the associations have been made
between certain cues and a fear response, these associations continue to be activated and
reinforced.
Some of the ‘cues’ that may have been associated with earlier trauma and a fear response
can be re-encountered in everyday life, though they are no longer associated with actual
danger. These cues can also be known as triggers because some aspect of the present
triggers (i.e. the re-experiencing of thoughts, feelings or behaviours associated with) past
trauma. Due to disruption of memory by the trauma, and the nature of traumatic memory,
this re-experiencing can feel ‘as if’ the trauma was happening in the present, or has only just
occurred.
In the previous section on the impact of trauma on the brain and on brain development, we
discussed the amygdala being formed (and functioning) from before birth. Therefore the
‘lessons’ we learn through the amygdala and the fear response will not (necessarily) have
words and context attached to them (because they may be pre-verbal). Anything we’ve

learned can become a memory. In the case of learning through fear these memories can be
particularly powerful, and can be triggered into awareness through the senses and
experienced in the body. This is what is meant by “the body remembers” (Rothschild 2000).
If a person can link the trigger to a memory, their own response might make more sense to
them. If they can’t make sense of the response, this is more likely to be frightening and leave
the person feeling unsafe in their own body (Rothschild 2000, p. 65). These partial memory
experiences are also called flashbacks. They are very often visual, but can also be
experienced in, and triggered by, any of the senses, i.e. smell, sensation, sound or taste.
The Window of Tolerance

The “window of tolerance” refers to a zone of brain, body and emotional arousal that
supports effective functioning and wellbeing (Ogden Minton & Pain, 2006; Siegel, 1999).
Siegel (2010) describes it as sailing on a river of well-being and having capacity to respond
to things that come our way without getting thrown off course.
The “window of tolerance” offers a way to understand what is happening when someone
gets triggered and how we can facilitate a return to safety. Most people with lived
experience of trauma experience too much arousal (hyper-arousal) or too little arousal
(hypo-arousal). They can move between these two extremes, or experience them both
simultaneously. When people are outside of their window of tolerance, the nervous system
responds by going into survival mode – fight/flight/freeze/appease. People can then feel
overwhelmed and go into hyper-arousal, which may be characterised by hypervigilance,
emotional reactivity, intrusive thoughts/images, obsessive or cyclical cognitive processing,
tension and shaking. They can also shut down and go into hypo-arousal which may be
characterised by flat affect, inability to think clearly, sense of deadness or emptiness,
numbing and collapse (Ogden, Minton & Pain, 2006).
The window of tolerance can be narrow or wide and is different for all people at different
times in their lives. When people are situated within their “window of tolerance” they are
much more likely to feel safe enough to integrate information from both internal and external
environments. A trauma informed approach involves supporting people to identify when they

are activated and to offer the use of grounding techniques to facilitate a return to optimal
level of tolerance.
Activity 5: Grounding
What are some examples of different types of grounding techniques? If you can’t think of
any there are many in Appendix C that may prompt you.
When might these be helpful? When might they be unhelpful?
Have you used grounding yourself? What was that like?
How might you introduce the idea of grounding to a person in a way that respects safety
and choice?
The following activities are included, with permission from Heidi Hanson, a trauma survivor
and artist. Her blog – The Art of Healing Trauma has many illustrated trauma healing
exercises, as well as survivor stories & research
http://www.new-synapse.com/aps/wordpress/?page_id=2
Remember that: some grounding activities may represent something different for one person
than another. Just like an open door may represent safety for one person and danger for
another. Check in with the person whether the ‘type’ of grounding technique to be used is
one that they are comfortable with.
Activity 6a “your hand and your 5 senses”

1. Begin by tracing your hand on a piece of paper and label each finger as one of the
five senses (taste, smell, sight, hearing, sensation).
2. Write something special and safe representing each of the five senses inside each
finger. E.g.: little finger represents sight and a label for sight might be butterflies or
the ocean; middle finger represents your sense of smell and it could be represented
by roses or freshly cut grass.
3. After drawing this on paper you could post it on your refrigerator or other safe places
in the home where it can be easily seen and memorize it.
4. Whenever you get triggered, breathe deeply and slowly, and put your hand in front of
your face where you can really see it – stare at your hand and then look at each
finger and try to do the five senses exercise from memory.
Adapted from Najavits, L.M., (2001)

Activity 6b: Practicing Physical Grounding Techniques – “Self-Holding”
These exercises introduce some simple yet effective techniques that can be used to anchor
and calm the nervous system through body positioning. Self-holding or self-therapeutic
touch supports people to feel “contained.” Levine (2010) describes the body as the container
of all our sensations and all our feelings. These exercises can help people to become aware
of their container and create an internal sense of calm as they begin to know the parameters
of their bodies and that they are located in a specific location in space. Self-holding can
result in a person’s emotions and sensations not feeling as overwhelming because they are
contained.
Exercise 1:
STEP 1
1. You may have your eyes opened or closed, whatever
feels most comfortable for you. You may lie down or be
seated.
2. Get into a comfortable position.
3. Place one hand on your forehead. If you are laying down
at home, you may place 3 pillows to one side so you can
relax your arm onto the pillows as you rest your hand on
your forehead.
4. Place the other hand on your heart.
5. Pay attention to what is going on inside your body. Gently
place your attention on the area between your two hands,
the area inside yourself between your head and heart.
STEP 2
1. Take the hand that is on your forehead and place it onto
your belly.
2. Repeat as in STEP 1. Pay attention to inside your body, to
any feelings between the hands or sensations where the
hands are laying. Wait until there is a shift.
Exercise 2:
1. Place one hand under the opposite arm, and then place the
other hand over the upper part of the other arm; you are
giving yourself a hug.
2. Pay attention to your body.
3. Let yourself settle into the position; allow yourself to feel
supported by it. Allow yourself to feel contained.
4. Watch and see if anything shifts with your breathing, bodily
sensations, and how you feel in space. See if you can sit
with it a while and let it shift your perceptions of yourself
and the world somewhat before coming out of it.

A safe place
A ’safe place’ can be a real place that we can go to in actuality, or a real place that we can
go to in our imagination, or an imaginary place (Schiraldi 2009, p. 139). It is the ’felt sense‘ of
safety that is important; a place no one can enter without permission that is not dependent
on anyone else and where we are in control. A safe place, real or imagined, can be used as
a way of ‘switching off’ the sympathetic nervous system when it has been activated, and
helps the person feel safe in the present.
See Appendix C for more information about grounding.
Key messages
• Understanding the trauma response requires an understanding of
normal and adaptive responses to threat.
• Trauma survivors adapt to trauma in ways that make survival more
likely but may have negative long-term consequences.
• Trauma impacts on memory.
• Memories of trauma can be triggered and re-experienced in the
present.
• The ‘window of tolerance’ offers a way of understanding what is

happening when someone gets ‘triggered’ and how they may return to
safety.

Trauma-informed care and practice — recognition of safety
Principle 2 - Promoting safety
Trauma-informed care and practice promotes safety - Establishing a safe physical,
psychological and emotional environment where basic needs are met, which recognises
the social, interpersonal, personal and environmental dimensions of safety and where
safety measures are in place, and provider responses are consistent, predictable, and
respectful.
The experience of trauma undermines a person’s safety. Interpersonal trauma threatens the
person’s safety in relationships. Understanding and responding to the impact of trauma
requires an understanding of the impact of fear and its opposite, safety. In Section 1 you
learned about the fight or flight response and other strategies which function to give the
person the ‘best chance’ of survival and achieving safety.
Feeling safe means we have tolerance and are flexible and adaptive, open to new situations and
ways of thinking and feeling. Feeling unsafe means we tend towards “rigidity and feeling stuck”,
or towards “chaos—life feels unpredictable and out of control” (Siegel 2009, pp. 70–71).
However, for many people, they have not found safety, do not feel safe and have lived with
and continue to experience fear, threat and further trauma.
Since safety is a pre-requisite for recovery after the experience of trauma, services will be
unable to contribute meaningfully to recovery without addressing the establishment of safety
for the individual when providing a service. Trauma-informed care and practice requires that
key safety issues are considered first from a consumer perspective.
Contact with service providers needs to not only be safe (in that they do not cause harm) but
also to feel safe from the survivor’s point of view. However, safety needs to be mutual and
needs to be mutually negotiated over time.
Services may be accustomed to considering safety from the perspectives of professionally

conducted ‘risk assessments’, seeking to ensure the safety of the person from risk of self-
harm and risk of harm to others.
Safety can be explored and understood in a

number of ways and from several perspectives.
Cultural
safety This section will assist you to explore and
understand the dimensions of safety and
Systemic
safety
recognise when adopting a trauma-informed
approach, the importance of keeping safety in
Environment mind at all times.
safety
Relationship When we think of safety we usually think of
safety physical or bodily safety, however feeling safe
means not only this sense of personal safety but
safety within relationships, environments and
Personal
safety systems as well as experiencing cultural safety.
One way we ‘unlearn’ a fear response is to be

directly exposed to those cues associated with
the danger, but this time in the absence of actual
threat AND experiencing clear and tangible signs that we are safe in the present (cues for
safety). Sometimes this occurs naturally over time, in the context of safe relationships and

communities. However, if further assistance is needed this is something that only a practiced
therapist should undertake.
Self reflection - safety in relationships

• What does a ‘safe relationship’ mean to you?
• What qualities are important in the other person?
• How do you know when you are ‘safe’ in that relationship?
• How can you promote these relationships in your work?
Attachment relationships
Our first relationships may be the most important in determining our expectations of other
relationships. They are critical for our development because our very survival depends on them
for many years. The purpose of this section is to offer a framework to assist in understanding
why childhood trauma has such a powerful impact on subsequent relationships.
Our first relationships with the adults who care for us are known as ‘attachment
relationships’. Attachment theory was developed by psychiatrist John Bowlby in the 1950s
who proposed that forming strong, secure and safe attachments with a caregiver from birth
is pivotal to the healthy physical, psychological and intellectual development of a child.
Parenting does not need to be perfect, it just needs to be ‘good enough’ for the child to feel
safe, to experience enough security to be able to explore the world, and return for nurture
and protection when needed.
The three functions of attachment are to provide:

• a secure base (from which to explore)
• a safe haven (to return to when distressed or in pain)
• regulation of emotional (and physiological) arousal (e.g. Zeanah, et al 2011).
A safe haven provides a child with a physically and emotionally safe environment in which
to thrive. They are totally reliant on their caregiver to provide this. The caregiver needs to
provide a safe haven that the baby and young child can rely on to keep them safe and
secure. If the caregiver does not provide a reliable safe haven, the child retains a default
position of suspicion rather than trust.
An integral sense of safety is something that is created in our brain, or not, when we are
young. It is dependent on us communicating a need and having our communication
received, made sense of and responded to. In this way an experience of safety is linked to
’secure attachment’ with our primary caregiver.
A secure base enables a child to explore the world and ultimately to develop autonomy and
differentiate from the caregiver. It allows a child to move beyond the immediate proximity of the
caregiver with the knowledge that they can return to that base if they feel unsafe. Toddlers at
play will regularly check that their caregiver is there and close at hand. If the base is secure they
will learn to explore further afield. This promotes confidence and exploration in good times and
allows the child to explore solutions and take risks when they encounter problems.
Learning to regulate physiological arousal (including the stress response) develops

within the safe haven and secure base of relationships with caregivers. The ‘soothing’ of
parents and caregivers helps the child develop ‘self-soothing’ and emotional regulation as an
adult. Children learn about emotions, what they are called and how to manage them.

Attachment relationships can be assessed along a continuum and considered as:
• insecure/avoidant
• secure
• insecure/ ambivalent.
All attachments to primary caregivers are significant; they vary in the degree of security that is
experienced by the infant or child. An insecure attachment can still be a predictable and
organised pattern of responding and being cared for. An insecure attachment is not a mental
health problem; it is a variation of the range of ways of ‘becoming attached’ that is associated
with greater difficulties with emotions and relationships later in life (Cozolino 2006).
The following descriptions (Cozolino 2006, p.146) are very brief summaries of a broad and
complex body of literature. They should not be used to determine any individual’s
attachment style, but are offered to provide a framework for thinking about the variation of
human responses to relationships.
The four different attachment styles accessed from

https://agileleanlife.com/attached-science-of-adult-attachment/
The secure attachment relationship is characterised by an infant that seeks closeness in

order to be soothed and can return to play. The parent doesn’t ‘read’ every signal perfectly
but endeavours to understand and meet the infant’s need to be close and be soothed. The
secure infant becomes an adult who can negotiate the complex world of relationships,
knowing they have inherent worth and an ability to love. They know they can turn to others to
receive comfort when distressed.
The avoidant attachment relationship may be characterised by dismissive parental

behaviour and an infant that learns that he or she cannot rely on the closeness of others to
soothe and nurture them. The parent may not recognise their own importance to the infant,
and the infant becomes an adult that dismisses the importance of relationships but
experiences anxiety about them.
The ambivalent attachment relationship may be characterised by parental attention that is

inconsistent and an infant that seeks comfort but is difficult to soothe. The parent may have
competing demands, or trouble with their own emotional regulation, and the ambivalent infant
becomes an adult that feels conflicted about being close and receiving comfort when distressed.

When the child experiences a stress response, the caregiver represents safety and security
and helps the child ‘regulate’ or switch off the stress response. Secure attachment
relationships result in more ‘efficient’ functioning of the stress response; i.e. it is activated
when needed, and can be switched off when no longer needed. Infants and children with
less secure attachments may be as well cared for and as deeply loved by their parents, but
have greater challenges recognising and regulating emotion, especially in the context of
relationships.
A further category of attachment relationship is known as ‘disorganised’; this shows less

predictability when relating to, and expectation of response by, the caregiver (this will be
explored further in the impact of trauma on relationships).
All attachment relationships (whether secure or not) are said to form a schema (Cozolino
2006 p.139). This is a pattern of unspoken expectations that we carry into adulthood that tell
us what it means to be close to others, to be connected and safe, and to be loved. Our
attachment relationships also influence our beliefs about the ‘self’, others and our place in
the world. We have all been affected by our earliest attachment relationships and while
these templates or schemas for relationships are powerful, poor attachment experienced in
childhood can be ‘re-learned’ in safe, trusting relationships throughout our lives.
The concepts explored above apply to all of us, whether we have experienced trauma or not.
They are some of the systems and capacities that we rely on to keep us safe, survive and
thrive in close relationships. Trauma can disrupt, disorganise and profoundly influence the
development of these systems, and a sound understanding of this assists workers and
services in providing trauma-informed care.
The impact of trauma on relationships

Trauma in early childhood can have a profoundly disruptive and disorganising impact on the
development of attachment relationships (Lieberman 2004).
If a child experiences traumatic events they can recover much more easily if they can turn to
nurturing, secure relationships with others. Their experience will be validated and they will be
supported to cope with the impact and to understand the event in age-appropriate ways.
Young children’s ability to recover from the damaging impact of traumatic events is deeply
influenced by the quality of the child’s attachments and by the parents’ ability to respond
sensitively to the infant’s traumatic responses (Lieberman 2004, p. 338).
However, when attachment relationships are less secure, the child will need to find other
means of coping and self-soothing. When traumatic events in childhood take place within the
orbit of the caretaker and home environment, this directly erodes the child’s safe haven,
secure base and ability to self-soothe.
If the trauma is experienced at the hands of an attachment figure the child is faced with an
impossible dilemma. Survival relies on both proximity to the attachment figure and
avoidance of and getting away from the same person or people. This conflict between
approach and avoidance can persist as a pattern into adulthood, and be difficult for the
person themselves to understand (Cozolino 2006, p. 229). Children who experience abuse
at the hands of attachment figures (or care that is frightening, or received from a frightened
parent) are more likely to develop disorganised attachments.
A disorganised attachment style is characterised by chaotic and unpredictable responses to

soothing, perhaps seeking comfort from unexpected sources, or attempting to self-soothe in
ways that may alarm others (Cozolino 2006, p. 146). Disorganised attachment styles are most
likely to be seen in children who have frightened or frightening caregivers (Lieberman 2004).

Harris and Fallot (2001) outline the themes that characterise abusive relationships in
childhood which undermine attachment relationships:
• Betrayal occurs at the hands of a trusted caregiver or supporter

• Hierarchical boundaries are violated and then re-imposed at the whim of the abuser
• Secret knowledge, information, and relationships are maintained and even encouraged
• The voice of the victim is unheard, denied, or invalidated
• The victim feels powerless to alter or leave the relationship
• Reality is reconstructed to represent the values and beliefs of the abuser
• Events are reinterpreted and renamed to protect the guilty.
The behaviour of perpetrators of abuse will also affect the child’s understanding of
relationships in general. When abuse occurs in the context of families, the perpetrator of the
abuse makes use of the child’s attachment needs and behaviours to facilitate the abuse and
to ensure secrecy.
The perpetrators of sexual abuse of children can use deliberate strategies to identify
children's vulnerability and need for affection and acceptance and exploit this in order to
abuse them (Conte, Wolf and Smith 1989). Some offenders deliberately target children who
have been abused previously, as they are perceived to be less likely to report the abuse.
The process of engaging the child in a relationship, isolating them from others and
desensitising them to touch through games and 'accidental' touching is known as 'grooming'.
The perpetrators of abuse make deliberate use of children's natural need for adult attention
and their inherent power and authority as adults. For many survivors there is an impact on
other relationships of trust and authority.
Psychologist and psychotherapist Louis Cozolino summarises the impact on the
development of adaptive responses into long-term problems. He states that when faced with
early interpersonal trauma:
[...] attachment schemas are used as battle plans instead of ways of connecting.
Faces are explored for signs of disapproval. Regulatory systems become biased
towards arousal and fear, priming our bodies to sacrifice wellbeing in order to stay on
full alert at all times. Reward systems designed to make us feel good through contact
with loved ones are manipulated with drugs, alcohol, compulsive behaviours, and
self-harm. When the brain is shaped this way, social life is converted from a source
of nurturance into a minefield. (Cozolino 2006, p. 231)
Survivors of trauma at the hands of an attachment figure (or family) therefore approach
relationships with heightened concerns about safety and betrayal and learning to trust and to
feel safe can be extraordinarily difficult. This can be seen as adaptive and ‘makes good
sense’ when we consider what the person has experienced and has survived (Cozolino
2016).

Activity 7: Relationships and providing support.
Scenario: ________________________
How might this person have learned to relate?
How might this affect how you relate to them?
Activity 8: A safe (enough) place

This activity will be conducted in class. Afterward you may wish to reflect on the following:
• What helps you to feel safe?
• What causes you to feel unsafe?
Activity 9: Self care commitment

One thing I will do for my self-care tonight is…

Self Reflection
My key learning points for Day 1:
Key messages
• The impact of trauma in childhood is complex and cumulative.
• Brains and biology are affected by trauma, but people can (and do)
heal and recover.
• Safety is a pre-requisite for healing and recovery and is a critical
element of trauma-informed care.
• Safety in relationships needs specific attention in trauma-informed
care.
• Trauma survivors may have particular challenges feeling safe even
many years after the trauma.

Safety in service environments
One aspect of safety in trauma-informed care is the physical environment in which care and
support takes place. People who have experienced prior trauma may be more likely to feel
unsafe in service environments (Frueh et al. 2005; MHCC 2013). An environment that feels
safe is best for people accessing a service as well as for the staff.
Conflicting definitions of safety

Safety from the perspective of a consumer often looks and feels very different to safety from
the perspective of service providers.
In the table below, Blanch and Prescott (2002) outline the meaning of safety from the
perspective of consumers and of services.
SAFETY FOR CONSUMERS MEANS: SAFETY FOR PROVIDERS MEANS:

minimising loss of control over their lives minimising loss of control over the
environment and risk
• maximising choice • maximising routine and predictability

• authentic relationships • assigning staff based on availability
• exploring limits • setting limits and rules
• defining self • designating diagnoses
• defining experiences without • judging experiences to determine
judgement competence
• receiving consistent information • rotating staff and providing
ahead of time information as time allows
• freedom from force, coercion, threats • use of control such as medication,
and punishment restraint and seclusion to prevent
• owning and expressing feelings dangerous behaviour
without fear • reducing expressions of strong
emotion
( Blanch & Prescott 2002)
The nature of a contact with services involves a relationship with a service or service
providers that are in a position of greater relative power. The very nature of this power
imbalance means that extra care needs to be taken to consider what may be experienced as
threatening for consumers and what may be required for consumers to feel safe.
A trauma-informed approach understands the nature of triggers and flashbacks. It assists

people to identify the things that make them feel unsafe, and supports them in developing
ways to feel safe (Guarino et al. 2009, p. 76). The trauma-informed approach also
recognises that staff need to feel safe and develop their own self-awareness around ‘felt
safety’.
If you work in a service that is based in a building, consider the following questions regarding
the perception of safety:
• Are there separate spaces for male and female consumers if they want this?
• Are there comfortable and safe time-out spaces for consumers?
• Is there a high level of respect for personal modesty?
• Are same-gender staff always available?

• Is there a high level of respect for personal space and boundaries?
• Do staff know which people the consumer does not feel safe with, either in the
service or their wider life, and have they discussed plans with the consumer about
how these people need to be dealt with?
• Do staff know what elements of the service’s physical space and routines the
consumer my find difficult?
• Have staff checked that a consumer is comfortable to be in a room with a closed door
with only the two of them in there?
• Are all staff trained in strategies for safe and non-physical de-escalation?
• Do consumers have access to private locked spaces for their belongings?
• Are consumers asked about the least intrusive way for staff to check on them and
their spaces?
• Are there private spaces for staff and consumers to discuss personal issues?
(Harris & Fallot 2001; Guarino et al. 2009)
If you go to the person’s home or meet in other areas outside of your organisation, ensuring
an environment that feels safe for both of you is just as important. Don’t assume because
you feel safe that the consumer will or vice versa.
For people with a lived experience of trauma they may feel unsafe if their physical location is:
• noisy
• full of strangers
• quite visible to others
• too secluded
• sparsely populated
• lacking a quick exit
• too big or too small.
Personal Reflection
What environments feel unsafe to you? What are the features of that environment that
might lead you to feel that way?
Personal reflection
What environments feel unsafe to you? What are the features of that environment that
might lead you to feel that way?

Activity 10: Feeling safe in services
What are potential triggers in your service? How might you address these?
What new questions might you ask, or what new approaches might you take, with regard
to safety, in your own practice and in your service?
Re-traumatisation of consumers and carers within services
Safety warning: This section includes topics which may be triggering for some people. It
includes information about potentially traumatising practices within mental health services.
Even in a consciously non-threatening environment, a number of triggers may evoke

traumatic responses from consumers; for example being touched; or experiencing the power
differential between themselves and the worker.
Through their practice approach and relationship with the consumer, workers need to ensure
that they do not inadvertently replicate the characteristics of abusive relationships: e.g.
where there is secrecy; where the voice of the victim is unheard, denied or invalidated;
where the victim feels powerless to change anything; where the victim feels they may be
punished or excluded from services; and where the worker defines the ‘story’ according to
their own values and beliefs (Harris & Fallot 2001).
A trauma-informed approach recognises that receiving mental health care can also be
traumatic (Mueser, Rosenberg & Wolfe 2010). Some events occur within the process of
accessing and receiving mental health and other medical services, which may bear
similarities to the primary trauma, because some aspects of the treatment or care reflect
similar dynamics to that prior trauma. This is said to be re-traumatising. Some experiences
related to the symptoms of mental health conditions can also result in long-term impacts of
trauma (Mueser, Rosenberg & Wolfe 2010).
Examples of events that are likely to be harmful or traumatising for consumers include:
• being apprehended by police
• being transported to hospital by police
• being subjected to isolation or seclusion
• being subjected to a ‘take down’ or being physically subdued by one or more others
• being subject to physical and mechanical restraint
• being forcibly injected with medication
• being called names
• being denied the privacy to shower or dress
• witnessing any of the above happening to others.

Even routine treatment and processes in the context of mental health services may be
experienced as distressing for consumers. Frueh et al. (2005) interviewed 142 patients who
were receiving mental health care in a public mental health unit. They collected information on
their lifetime experience of a range of potentially traumatic events, aspects of the mental health
service environment and the degree of distress, trauma symptoms and perception of safety
within the service. They noted the distress associated with a loss of control for consumers in
this environment, and made strong recommendations for increased attention to safety within
inpatient settings in particular. Frueh et al. (2005) also found some evidence for an increased
likelihood that those who have survived previous trauma (sexual and physical abuse as
children and sexual assault as an adult) are more likely to experience coercion and restraint.
Invasive procedures are the most dramatic examples of trigger events occurring in a medical
setting. Additionally, survivors of previous trauma were more likely to report they had
experienced unwanted sexual advances, a lack of privacy for bathing and dressing, and
feeling bullied or labelled as ‘crazy’ by staff. Survivors of sexual assault and those who were
reporting symptoms of PTSD also reported significantly higher scores on measures of
feeling unsafe, helplessness, fear and distress.
Even if you are working in a service setting where these practices are not used, keep in
mind that the people you support may have experienced some or all of the above in
their prior contact with services directly, or indirectly. Likewise keep this in mind with
regards to referrals to health professionals who may not be trauma-informed.
Activity 11: Re-traumatisation – when services are not safe

In what ways might carers and consumers perceive workers:
• to hold secret knowledge and information?

• to betray their trust?
• to invalidate their experience and define their story for them?
• to take power away from them?
• to control them?
If you became aware of work practices or policies that are experienced by trauma
survivors as unsafe, or a barrier to recovery, what would you do?
Who would you refer the matter to and how?

Using an understanding of trauma to support safety and recovery
Trauma-informed care recognises the impact of trauma on the emotional, psychological and
social wellbeing of survivors of trauma. Trauma-informed practise includes the ability to offer
information to survivors and to share knowledge. It assists and supports survivors to
integrate this information or knowledge for recovery and healing.
Trauma creates feelings of powerlessness–but knowledge brings power. Because many

people who experience trauma have never talked to others about their experiences, it is very
likely that the person does not understand the ways in which trauma might have impacted
them emotionally, mentally and behaviourally. Many people feel ashamed or confused about
these feelings, thoughts and actions.
Supporting a person to learn more about the impacts of trauma can help the person in a number
of ways including:
• feelings of empowerment
• a sense of relief
• reduced feelings of difference, a kind of ‘normalisation’
• validation
• self-forgiveness and acceptance
• self-awareness and understanding, and
• self-esteem and confidence.
However, like all conversations about trauma, building knowledge also brings risks. It is likely
that the person will be thinking more about the trauma and as a result may experience an
increase in distress. As with all trauma work, the most important strategy is to ‘go slow’.
This means:
• small chunks of learning, not a whole session
• sandwich learning sessions between less stressful conversations
• check in with the person’s feelings and thoughts regularly
• use grounding strategies
• don’t meet at the end of the day or week, and
• be validating, accepting and gently encouraging.
Tips for trauma-informed conversations

• Recognise that the past can influence the present, but stay in the present
• Share information openly–knowledge is power
• Assume (and value) self-knowledge and expertise
• Value coping strategies (even those that are costly or over-developed)
• Support self-direction and choice (autonomy)
• Each person will have different knowledge and learning needs. Take your cues from
the person.

Some ways to introduce information about trauma may include saying things like:
Did you know that [whatever impact the person may be struggling with] is quite
common for survivors of [type of trauma experience]? I would like to share some
information with you about this, if you would like to hear it?
Many people who have experienced the things you have find it hard to feel safe with
other people.
I know that the [type of trauma experience] was a long time ago, but I also know that
it is very common for memories to get stirred up many years later. Do you think that
there has been a trigger recently that has stirred these memories up?
I’ve heard that part of the impact of the kinds of things that have happened to you is
to make people especially ‘jumpy’ and on edge even many years later. Do you think
that the past has a connection to how you are feeling now?
Did you know that it is common for people to find ways to…?
(situation) is stressful. I guess that you may have found some ways of coping with
this?
When stressful things happen it’s quite common to (feeling/ thought/ behaviour) but
it’s often hard to think clearly until our bodies become calmer.
Given what you’ve been through in your life, it makes sense to me that you would
(feeling/ thought/ behaviour).
Safety considerations when sharing lived experience

Sharing our lived experience about trauma is similar to sharing our lived experience about
mental health and recovery. For many people the two topics will be the same journey, while
for others they may be different.
There are some ways of talking about trauma that are likely to retraumatise people. In
particular, sharing graphic details about trauma can be very triggering for some people to
hear. There are other ways of talking about trauma that are more likely to promote recovery.
But we can never know for certain how each individual will respond.
There are many different ways to talk about trauma from a peer perspective.
• We can talk about personal traumatic events and tell the story of what happened to
us. We can do this in detail or in a generalised way.
• We can talk about traumatic experiences of consumers as a group without sharing
our own personal story.
• We can talk about the impacts that trauma has had on our lives without necessarily
sharing details of the actual traumatic experience.
• We can talk about how trauma has been related to our mental health.
• We can share stories about how experiences in the psychiatric system has triggered
memories of trauma.
• We can talk about trauma actually experienced as a result of the psychiatric system.
• We can talk about what has helped us to heal from past trauma, and why.
• We can talk about what helped us to begin acknowledging and talking about trauma
with others.
• We can talk about what stopped us from talking about trauma with others, and the
impact this had on us.

• We can be honest about our own stage of trauma recovery and what are still learning
or struggling with.
• We can talk about what helps us to cope and feel strong.
• We can talk about the impact of discovering you are not alone in experiencing
trauma.
• We can talk about common myths that people believe about trauma and how these
affected us.
These are just some options for how peers may talk about trauma in their work. Common
ways of talking about trauma within peer relationships are these factors:
• Creating our own narratives and meanings;
• Reflecting on recovery processes more than specifics;
• Noting our strengths but also respecting our vulnerabilities;
• Avoiding pathologising language and meanings; and
• Not having the answers for someone else.
Many of these conversations involve peers relating to each other about personal
experiences of trauma. But what if you haven’t experienced trauma, or if you do not wish to
talk about it in your role as a peer worker?
Blanch et al. (2012) question what we mean by ‘common experience’ in woman to woman
peer support, but this thinking can apply to all peer work:
It is easy to make the mistake of basing relationships with women survivors on the
trauma-uninformed question “What is wrong with you?” This is especially true if you
work in a system that reinforces deficit-based relationships. For example,
relationships based on a label of “mental illness” or on the experience of
incarceration or homelessness or substance use: “You and I share a lived experience
of addiction.” This is only part of the picture; these experiences alone do not define
you or the women you support. Basing peer relationships only on these factors may
keep the relationship on superficial ground. This narrow definition of common
experience can increase the likelihood of disconnection by excluding anyone who
does not share exactly the same experience. (p 51)
Shery Mead reminds us that the peer support principle of mutuality means that peer work is
not about having had the same experience as someone else, but about being willing to shift
roles from ‘helper and helpee’ to ‘co-travellers’: two people willing to learn together about
their experiences:
Mutual help in peer support (and obviously in community) implies both people taking
on both roles with each other. It means sharing our vulnerabilities and our strengths
and finding value in each other’s help. (Mead, n.d.)
(MHCC 2014, p 54-55)
Self reflection: Working with different lived experiences

Peers who have very similar lived experiences may still have very different life impacts
and paths to recovery? What does this in terms of how we share and use our lived
experience?
What can this mean in terms of peer workers who do not have a lived experience of
trauma to share?

Activity 12a: Using information about the impacts of trauma
This activity will give you an opportunity to reflect upon your understanding of the impact of
trauma and practise ways in which you may consider, share or discuss this information with
survivors.
In pairs, pick one scenarios you are both comfortable with, which is unlikely to be
triggering for either of you. Imagine that you meet with this person today. Later one
of you will play this role, while the other plays the role of the peer worker.
What information might What you will need to How might this strategy
you be able to offer this consider about safety support recovery?
person? Consider timing, pace, location, how
Consider general information about to gauge safety of the person and
trauma, as well as your own lived yourself.
experience.

Amanda feels on edge all the time. She is fidgety and can’t concentrate on what you are
talking about today. She cries easily and apologises frequently, saying that you must think
she is ‘crazy’. She is upset about things a colleague said to her today and can’t get her
mind off it.
Ray is hearing a voice saying how worthless and useless he is. He is bothered by beliefs
that he has been responsible for events that don’t seem connected to him at all. He says
he smokes marijuana when he can afford it, and he’s been spending a lot of time alone in
his flat and avoiding people.
Amina says she is fine now, that she knows what she needs to do and accepts her
responsibility to her family. She says she can’t remember why she cut herself last month,
that it was probably ‘nothing’.
Trisha tells you that she’s having trouble concentrating at uni. Every assessment task
sends her into a ‘spin’ and she doubts that she is really capable of being a nurse at all.
Greg is upset and tells you how angry he has been getting with his girlfriend, Jo. He
doesn’t trust her and believes she may be sneaking behind his back to see someone else.
He threw things around their flat last night and broke the TV.
Carol is much happier today; she tells you she has a new boyfriend who she met on the
weekend. She tells you that he is kind because he offered her a joint when she first met
him, and that he is going to stop seeing his ex-wife now to be with her. They are talking
about moving in together.
Activity 12b: Role play

Decide who will play the role of person and who will be the peer worker. The peer worker
will practice sharing information about trauma. Afterwards reflect together:
What worked well?
What would you do differently next time?
Key messages
• People who use services and people who provide services may have
very different understandings of safety.
• Safety in relationships needs specific attention in trauma-informed

care.
• Trauma survivors can be retraumatised by contact with services.

Families and communities – ripples of trauma
The experience of Aboriginal and Torres Strait Islander Peoples
The impact of trauma commonly does not just affect the individual. Like a ripple in a pool one
person’s experience can be felt by others around them. A person’s family or community may
experience distress, concern and grief about what has occurred. Loss and grief are common
reactions within the family and community and may have profound impacts. In addition,
some people may experience guilt, either because they did not act in a way that might have
stopped the traumatic events or because they experience ‘survivor guilt’; they feel it was
unfair they avoided the trauma while the other person didn’t. Even the process of hearing the
details or listening as the person retells or relives their experience can result in vicarious
experiences of trauma and may affect the listener emotionally, spiritually or physically. They
may have anxiety or nightmares or a myriad of other reactions.
This ripple effect is clearly demonstrated in the devastating way trauma experiences have
impacted on the Australian first nation’s people as a result of the government policy of forced
removal of Aboriginal children. The Australian Human Rights Commission, previously the
Human Rights and Equal Opportunity Commission (HREOC), published the Bringing them
Home report detailing the effects of this trauma on children and their extended families and
communities. The report found that the families and communities of those taken were
significantly and profoundly impacted, as they experienced the trauma of the removal of
children.
The National Inquiry into the Separation of Aboriginal and Torres Strait Islander
Children from Their Families concluded that over the period between 1910–70
between one in three and one in 10 children were forcibly removed from their families
and communities and, in some places and at some times a much higher proportion.
Inquiry further concluded that: ”not one Indigenous family escaped the effects of
forcible removal, with many affected over a number of generations” (Burns, Burns &
Menzies 2008, p. 190).
The magnitude of this trauma is extraordinary and deserves particular exploration and
understanding.
Every single Aboriginal person is directly affected by the forcible separation laws,
practices and policies and continues to feel the effects of trauma and loss. It is
unlikely that any other Australian today would have great grandparents, grandparents
and parents who were starved, murdered, forced off traditional lands, imprisoned
and/or stolen from their mothers (Menzies & McNamara 2008, p. 46).
We note here that there are survivors of the Holocaust in Australia perpetrated by German
National Socialism1933 – 1945. These survivors would have experienced such trauma as
described above as well as many other inhuman practices (LaCapra 2001).
The Aboriginal and Torres Strait Islander Healing Foundation Development Team (2009, p.
3) suggested that as “a result of the violent history of colonisation, dispossession and forced
separation, Aboriginal and Torres Strait Islander peoples are experiencing four types of
unresolved trauma”:
• situational trauma—where specific situations such as death or forcible removal

produce traumatic responses
• ecological trauma—where chaotic environments contribute to trauma
• cumulative trauma—where traumas such as daily racism, daily abuse or violence or
poverty are repeated

• intergenerational trauma—where trauma left unresolved in one generation is often
unwittingly handed down to the next generation through fear, shame, violence or
abusive behaviour, for example.
Judy Atkinson, who has written and researched extensively on trauma, particularly in
Aboriginal contexts, “linked the historical events associated with the colonisation of
Aboriginal lands (‘accidental’ epidemics, massacres, starvations, and the removal of people
to reserves) to increases in the rates of family violence, child sexual abuse and family
breakdown in Indigenous society. She traced one family line across six generations, listing
the known memories of being victims of sexual and/or physical violence, being a perpetrator
of violence, suffering from mental health illness, attempting suicide, and having substance
misuse problems.” (Atkinson, Nelson & Atkinson 2010, p. 137)
Intergenerational trauma
Trauma, as previously discussed, can result in attachment issues and relationship
challenges later in life. This can in turn affect the way survivors of trauma parent and relate
to their children (Atkinson, Nelson & Atkinson 2010; Van der Kolk 2007).
If the impacts of the trauma are not addressed and healed they can inadvertently be passed
on to further generations. This is known as intergenerational trauma. For example, Eduardo
Duran in his book Healing the Soul Wound (2006) describes historical and intergenerational
trauma as experienced by American First Nations peoples.
Intergenerational trauma involves the recognition that horrifically violent experiences inflicted
on individuals in the past result in unhealthy outcomes that are passed on to one’s offspring
and manifested in future generations (Daniels & D’Andrea 2007).
Evans-Campbell (2008) provided a definition of intergenerational trauma stating it was: “A

collective complex trauma inflicted on a group of people who share a specific group identity
or affiliation—ethnicity, nationality, and religious affiliation. It is the legacy of numerous
traumatic events a community experiences over generations and encompasses the
psychological and social responses to such events”.
Intergenerational trauma has also been seen as a ‘cycle of damage’ that can either be
passed on directly (e.g., through listening to stories of trauma, violence and oppression) or
indirectly (e.g. through experiencing the impacts of poor parenting; mental health issues;
violence; relationship issues; drug and alcohol abuse; or emotional distress, resulting from a
lack of healing of the prolonged effects of trauma).
It is difficult to capture the complexity of the effects for each individual. Each
individual will react differently, even to similar traumas. For the majority of witnesses
to the Inquiry, the effects have been multiple and profoundly disabling. An evaluation
of the following material should take into account the ongoing impacts and their
compounding effects causing a cycle of damage from which it is difficult to escape
unaided. Psychological and emotional damage renders many people less able to
learn social skills and survival skills. Their ability to operate successfully in the world
is impaired causing low educational achievement, unemployment and consequent
poverty. These in turn cause their own emotional distress leading some to perpetrate
violence, self-harm, substance abuse or anti-social behaviour. (Human Rights and
Equal Opportunity Commission 1997)
As one person explained:
There’s things in my life that I haven’t dealt with and I’ve passed them on to my
children. Gone to pieces. Anxiety attacks. I’ve passed this on to my kids. I know for a
fact if you go and knock at their door they run and hide.

(Human Rights and Equal Opportunity Commission 1997)
The Western Australian Aboriginal Child Health Survey (Zubrick et al. 2005) provided
empirical research that verified the intergenerational impacts of trauma for Australian
Aboriginal people. It highlighted some of the intergenerational effects of forcible removal for
the children, their parents and other children not removed. In particular, there is a higher risk
of both emotional and behavioural problems as well as the overuse of alcohol; and an
increased likelihood of being arrested and charged with an offence during their lives.
Milroy, in the preface to volume two of the Western Australian Child Health Survey, provided
an explanation of the transmission of intergenerational trauma effects and the role of family
and community in this transmission.
The trans-generational effects of trauma occur via a variety of mechanisms including

the impact on the attachment relationship with caregivers; the impact on parenting
and family functioning; the association with parental physical and mental illness;
disconnection and alienation from extended family, culture and society. These effects
are exacerbated by exposure to continuing high levels of stress and trauma including
multiple bereavements and other losses, the process of vicarious traumatisation
where children witness the ongoing effect of the original trauma which a parent or
other family member has experienced. Even where children are protected from the
traumatic stories of their ancestors, the effects of past traumas still impact on children
in the form of ill health, family dysfunction, community violence, psychological
morbidity and early mortality. (Milroy 2005, p. xxi)
These broader community and intergenerational effects are not just experienced by
Aboriginal people in Australia and in other First Nations peoples. They are also seen in other
groups who experience community or family trauma; for example refugees, Vietnam War
veterans and the survivors of the Holocaust (Eisenbruch 1991, Menzies & McNamara 2008,
Milosevic 2009).
Historically, the trauma for many of these groups went further than forcible removal of
children; it included violence, dispossession, discrimination and oppression which result in
repeated experiences of trauma for the individual, the family and community. As Zeilinger
(2011) points out “the impacts of historical trauma have resulted in communities that are
often fractured” (p. 5).
Menzies and McNamara draw on Erikson’s concept of collective trauma as a “blow to the
basic tissues of social life that damages the bonds attaching people together and impairs the
prevailing sense of community” (Erikson 1994, p. 233). They see it as a “direct assault on
the continuity and integrity of the cultural system” (Menzies & McNamara 2008, p. 46).
Connecting this with Eisenbruch’s (1991) notion of cultural bereavement they view it as the:
Experience of the uprooted person or group resulting from loss of social structures,
cultural values and self-identity. As a result, there is an enormous ‘load’ of trauma
and grief borne by Aboriginal people across generations that is expressed as
violence, injury, poor parenting, unresolved grief, depression and mental illness.
(Menzies & McNamara 2008, p. 46)
In fact, Atkinson and Atkinson (1999, p. 7) found “violent behaviours become the norm in
families where there have been cumulative intergenerational impacts of trauma on trauma
on trauma, expressing themselves in present generations as violence on self and others”.
Zeilinger wrote from the context of the American First Nations peoples, however her words
parallel and are equally applicable to the Australian Aboriginal experience (Menzies &
McNamara 2008).

The trauma of land, culture, and loved ones taken, without sufficient time to mourn
the losses, has created an unresolved grief that is enduring. The assimilationist
policies of this century have resulted in the continued fracturing of traditional
societies, leaving many without a solid base of support and often living in abject
poverty. (Zeilinger 2011, p. 6)
Impacts of trauma in a community

The impact of collective and intergenerational trauma can be reflected in a community and seen as:
• fear, vigilance and hyperarousal
• numbing, avoidance and withdrawal
• loss of memory, impaired learning
• role confusion, breakdown of boundaries and social norms
• loss of sense of belonging
• lateral violence.
Lateral violence and trauma

There is extensive evidence now that indicates these experiences of trauma and oppression
can be turned inward and become what Paolo Friere calls “internalised oppression”. In
Australia this is more commonly now referred to as lateral oppression or lateral violence. It
refers to the process of the oppressed person or people beginning to identify with the
oppressor and to act in damaging and aggressive ways to others in their community or family.
The Social Justice Report 2011 by the Aboriginal and Torres Strait Islander Social Justice
Commissioner (Gooda 2011) is primarily focused on the importance of identifying and
addressing lateral violence to assist Aboriginal people to overcome the effects of
intergenerational trauma and oppression. Gooda (p. 8) states that “while lateral violence has
its roots in our history, it thrives today because power imbalances, control by others, identity
conflict, negative stereotypes and trauma continue to feed it”.
According to Gooda (p. 54), lateral violence can manifest itself through a range of behaviours.
Lateral violence ... is a product of a complex mix of historical, cultural and social dynamics
that results in a spectrum of behaviours that include: gossiping, jealousy, bullying,
shaming, social exclusion, family feuding, organisational conflict, physical violence.
Implications for workers

Son Of Mine
My son, your troubled eyes search mine,
Puzzled and hurt by colour line.
Your black skin soft as velvet shine;
What can I tell you, son of mine?
I could tell you of heartbreak, hatred blind,

I could tell you of crimes that shame mankind,
Of brutal wrong and deeds malign,
Of rape and murder, son of mine;
But I’ll tell instead of brave and fine

When lives of black and white entwine,
And men in brotherhood combine-
This would I tell you, son of mine.
Oodgeroo Noonuccal Kath Walker (1966)

Self-reflection - What do you think Oodgeroo Noonuccal was saying in this poem about
Aboriginal trauma, resilience or reconciliation? What might this mean to us in our role and
responses as workers?
While a systems-level human rights approach is essential, these principles also need to be
applied at the individual worker and service level. Herman in her seminal book Trauma and
Recovery argues we need to approach complex trauma at both the societal and individual level.
To hold traumatic reality in consciousness requires a social context that affirms and protects
the victim and joins the victim and witness in a common alliance. For the individual victim,
this social context is created by relationships with friends and lovers and family. For the
larger society the social context is created by political movements that give voice to the
disempowered (Herman 1992, p. 9).
At the individual level, Maria Yellow Horse Brave Heart argues “unless indigenous people
face the past with all of its destruction and oppression, and grieve over those memories,
healing will not occur and this intergenerational historical trauma which has been handed
down from prior generations will continue to impact their descendants” (Zeilinger 2011, p. 4).
Brave Heart (2005) also believes that this historical trauma is a “cumulative emotional and
psychological wounding across generations, including one’s own lifespan, because
everything up to a minute ago is history” (p. 4).
It is important to understand that while healing programs remain the role of specialist trauma
services and healing services, it is the role of all workers to be aware of the language they
are using and that the person they are supporting uses, and to maintain a strength-based
perspective. All workers need to understand the trauma people have experienced, and the
complexity of the effects of intergenerational trauma at the individual, family and community
level.
There is also a role for community education so that non-Aboriginal people have a greater
understanding of intergenerational trauma in the Aboriginal community, and that Aboriginal
people also have the opportunity to understand and reframe many of their own experiences. As
Menzies and McNamara (2008) point out, “some Aboriginal people have not had the opportunity
to develop this analysis or use this information to frame their own experience” (p. 46).
All of our actions as workers also need to be guided by the UN Declaration’s four principles
(Gooda 2011, p. 9):
• self-determination;
• participation in decision making;
• non-discrimination and equality; and
• respect for and protection of culture.
Ripples of healing
Acknowledgement of traditional indigenous healing practice and its impact on
family, community and Country
Dadirri – “A unique gift of the Australian Aboriginal People”

Miriam Rose Ungunmerr was born near the Daly River in 1950 and is a member of the
Ngangiwumirr language group. Miriam describes Dadirri as a special quality or healing

practice of the Australian Aboriginal People and the “greatest gift we can give to our fellow
Australians” (Ungunmerr, 1993, p 35).
Dadirri is a process of listening, reflecting,

observing feelings and actions, and learning
through re-listening at deeper levels of
understanding and knowledge building. Dadirri
means listening to and observing the self as well
as, and in relationship with, others (Atkinson,
2002). This traditional Australian Aboriginal
practice offers a way of engaging in deep and
respectful listening to move toward healing from
trauma and building community.
https://www.youtube.com/watch?v=pkY1dGk-LyE
Atkinson (2002) has identified the principles and knowledge of Dadirri as:
• Knowledge and consideration of community
• Ways of relating and acting in community
• Non-intrusive observation or quietly aware watching
• Deep listening, hearing with more than ears
• Reflective non-judgemental consideration of what is seen or heard
• ‘Tuning in’ experience to deeply understand nature
• Learning from listening with purposeful plan to act, with actions informed by learning
and wisdom
Ungunmerr (2002) suggests that Dadirri is “not just an Aboriginal thing” but is inside
everyone and offers a way for all people to experience Dadirri.
Experiencing Dadirri
1. Clear a little space as often as you can, to simply sit and look at and listen to the
earth and environment that surrounds you.
2. Focus on something specific, such as a bird, a blade of grass, a clump of soil,
cracked earth, a flower, bush or leaf, a cloud in the sky or a body of water (sea, river,
lake…) whatever you can see. Or just let something find you be it a leaf, the sound of
a bird, the feel of the breeze, the light on a tree trunk. No need to try. Just wait a
while and let something find you, let it spend time with you.
3. Lie on the earth, the grass, some place. Get to know that little place and let it get to
know you - your warmth, feel your pulse, hear your heart beat, know your breathing,
your spirit. Just relax and be there, enjoying the time together. Simply be aware of
your focus, allowing yourself to be still and silent…, to listen…
4. Following this quiet time there may be, on occasion, value in giving expression in
some way to the experience of this quiet, still listening. You may wish to talk about
the experience or journal, write poetry, draw, paint or sing… This needs to be held in
balance - the key to Dadirri is in simply being, rather than in outcomes and activity.
Adapted from: Ungunmerr, 2002

Principle 3
Supporting consumer control, choice and autonomy - A trauma-informed care and
practice approach values and respects the individual, their choices and autonomy, their
culture and their values.
Principle 4
Ensuring cultural competence - A trauma-informed care and practice approach
understands how cultural context influences perception of responses to traumatic events
and the recovery process; respects diversity; and uses interventions respectful of and
specific to cultural backgrounds.
Culture, gender and privilege

Culture and upbringing influence our identities, values and the meaning we make of the
things that happen to us (See earlier section on the experience of Aboriginal and Torres
Strait Islander Peoples). How we experience and understand trauma is no exception. For
instance, the cultural model for the recognition of the impact of trauma in western society is
centred on the construct of PTSD (Lemelson, Kirmayer & Barad 2007, p. 470). This does not
necessarily mean that we can assume this will be a meaningful or helpful model for people
who have not grown up within a western culture (or even for many who have).
Our own upbringing and culture can leave us with biases towards other identifiable groups
based on race, culture, gender, sexual identity or ethnicity. Singh defines culture in this way:
The shared values, traditions, arts, history, folklore, and institutions of a group of
people that are unified by race, ethnicity, nationality, language, religious beliefs,
spirituality, socioeconomic status, social class, sexual orientation, politics, gender,
age, disability, or any other cohesive group variable. (N. N. Singh in Blanch, Filson &
Penney 2012, p. 25)
When two or more people come together in any relationship, they bring with them their own
culture and their perceptions of the culture of others. If a person has experienced oppression
or discrimination on the basis of race or cultural identification, these dynamics may affect the
relationship.
Conversely, the membership of some cultural groups may confer advantages, privilege or
benefits that the individual may not be aware of, or find it difficult to acknowledge. The
following quote is from the trauma-informed care guidebook for the peer workforce, but
applies equally to all workers in support relationships:
Acknowledging your own advantages and recognizing racial or other cultural biases
may be difficult or feel shameful, but having honest conversations about these issues
can help you to build effective peer support relationships. This is particularly
important when working with trauma survivors, who are often skillful at detecting
dishonesty and who have good reason to be attuned to issues of power and
authority. Also, it is essential that you recognize any areas that create a sense of
powerlessness in you, whether they are related to trauma or to discrimination. Topics
that touch on your own history with oppression can be particularly challenging.
(Blanch, Filson & Penney 2012, p.26)
A trauma-informed care and practice approach must be a culturally competent approach.

Responses and services that are not culturally competent risk doing further harm through the
invalidation of culturally significant beliefs, and a failure to recognise cultural contexts for

both trauma and healing. Cultural competence in health and social services requires more
than awareness of the culture of the service recipient, but also the contribution of the service
providers culture, assumptions, beliefs and rituals.
A “culturally competent” health care system has been defined as one that
acknowledges and incorporates—at all levels—the importance of culture,
assessment of cross-cultural relations, vigilance toward the dynamics that result from
cultural differences, expansion of cultural knowledge, and adaptation of services to
meet culturally unique needs.
(Betancourt et al. 2003)
Cultural competence requires more than awareness. It also requires a valuing of diversity
and preparedness to modify responses and systems to adapt to culturally unique needs.
As a peer supporter it is important to:
• Avoid making assumptions

• create space in your conversations for each person to explore and define their own
cultural identity.
• connect the people you support to culturally relevant supports and healing resources
in the community.
Activity 13: Cultural safety and peer support

This activity will give you an opportunity to reflect upon your gender, culture, background and
other influences.
Thinking about either Amanda, Amina, Trish, Carol, Greg or Ray:

How might your culture, gender, sexual orientation, age, ethnicity, socio-economic
background, upbringing be barriers to a peer support relationship with this person?
How might you address this?
How might your cultural influences be helpful in your work with this person?

The importance of safe and healing relationships
Principle 5
Safe and healing relationships – A trauma-informed care and practice approach fosters
healing relationships where disclosures of trauma are possible and are responded to
appropriately. It also promotes collaborative, strengths-based practice that values the
person’s expertise and judgement.
In a trauma-informed organisation and system of care, the type of relationships formed

between the worker and the s are recognised as pivotal. This relationship is the major ‘tool’
in working with people who have experienced trauma and without a healing relationship
other techniques or strategies will not be effective (Saakvitne et al. 2000).
Human relationships are a foundation for healing, especially from interpersonal trauma.
Judith Herman (1992a) states this in the following:
… the core experiences of psychological trauma are disempowerment and

disconnection from others. Recovery therefore, is based upon the empowerment of
the survivor and the creation of new connections. Recovery can take place only
within the context of relationships; it cannot occur in isolation. In her renewed
connections with other people, the survivor re-creates the psychological faculties that
were damaged or deformed by the traumatic experience. These faculties include the
basic capacities for trust, autonomy, initiative, competence, identity and intimacy.
Just as these capabilities are originally formed in relationships with other people, they
must be reformed in such relationships. (p. 133)
A positive, respectful and collaborative relationship for an individual who has experienced
trauma can provide a positive alternative to prior relationship experiences. In a positive
relationship the consumer can
learn to rely on a safe haven,
experience a secure base and Largest determinant of positive
develop and enhance their change in mental health
ability to understand and Other things
regulate emotion. This is known Therapeutic
in the
as a ‘corrective experience’. Relationship
person’s life
30%
Lambert and Barley (2001) 40%
undertook a meta-analysis of
100 studies to find out what Techniques
Expectancy
factors led to positive changes 15%
and hope
in the mental health of people
15%
who were in psychotherapy.
Lambert and Barley, 2001
The factors that positively
influence client outcomes can be divided into four areas:
• extra-therapeutic factors (other things in a person’s life)
• common factors in the therapeutic relationship, such as empathy, positive regard or
warmth, and congruence or credibility of the therapist
• the positive impact expectancy and hope generates
• specific therapeutic techniques.

Hubble, Duncan and Miller (1999) also reviewed a large number of studies on what
influences therapeutic outcomes, largely in mental health settings. They found that 60 per
cent of positive outcomes are dependent on elements of service delivery and half of this
relates to the relationships between workers and consumers. This includes factors such as
the worker’s ability to be empathetic, warm and non-judgemental.
These studies, and many following, suggest that the greatest source of positive change
comes from things that are happening in the person’s life outside the provided service or
support relationship. The challenge then for workers is to assist the person to amplify or
make the most of any positive factors occurring in the broader context of their lives.
The second most important factor is the nature of the relationship that is formed between a
mental health professional and the person receiving care.
The ‘take home’ message of these studies is that the relationship you form with a person
seeking or receiving mental health care is of critical importance to the outcome of that care.
Given that trauma has often been experienced in the context of relationships this is
especially true of a trauma-informed approach to care (Briere 2002).
The following quotes from people accessing services, show what kind of relationships are
perceived as helpful to them. In the words of survivors these statements illustrate the
attitudes of workers that are respectful, caring and healing:
[A worker who] treats me like a person, and not a ‘patient’, like this is my life and I
have some idea what it’s about.
You can talk to them as to a friend—someone on your own level—they don’t think
they are better than you.
They treat me with respect. They treat me as an equal.
[You] care and let me know you do.
The only way we will heal is with someone who knows, understands, who is kind, and
who we can trust.
Offers feedback in compassionate and thoughtful manner which allowed for the
opening of deep wounds which they then applied salve to before I left.
They don’t treat me as if I am diseased.
People who have believed in me have been the ones who have been most helpful.
Someone to bear witness to your present self and emotions, someone who doesn’t
have to turn it off, make it go away—who will simply witness it. The essence of the
survivor of abuse is being alone with no witness.
(Jennings & Ralph 1997)
Survivors want a relationship where they feel liked, respected and taken seriously; where
they feel heard; where control is not taken away and autonomy is optimised; where they can
trust and feel trusted; and where the person knows that the worker has genuine hope for
their recovery or the recovery of the person they care for.

Peer worker characteristics and contribution to the relationship
All peer workers will bring their own personal attributes to the relationships in mental health
work. Not all relationships will form as easily with all people you offer support to, and some
consumers will experience you as more helpful than others even if you share similar lived
experience. Just as with all other relationships in your life, no two relationships will be the
same, as each person will bring their own unique characteristics.
(MHCC 2014, p 64-65)
However, there are some general characteristics that emerge in relationships that are more
likely to be experienced by consumers and carers as helpful. Characteristics of the worker
that influence the quality of the relationship include the ability to:
• display a flexible, honest, respectful, trustworthy, confident, warm, interested and

open style
• employ techniques such as reflection, noting past successes, accurate interpretation,
facilitating the expression of emotion and attending to the consumer’s experiences.
(Ackerman & Hilsenroth 2003)
The Sidran Foundation provides training for services in the US who are adopting a trauma-
informed approach. Within its training curriculum, the Risking Connection (Saakvitne et al.
2000), (RICH) framework, outlines the features of a trauma-informed relationship with a
person using a support service (pp.13–15).
Respect. The worker has a profound respect for the person they are working with.
This respect is not solely based in their shared humanity but also recognition that
despite the odds, the person in front of them has survived.
They are survivors. If you don’t have respect for their strength, you can’t be of
any help. It’s a privilege that they let you in. There is no reason they should
trust you—none (Lori G in Saakvitne et al. 2000, p. 35).
Information. The worker needs to be honest and transparent in interactions and

provide people with information that helps them make sense of their experiences.
Connection. The worker demonstrates they can be trusted, by showing that the
consumer’s perspective matters, and that they want to understand the consumer’s
experience and perspective regarding what works or doesn’t work for them.
Connection develops over time and is made through careful listening and sensitive
responding (Saakvitne et al. 2000, p.14).
Hope. The worker believes that the consumer can reclaim their life in a way that is
meaningful to them, and can convey their beliefs and hope to the survivor.
Saakvitne et al. (2000) suggest that for survivors of child abuse, experiencing an alliance
with a worker assists with healing by directly contradicting an assumption that all
relationships will be abusive. This can show that relationships can be a base for a secure
attachment over time, and that relationships diminish the experience of isolation.
Whenever you remind your client ‘you don’t have to do it alone’, you offer a radically
different model for coping. (Saakvitne et al. 2000, p. 38)

Activity 14: RICH relationships
Pick a relationship you are currently struggling with and reflect using RICH:
• Do they feel respected? By me? By the service? Is the respect mutual?
• Is information being conveyed honestly and transparently? Is all important

information being conveyed?
• How are we connected? What barriers exist for connection? What is this person’s
history of connectedness?
• How am I conveying hope? How does the service convey hope? Do I know what
the person’s hopes are for themselves?
Boundaries and relationships

Trauma often annihilates personal boundaries, rupturing the survivor’s sense of
herself/himself and what makes her/him unique.
(Blanch et al 2012)
Consumers interviewed in the Jennings and Ralph (1997) study expressed the importance of
workers having healthy personal boundaries in the following way:
Professionals who have the ability to take care of themselves, be centred, and not
take on what comes out of me – not be hurt by what I say – sit, be calm and centred,
and not personally take on my issues. They have good boundaries. They know
where they stop and the other person begins. Don’t take on my feelings, for example,
being scared when I’m scared. (p. 44)
Traditionally, boundaries are rules and guidelines that define and delineate the context of the
relationship between worker and client. These rules and guidelines are set by professional
bodies as a way of
maintaining a healthy
separation between worker
and client. They are likely to
be written and formalised,
and may include ethical
guidelines, codes of conduct,
rules of the service, and
delineation of your work role.
However, boundaries also

refer to the less tangible
features of a relationship that
Figure 4 O'Leary et al, 2011 may not be formally specified
but are in constant
negotiation between two people or between a person and a service.

In a trauma-informed system, boundaries need to be negotiated in a flexible, equitable and
collaborative way that ensures the survivor maintains a sense of control and predictability in
the relationship.
It is important for workers to focus on what is within the relationship boundary at least as
much as what is outside it. They need to see most of the boundaries they observe not as
solid rigid fences, but as flexible and negotiable transition zones. As in any relationship,
some boundaries are non-negotiable, but the central reference point should be the safety
and wellbeing of the consumer.
Service providers, including peer workers are in a position of greater power. It is always the
role of the worker to maintain boundaries. Boundaries in relationships that have power
differences are especially important in trauma-informed care as many trauma survivors have
experienced violation of safe boundaries in relationships.
It is important that you can work through possible boundary issues taking into consideration:
• the mutual safety of the consumer or carer and yourself;
• power in the setting or relationship; and
• your responsibility to abide by rules, guidelines, policies and laws.
It is equally important that you can monitor boundaries for their impact on the person, and
yourself, over time.
Workers need to find ways of communicating about boundaries that minimise the potential
for the consumer to feel shamed or rejected.
Activity 14a Negotiable and non-negotiable boundaries

Consider the following examples and whether these are negotiable or non-negotiable
boundaries. Think about how they are dependent on your role, the service expectations and
the nature of the relationship. Carefully consider why these boundaries are in place, who
they are important for, and why they need to be considered.
Non- Why? What factors are

Negotiable
negotiable important?
Accepting a Facebook friend

request from a consumer or carer
Having coffee with a consumer or

carer on a non-work day
Giving a consumer or carer your

personal phone number
Sharing a meal in the consumer

or carers home
Commenting on the personal

hygiene of a consumer or carer
Loaning money to a consumer or

carer

Accepting that a consumer or
carer pays for your meal or
coffee
Making flirtatious compliments to

a consumer or carer
Sharing sexual jokes and humour
Accepting gifts from a consumer

or carer
Having an alcoholic drink with a

consumer or carer
Activity 14b Negotiating boundaries

Pick one of the examples above and share in pairs how you would discuss this with a
consumer or carer in a way that minimises the potential for the person to feel shamed or
rejected. Practice in pairs and give each other feedback.
Responding to disclosure
Trauma-informed mental health services and systems will include planned and systematic
attention to asking about trauma. However, this may not be part of your specific role.
Asking about trauma needs to be guided by safety; of the person and of the worker.
Trauma screening refers to a brief but focused inquiry into whether the person has
experienced any traumatic events in their lives. Where a service does provide screening for
prior trauma they should read, Blue Knot Foundation, Talking about Trauma: Guide to
Conversations and Screening for Health and Other Service Providers (2018). It is important
to plan conversations with people who have experienced trauma. In some cases, the person
may start a conversation to disclose their trauma. However, because many people are
understandably reluctant to disclose, it is more likely that service-providers will need to
initiate such conversations. It is important to consider how to help the person feel safe during
such a conversation. This can be done by implementing the trauma-informed principles (p.
54).
Screening for exposure to and the impact of trauma should not be a ‘one-off’ event but an
ongoing opportunity for the consumer to disclose. Questions should be prefaced with some
context and include a statement that recognises that people have a choice in responding.
Trauma assessment refers to a much more in-depth inquiry about the nature and extent of
the trauma after the initial screening has taken place. This course is not intended to provide
the skills and capacity to prepare workers to conduct an in-depth trauma assessment.

Whether or not it is your role to conduct trauma screening or trauma assessment, trauma-
informed relationships allow for the possibility that a person receiving support will disclose to
the worker about an experience of trauma, interpersonal violence or other form of harm.
Do not assume that if people have had contact with mental health or community services,
they will have previously disclosed experiences of abuse or trauma - many will not have
been asked (Blue Knot Foundation 2018).
Activity 16: Barriers for non-disclosure

Brainstorm as a group the multitude of barriers to disclosure for people accessing
services.
What makes it hard for workers to receive, What makes it hard for trauma survivors
and respond effectively to disclosure? to disclose?
Barriers to disclosure
Some of the possible reasons for not disclosing include:
• Shame;
• Fear (e.g. threats made by abusers, fear of being unable to cope);
• Anger (e.g. fear of losing control);
• Memory (e.g. not clearly remembering the details);
• Trust – including trust in you, in the system, in the process or purpose of asking;
• Not understanding what trauma is (e.g. many people don’t identify that their
experiences were traumatising);
• Cultural constraints;
• Not thinking it’s relevant to their mental health;
• Politeness (e.g. not wanting to upset you);
• Shyness;
• Hopelessness; and
• They may have disclosed in the past with a bad outcome.
Previous attempts to speak with others about abuse or its impacts may have been
associated with shame, denial, disbelief, anger, distress or disgust (by self or others). Prior
disclosure to workers may have also been responded to with minimisation, a lack of
understanding and a lack of any follow-up (Henderson & Bateman, 2010; Read & Fraser,
1998a).

When somebody discloses that they have experienced trauma, abuse or other forms of harm
they are likely to be in a position of vulnerability and therefore the ways in which workers
respond is critically important.
Supportive responses to disclosure are associated with better outcomes and non-supportive
responses can do further harm (Ullman 2003).
Previous attempts to speak to others about abuse or its impacts may have been associated
with shame, denial, disbelief, anger, distress or disgust (by self or others). Prior disclosure to
workers may have also been responded to with minimisation, a lack of understanding and a
lack of any follow up (MHCC, 2010; Read & Fraser 1998a).
Henderson & Bateman (2010, p. 70) highlight the features of a helping relationship that assist
people to feel safe to disclose. In such a relationship the helper:
• Is approachable and understanding;
• Has an open, honest and transparent professional agenda;
• Is an interested and engaged professional;
• Provides a supportive, safe environment;
• Is willing to listen non-judgementally to disclosures of trauma and abuse;
• Receives the client’s story calmly and does not dramatise or treat the story as
unspeakable; and
• Maintains confidentiality.
Principles to use when a person discloses a history of trauma or abuse:

• affirm that it was a good thing to tell
• do not try to gather all the details
• ask if the person has told anyone before - and how did that go
• offer support (make sure you know what is available)
• ask whether the person relates the abuse to their current difficulties
• check current safety from ongoing abuse
• check emotional state at end of session
• offer follow-up/‘check-in’.
(Read, Hammersley & Rudegeair 2007)
Organisational policy and legal obligations apply if a person discloses a risk of

current harm or ongoing/current abuse or a recent assault.
If you become aware of a person less than 16 years old who is currently at risk, you
are legally required to follow mandatory reporting procedures for your workplace.
An ongoing response to trauma disclosure - Setting trauma-related recovery goals

As a support worker it is not your role to try and be a specialist trauma worker. This means it
is not appropriate for you to conduct detailed trauma assessments or offer trauma
counselling and therapy. These roles require training and skills in environments that ensure
safety for the person.
Whilst some clients may not have lived experience of trauma, working in a trauma-informed
way is beneficial for all clients, and there are many ways in which all workers can respond
that support trauma disclosure and recovery. Some of these include:

• taking universal precautions: assuming that every person may have experienced
trauma;
• working in ways that incorporate the principles of trauma-informed care;
• providing trauma-informed environments and services in ways that avoid vicarious
traumatisation;
• acknowledging and validating the existence, prevalence and impact of trauma;
• supporting disclosures of trauma, if they wish to;
• responding to disclosures of trauma;
• listening that is validating, normalising and non-judgemental and especially for how
the person makes meaning of their experience;
• providing information and education about trauma and its impacts;
• supporting people to set goals around trauma recovery;
• linking people to trauma specialist supports and services;
• promoting safety and coping around trauma (including checking that the person is
safe right now);
• offering opportunities and materials to support different ways of telling their story
such as through art, poetry, journaling, dance and movement; and
• supporting people to explore taking action in relation to trauma such as legal action, ,
speaking out, advocacy, sharing stories, and providing advocacy services.
• providing appropriate referrals and information about other resources.
Supporting people to set goals around trauma recovery

Building a sense of control is one of the most effective recovery strategies for trauma
survivors. Setting and working towards goals is a great way to feel in control of your life.
When people first start thinking about trauma they are not likely to realise all of the options
available to them. Workers can help inform people about their options, support them to set
goals and work towards them in relation to trauma recovery.
As with all work on goals, the little goals are rarely motivating, even though they are more
achievable. We need to start with the end goal: the big dream. Support people to work out
where they ultimately want to be in relation to their experiences of trauma. Then it is time to
set little goals that work towards the big dream.
A note about goals – It is important to realise that not everyone is comfortable with goal
setting or thinking about goals. Some people even feel threatened by the word ‘goal’, and
may associate feelings of failure and distress with past experience of working toward goals.
For some, their goals feel so big and impossible to achieve. Thinking through the steps to
achieve a goal can be a very complex process. We use the word ‘goal’ to refer to plans set
up to support an individual to achieve the things they want for the future. It might be more
helpful to use terms like ‘wishes’, ‘dreams’ or ‘vision for the future’ or what makes a ‘good
life’. As always, we should use the person’s preferred terms and language. Asking about
what a person would like to be doing, have and enjoy, as well as discussing possible steps
towards their preferred picture of the future can be a helpful approach to discussing goals
and plans with a person (MHCC 2017).
Trauma recovery goals can be almost anything, but include subjects such as:
• sharing their story;

• learning about the impacts of the trauma experience/s;

• building safety/a better ability to cope;
• exploring options for recovery work, such as:
a. specialist support services
b. psychotherapy
c. counselling
d. peer support (online support and groups)
e. self-help (books, online resources, journaling)
• pursuing justice/criminal prosecution;
• sharing their story/writing about their experience; and
• building emotional understanding and coping.
Building readiness and safety for specialist trauma work

An important role of all workers is to inform people about trauma specialist services that are
available and, if desired by the person, link them to these specialists.
Trauma therapists and counsellors have received specialist training in supporting people to
process traumatic memories and to move towards recovery. There are many different
evidence-based practices that can support recovery, but key to all of them is expert skills in
maintaining safety for clients while working through the impacts of trauma.
Trauma specialists will typically be qualified and professionally registered psychologists,

counsellors or psychiatrists.
While these services can be invaluable for many people, most trauma survivors will not
access specialist trauma services, because:
• for many people these services are not affordable

• there is a shortage of services available particularly in rural and regional locations
• some people are never offered specialist services
• some people choose to not access specialist services. This may be because the
thought of accessing trauma recovery services can be frightening, while others will
not realise the impact of past trauma or recognise the potential benefit of specialist
support
• many people are not aware of what specialist services are available
• They receive insufficient knowledge from primary health care providers about
specialist skills.
Note: support workers must also appreciate that some people who do not want to work on
their trauma have succeeded in overcoming their difficulties, and are not being avoidant as a
coping strategy. We must be respectful of resilience and focus on whatever a client’s goals
might be.
Unfortunately, for many survivors it can take years to access trauma therapy, if at all.
Access to trauma specialist services is dependent on at least three factors: the person must
know that support is available, want to work on their trauma, and be ready to do so.
Support workers can assist with the first and last of these factors – and they can be there to
listen and provide support as people work out the second factor for themselves.

When it comes to readiness there is a lot that people can do to prepare themselves for this
journey if it is something they want. Disclosure can increase safety risks – because it will
bring difficult memories to the surface. Support workers can be of great help in building
coping and self-soothing skills to manage distress.
Some of the most helpful ways in which a support worker can assist in this domain include:
• ensuring the person is currently safe;

• helping a person fully explore their options and build confidence about making
choices that lead towards trauma recovery;
• encouraging all choices that build control and personal empowerment;
• addressing responses to feelings of distress, including self-harm, dissociation,
flashbacks, drug and alcohol use, an increase in voices, visions or unusual beliefs or
fears, and suicidality;
• helping the person build an awareness of their emotions and body states;
• assisting the person to discover, develop and practice coping skills;
• supporting the person to plan ahead for crises; and
• encourage and support families, carers and other supports to take care of their own
wellbeing
Building confidence, control and personal empowerment: Trauma promotes feelings of

powerlessness, and so the most common casualties of traumatic experiences are a person’s
sense of confidence and control. One of the most helpful things that a support worker can do
is to work in ways that validate, encourage and support self-determination. This requires
careful reflective listening, and an authentic relationship in which we support people to make
their own decisions, stand by them as they do so, and encourage the celebration of small
achievements. Learning coping skills and building knowledge about trauma impacts and
recovery will also help to build a sense of control.
Note: MHCC offer professional development training in Supported Decision-Making.
Awareness of emotion and body states: Many trauma survivors have difficulty noticing
and interpreting their emotional reactions. It can be extremely helpful to assist people to
learn about different emotions, and to practice noticing and recording what they are feeling.
The better that people understand and notice their emotions, the more able they will be to
self-manage and cope with the challenge of working with trauma.
Some people will find it too confronting to notice their body– gently introduce these ideas
and work in a way that is comfortable for the person.
Increasing emotion and body awareness helps a person to understand:

• the purpose of different emotions (e.g., fear keeps us safe, shame reminds us of our
values, anger tells us when something doesn’t feel fair)
• the basic urges that relate to different emotions, for example:
o Fear: Fight, flight or freeze. Tense muscles, urge to run or fight or hide, or an
inability to move. Rapid heartbeat and breathing. Sweating, dry mouth,
tremors, ‘butterflies’ in the stomach
o Anger: Fight for change – and in people who are afraid of anger -
suppression. Increased muscle tension, headaches, ‘pent up’ energy, upset
stomach
o Shame: Hiding, self-punishment. Feeling uncomfortable, wanting to run away
or not go out, upset stomach, feeling flushed, can lead to fear as well.

Once people know about these urges, it can help in determining what they are feeling.
• Practice doing a ‘body scan’ – noticing how your body feels including your stomach,
throat, face, limbs and skin.
• As people increase their awareness of emotions it can become easier to relate them
to thoughts and to begin to establish some control over the
Impact on workers
People who work in human services encounter many distressed people and need to practice
self-care in order to remain effective. Self-care and support for staff are considered important
in a trauma-informed system because without them the worker will not be able to fully
engage in helpful relationships with people (Bloom 2010; Saakvitne et al. 2000).
A trauma-informed approach considers safety for all, staff and consumers alike (MHCC
2013).
Re-traumatisation and vicarious traumatisation of workers

With reference to the adverse impact of the trauma that a consumer has endured,
interactions with consumers may impact on workers in two ways:
Re-traumatisation
If the worker has experienced interpersonal trauma, the impact of hearing and witnessing
other peoples’ stories of trauma can trigger thoughts, feelings and memories that may
interfere with the worker–consumer relationship. These may manifest as memories of
experiences that the worker has lived through and has resolved, however distress can
reoccur even after many years.
Vicarious traumatisation (sometimes called secondary trauma)

Workers with no trauma history can undergo a continuing process of change over time
through witnessing or hearing about other people’s suffering and trauma.
Vicarious trauma is described as a transformation in a worker as a result of working with a

person who has been traumatised. Vicarious trauma is a cumulative effect of working with
trauma, which can affect many aspects of a person’s life. It may consist of short-term
reactions, or longer-term effects that continue after the work has finished. Some effects of
vicarious traumatisation parallel those experienced by the survivor, and can lead to a person
experiencing the symptoms of post-traumatic stress disorder (PTSD) (MHCC 2013).
Saakvitne et al. (2000) describe vicarious traumatisation (VT) in the following way:
VT is a process, not an event. It happens over time. It is individual; the specific things
that are hard for one worker may be less difficult for others, and one worker’s signs
and symptoms of VT may differ from those of others. VT includes both our strong
feelings and our defences against these feelings. Thus, VT shows up in our strong
reactions of grief, rage and outrage, which grow as we repeatedly hear about and
see people’s pain and loss. At the same time, VT is also evident in our numbing, our
protective shells, and our wishes not to know, which can follow. This experience can
be compounded when we work in an environment that feels pressured or
unsupportive, we can come to feel isolated, battered, helpless, guilty or confused. If
we do not attend to this, we can potentially become resentful, exhausted and numb.
(p. 158)

Vicarious traumatisation approximates terms such as ‘compassion fatigue’ or ‘burnout’. It
profoundly interferes with the ability of the worker to engage in therapeutic or supportive
relationships with consumers and it can feel devastating for people who want to care and be
supportive to others.
Traumatised systems
Trauma-informed care recognises that not only individuals exhibit signs of exposure to
trauma, but whole teams and systems can exhibit signs of trauma. This is clearly
demonstrated in the following table informed by the work of American Psychiatrist, Sandra
Bloom (2013):
Clients Staff
Feel unsafe and act aggressively Feel unsafe with clients, each other or
authority
Difficulty managing anger Chronically frustrated and angry, punitive
Express hopelessness and act helplessly, Hopeless about efforts to treat and change
not making effective choices people
Learned helplessness, or problematic Helpless in the face of enormity of
efforts to exert control challenges
Hyperarousal – with attempts to control Chronically hyperaroused, crisis oriented,
mind and body more attempts to control; self and others
Memory and learning problems Loss of staff = loss of organisational
memory, learning is impaired
Poor communication, leading to conflict Communication is impaired; results in
conflict
Overwhelmed, confused, depressed, poor Overwhelmed, confused, depressed,
self esteem ineffective
To address this widespread impact of trauma Bloom (2013) created “The Sanctuary Model”,
a blueprint for clinical and organizational change which, at its core, promotes safety and
recovery from adversity through the active creation of a trauma-informed community. The
Sanctuary Model recognises that trauma is pervasive in the experience of human beings and
focuses not only on the people who seek treatment, but equally on the people and systems
who provide that treatment.
In an attempt to create safe and healing environments for both service users and workers,
the Sanctuary Model is now used across a wide range of settings, including: juvenile justice,
drug and alcohol treatment, school and community-based programs, hospitals, domestic
violence and homeless shelters. A trauma-informed organisation recognizes the inherent
vulnerability of all human beings to the effects of trauma and organizes system-wide
interventions aimed at reducing the negative effects of adversity and stress that can be
experienced by people accessing services and people working within the organisation itself
(Bloom, 2007; 2010).

Trauma informed organisations seek to actively acknowledge that workers may have
experienced their own trauma histories and that working with people who have experienced
trauma will have an impact on workers. A trauma informed approach promotes the
development of supportive recruitment and workforce development strategies to prevent
vicarious trauma (Bloom, 2013).
Trauma informed organisations that actively engage in trauma informed care approaches
report greater collaboration with consumers and carers, enhanced skills, a greater sense of
self-efficacy among consumers, and more support from their agencies. Supervisors report
more collaboration within and outside their agencies, improved staff retention and morale,
fewer negative events and more effective services (Domino et al., 2005)
Organisations and services providing trauma-informed environments and care and practice
approaches report greater collaboration with consumers, enhanced skills, a greater sense of
self-efficacy among consumers, and more support from their agencies. Supervisors report
more collaboration within and outside their agencies, improved staff retention and morale,
fewer negative events and more effective services (Domino et al. 2005)
Supervision
All people who work in mental health should have access to appropriate supervision and
support. This usually includes internal supervision from management (generally their line
manager) and sometimes external supervision from a trained practitioner they have no work-
related accountability to.
External supervision provides a process whereby the worker feels safe to talk about what is
happening for them in their work without fear of judgement or breach of confidentiality. In a
trauma-informed service system external supervisors should have knowledge of trauma.
Saakvitne et al. (2000) suggest there are five critical elements to supervision that is trauma-
informed. It is a place where:
1. information is exchanged about common responses to trauma for both the consumer
and the worker
2. suggestions can be discussed about how to work with some of the difficult coping
mechanisms that consumers sometimes use
3. there is a strong and robust discussion about the relationship between the worker
and the consumer
4. there is open and honest discussion about how the worker is experiencing their
relationships with consumers
5. intentional attention is paid to vicarious traumatisation, with support for self-care for
the worker.
Where a peer worker has their own distress or trauma that has been triggered through their
work, they should be supported to utilise their wellbeing strategies, seek peer support or
access counselling (for example, through the organisation’s employee assistance program
(EAP).)
Self-care
The consumers who contributed to In Their Own Words (Jennings & Ralph 1997) noted that
they appreciate being supported by workers who “know how to look after themselves” and
do not “take on” the feelings of the consumer.
When that happens with a professional, I feel I have to take care of them.

Do their own recovery work and take care of self and has the ability to and does
share their own experience, strength, and hope, and therefore by example is a
powerful positive influence. They do their own emotional work (p. 44).
Workers cannot meet the needs of the person or family they are supporting when they are
ignoring their own experiences and needs. Self-care has been promoted as an ethical and
“moral imperative” (Barnett et al. 2007; Carroll, Gilroy & Murra 1999).
Workers can look after themselves by creating as much balance as possible in their lives
and having strong and caring connections with people outside of work. Everett and Gallop
(2001) offer the following:
Although it seems all too obvious to begin a discussion of self-care with such basics
as exercise, nutrition and a good night’s sleep, these essential building blocks of
physical health remain true. So, too, do those many things that make up a balanced
life—having a full life outside of work, maintaining supportive relationships with family
and friends, pursuing personal hobbies and interests, participating in our
communities and enjoying holidays. We also need to feed our souls, in whatever may
is meaningful to us. (p. 294)
Workers can monitor themselves through reflecting about their thoughts and feelings about
work and checking for common signs of vicarious traumatisation:
• social withdrawal
• shutting down emotionally
• work-related nightmares
• work-related intrusive thoughts
• feelings of despair and hopelessness
• lowered self-esteem, sense of competence in your work
• loss of sense of control over your work and your life
• reduced motivation for your work
• reduced sense of respect for the consumers and carers you support in your work
• reduced sense of hope and optimism for the consumers and carers you work with
• increased illness or fatigue, aches and pains
• increased absenteeism.
These experiences are not always related to vicarious traumatisation but workers need to
address them no matter what their cause. This includes being more mindful and proactive
about self-care and removing ourselves from stressors through activities like reading,
holidays, exercise, games, movies, music and art.
Lastly, as the material on vicarious resilience has illustrated, workers need support to
actively reflect on the ‘positives’ of the work they engage in and their own strengths.
In writing about trauma and mental health services, Sandra Bloom notes that like individuals,
whole organisations can become ‘stressed’, and bear the same indicators of vicarious
traumatisation in their processes, even in buildings and furnishings (Bloom 2007, p. 132).
She argues that every individual in an organisation shares responsibility with the
administration (management) of that organisation for becoming trauma sensitive and
attending to the stress and healing of the organisation itself.

Activity 15: Self-care planning
In the following table, note as many things as you can in each section, that you already do.
Note when you engaged in this activity/practice most recently.
Discuss in pairs and note any additions you would like to make to this grid, including when
and how you would implement this.
Intrapersonal work Professional development

Focus: increasing self-awareness (e.g. Focus: professional renewal and growth
personal journaling, participating in your (e.g. professional and peer supervision,
own therapy, spiritual activities, reflection) study, developing workshops, trying a new
role, finding a mentor)
Physical and recreational activities Interpersonal support

Focus: fun, non-work-related (e.g. hobbies, Focus: healthy supportive relationships
exercise, vacations and travel, local events, (e.g. ensuring you make time for partner,
art and creative pursuits) children, relatives and friends, spending
time with people)
( Adapted from Carroll, Gilroy and Murra 1999)

Vicarious resilience
Vicarious resilience is a term that describes the factors that protect people from vicarious
traumatisation. Hernandez, Gangsei and Engstrom (2007), explain it as a positive and
unique transformation in the lives of workers who work with people with trauma histories,
that results from empathic engagement with survivors. It is a complex process that is
comprised of a number of elements. These include:
• reflecting on peoples’ capacity to heal
• reassessment of how the ‘worker’ views their own problems
• the value that many people assign to spirituality in their healing process
• a strong commitment and belief in hope
• development of the ability to deal with own frustrations
• greater ability to use ‘self’ in relationships with consumers and carers.
Vicarious resilience takes the witnessed resilience of others and applies it to one’s own life
and work. It is important that workers understand both vicarious traumatisation and vicarious
resilience (Hernandez, Gangsei & Engstrom 2007).
Activity 16: Vicarious resilience

• How has work with (or knowing) trauma survivors enriched your life?
• What have you learned from survivors?
Key messages
• Relationships are key to healing.
• RICH relationships convey respect, offer information, help a person
remain connected and support hope.
• Trauma-informed relationships are kept safe by the negotiation of
mutually agreed boundaries.
• Trauma-informed relationships recognise the possibility of disclosure of
past or present abuse.
• A trauma-informed approach is sensitive to the impact on workers and
supports worker self-care through supervision.
• Some of the impacts of working with trauma survivors on workers are
positive - recognising this helps workers remain resilient.
• Trauma-informed relationships require self-awareness and self-care on
the part of the worker.

Trauma-informed responses to heightened distress
Principle 6 - Sharing power and governance

A trauma-informed care and practice approach recognises the impact of power and
ensures that power is shared.
When people are at their most distressed or vulnerable, we may be most at risk of ‘taking
over’ and find it hard to share power. For people who have had power used and misused,
further experience of powerlessness can not only be harmful but also re-traumatising.
In this section we will explore some of the circumstances where being able to remain
collaborative, recognise and rely upon strengths and share power are perhaps most
challenging—namely when responding to distress, including self-injury, alcohol and other
drug use, an increase in voices, hallucinations or delusional beliefs, and suicidal ideation.
It is not the objective of this course to provide adequate

preparation for working effectively in mental health services with
people who are experiencing distressing voices or hallucinations,
suicidal ideation, alcohol and drug use or expressing their distress
with self-injury. However, it does aim to address some aspects of
responding from a trauma-informed perspective. We strongly
recommend that you undertake additional training in these areas if
you have contact with people experiencing these symptoms.
This section will assist you to explore the multitude of ways that services and workers can
offer trauma-informed care in everyday practice through the use of an extended learning
activity.
Activity 19: Collaboration and sharing power

How does this workshop embody the principles of sharing power and collaboration?
What could you implement in your work?

Strengths-based practice
The following is a brief reminder about strengths-based practice—it is assumed that all
participants have had some training in a strengths-based approach.
Strengths-based practice is not telling a person what you think their strengths are.
Receiving praise and compliments may feel good, but equally may be unsettling or difficult
for people who have experienced interpersonal abuse and trauma. Always seek feedback
about how people receive compliments, and do not mistake this for strengths-based
practice, no matter how good it makes us feel.
………we learn that even when people present

with obvious vulnerabilities they also have
strengths. Their strengths are in their passions,
in their skills, in their interests, in their
relationships and in their environments. If
mental health practitioners look for strengths
they will find them
Patricia Deegan, The Strengths Model: A Recovery-Oriented Approach to
Mental Health Services, Rapp and Goscha 2011.
Strengths-based practice can take many forms but the underlying assumptions are that:
• people set their own goals, reflecting what they want for their own lives
• strengths are always present and are worthy of a systematic assessment (i.e. rather
than only assessing ‘the problem’)
• the environment is rich in resources, including people
• support relationships need to be hope inducing
• meaningful choices are offered and people have the authority to make choices.
(Rapp, Saleebey & Sullivan 2005)

Collaborative and strengths-based ways of responding to distress
In a trauma-informed system the feelings and behaviour that accompany heightened distress
can be viewed as:
• resulting from the impact of trauma
• the person’s means of coping with that trauma over time
• any triggers in the present that have aroused feelings, thoughts or behaviours that
may be associated with past trauma.
Being trauma-informed includes an understanding that events in the present can ‘trigger’
intense feeling, thoughts or behaviours that are directly (or indirectly) related to past trauma.
Consumers in the In Their Own Words study (Jennings & Ralph 1997) described some of
the responses they needed when they were in crisis.
Know how to be with me when I am in distress and pain.

Acknowledge my pain without trying to fix it.
Know their own pain and are not afraid of it or mine.
Ask what helps and trust that I know what I need.
Understand the coping role of suicidal thoughts.
Prevent me from seriously hurting myself but continue to give me options and
choices.
Respect me and don’t treat me like an animal.
People will express heightened distress in a number of ways including:
• sudden escalation of risky coping strategies such as alcohol and other drug use or
misuse
• heightened irritability, disorganisation and anger
• sudden withdrawal from contact with others.
The goal is to support consumers to gain or regain a sense of control over their daily lives
and build competencies that will strengthen self-determination and their sense of autonomy.
This is achieved through working collaboratively to find a way that will help the person deal
with their needs in a way that ultimately supports them to move beyond the crisis.
Two expressions of extreme distress that will require your immediate attention are:
• the disclosure of recent self-injury or thoughts or feelings of being at risk of self-

injuring
• the expression of suicidal thoughts, feelings or plans.
A trauma-informed approach to acute distress, self-injury and suicidality demonstrates an

understanding that the distress experienced in the present may have a direct and tangible
relationship to the past.
Valuing safety and assisting the person to be safe, in the present and in the future, are the
primary imperatives in trauma-informed responses and effective responses to suicidality.

Key messages
• A trauma-informed care and practice approach is collaborative and strengths-
based, especially when people are at their most distressed and vulnerable.
• The dynamics of power must be recognised and decisions made
collaboratively.
• Self-injury may be connected to the experience of trauma - experiencing
judgement and shaming responses from health services is a source of further
trauma for survivors.
• The distress leading to suicidality may have a direct and tangible relationship
to past trauma or current fear.
• A trauma-informed approach recognises these connections and takes care not
to re-traumatise people when responding to acute distress.
• Everyday interactions can be trauma-informed.
Contributing to organisation and system change

Realising that one’s trauma lies behind experiences of ‘mental illness’, and that no one has
ever asked about or supported recovery from the trauma, can lead many to question the
systems and process of power within mental health services. When services that are
supposed to help us heal end up further traumatising or re-traumatising us, this has an even
bigger impact.
Shery Mead reflects on these processes:
Peer support programs must challenge the current system’s approach to how people
with histories of abuse are treated. The devastating impact of abuse must be
recognised for what it is and not viewed as psychiatric pathology or biological brain
disorders. Through peer support services, we can offer each other relationships that
are respectful of our experiences, our ways of communicating, and how we have
learned to tell our story. We can challenge each other to both face and to move
beyond these stories and patterns. We can build new community norms that replace
the illness environments that have kept us trapped. Finally, we can conscientiously
name and expose the cultural violence that caused us to end up in these institutions.
If we can learn to tell our stories in new ways, we can create communities where the
sanctioned outcomes include non-compliance to “mental patient” identities or
expectations, rejection of unhelpful treatment regiments, questioning the overuse of
medication, and speaking out about the prevalence of trauma and abuse. Finally, we
can to call into question whose “problem” it really is.
(MHCC 2014, p 82)
The experience of trauma can leave survivors feeling both powerless and full of rage. When
people with lived experience connect with each other to take action on the social and
political issues surrounding trauma and mental health this can be a productive and healing
way to channel anger and be exceptionally empowering for survivors and their support
network.

Depending on their role, support available and level of interest, peer workers can contribute
to trauma informed care at many different levels:
• their individual practice

• the workplace (team, organisation)
• the mental health system
• their communities, including peer support communities
• Australian society
Continuous improvement and trauma informed care

In a trauma-informed service, every person has a responsibility to practise in ways that are
trauma-informed, including managers, administrators and supervisors.
To provide trauma-informed services, all staff of an organization, from the

receptionist to the direct care workers, to the board of directors, must understand
how violence impacts the lives of the people being served, so that every interaction is
consistent with the recovery process and reduces the possibility of retraumatisation.
(Elliot et al. 2005, p. 462)
Trauma-informed services have benefits for all who participate in a service including staff
(Cocozza et al. 2005; Finklestein et al. 2005; Bloom 2010).
In this course we’ve covered many ways peer workers can embed trauma informed care in
their own work. We’ve also reflected on barriers to safety and disclosure in organisations
and discussed how you might respond to these at an individual level and in your
organisation.
An important way you can contribute to continuous improvement in trauma informed care is
to seek feedback from consumers and carers about their experience of the service or
organisation, and provide this feedback to your manager.
Organisations can evaluate how trauma-informed they are by conducting an audit or a self-
assessment. One example developed for Australian service context is the MHCC Trauma
Informed Care and Practice Organisation Toolkit (TICPOT). Ideally consumers, carers, staff
from all areas of the organisation, as well as other stakeholders would complete the audit
and the responses would be collated and used to identify strengths, areas for improvement,
gaps and to prioritise tasks required.
The following are some examples of the types of questions in the TICPOT.
In a few
In most
In one
Sample questions and examples, adapted from

areas
areas
area
TICPOT
Yes
N/A
No
1. The organisation expresses its commitment to trauma informed care and practice
(TICP) in the following e.g.:
• vision statement
• policies, standards and guidelines
• assessment and service delivery approach
• complaints handling mechanisms

In a few
In most
In one
Sample questions and examples, adapted from
areas
areas
area
TICPOT
Yes
N/A
No
2. Training and information on trauma and TICP
• Is provided in new staff orientation

• is provided to all staff (including volunteers,
admin and managers)
3. All services are person and family-centred, safe and reflect the principles of TICP
e.g.:
• recognises the effects of trauma
• reduces risk of re-traumatisation
• guided by service user choice and
autonomy
4. The organisation promotes safety for all (staff, consumers, volunteers, carers) e.g.:
• environment evaluated as safe by users

and staff
• staff supervision, and wellbeing support
• cultural safety
• ensures that only those appropriately
qualified provide trauma specific services
5. The workplace culture supports staff self-care and wellbeing through
• training and information about vicarious

trauma, safety and self-care
• recognition of the potential that staff may
be survivors
• opportunities for staff to regularly engage
in consultations and reviews
6. The organisation has identified roles for consumers and carers at all levels e.g.
• Board, advisory committees

• development of the organisation’s policies,
standards and guidelines
• advocacy and lobbying endeavours
• developing programs and forward planning
• evaluation of service environment, culture
and service delivery
• peer workforce including peer leaders and
managers

Activity17: Contributing to trauma-informed care and practice
This activity requires you to reflect on your own practice and work environment and identify
opportunities to embed trauma informed care and practice in service delivery.
Take some time to reflect upon:
• What is the change to your practice or the work environment?
• Why make this change? What are the benefits of this change to the organisation;
including staff, consumers, carers and others? Which principles of trauma informed
care does this change reflect?
• How? What are the steps required? What resources are needed to support this
change (such as funding, staff training, equipment)? Who needs to be involved?
Who needs to be consulted?
• What are the barriers that could prevent the change from occurring? What can be
done to overcome these barriers? Consider what strengths and resources are
available in the organisation or in the community that you can draw on to overcome
these barriers.
Step 1 - Use the table to record your recommendations.
Step 2 - After you’ve completed the table write down who would you speak to about your
ideas? How could you make these suggestions?
Step 3: Present one of your ideas to the group.

Barriers
Why? How? What could prevent the change
What?
Benefits of the change. What are the steps required and from occurring?
Outline of the change to your
Trauma informed principles are resources needed, who needs to
practice or the work environment. What can be done to overcome
reflected in this change? be involved?
these barriers?
1.
2.
3.

Note: Whilst this resource book does not have specific sections attached to these two
principles MHCC propose these are important elements of a trauma-informed care and
practice approach that should be considered throughout the work that you do.
Principle 7 - Recovery is possible

Understanding that recovery is possible for everyone regardless of how vulnerable they
may appear; instilling hope by providing opportunities for consumer involvement at all
levels of the system; facilitating peer support; focusing on strength and resiliency; and
establishing future-oriented goals.
Principle 8 - Integrating care

Maintaining a holistic view of consumers and their recovery process; and facilitating
communication within and among service providers and systems.

Appendix A: A short history of interpersonal trauma and its
relationship to mental health
Trauma-informed care is a term which began to appear in literature during the past decade.
However, recognition of the impact of trauma on mental health and wellbeing is not new.
Therefore, some historical context of the relationship between understanding trauma and
psychiatry is presented here. The aim is to assist in understanding current developments in
theory and service delivery approaches, to articulate any lingering influences of history on
current tensions in practice.
Early psychiatry and child abuse

Psychiatry is not alone in recognising the profound distress that trauma can inflict on
survivors. Indeed, it could be argued that people have always known that overwhelming
experiences result in profound distress.
Early developments in western psychiatry (primarily in Europe) explored a number of

questions with regard to trauma and psychological symptoms: Did trauma cause these
symptoms? Are the symptoms being expressed caused by psychological/emotional
disturbance or an organic/biological disturbance? Or is the person affected weak or deficient
in some way? Is the cure biological, psychological or social?
In the late 1800s French neurologist Jean-Martin Charcot described the connection between
unbearable experiences and symptoms of psychological distress, including dissociation. Charcot
influenced Pierre Janet (a physician) to further explore the nature of trauma and dissociation.
Both men were influential in the early work of Sigmund Freud, arguably one of the most
influential figures in the development of western psychiatry, and the founder of psychoanalysis.
Freud presented his first paper ‘The Origins of Hysteria’ in 1896, and within this claimed that
the women he saw with ‘hysteria’ had been abused, most often sexually, as children or
young women. Freud’s colleagues rejected these claims, it is thought mainly due to fears
that this theory would undermine the new field of psychoanalysis. They believed the moral
standing of society was being brought into question by suggestions of abuse in patients with
these symptoms. Freud retracted this theory and published an alternative theoretical account
of his patients’ ‘stories’ being based in sexual fantasy. Janet continued to pursue the
relationship between trauma and psychological symptoms. He proposed that psychological
health was dependent upon being able to ‘integrate’ traumatic memories. Janet noted the
traumatic origins of psychological symptoms in almost half of his published case descriptions
(van der Kolk, Weisaeth & van der Hart 1996, p. 52). However, Freud continued to repudiate
the claims of abuse or trauma made by his patients (van der Kolk, Weisaeth & van der Hart
1996, p. 54) and sought alternate explanations for their distress in a theory of repressed
unacceptable impulses and fantasies (Masson 1986, p. 5).(Freud’s interest returned to
‘traumatic neurosis’ during WWI, but was restricted to the trauma of war.)
The early 1900s saw continued debate on the nature of people’s responses to traumatic
events, most notably the effect of war on soldiers. In Europe, at the time of WWI, soldiers
suffering from ‘war neuroses’ were thought to be personally deficient and lacking in
‘willpower’ (van der Kolk, Weisaeth & van der Hart 1996, p. 50).
Natural disasters and the psychological impact upon survivors also drew attention from
psychiatrists in the early 1900s. Swiss psychiatrist Edouard Stierlin described the post-
traumatic responses of survivors of a catastrophic earthquake and argued that a
‘predisposition’ or personal weakness did not predict who would be affected. He argued that
the fear-based psychological distress generated by trauma was not a rare phenomenon as
others were claiming at the time.

Van der Kolk, Weisaeth and van der Hart (1996) argued that Freud’s psychoanalytic theory
resulted in a lack of serious consideration of the impact of childhood trauma on adult mental
health until the end of the 20th century (p.56). They do note however, that psychiatrist
Sandor Ferenczi presented a paper to the Psychoanalytic Congress in 1929. It explained the
devastating impact on children who were exploited by adults for sexual gratification, but this
did not receive widespread support or recognition.
Given that psychiatry broadly informs mental health service responses to distress,
recognition that the development of an understanding of trauma has not been ‘smooth
sailing’ may be critical for future developments.
...[P]sychiatry as a profession has had a very troubled relationship with the idea that
reality can profoundly and permanently alter people’s psychology and biology.
Psychiatry itself has periodically suffered from marked amnesias in which well-
established knowledge has been abruptly forgotten, and the psychological impact of
overwhelming experiences has been ascribed to constitutional or intra-psychic
factors alone. (van der Kolk, Weisaeth & van der Hart 1996, p. 47)
Child abuse as trauma

A resurgence of research interest in child abuse as a form of trauma emerged from other
fields in medicine, including radiology and orthopaedics, and was attended to as a medical
social problem. ’Battered child syndrome’ was coined in 1962, and largely described the
pattern of physical injuries that should alert doctors to a child having sustained the injuries in
a ‘hostile environment’ from which they should be removed. The psychiatric aspects of
concern in this early literature were confined to the presumed psychopathology of the
parents (Kempe 1962, reprinted 1985).
Reference to ‘child abuse and neglect’ emerged in the 1970s. This concept stressed the
pervasive and often long-term adverse effects on emotional wellbeing and psychological and
physical development, although initially it did not include sexual abuse. At this time, there
was still social resistance to the idea that parents could or would sexually abuse their
children. Indeed, the 1980 edition of Kaplan, Freedman and Saddock’s text Comprehensive
Textbook of Psychiatry cited estimated rates of incest as 'less than one in a million' in the
population (based on a 1955 study). Instead it referred to studies of the psychopathology of
the children and the wives of perpetrators of the abuse.
Domestic violence as trauma

Lenore Terr described the characteristic psychological and behavioural features of women
subjected to violence in relationships as ‘battered woman syndrome’ in the 1970s. This
concept was used to explain the apparent ‘helplessness’ of women who remained in
domestic arrangements characterised by abuse, and was used as a legal defence in cases
of women maiming or murdering abusive partners. Advocates for the recognition of the
psychological consequences of domestic violence were partially vindicated with the inclusion
of post-traumatic stress disorder (PTSD) in this list (which could include domestic violence
as a causal event). However, they continued to argue that PTSD was not sufficient to
capture the long-term psychological impacts of women who were essentially ‘in captivity’ for
long periods with a person they had initially trusted.
Combat and the impact on soldiers

Charles Samuel Myers (a British military psychiatrist) first wrote about ‘shell shock’ affecting
soldiers returning from battle in WWI. Many returning servicemen showed behaviours such
as crying uncontrollably, becoming mute and unresponsive, not being able to move, losing
their memory and losing their capacity to feel. This condition was initially viewed as a
physical disorder arising from the concussive effects of exploding shells. However, Myers

came to believe the cause of this distress could be purely emotional, rather than organic,
and noted the similarities to the ‘hysteria’ of other (primarily female) patients (van der Kolk,
Weisaeth & van der Hart 1996, p. 49).
Recognition of ‘illness’ did not necessarily mean that the men were treated with
understanding and compassion. Many were charged with ‘cowardice’ and their distress
viewed as being motivated by secondary gain. Canadian psychiatrist Lewis Yealland,
working in England during WWI advocated treatment based on shaming, threats and
punishment which included electric shock treatment and the threat of court martial.
Judith Herman (1992) notes that within a few years after the end of WWI, medical interest in
the subject of psychological trauma faded. Though many men with long-lasting psychiatric
disabilities crowded the wards of veterans’ hospitals, their presence had become an
embarrassment to civilian societies eager to forget.
World War II brought a renewed medical interest in ‘combat neurosis’ as shell shock had
become known. Experts began to recognise that any man could breakdown if the severity of
combat exposure was high enough. Interestingly, there was also recognition that emotional
attachments among soldiers was a protective factor against combat neurosis. Affected
soldiers were often treated with hypnosis and sodium amatol to retrieve memories and
facilitate a cathartic experience, with the aim of getting them back to the frontline. The long-
term consequences of combat neurosis were not recognised until the men returned home
after the war.
During the Vietnam War increased interest in trauma re-emerged, fuelled by the returning
soldiers’ protest activities. They focused public attention on the lasting psychological impact
of war. After the war ended, the US Veterans Association commissioned studies on the long-
term impact of war on returning soldiers. These proved beyond doubt that there was a direct
relationship between combat and mental health problems.
In 1980, ‘post-traumatic stress disorder’ was added to the Diagnostic and Statistical Manual
of Mental Disorders: Third Edition—the first diagnosis of psychological trauma to become
mainstream. However, a later version of the manual (2000) stated:
If the symptom response pattern to the extreme stressor (i.e. event), meets criteria
for another mental disorder (e.g. Brief Psychotic Disorder, Conversion Disorder,
Major Depressive Disorder), these diagnoses should be given instead of, or in
addition to Post Traumatic Stress Disorder. (p. 467)
This statement meant that the causal role of traumatic events may not be accounted for in
the diagnosis of these other disorders (for which a causal event is not specified in order for a
diagnosis to be made).
Longitudinal studies
The use of computer technology and data-gathering programs has allowed researchers to
undertake large longitudinal studies which focus attention on specific details to test
hypotheses as never before. One such study is the Adverse Childhood Events (ACE) study
which includes over 17,000 people. The authors and contributors to this series of studies
acknowledge that research links between some child abuse and health consequences are
relatively new in medical literature.
Viewing child maltreatment and related experiences as a set of exposures that have
broad implications for human development and prevention of public health problems
is a relatively new concept. Only since 2004 has child sexual abuse been included in
the global burden of disease estimates of death and disability attributable to
particular avoidable risk factors, and medical journals have recently begun to

acknowledge the concept of abuse and related it as a major public health issue by
raising awareness of the body of literature that supports this concept. (Anda et al.
2010, p. 93)
This ongoing longitudinal study is analysing the effects of adverse and traumatic
experiences during the first 18 years of life, on a range of social and health outcomes,
including medical and psychiatric conditions. These analyses have confirmed that adverse
childhood experiences have a long-lasting effect on mental health and physical health,
including higher incidence of liver disease, lung disease, coronary heart disease and
autoimmune disease. They advocate systematic attention to adversity and trauma in
childhood as a means of implementing public health measures far beyond the scope of
individual treatments for individual problems.
The concept in using ACEs as a framework for the primary prevention of public
health problems is that stressful or traumatic childhood experiences such as abuse,
neglect, or forms of household dysfunction are a common pathway to social,
emotional, and cognitive impairments that lead to increased risk of unhealthy
behaviors, violence or revictimization, disease, disability, and premature mortality
(Anda et al. 2010, p. 95).
The introduction of CAT and PET scans allowed biomedical scientists to study the
physiology of the body, including the brain, in much greater detail. This has resulted in a
growing body of evidence that shows traumatic events in childhood can alter the brain,
helping to resolve the earlier debate over psychological versus organic impacts of trauma
and manifestations of distress (Anda et al. 2010, p. 95).
The consumer movement

The consumer movement in mental health has also had an impact on the recognition of
trauma as being part of the ‘lived-experience’ of consumers.
The consumer movement began in the early 1970s, around the same time as the civil rights’
movement, the gay rights’ movement, the women’s movement and Aboriginal and Torres
Strait Islander rights’ movements. All these movements have in common the experience of
oppression and the quest for self-determination. People with major mental distress
complained they had been oppressed by institutions, involuntary treatment and social
exclusion that condemned many to psychosocial disability, including poverty, inactivity, low
self-esteem, inadequate housing, isolation and further exploitation. Many who had trauma
histories experienced similar oppression inside their families or communities. In many ways
the assaults and silencing that happened inside abusive or neglectful families had been
replicated in the mental health system where coercion was common and dissent is seen as a
symptom of illness.
The early consumer movement directly challenged coercion and silencing through
advocating for ‘choice and voice’. The movement asserts that people with mental distress
need to be supported to be autonomous and self-determining. They need access to a
diversity of choices in the services available to them rather than the standard regime of
‘meds and beds’. They also need to play a central role in the development of policy and
service-delivery planning and participate meaningfully in leisure, recreational and
employment opportunities.
‘Choice and voice’ helps to heal the trauma of mental distress and retraumatising services,
as well as the original traumas many have experienced. Since the 1990s many consumer
views have been expressed in the recovery paradigm or framework which should underpin
service and societal responses to people with mental distress. The recovery approach is
entirely compatible with trauma-informed care and practice.

Recent history
Around the year 2000, publications started to emerge stating that childhood abuse and
neglect was a significant if not casual factor in people developing mental illnesses and
coexisting health problems and psychosocial disability.
Alongside this, people recognised that mental health services in general were not
responding in any coherent or systemic way to trauma. Trauma-informed care became an
evolving approach and practice that offers a far more humane and effective way of working
with people with trauma histories across service sectors.
In Australia, since 2010, the Mental Health Coordinating Council, along with Adults Surviving
Child Abuse, Private Mental Health Consumer Carer Network and Education Centre Against
Violence have been leading an initiative promoting trauma-informed care and practice as an
important national agenda.
For more information see the NSW Mental Health Coordinating Council website
www.mhcc.org.au and click on the trauma-informed care and practice link.

Appendix B: Prevalence of interpersonal violence in
Australia
Up to two-thirds of Australians will be exposed to events or circumstances that could be
considered traumatic (Australian Centre for Posttraumatic Mental Health 2007, p. xiv). This
includes accidents, natural disasters, interpersonal violence and abuse. For many, if not
most people, resilience in the face of these events will be the norm. However, exposure to
some forms of trauma are more likely to be associated with longer-term psychological
distress—notably exposure to interpersonal violence.
Rates of interpersonal violence in Australia

Over half of the Australian women surveyed (57 per cent) in the International Violence
Against Women Survey had experienced at least one incident of physical or sexual violence
over their lifetime (The European Institute for Crime Prevention and Control 2003).
In 2013 the Australian Bureau of Statistics published the results of the 2012 Personal Safety
Survey (PSS) survey, a representative sample of 17,050 men and women across Australia
about their experiences of violence.
The survey used the following definitions:
• Violence means any incident involving the occurrence, attempt or threat of either
physical or sexual assault.
• Assault involves the use of physical force with the intent to harm or frighten, or an
act of a sexual nature carried out against a person’s will. It does not include threats.
The survey found:
• during the 12 months prior to the survey, 7 per cent of Australians experienced some
sort of violence
• men are most at risk in public spaces and licensed premises from men they do not
know
• women are at more risk of violence in the home from men they know
• both men and women most often experience violence from male perpetrators
• women in Australia still experience high rates of sexual violence
• there was a small decrease in the overall incidence of sexual violence over the 12
months preceding the 1996, 2005 and 2012 surveys.
When asked about experiences of violence:

• a larger proportion of people experienced physical violence than sexual violence
• a larger proportion of men than women experienced physical violence
• a larger proportion of women than men experienced sexual violence.
• for men over 25 than women over 25.
Child sexual abuse

Conservative estimates indicate that one in five girls and one in seven boys experience
some form of sexual abuse before reaching adulthood (Dunne et al. 2003).
The Australian Institute of Family Studies reports:

[Australian s]tudies that comprehensively measured the prevalence of child sexual
abuse found that males had prevalence rates of 4-8% for penetrative abuse and 12-
16% for non-penetrative abuse, while females had prevalence rates of 7-12% for
penetrative abuse and 23-36% for non-penetrative abuse. (Price-Robertson,
Bromfield & Vassallo 2010)
There is evidence that figures may be much higher due to unreported or uncorroborated
evidence. Evidence in the United States has identified that one in three girls and one in six
boys are sexually abused before the age of 18. Some of these differences may also be
accounted for by the definition of sexual abuse or assault used in each study.
These statistics show that girls are sexually abused more often than boys. However,
therapists working with boys and men report than males tend not to report victimisation,
which may affect reported statistics. This may be because they blame themselves, minimise
the abuse or are ashamed that they were unable to defend themselves. Further, males may
in some way relate the abuse to either real or perceived homosexuality and they fear stigma
and discrimination (Lew 2004).
A report published by the Australian Institute of Family Studies found that girls were about
three times more likely to be the subject of a substantiated sexual abuse claim. Significantly,
girls are equally likely to be the subject of a substantiated claim of physical abuse. In
addition, the rates of substantiated abuse or neglect decreased as age increased (AIFS,
2008).
Sexual assault (adulthood)

The PSS (Personal Safety Survey) 2016 found:
• both men and women who had experienced sexual assault since the age of 15 were
more likely to have been sexually assaulted by someone they knew than by a
stranger
• of the women who had been sexually assaulted since the age of 15, 15% of women
had been sexually assaulted by a known person whereas 3.8% of women had been
sexually assaulted by a stranger
• of the men who had been sexually assaulted since the age of 15, 3% had been
sexually assaulted by a known person compared to 1.6% who had been sexually
assaulted by a stranger.
Domestic/intimate partner violence

More than a third of Australian women (34 per cent) participating in the International
Violence Against Women Survey (Australian Centre for the Study of Sexual Assault 2003)
had experienced violence from a former or current partner. Violence from a former partner
was more common, and more likely to result in women being injured and feeling that their
lives were in danger.
12 per cent of women reported experiencing sexual violence by an intimate partner

(current or former) over their lifetimes, including instances of attempted (3 per cent)
and completed (6 per cent) forced intercourse (i.e. rape).
(The European Institute for Crime Prevention and Control 2003)
One in seven women who reported experiencing violence from an intimate partner reported
this to police; one in six who experienced violence from someone other than a partner
reported this to police.

The Australian Institute of Family Studies reports that the best available evidence suggests
that between 12 per cent and 23 per cent of children witness family violence ((Price-
Robertson, Bromfield & Vassallo 2010).
The PSS found that women were more likely than men to have experienced emotional
abuse by their current partner since the age of 15. Women were also more likely than men to
have experienced emotional abuse by a previous partner since the age of 15.
For the purposes of this survey, a person was considered to have experienced emotional
abuse where they reported they had experienced one or more of the following behaviours
intended to cause emotional harm or fear:
• controlled or tried to control where they went or who they saw

• stopped or tried to stop them from contacting family, friends or community
• stopped or tried to stop them from using the telephone, internet or family car
• monitored their whereabouts (e.g. constant phone calls)
• stopped or tried to stop them knowing about or having access to household money
• stopped or tried to stop them from studying, working or earning money
• deprived them of basic needs such as food, shelter, sleep or assistive aids
• damaged, destroyed or stole any of their property
• constantly insulted them to make them feel ashamed, belittled or humiliated
• lied to their child/ren, other family members or friends with the intent of turning them
against them
• threatened to take their child/ren away from them
• threatened to harm their child/ren, other family members or friends
• threatened to harm or harmed any of their pets
• threatened or attempted suicide.
Multiple abuse types

A study conducted by Palmer, Brown, Rae-Grant and Loughin (2001) identified that most
survivors of any abuse reported a combination of abuse types:
• physical, emotional and sexual (45 per cent)
• physical and emotional (21 per cent)
• sexual and emotional (17 per cent)
• sexual only (11 per cent)
• emotional only (6 per cent).
Of the survivors in the study who could recall the age of onset of the abuse, they reported
that they had been very young (between four and six) and that the reported perpetrators
were:
• biological fathers (34 per cent)
• biological mothers (19 per cent)
• stepfathers, adoptive fathers and foster fathers (8 per cent)
• stepmothers, adoptive mothers and foster mothers (5 per cent)
• both parents equally (7 per cent)
• other relative (14 per cent)
• and siblings (10 per cent).

(Henderson & Bateman 2010)
Re-victimisation
Re-victimisation is also a common phenomenon among people abused as children.
Research has shown that child sexual abuse victims are more likely to be the victims of rape
or to be involved in physically abusive relationships as adults (American Psychological
Association 2006).
The PSS found that men and women who experienced physical or sexual abuse before the
age of 15 were more likely to have also experienced violence by a partner since the age of
15 (compared to those who had not experienced abuse before the age of 15). Women who
experienced abuse before the age of 15 were more likely than men who experienced abuse
before the age of 15 to have experienced violence by a partner since the age of 15.
In a six-month telephone survey of 6677 women conducted over a period during 2002–2003,
data provided about their experiences of sexual and physical violence suggested that risk of
sexual violence in adulthood is doubled for those women who have experienced childhood
sexual abuse. Of the participants interviewed 18 per cent reported that they had been
sexually abused before age 16 (Australian Centre for the Study of Sexual Assault 2003).
Aboriginal families
An Australian study (O’Donnell et al. 2010) investigated de-identified records from child
protection, disability services and health data for the nearly 400,000 children born in Western
Australia from1990–2005. The study showed rates of child abuse and/or neglect for both
Aboriginal and non-Aboriginal families. The material does not capture children where no
report or allegation has been made. The authors also point out that there may be a bias in
increased reporting of Aboriginal families and those of low socioeconomic families to child
protection services.
An allegation is defined as substantiated when an outside investigation has shown that there
are reasonable grounds to believe the child has been abused, neglected or otherwise
harmed. It is defined as unsubstantiated when no investigation was carried out, or, on
investigation, no abuse was found.
Child abuse and neglect in Western Australia
Not substantiated (%) Substantiated (%)
All children 3.4 1.6
Non-Aboriginal children 2.9 1.3
Aboriginal children 12.5 7.2
Non-Aboriginal children with Female: 48.6 Female: 52.6

abuse/neglect by gender Male: 51.4 Male: 47.4
Aboriginal children with Female: 48.8 Female: 50.6

abuse/neglect by gender Male: 51.1 Male: 49.4
In homes where there was substantiated abuse and neglect the strongest risk factors were:
• poverty
• parental substance use

• parental mental health problems
• domestic violence
• children with intellectual disability who had twice the risk of abuse and neglect
• age of parents, particularly parents younger than 20 years and fathers older than 39
years.
Women with a disability

The PSS found that both men and women who had a disability or long-term health condition
were more likely to experience violence than those with no disability or long term health
condition. A person was defined as having a disability or long-term health condition if they
had one or more conditions which had lasted, or were likely to last, for six months or more,
and that restricted every day activities (ABS, 2012).
Women with disability are more likely to be physically and sexually assaulted over their
lifetime (Smith, 2008; Henderson and Bateman 2010). Women with a range of disabilities
(cognitive, psychiatric, sensory or physical) may be more vulnerable to assault, however
vulnerability alone does not account for the increased risk. For a community sample of
women with disability in Canada (Brownridge, 2006), characteristics of the partner
accounted for the increased incidence of intimate partner violence. This was reported at a
rate 40 per cent greater than non-disabled women. Perpetrators may perceive women with
a disability as less likely to report an assault (Martin et al 2006) and those women may also
have more difficulty accessing and receiving appropriate assistance from services (Walter-
Brice et al 2012).
Women who are dependent on others for daily care may also be harmed by actions that
would not be experienced by women without a disability (e.g. refusing access to needed
resources or services). Dependence on and fear of caregivers could be a further barrier to
disclosure (Smith, 2008). Assumptions made by health professionals and supporting
services about intimate partnerships for women with disabilities may also inhibit detection
and disclosure of abuse and violence. Programs designed to promote sexual safety may not
be accessible or appropriate for women with disability (Barger et al 2009).
Consumers in mental health services

Any group of people accessing mental health services are likely to have a much higher rate
of exposure to interpersonal violence than the general population. This reflects the violence
consumers’ experience that pre-dates or precipitates their experience of mental health
problems. It also reflects the subsequent interpersonal violence as a result of the experience
of mental health problems and contact with services.
One in five women (and one in 13 men) participating in a multi-site study across four states
in the USA (Goodman et al. 2001) reported a sexual assault in the year prior to their current
contact with a mental health service. One quarter of the women and more than a third of the
men reported a physical assault in the year prior to the study. Homelessness, drug and
alcohol use, and a history of childhood sexual or physical abuse were associated with a
greater risk of recent assaults.
Of this group of 789 mental health consumers (ibid), 87 per cent of the men and women
reported experiencing either sexual or physical assault in their lifetime. Two thirds reported
either physical or sexual assault as children (in this study, sexual assault was defined as
forced or threatened oral, anal or vaginal intercourse). Nearly half of the women (48.7 per
cent) and 29 per cent of the men reported sexual assault as children. Four in five adults
(men and women equally) reported a physical assault as adults.

Consumers of mental health services can also experience harm during contact with those
services. Statistics for the experience of assault and the use of seclusion and restraint within
Australian services are not readily available. The use of coercive practises which may be
experienced as traumatic are being addressed in many services and are reducing in their
occurrence in accordance with national strategic approaches. The National Mental Health
Consumer & Carer Forum (2009) report a conservative estimate of 12,000 instances of
seclusion in Australian inpatient mental health services annually (p. 8).

Appendix C: Grounding strategies
What is grounding?
Grounding is a set of simple strategies to detach from emotional pain (e.g. craving, anger,
sadness). Distraction works by focusing outward on the external world, rather than inward
towards the self. You can also think of it as ‘distraction’, ‘centering’, ‘a safe place’, ‘looking
outward’, or ‘healthy detachment’.
Why do grounding?
When you are overwhelmed with emotional pain, you need a way to detach so that you can
gain control over your feelings and stay safe. Grounding ‘anchors’ you to the present and to
reality.
Many people who struggle with feeling overwhelming emotions and memories, or those
feeling numb with dissociation, benefit from grounding. In grounding, you attain a balance
between being conscious of reality and being able to tolerate it. Remember that pain is a
feeling; it is not who you are. When you get caught up in it, it feels like you are your pain,
and that is all that exists. But it is only one part of your experience – the others are just
hidden and can be found again through grounding.
Guidelines:
• Grounding can be done any time, any place, anywhere, and no one has to know.
• Use grounding when you are faced with a trigger, enraged, dissociating, having a
craving, or whenever your emotional pain goes above 6 (on a 0-10 scale). Grounding
puts healthy distance between you and these negative feelings.
• Keep your eyes open, scan the room, and turn the light on to stay in touch with the
present.
• Rate your mood before and after grounding, to test whether it worked. Before
grounding, rate your level of emotional pain (0-10, where 10 means “extreme pain”).
Then re-rate it afterwards. Has it gone down?
• No talking about negative feelings or journal writing – you want to distract away from
negative feelings, not get in touch with them.
• Stay neutral – avoid judgments of ‘good’ and ‘bad’. For example, instead of “The
walls are blue; I dislike blue because it reminds me of depression”, simply say “The
walls are blue” and move on.
• Focus on the present, not the past or future.
• Note that grounding is not the same as relaxation training. Grounding is much more
active, focuses on distraction strategies, and is intended to help extreme negative
feelings.
Ways of grounding
There are three major ways of grounding: mental, physical and soothing. ‘mental’ means
focusing your mind; ‘physical’ means focusing on your senses (e.g. touch, hearing) and
‘soothing’ means nurturing yourself in a very kind way. You may find that one type works
better for you, or all types may be helpful.

Mental grounding
Describe your environment in detail, using all your senses. For example, “The walls are
white; there are five pink chairs; there is a wooden bookshelf against the wall”. Describe
objects, sounds, textures, colors, smells, shapes, numbers and the temperature. You can do
this anywhere.
• Play a ‘categories’ game with yourself. Try to think of “types of dogs”, “jazz
musicians”, “states that begin with A”, etc.
• Do an age progression. If you have regressed to a younger age (e.g. 8 years old),
you can slowly work your way back up until you are back to your current age.
• Describe an every-day activity in great detail. For example, describe the meal that
you cook (e.g. “First I peel the potatoes and cut them into quarters …”).
• Imagine. Use an image: glide along on skates away from your pain; change the TV
channel to get to a better show; think of a wall as a buffer between you and your pain.
• Say a safety statement. “My name is ______; I am safe right now. I am in the
present, not in the past.”
• Read something, saying each word to yourself. Or read each letter backwards so that
you focus on the letters and not on the meaning of the words.
• Use humor. Think of something funny to jolt yourself out of your mood.
• Count to 10 or say the alphabet, very s…l…o…w…l…y.
Physical grounding
Calming
• Touch various objects around you: a pen, keys, your clothing, the wall, etc.
• Run cool or warm water over your hands.
• Carry a grounding object in your pocket, which you can touch whenever you feel
triggered.
• Notice your body: the weight of your body in the chair; wiggle your toes in your socks;
the feel of your chair against your back, etc.
• Walk slowly; notice each footstep, saying “left or “right”.
• Repetitive, rhythmic movement e.g. a rocking chair.
• Focus on your breathing, notice each inhale and exhale.
• Eat something, describing the flavours in detail to yourself.
• Stretch. Roll your head around; extend your fingers, etc.
• Dig your heels into the floor – literally grounding them! Notice the tension centered in
your heels as you do this. Remind yourself you are connected to the ground.\
Discharging or releasing energy

• Clench and release your muscles (e.g. your fists).
• Grab tightly onto your chair as hard as you can.
• Jump up and down.
• Air boxing.
• Hit or throw a cushion.
• Shout or scream into a cushion.
• Climb stairs.
• Tear up paper, crumple into a ball and toss it into a basket (old phone books are great).

• Scribble on old paper.
• Go for a walk.
• Push against a solid wall.
Soothing grounding
• Say kind statements, as if you were talking to a small child. For example, “You are a
good person going through a hard time. You’ll get through this”.
• Think of favourites. Think of your favorite colour, animal, season, food, time of day,
etc.
• Picture people you care about (e.g. your children), look at a photograph.
• Remember the words to an inspiring song, quote, or poem.
• Remember a safe place. Describe the place that you find so soothing.
• Say a coping statement: “I can handle this”.
• Plan a safe treat for yourself, such as a certain dessert.
• Think of things you are looking forward to in the next week, perhaps time with a
friend, going to a movie.
What if grounding does not work?

GROUNDING DOES WORK! But, like any other skill, you need to practice.
• Practice as often as possible, even when you don’t need it.
• Try grounding for a loooooonnnnnnngggggg time (20-30 minutes).
• Notice which methods you like best.
• Create your own methods of grounding.
• Start grounding early in a negative mood cycle.
• Make up index cards.
• Have others assist you in grounding.
• Prepare in advance.
• Create a tape of a grounding message.
• Think about why grounding works.
DON’T GIVE UP!

Adapted from Maryann Rigoni, Behavioural Health Resources
http://www.bcbhr.org/Articles.aspx?7

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Glossary of terms
For the purpose of this course and associated workshop, terms are used with the following
definitions:
Mental disorder, mental distress, mental health, mental illness

The term mental health can be used in different ways: to emphasise positive mental
wellbeing, to focus on the absence of mental health problems, or to indicate a system or
service for the treatment of ‘mental illness’ (such as in a ‘mental health service’). The World
Health Organisation (WHO) defines mental health as follows:
Mental health is not just the absence of mental disorder. It is defined as a state of
wellbeing in which every individual realises his or her own potential, can cope with
the normal stresses of life, can work productively and fruitfully, and is able to make a
contribution to her or his community (WHO 2007).
Simply stated, ‘a mental illness or mental disorder is a diagnosable illness that affects a
person’s thinking, emotional state and behaviour and disrupts the person’s ability to work or
carry out other daily activities and engage in satisfying personal relationships’ (Kitchener,
Jorm & Kelly 2010, p. 4).
It should be noted that under the Mental Health Act 2007 (NSW), mental illness and mental
disorder are differently defined. ‘Mental illness’ in this context refers to a condition that
seriously impairs, either temporarily or permanently, the mental functioning of a person and
is characterised by the presence in the person of any one or more of the following
symptoms: (a) delusions, (b) hallucinations, (c) serious disorder of thought form, (d) a severe
disturbance of mood, (e) sustained or repeated irrational behaviour indicating the presence
of any one or more of the symptoms referred to in paragraphs (a) to (d). In considering
whether a person is a mentally ill person, the continuing condition of the person, including
any likely deterioration in the person’s condition and the likely effects of any such
deterioration, are to be taken into account.
A person (whether or not the person has a mental illness) is defined as a mentally
disordered person if the person’s behaviour for the time being is so irrational as to justify a
conclusion on reasonable grounds that temporary care, treatment or control of the person is
necessary: (a) for the person’s own protection from serious physical harm, or (b) for the
protection of others from serious physical harm. These definitions apply to considerations of
people detained and treated under the Mental Health Act.
Stigma and discrimination associated with mental health must be challenged, and this
process has included questioning the language and labels used in reference to ‘mental
illness’ and ‘mental disorder’—terms that are subject to debate and advocacy for reform. In
recovery-oriented practice the term mental distress is often used, as this term denotes the
idea that people are recovering from more than illness, and allows for a variety of ways in
which people can make sense of their experience.
Derogatory terms such as ‘schizo’, ‘psycho’, ‘loony tune’, ‘fruit
loop’, ‘nutcase’, ‘crazy’ and others, apart from being
dehumanising, can be unlawful according to the Commonwealth’s
Disability Discrimination Act 1992 if they are used in workplaces or
in the delivery of goods and services.

Recovery
There is no single definition of recovery in the context of lived experience of mental illness.
This is partly due to the two very different understandings of recovery: ‘clinical recovery’ and
‘personal (or social) recovery’. Personal recovery is a process that is person driven, defined
and directed. Recovery is a journey that is facilitated by the person’s own decisions, actions
and choices as well as resilience and often occurs outside the mental health service system.
Recovery-oriented practice
This refers to the application of capabilities that support people to recognise and take
responsibility for their own recovery and wellbeing, and to define their own goals, wishes and
aspirations.
The lived experience and insights of people with mental health conditions and their families
are at the heart of the recovery-oriented approach. Recovery-orientation recognises the
value of lived experience and brings it together with the expertise, knowledge and skills of
mental health practitioners, many of whom have experienced mental illness in their own lives
or in their close relationships. Recovery-oriented approaches respect the person for the
experience, expertise and strengths they contribute. Recovery-oriented approaches focus on
the needs of people who use services rather than on organisational priorities
(Commonwealth of Australia, 2013).
Clinical recovery
Clinical recovery is the term which implies the absence of symptoms either due to them being
eradicated by treatment and the person being cured, or the absence of symptoms because
the treatment is suppressing or controlling them. The essence of the term relates to the theory
underpinning it which is that the recovery process occurs because of the effectiveness of the
clinical treatment. This is usually considered to represent the ‘medical model’ in psychiatry.
Personal recovery
This is defined as being able to create and live a meaningful and contributing life within a
community of choice, with or without the presence of mental health issues. ‘Recovery’ can
mean different things to different people. From the personal perspective, recovery means:
gaining and retaining hope; understanding of one’s abilities and difficulties; engagement in
an active life; personal autonomy; social identity; meaning and purpose in life; and a positive
sense of self. See also clinical recovery.
“Complex Needs”
This term is often used to define suitability for multiple supports or services. Within a recovery-
oriented approach, we consider that a person and their needs are not complex, rather their
circumstances and/or the environment they experience is complex. The term Complex Needs
is commonly used to refer to individuals who present with an inter-related mix of diverse mental
health and physical health issues, or developmental and psychosocial problems. People who
have lived experience of trauma (emotional, physical and/or sexual abuse), as well as other
types of interpersonal trauma experienced in childhood, including but not limited to chronic
neglect and the effects of family violence, are often described as having complex needs.
Complex trauma
Characteristically, complex trauma occurs as a result of traumatic stressors that are
interpersonal, premeditated, planned and perpetrated by one human being on another. It is
particularly damaging if it occurs in childhood. These actions can be both violating and
exploitative of another person. It is mostly cumulative, repetitive and interpersonally
generated, and includes ongoing abuse which occurs in the context of the family and intimate
relationships. Complex trauma usually involves a fundamental betrayal of trust in primary care

relationships, because it is often perpetrated by someone in close contact with the victim.
Unlike a one-off event, the cumulative impact of premeditated and multiple episodes of abuse
involves compounded impacts and persistent effects. Complex trauma places the person at
risk of mental illness and complex post-traumatic stress disorder and may impact physical
health and psychobiological development (Kezelman & Stavropoulos 2012; Courtois et al.
2009).
Consumer
Many mental health services internationally and in Australia have adopted the term
consumer to describe anyone who has used or is currently using mental health services.
However, the term means far more than being a user of a service (something health services
often fail to recognise).
A ‘consumer’ is a person with personal lived experience of mental illness or distress

who exercises freedom of choice over their mental health and wellbeing. (S Watson
pers. comm. 2009)
Some people find the term empowering, as consumers should have choices about the
services they access and the right to quality service. However, not everyone likes or adopts
this term for a range of reasons, including the fact that some health services have
appropriated its meaning. Some people use terms such as ‘survivor’ or ‘ex-patient’ to better
define themselves.
Lived experience
This refers to the experience people have of their own or others’ mental health issues,
emotional distress or mental illness, and of living with, and recovering from, the impacts and
consequences of their own or others’ mental health issues, emotional distress or mental illness.
One of the beauties of the term ‘lived experience’ is that it talks about a far wider array of
experiences than the term ‘consumer’. ‘Consumer’ implies that we must have consumed mental
health services. ‘Lived experience’ is also inclusive of those people who share similar
experiences of difference and distress but who have not used been consumers/survivors/guests
of the mental health system.
Trauma
An inescapably stressful event that overwhelms a person’s coping mechanisms
(Bessel Van der Kolk)
Traumatic events are extraordinary, not because they occur rarely, but rather
because they overwhelm the ordinary human adaptations to life (Judith Herman)
Trauma particularly that which arises from interpersonal abuse and/or neglect in childhood, as
well as victimisation in adulthood, can lead to serious long-term consequences. Many
survivors adopt extreme coping strategies which can persist into adult life (as an attempt to
manage overwhelming traumatic stress). These strategies include suicidality, substance
abuse and addictions, self-harming behaviours, dissociation, and re-enactments of past
abusive relationships. Trauma can be trans-generational for individuals and/or affect whole
communities (MHCC, 2013).
The word trauma will be frequently used in this course to reflect both the nature of events or
circumstances and their impact. However, in the literature more broadly, trauma can refer to
an event on its own irrespective of the known impact; or to the impact on a person
irrespective of objective features of the event (e.g. traumatisation).

Trauma-informed
The re-conceptualisation of traditional approaches to health and human service delivery
whereby all aspects of services are organised acknowledging the prevalence of trauma
throughout society. A trauma-based approach primarily views the individual as having been
harmed by something or someone (Bloom, S 1997:2000, p 71). It is a strengths-based
framework that is responsive to the impact of trauma, emphasising physical, psychological,
and emotional safety for both service providers and survivors.
Abuse
Abuse will be used to refer to harmful acts perpetrated by others, as well as acts of neglect
that were not performed that could have been reasonably expected by others, entrusted with
care and protection.
Victim
The use of this term identifies that some harm was done to the person; that they have been
victimised. For some, this may assist in their locating responsibility with the perpetrator(s) of that
harm which validates their experience of being harmed by another (Clements & Ogle 2009).
Survivor
The use of the term survivor places emphasis on having survived abuse or assault. In the
literature, some people who identify as a ‘survivor’ rate themselves as coping better with the
effects of trauma in self-assessments (Agaibi & Wilson 2005, p. 203). The Australian Centre
for the Study of Sexual Assault (ACSSA) uses ‘victim/survivor’ throughout its literature,
recognising that neither term adequately identifies the person’s position in relation to the
abuse or assault.
Aboriginal & Torres Strait Islander People

This resource only refers to ‘Aboriginal’ people and does not make reference to Torres Strait
Islander people unless specifically indicated, as this resource is for NSW, and Aboriginal
people are the First Nation Persons of NSW. There was no specific consultation with Torres
Strait Islander groups in the development of this document. MHCC and its trainers
acknowledge that Torres Strait Islander people are among the First Nations of Australia. All
MHCC programs and services are available to Aboriginal & Torres Strait Islander People,
but specific training concerning Aboriginal & Torres Strait Islander Peoples is designed,
developed and facilitated by a person from the culture.

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(Certificate IV in Mental Health Peer Work)
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Acknowledgements © 2018 Mental Health Coordinating

Council. Apart from any use permitted

MHCC thanks everyone else involved in

Version number: 1.2.0

Original release: April 2016

Last revised: December 2018

Release for use: February 2019

Published and distributed by: Mental

Resource Book v1.2.0 1 © MHCC 2018

National Training Package N/A

Version number: 1.2.0

Original release: January 2016

Last revised: January 2019

Release for use: January 2019

Published and distributed by: Mental Health Coordinating Council © 2018

Resource Book v1.2.0 2 © MHCC 2018

Resource Book v1.2.0 3 © MHCC 2018

Resource Book v1.2.0 4 © MHCC 2018

Aims of the workshop

• understand contemporary thinking about trauma-informed care and practice and

• understand the relationship between recovery-orientation and a trauma-informed

Resource Book v1.2.0 5 © MHCC 2018

Language and definitions

The language (and conceptual) preferences of people using

Resource Book v1.2.0 6 © MHCC 2018

Note: There is a glossary of terms on page 114 of this book.

Resource Book v1.2.0 7 © MHCC 2018

• A high proportion of people have a lived experience of trauma, so the likelihood is

• We encourage participants in the course to do what they need to do in order to keep

Notes: Group agreement/ self-care agreement

Resource Book v1.2.0 8 © MHCC 2018

The objective of trauma-informed care is that service delivery is informed by an

Trauma-informed care is a strengths-based framework that is grounded in an

Principles of a trauma-informed care and practice

• based on current literature

• informed by research and evidence of effective practices and philosophies

• culturally safe and inclusive.

Resource Book v1.2.0 9 © MHCC 2018

Principle 1 - Understanding trauma and its impact - A trauma-informed approach

Principle 2 - Promoting safety - A trauma-informed approach promotes safety -

Principle 3 - Supporting consumer control, choice and autonomy - A trauma-

Principle 4 - Ensuring cultural competence - A trauma-informed care and practice

Principle 5 – Safe and healing relationships - A trauma-informed care and practice

Principle 6 - Sharing power and governance – A trauma-informed care and practice

Principle 7 - Recovery is possible - Understanding that recovery is possible for

Principle 8 - Integrating care - Maintaining a holistic view of consumers and their

To provide trauma-informed services, all staff of an organization, from the receptionist to

Resource Book v1.2.0 10 © MHCC 2018

Resource Book v1.2.0 11 © MHCC 2018

Recovery-oriented practice and trauma-informed care: the common factors

• It has benefits for all involved in and with the organisation.

Resource Book v1.2.0 12 © MHCC 2018

Principle 1 - Understanding trauma and its impact

Events that lead to trauma include:

Resource Book v1.2.0 13 © MHCC 2018

Post-traumatic stress disorder (PTSD)

Post-traumatic stress disorder is a pattern of responses to a ‘traumatic stressor’ that persists

The DSM V defines a ‘traumatic stressor’ as follows:

• ‘Intrusion symptoms’ - The traumatic event is persistently re-experienced in the