Responding to the public health issue of complex trauma

Responding to the public health issue of complex trauma

14 May 2014
Responding to the public health issue of complex trauma

Dr Cathy Kezelman, President of Adults Surviving Child Abuse (ASCA), discusses the experience of ASCA in developing resources to inform responses to complex trauma.

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ASCA is the leading national organization working to advance the needs of adults who have experienced childhood trauma. Childhood trauma is interpersonal and includes child abuse in all its forms, neglect and the impacts of other adverse childhood experiences including domestic violence or having a parent with a mental illness.

Such trauma, referred to as complex trauma, needs to be distinguished from that of a single incident (e.g. a natural disaster or physical or sexual assault in adulthood), and requires a different treatment pathway. It is more common, destructive, often extreme, repeated and prolonged and occurs during a child’s crucial developmental years. While it is often perpetrated by a primary care-giver, a person in a position of trust and power, care-givers do not need to be actively abusive for harm to occur. Inconsistent care-giving or not being attuned to the child’s needs can be profoundly damaging too.

In Australia, data from a range of sources indicate that an estimated 5 million adults are living with the long-term impacts of many forms of childhood trauma.1 I am one of them. One would have assumed that I, a general practitioner, would understand how my trauma was affecting me and what I needed to do to work through it. However I soon learnt how little my training and practice and, for that matter, that of many of my colleagues had informed me about trauma.

As the majority of existing guidelines focused on single incident PTSD only, in 2012 ASCA developed and released Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery to inform responses to complex trauma. TheASCA Guidelines collate and distil 20 years of research in this area. They provide the evidence base for and principles of two sets of Guidelines, one for the treatment of complex trauma (clinical) and one for services (trauma informed guidelines).

When people do not receive the right help, childhood trauma can impact functioning and wellbeing right through the life cycle and it can also have ongoing effects on the next generation. I was fortunate to find a practitioner who helped me recover. Research shows that even profound early trauma can be resolved, and its negative intergenerational impacts can be intercepted. People can recover and their children can do well. It is a time for hope and optimism.2 All survivors need access to affordable specialist clinical services to help them recover and live healthy productive lives.

As we have witnessed through testimony before the Royal Commission into Institutional Responses to Child Sexual Abuse, trauma from different causes is often compounded over time. Many people were re-traumatised even in situations of care or when seeking help.

That’s where the trauma informed guidelines come in. A service which is trauma-informed is less likely to re-traumatise people seeking its services. While it does not treat trauma per se it is always alert to the possibility of trauma – what has happened to a person, how they coped and how they are coping now. It shifts the focus from what is wrong with a person to understanding them in the context of their lives.

Trauma informed practice is grounded in five core principles:3

  • safety;
  • trustworthiness;
  • choice;
  • collaboration; and
  • empowerment.

It is also attuned to cultural and individual diversity.

Just as complex trauma occurs in intimate relationships, so too does recovery. While damaging relationships have negative impacts on the brain, new positive relationships have great healing potential. For safe, positive interactions to occur in all health and community service settings, a trauma-informed approach needs to be embedded within all human services.4

Trauma-informed practice is cost effective5 and benefits both clients and staff6. It not only reduces the risk of inadvertent harm but also promotes staff wellbeing.

The broad-based implementation of research into practice through trauma-specific clinical services and trauma-informed practice will help improve outcomes for the large numbers of Australians affected by the public health challenge of complex trauma.


ASCA Resources:

  • Download or purchase a copy of ASCA’s Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery. The Practice Guidelines provide the evidence base to translate research around complex trauma into practice and the framework to respond to the public health challenge of trauma. The Guidelines set the standards in each of the following domains:
    • ‘Practice Guidelines for Treatment of Complex Trauma’ are for the clinical context, and reflect growing insights into the role of trauma in the aetiology of mental illness and new possibilities for clinical treatment.
    • ‘Practice Guidelines for Trauma-Informed Care and Service Delivery’ are directed to services that people with trauma histories come into contact.
  • ASCA’s 1300 Professional Support Line, 1300 657 380, operates 9-5 Mon-Sun and provides short term professional counselling support, information and guidance to adult survivors, their family, friends and partners as well as to workers and health professionals. The ASCA 1300 line has a referral database of practitioners and agencies with the experience and expertise to work therapeutically with adult survivors of complex trauma
  • ASCA’s education, training and professional development workshops are scheduled regularly around the country and can be delivered in-house on request. ASCA’s suite of workshops/training includes psycho-educational workshops for survivors, their family, friends and partners, trauma informed training to organisations, including for front-line workers, staff and managers, as well as professional development for health professionals. For more information go to or email, or call 02 8920 3611.

Further reading:

For further information on complex trauma in relation to sexual victimisation, see Acknowledging complexity in the impacts of sexual victimisation trauma.

For further information on understanding child victimisation and trauma, see Rarely an isolated incident: Acknowledging the interrelatedness of child maltreatment, victimisation and trauma.

1. Estimated from a range of key sources placing the figure at estimated 5 million adult survivors of childhood trauma.

2. Solomon, M. T. & Siegel, D. J. (2003). Healing Trauma: Attachment, Mind, Body and Brain. New York: Norton.

3. Fallot, R. Harris, M. (2009). Creating Cultures of Trauma-Informed Care (CCTIC): A Self-Assessment and Planning Protocol. Washington, DC: Community Connections.

4. Mental Health Coordinating Council (MHCC). (2013). Trauma-Informed Care and Practice: Towards a cultural shift in policy reform across mental health and human services in Australia, A National Strategic Direction, Position Paper and Recommendations of the National Trauma-Informed Care and Practice Advisory Working Group, Authors: Bateman, J., Henderson, C.(MHCC), & Kezelman, C. (Adults Surviving Child Abuse, ASCA).

5. Domino, M. E., Morrissey, J. P., Chung, S., Huntington, N., Larson, M.J., & Russell, L.A. (2005). Service use and costs for women with co-occurring mental and substance use disorders and a history of violence. Psychiatr Serv. 56: 1223-32.

6. Community Connections. (2002). Trauma and abuse in the loves of homeless men and women. Online PowerPoint presentation. Washington, DC.


The feature image is by Suvodeb Banerjee, CC BY 2.0.



these stats don't surprise me. As a former school counsellor and observing anecdotally, there is a lot of poor parenting/ emotional abuse out there; plus very high levels of trauma from childhood sexual abuse/ emotional abuse ( eg by a grandparent/ parent) compounded in adulthood by sexual assault. Many go on to develop incapacitating anxiety/ depression which means steady, everyday work is not something these young women ( who are very intelligent and would otherwise be very able) can manage.
Dear Dr Cathy Kezelman, it is marvelous that this information is getting into the public arena. Historically the silence has been deafening. I am completing my Honours in Fine Art and my thesis is on trauma, affectivity, visual art and empathy. I am doing this to make sense of my own life. The stand out statement in your article is "I am one of them". Thank you for not hiding as a large number of health professionals do.
Christopher Hardwick

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