Acknowledging complexity in the impacts of sexual victimisation trauma

ACSSA Issues No. 16 – February 2014

Acknowledging complex trauma in service delivery

In view of the many hurdles and additional social problems that some people with complex trauma face, some of which are outlined above, a protracted issue is the difficulty involved in negotiating a variety of life issues at once within a fragmented service system. The term "complex needs" refers to the span of need for an array of services that some service users require over a lifetime. Often, people with complex trauma have complex needs. Service delivery that acknowledges trauma as the basis of this need can respond accordingly and overcome some of these difficulties (Huntington et al., 2005). As discussed earlier, homelessness, poverty and substance abuse feature strongly for many people with trauma histories. These needs can change over time and at different phases of the lifespan. For example, accessing housing or employment might be difficult for someone who is also dealing with substance abuse issues or parenting concerns. A focus on individual problems or symptoms, rather than targeting the basis of need as a whole, means that service users can find themselves on a sequence of service use with no clear direction for moving forward. Unless trauma is treated as the underlying driver for service use, re-traumatisation can occur with a compounding effect that will be costly for services and to the individual (Kezelman & Stavropoulos, 2012).

Understanding healing and recovery

People experiencing complex trauma have a very strong need to feel safe (Herman, 1992). Healing and recovery is stage-based and emphasises establishing safety first. The trauma literature recognises core stages for treatment and recovery. These are: stabilisation or establishing safety; processing trauma - the exploration and reintegration of traumatic memories into a personal narrative; and the positive reconnection with others (Herman, 1992; Kezelman & Stavropoulos, 2012).

Although there may be no "final" resolution, healing from an experience of trauma should be focused on the need to increase the capacity of survivors to be aware of and control their reactions to a range of trauma stimuli, including flashbacks, extreme emotion states, and interactions with others. Importantly, this needs to occur within a safe and predictable external environment. A safe environment is one which supports and encourages this, and which does not recreate situations of humiliation, disempowerment, isolation, danger, unpredictability and disempowerment. It is important to be aware that such situations may be created unwittingly and by unintentional omission or commission of certain procedures and processes. By understanding the impacts of trauma, service organisations will be more aware of the possibility of retraumatising people inadvertently.

Service support for sexual abuse histories and complex trauma

The needs of service users with complex trauma often transcend just the mental health or medical sector to encompass social issues such as employment and housing (Rankin & Regan, 2004). Usually these issues are dealt with by fragmented systems with different treatment approaches and little referral and connected follow-up (Kezelman & Stavropoulos, 2012). Although it has been acknowledged that services are not meeting the needs of people whose problems may be a result of trauma, and that this is expensive in terms of service failure (Rankin & Regan, 2004), there hasn't been a consistent approach to guiding services to become more responsive to trauma.

Sexual violence is so prevalent in our society that it is likely that most, if not all, human services would at some point deal with people suffering trauma (Elliot, Bjelajac, Fallor, Markoff, & Reed, 2005). Where there is a lack of understanding and sensitivity to trauma in service delivery, some programs and services may inadvertently trigger trauma symptoms so that patients or clients revert to using coping mechanisms that can impact on their ability to successfully engage with the service (Savage et al., 2007).

Siloing of different services may have ramifications for women with complex trauma symptoms in that each particular problem she faces may be dealt with out of context and individually with little focus on the core problem, instead short-term goals, such as stopping drinking or dealing with family violence are addressed in isolation (Fels Smyth & Goodman, 2006). The literature around services and people with complex trauma supports the use of a trauma-informed person-centred approach for helping the recovery from trauma inflicted on victim/survivors of sexual abuse and polyvictimisation (Chung, Domino, & Morrisey, 2009; Huntington et al., 2005; Kezelman & Stavropoulos, 2012). One of most influential developments in the evidence around service provision for women with complex trauma, was the US-based Substance Abuse and Mental Health Services Administration's (SAMHSA) 5-year study into Women, Co-occurring Disorders and Violence Study (WCDVS). The study was a multi-site, longitudinal, quasi-experimental study to determine the effectiveness of integrated services for women affected by substance abuse and mental illness who were also victims of violence (Toussaint & VanDeMark, 2007). This study helped formulate the principles and application of appropriate services to deal with women who have complex trauma linked to histories of violence (Elliot et al., 2005). These principles are discussed in more detail below.

Trauma-informed services

Trauma-informed services understand trauma, particularly complex trauma, but the service they provide is not specifically targeted at the trauma. Their core service may be dealing with features of complex trauma - for example, relationship counselling or substance abuse - but they are attuned to the possibility of trauma in each individual, regardless of whether it is apparent in their presentation. Trauma-informed services are adept at responding to the issues and complexity of needs that a traumatised person may have within a particular setting and are able to incorporate principles of care appropriate for traumatised people including trust, safety, person-centred care, choice, collaboration, and empowerment (Kezelman & Stavropoulos, 2012; Salasin, 2005).

For some services, the adoption of trauma-informed care may require organisational change, including policy and procedure review to ensure the safety and relevance of the service for trauma survivors. Staff within the relevant fields should understand the connective relationship between complex trauma and the array of needs that clients may have (Elliot et al., 2005; Kezelman & Stavropoulos, 2012).

Huntington et al. (2005) outlined the core principles of a comprehensive approach for providing services to women with co-occurring disorders or complex trauma. Developed based on findings from the Women, Co-Occurring Disorders and Violence Study, Huntington et al. indicated that services must be:

  • integrated: services are linked and able to share information and resources to enable treatment of the whole person in a coordinated fashion;
  • trauma-informed: services are based on an understanding of trauma and its impacts on victims;
  • consumer integrated services and systems: services seek input and consultation with service users to empower them to have a significant say in shaping the services they use; and
  • comprehensive: core services that are necessary to meet the needs with regard to complex trauma including outreach, screening, ongoing treatment for specific issues, parenting skills training, resource coordination and advocacy, trauma specific services, crisis interventions and peer-run services.

Kezelman and Stavoroupoulous (2012) further indicated that trauma-informed services are:

  • committed to safety, trustworthiness, choice, collaboration and empowerment;
  • have considered systemic components in acknowledgement of the role violence plays in the lives of service users;
  • apply the understanding to service system design to avoid re-traumatisation; and
  • have close collaborative relationships with other relevant services.

Trauma-specific services

Trauma-specific services are those that aim to deal directly with the trauma and aim to treat it and manage trauma related symptoms. This should be done within a trauma-informed environment (Elliot et al., 2005; Kezelman & Stavropoulos, 2012). Trauma-informed services can be delivered across the service settings (e.g., mental health, general healthcare, substance abuse). Some recommendations are made in the literature that most of the users of human services have experience of trauma, whether that appears directly apparent or not, and therefore best practice is to rely on procedures that treat all women as if that is the case and utilise those least likely to be retraumatising (Elliot et al., 2005). Many standard procedures in service environments have the potential to trigger trauma responses in victim survivors and can be disempowering for them. As a result, there can be a cost in terms of failing to engage clients in the services/programs or see an unnecessarily high drop-out rate (Elliot et al., 2005).

A recovery-oriented approach

Another framework for considering support for complex trauma is a recovery-oriented approach based on the concept that people with severe mental illnesses can recover and go on to participate fully in a healthy and fulfilling life (Farkas, Gagne, Anthony, & Chamberlin, 2005). A recovery or person-centred approach will ensure an approach in which the individual is centralised and has full rights to a partnership in their recovery, including individual choices about service use. At the organisational level, services will need to focus on the inherent capacity of the individual to recover, including by ensuring policies, programs, staff and processes are consistent with this (Farkas et al., 2005). A recovery approach is consistent with the principles of trauma-informed care in terms of placing the individual at the centre of service need.

A guideline-based treatment for complex PTSD

Connor and Higgins (2008a) outlined the use of guideline-based treatment for complex PTSD for use by therapists called the HEALTH treatment program. This type of treatment acknowledges the inadequacy of approaches that are based solely on a PTSD formulation and that fail to address some of the complex PTSD symptoms. This particular program focuses on the needs of the individual by working to strengthen a person's capacity to deal with the basis of the complex trauma while reducing the symptomatology of the complex PTSD. The program provides a pathway to achieve the strengthening of the self, while allowing sufficient flexibility to tailor to the needs of the client (Connor & Higgins, 2008b).

Overcoming service delivery silos - collaborative and connected care

There are various ways for services to provide person-centred care to aid recovery from trauma. One way is to establish relationships between services that enable the person to be cared for in relation to each aspect of assistance they require.

In accordance with the recognition of trauma as underlying service need and with a focus on recovery, the way in which victim/survivors utilise health and care services should be holistic with the focus on the individual, not just one aspect of his/her needs. This requires strengthening connections between services and overcoming administrative/jurisdictional boundaries of responsibilities where the limitations of different objectives, budgets and accountabilities impede a shared vision of how to address service needs collectively.

In financially constrained environments, and without policy-driven structural change directing service connection, this type of connected care can fall to services to form informal relationships and connections.

Collaboration between, and integration of, services is one way of overcoming the short falls of siloed service systems that alone are unable to provide the range of services required by people suffering from complex trauma symptoms (McDonald & Rosier, 2011).

Collaboration is different to integration in that it is not a complete merging of services but is a culture of relationship building and information sharing between services (McDonald & Rosier, 2011). Informal and creative approaches to connecting services may include partnerships, cross-training and resource sharing (Rosengard, Laning, Ridley, & Hunter, 2007).

There are different types of integrated services, for example, those that operate by creating a network of organisations that coordinate services in a continuum, or those that coordinate provision of care for each particular instance it is required (Chung et al., 2009). Using one worker as a link or service navigator can be one way of more smoothly intersecting care between services (Rosengard et al., 2007).

Collaborative care has been shown to be effective, but there is less evidence to enable pinpointing which aspects of any particular model enhanced effectiveness the most. Therefore it is difficult to emphasise the benefits of any particular model over another (Butler et al., 2008; Sieber, Kessler, Kallenberg, Miller, & Patterson, 2012). Without service collaboration or relationships of some kind however, it is difficult to envisage how an individual can be at the centre of the recovery picture.

One argument against using trauma as a basis for connectivity of service is that these services are at best drawn together only as a collection of short-term, highly focused interventions (Fels Smyth & Goodman, 2006). This is where it becomes paramount to acknowledge and respond to the personalised and individualised needs of each victim/survivor (Briere & Jordan, 2004; Rosengard et al., 2007).

Briere and Jordan (2004) identified that complexity of individual victimisation experiences means that there are clear implications for service interventions. They should be customised to the various issues and problems of the victim, be multimodal, which means, individualised, and flexible with referrals to other supports as required.