By Jane Nursey MAPS, MCCNP, Dr Winnie Lau and Professor David Forbes FAPS MCCLP, Phoenix Australia – Centre for Post-traumatic Mental Health, Melbourne Victoria

Most Australians will be exposed directly or indirectly to at least one potentially traumatic event (PTE) in their lifetime. PTE’s can be one-off events, such as a home or workplace accident, physical or sexual assault, a natural disaster, act of terrorism; or repeated or persisting events such as domestic violence, childhood abuse or neglect, military and emergency services work or refugee and war experiences. The emotional impacts often include feelings of fear, shame, guilt, terror, anger, numbness, powerlessness or hopelessness.

For most people the intense emotional distress dissipates within a number of weeks after the event. However a significant minority will experience ongoing distress and potentially develop a trauma-related mental health condition such as posttraumatic stress disorder (PTSD), depression, an anxiety disorder or a substance use disorder. People who experience repeated traumas, and children who suffer ongoing abuse are at higher risk of adverse physical, mental health, and social impacts.

While psychologists may not always be involved in providing support to people in the immediate aftermath of a trauma, the pervasiveness of trauma means that a high proportion of our clients presenting across a range of service contexts are likely to have experienced a PTE. It is important that we recognise the signs of trauma impact and are aware of the best practice approaches to supporting people who may present at different time points along their post trauma recovery trajectory.

Given the variety of potentially traumatic events that people may be exposed to, and the broad response and recovery trajectories they demonstrate, an individually tailored stepped care approach is recommended. This approach applies across service settings whether it be private practice, community, primary, or tertiary care settings, industry/workplaces, or in-the-field support to military and emergency service personnel or disaster survivors. However we need to be mindful about adapting our approach to meet the specific needs of the individuals we are assisting.

Prevention and early intervention for all

Expert consensus currently recommends that following a PTE, practical and emotional support should be offered. This approach includes facilitating ways to manage distress, utilising social supports, providing information and psycho-education. It is also important to monitor people who maintain significant distress or are at risk of developing a trauma-related mental health disorder, to enable prompt assessment and referral for specialist help. This approach is based on five empirically supported early post trauma intervention principles endorsed by international trauma experts (Hobfall et al 2007). These principles include safety, calming, connectedness, self-efficacy and hope. An example of an intervention that follows these principles is Psychological First Aid (PFA), which is widely implemented in post-disaster contexts and increasingly embedded into the critical response policy and practice of high risk industries.

Community advice

These principles also guide our advice as psychologists to community members in the context of increased apprehensions about community trauma. We live in a world where news of natural disasters, war and terrorism are streamed 24/7 around the globe. Recent events at home include the devastating bushfires in South West Victoria and Western Australia; floods in the Northern Territory and Far North Queensland, and abroad such as the Paris terror attacks, war in Syria and the threat of further terror attacks in Europe. For those who have been through traumatic events in the past, media reports can induce a re-experiencing of trauma-related distress. They can also increase general public anxiety about their own vulnerability. As psychologists, we play an important role in assisting people to manage this anxiety by helping to put the probability of their own risk of exposure into perspective, developing their emotional regulation and stress management skills, and assisting them to enhance their resilience by planning and preparing for high impact events for which there is an identifiable risk (e.g., preparing a response plan for a natural disaster if they live in or are travelling to a high risk region). People should also be encouraged to engage in self-care strategies to proactively manage their mental health and promote resilience (e.g., minimise media exposure, healthy living, avoiding drugs/alcohol, spending time with loved ones and enjoyed activities, addressing unhelpful thoughts and rumination, maintaining routines). Children and adolescents, particularly, should be encouraged to talk about their fears and ask questions that elicit answers which reassure and help them manage realistic versus imagined fears.

Treating trauma-related disorders

Psychological trauma can lead to the development of a range of mental health disorders in vulnerable and high risk individuals. The most prevalent of these include PTSD, mood and anxiety disorders and substance use disorders. Children subjected to abuse and neglect are at risk of developing a range of comorbid developmental disorders including attachment disorders, disruptive behaviour disorders, and learning disabilities. In both children and adults the primary presenting disorder should be treated with the recommended evidence-based approach, paying particular attention to addressing any trauma specific symptoms which exacerbate or maintain the disorder being treated.

In the case of PTSD, the NHMRC-approved and APS-endorsed Australian Guidelines for the treatment of ASD and PTSD (2013) (www.phoenixaustralia.org) recommend Trauma-Focussed CBT and Eye Movement Desensitisation and Reprocessing Therapy (EMDR). Trauma-focused CBT includes Exposure Therapy, Cognitive Therapy, Cognitive Processing Therapy and Narrative Exposure Therapy. These therapies have at their core working through the memories of the trauma, exposure to avoided places and situations and addressing thoughts interfering in recovery. These recommendations apply to PTSD from both single and repeated events exposure. In the latter, where people have developed associated problems such as emotional dysregulation, interpersonal difficulties and/or dissociative symptoms, it is recommended that therapy be conducted at a slower pace with more time spent establishing a trusting therapeutic relationship and teaching emotional regulation skills.

While pharmacotherapy is considered a second line treatment, it can be important in promoting stabilisation or as an adjunct to trauma-focussed therapy. Other second line psychological treatments for PTSD include non-trauma focussed approaches. Some examples include interpersonal therapy and anxiety management. There continues to be considerable interest in testing new innovative treatments and adapting for PTSD existing treatments for other disorders such as depression. While there are too many to mention in this brief piece, a review of these emerging interventions will be published shortly (Metcalf et al., InPress). Clinicians are encouraged to be well informed about the evidence base around a specific therapeutic techniques’ application before offering it to their clients as a viable treatment option for PTSD.

Service system approaches – Trauma Informed Care for trauma affected populations

There is now a better understanding of the role trauma plays in the onset and maintenance of mental health and psychosocial problems across the lifespan. This has led to the development of Trauma Informed Care (TIC). Pioneered in America, TIC frameworks are burgeoning in social services and mental health sectors. TIC is based on the premise that many behaviours or responses (often classified as symptoms) expressed by people with mental health problems are related to and exacerbated by an experience(s) of trauma (DHHS 2015). It is a strengths-based approach to recovery that supports the resilience trauma survivors already have through application of the principles of understanding trauma and its impacts, safety and trust, choice and control, and empowerment (Harris and Fallot, 2001).

TIC is not a specific trauma intervention but a whole of service system approach whereby all aspects of a service system (e.g., practitioners through to administrative support, physical setting) need to be organised with knowledge of trauma and violence, an awareness of the pervasiveness of trauma and its impact, as well as a commitment to the multiple paths of recovery. Examples of service systems which have adopted the principles of TIC include homelessness agencies, drug and alcohol services and services caring for refugees and asylum seekers.

In Australia, TIC has been promoted through the development of the National Strategic Direction Position Paper for TIC (Mental Health Coordinating Council, 2013). This document includes recommendations for a whole of government policy reform, implementation of TIC principles into practice across mental health and human service systems, and the embedding of these within key strategic frameworks.

General Tips for Working with Psychological Trauma
  • Remember most people are resilient in the face of adversity – initial signs of distress are normal and will likely resolve within a few weeks
  • Take a stepped care approach, allow for natural recovery to occur in the first few weeks by ensuring safety, calm, and support are in place

When symptoms persist:

  • Screen all clients for current and past trauma exposure (for tools available see – phoenixaustralia.org)
  • If exposure history, assess for range of trauma-related mental health disorders including PTSD, depression, anxiety and substance use
  • When working with clients with a history of trauma exposure, always ensure stabilisation and safety first
  • Work from a developmental and trauma-informed perspective – understand how trauma-related mental health problems may present differently across the lifespan, and avoid re-traumatisation by using strategies that promote safety, choice and collaboration, trust, empowerment, and cultural competency.
  • Educate your clients on responses to trauma, and what different symptoms and disorders mean
  • Ensure strong engagement and stabilisation before embarking on trauma-focussed treatment for posttraumatic mental health problems
  • Provide first line evidence based treatments in the first instance – if insufficient response, try second line treatments
  • Comorbidity is common, so treatment planning is essential (see guidelines for sequencing approach –
    phoenixaustralia.org)
  • Ensure you are trained in evidence based treatments for trauma-related mental health disorders, refer on if not
  • Take care of yourself, seek supervision from experienced supervisors, monitor and manage your caseload, ensure good support

The authors can be contacted via dforbes@unimelb.edu.au

References

  • DHHS. (2015). Trauma and mental health technical paper mental health plan: 10-year mental health technical paper: Victorian government Department of Health and Human Services. Retrieved from https://www2.health.vic.gov.au/about/publications/policiesandguidelines/3/C/E/5/0/trauma-and-mental-health-technical-paper-mental-health-plan.
  • Harris, M. E., & Fallot, R. D. (2001). Using trauma theory to design service systems: New directions for mental health services. San Francisco: Jossey-Bass.
  • Hobfoll, S. E., Watson, P., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., . . . Ursano, R. J. (2007). Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence. Psychiatry, 70(4), 283-315.
  • Metcalf, O., Varker, T., Forbes, D., Phelps, A., Dell, L., DiBattista, A., Ralph, N & O’Donnell, M. (In Press). Efficacy of fifteen emerging interventions for the treatment of posttraumatic stress disorder: A systematic review. Journal of Traumatic Stress.
  • 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. Lilyfield, NSW: Mental Health Coordinating Council.
  • Phoenix Australia Centre for Posttraumatic Mental Health. (2013). Australian guidelines for the treatment of acute stress disorder and posttraumatic stress disorder. Melbourne, Victoria: Phoenix Australia (ACPMH). 

InPsych February 2016

 

Table of contents

Vol 38 | Issue 1