Transcript Definition of DV (NSW Health)

Domestic & Family Violence
and Complex Trauma:
Where do we start?
Met-West Violence Prevention Network
Conference , 4 November 2010
Sarah Stewart
Education Centre Against Violence
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• “In order to escape accountability…the
perpetrator does everything in his power to
promote forgetting. If secrecy fails, the perpetrator
attacks the credibility of his victim. If he cannot
silence her completely, he tries to make sure no
one listens…”
• “All the perpetrator asks is that the bystander do
nothing…the victim demands action, engagement
and remembering…”
• “When the truth is finally recognised, survivors
can begin their recovery…”
(Judith Lewis Herman, Trauma and Recovery,1992)
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Overview
• What are we talking about?
• What do we know about the links between
domestic & family violence (DFV) and
complex trauma?
• What are the impacts and outcomes of
complex trauma?
• What are the implications for practice,
policy, training and research?
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Complex trauma (C-PTSD)
• “The experience of multiple, chronic and
prolonged developmentally adverse
traumatic events, most often of an
interpersonal nature…and early life onset”
(Bessel van der Kolk, 2005)
• “A type of trauma that occurs repeatedly
and cumulatively, usually over a period of
time and within specific relationships and
contexts”
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(Christine Courtois, 2004)
Complex trauma (C-PTSD)
• Has a pervasive negative impact and is
qualitatively distinct from Post-Traumatic
Stress Disorder (PTSD)
• A clinically recognised condition (not yet
included in the DSM – currently subsumed
under ‘Disorders of Extreme Stress Not
Otherwise Specified’)
• Describes the dual problem of both the
exposure to trauma and the impact of the
trauma
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Complex trauma (C-PTSD)
• Includes range of traumatic experiences,
including DFV and other trauma occurring
within context of family and intimate
relationships
• Also used to refer to other types of
catastrophic and entrapping traumatisation
in both childhood and adulthood
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Complex trauma (C-PTSD)
• Develops in the context of:
– Captivity and lack of means of escape
– Entrapment
– Repeated violation of boundaries
– Betrayal and rejection
– Bewilderment and confusion
– Lack of control and disempowerment
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Complex trauma and DFV
• Numerous studies of children and
adolescents abused and witnessing violence
in the context of family relationships describe
problems experienced by victim/survivors
that do not ‘fit with’ other diagnoses (Scheeringa et
al 2003; Van der Kolk et al 2005; Briere 1992)
• Complicated adaptations to severe and
prolonged trauma have been noted in abused
women (Rollstin & Kern 1998; Walker 1984)
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Complex trauma and DFV
• Childhood abuse is the most frequent cause of
traumatisation in women (Kessler et al 1995)
• All types of childhood victimisation are associated
with increased risk of lifetime re-victimisation (Widom et
al, 2008)
• Among women in violent relationships, depression,
drug abuse and a history of childhood abuse
increase the likelihood of suicidality - depending on
the number of these risk factors involved – 10, 25
and 107 times respectively (Thompson et al 2002 in Koss et al
2003)
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Complex trauma in children
& adolescents
• Brain-based stress response -> constant high
arousal -> inability to regulate internal states (Perry
2006; van der Kolk 2005)
• Defining experience is feeling unsafe
-> mistrust of adults (Seita & Brendtro 2005)
 Enduring negative outcomes across a range of life
domains
(Kilpatrick et al 2003; Duba et al 2001; Cloitre et al 2001; Felitti et al
1997)
BUT…these impacts can be ‘undone’ to an extent
(Schore 10
2003)
Outcomes of complex trauma
in children & adolescents
Problems in
• Attachment
• Biology
• Emotional regulation
• Dissociation
• Behavioural control
• Cognition
• Self-concept
(Cook at al, 2005)
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Outcomes of complex trauma
in women:
Alterations in
• Regulation of affective impulses
• Attention and consciousness
• Self perception
• Perception of perpetrator
• Relationships to others
• Physical health
• Systems of meaning
(Courtois, 2004)
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An ecological framework
(Krug et al, 2002)
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Intersectionality
• Focuses on the interlocking patterns of
gender, race, ethnicity, class, disability
and sexuality
• Analyses social contexts and systems of
power and privilege
• Acknowledges that trauma may be
further amplified and compounded by
‘micro-aggressions’ of racism,
heterosexism and classism…
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(Bograd,1999)
Principles of trauma-informed
services
• Recognise the impact of violence and victimisation
on development and coping strategies
• Identify recovery from trauma as a primary goal
• Employ an empowerment model
• Strive to maximise survivor’s choices and control
over recovery
• Are based in a relational collaboration
• Create an atmosphere that is respectful of survivors’
needs for safety, respect and acceptance
(Elliott et al.,
152005)
Principles of trauma-informed
services
• Emphasise survivor’s strengths, highlighting
adaptations over symptoms and resilience over
pathology
• Work to minimise the possibilities of
retraumatisation
• Strive to be culturally competent and to understand
each survivor in the context of her life experiences
and cultural background
• Soliciting consumer input and involve consumers in
designing and evaluating services
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(Elliott et al., 2005)
Implications for practice
• The key elements of a healing
relationship:
R espect
I nformation
C onnection
H ope
(Saakvitne et al, 2000)
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Implications for practice
• The 3 ‘pillars of trauma-informed
care’
–Safety
–Connections
–Managing emotions
• You don’t need to be a therapist to be
part of the healing process
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(Bath, 2008)
Implications for policy
• Policy needs to
– reflect explicit links between complex
trauma and DFV so that ‘symptoms’ are
not misinterpreted as chronic
psychopathology
– incorporate clear pathways between
different service systems and practice
areas
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Implications for training
• Need to build a competent and supported
trauma-informed workforce through
– Single discipline and single agency
training tailored to specific practice
contexts
– Cross-sector and multi-agency training
that facilitates coordinated and integrated
service provision
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Implications for research
• Need for research that
– extends beyond traditional preoccupation
with PTSD as an outcome of trauma and
pay more attention to multidimensional
nature of complex trauma
– privileges the voices of survivors and
focuses on recovery
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• “The core experiences of psychological
trauma are disempowerment and
disconnection from others. Recovery,
therefore, is based on the
empowerment of the survivor and the
creation of new connections”
(Judith Lewis Herman, 1992)
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References
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Bath, H (2008) ‘The three pillars of trauma-informed care’, Reclaiming Children and Youth, 17(3):17-21
Bograd, M (1999) Strengthening domestic violence theories: intersections of race, class, sexual orientation,
and gender. Journal of Marital and Family Therapy, 25: 275-289.
Briere, J (1992) Child abuse trauma: Theory and treatment of the lasting effects, Newbury Park, CA: Sage
Cloitre, M, Cohen, L, Han, H & Edelman, R (2001) ‘Posttraumatic stress disorder and extent of trauma
exposure as correlates of medical problems and perceived health among women with childhood abuse’,
Women and Health, 34:1-17
Cook, A, Spinazzola, J, Ford, J et al (2005)’Complex trauma in children and adults’, Psychiatric Annals,
35(5):390-398
Courtois, C (2004) ‘Complex trauma, complex reactions: Assessment and treatment’, Psychotherapy:
Theory, Research, Practice, Training, 41(4):412-425
Duba, SR, Anda, RF, Felitti, VJ, Chapman, DP, Williamson, DF & Giles, WH (2001) ‘Childhood abuse,
household dysfunction and the risk of attempted suicide throughout the lifespan: Findings from the Adverse
Childhood Experiences Study’, Journal of the American Medical Association, 286(24): 3089-3096
Elliott, DE, Bjelajac, P, Fallot, RD, Markoff LS & Reed, BG (2005) ‘Trauma-informed or trauma-denied:
principles and implementation of trauma-informed services for women’, Journal of Community Psychology,
33(4):461-477
Felitti, VJ, Anda, RF, Nordenberg, D, Williamson, DF, Spitz, AM, Edwards, V et al (1997) ‘Relationship of
childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse
Childhood Experiences Study’, Journal of the American Medical Association, 14: 245-258
Herman, JL (1992a) Trauma and Recovery: The aftermath of violence – from domestic to political terror.
New York: Basic Books
Herman, JL (1992b) ‘Complex PTSD: A syndrome in survivors of prolonged and repeated trauma’, Journal
of Traumatic Stress, 5:377-391
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References
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Kessler, RC, Sonnega, A, Bromet, E, Hughes, M & Nelson, CB (1995) ’Post traumatic stress disorder in the
national co-morbidity survey’, Archives of General Psychiatry, 52:1048-1060
Kilpatrick, DG, Ruggeiro, KJ, Acierno, R, Saunders, BE, Resnick, HS & Best, CL (2003) ‘Violence and risk
of PTSD, major depression, substance abuse/dependence and comorbidity: Results from the National
Survey of Adolescents’, Journal of Consulting and Clinical Psychology, 71:692-700
Koss, MP, Bailey, JA et al. (2003). Depression and PTSD in Survivors of Male Violence: Research &
Training Initiatives to Facilitate Recovery, Psychology of Women Quarterly, 27: 130-142.
Krug, EG, Dahlberg, L, Mercy, JA, Zwi, A. & Lozano, R. (2002)World Report on Violence and Health,
Geneva: World Health Organization.
Perry, B (2006) ‘Applying principles of neurodevelopment to clinical work with maltreated and traumatized
children’, in Webb (Ed) Working with traumatized youth in child welfare, new York: The Guilford Press
Rollstin, AO & Kern, JM (1998) ‘Correlates of battered women’s psychological distress: severity of abuse
and duration of the postabuse period’, Psychological Reports, 82(2):387-394
Saakvitne, KW, Gamble, SG, Pearlman, LA & Lev, B (2000) Risking connection: A training curriculum for
working with survivors of childhood abuse, Lutherville, MD: Sidran Foundation Press
Scheeringa, MS, Zeanah, CH, Meyers, L & Putnam, FW (2003) ‘New findings on alternative criteria for
PTSD in preschool children’, Journal of the American Academy of Child and Adolescent Psychiatry,
42(5):561-570
Schore, A (2003) Affect regulation and the repair of the self, New York: W.W. Norton
Seita, J & Brendtro, L (2005) Kids who outwit adults, Bloomington, IN: Solution Tree
Van der Kolk, B, Roth, S, Pelcovitz, D, Sunday, S & Spinazzola, J (2005) ‘Disorders of Extreme Stress: The
Empirical Foundation of a Complex Adaptation to trauma’, International Society for Traumatic Stress
Studies, 18(5):289-399
Walker, LE (1984) The battered woman syndrome, New York: Springer
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Widom, C. Czaja, S & Dutton, M (2008) ‘Childhood victimisation and lifetime revictimisation’, Child Abuse
&
Neglect, 32: 785-796
Contact details:
[email protected]
Ph: 9840 3977
THANK YOU
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