The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has developed this position statement to affirm the importance of trauma-informed practice (TIP) for psychiatrists. TIP for psychiatrists includes recognising diversity in trauma presentation, appreciating the unique experiences of particular communities, and practicing in a manner that supports recovery and limits risks of re-traumatisation.
- Trauma-informed practice is an evolving concept which emphasises that trauma is a possibility in the lives of all individuals and communities.
- Trauma may be defined as the broad psychological and neurobiological effects of an event, or series of events, that produces experiences of overwhelming fear, stress, helplessness or horror.
- Many people who have experienced trauma, report adverse experiences and outcomes when engaging with psychiatric and/or mental healthcare services.
- Psychiatrists have a responsibility to practice in a trauma-informed manner, in order that individuals receive care that maximises their potential for recovery and minimises the risk of re-traumatisation.
- An individual’s experience of a potentially traumatogenic stressor may vary according to a range of factors including; genetics, developmental stage, previous life experiences, cultural beliefs and available social supports.
- Future approaches to trauma-informed practice must be developed using the complementary expertise of individuals, family, carers and community, psychiatrists and other mental healthcare professionals.
TIP is an evolving concept that emphasises the importance of considering trauma in all aspects of mental healthcare.[1-6] Trauma can present in various forms and in varied contexts and may be defined as the broad psychological and neurobiological effects of an event, or series of events, which produces experiences of overwhelming fear, stress, helplessness or horror.[2, 6] The Diagnostic and Statistical Manual of Mental Disorders delimits such events to those which, ‘may cause death or threaten death, serious injury, or sexual violence’. Other definitions emphasise the interpersonal and prolonged nature of trauma,[6, 8] the interplay of power dynamics and vulnerability,[5, 6] subjective experiences of stress levels, and the suddenness and uncontrollability of the stressor/s.
Complex trauma may arise through a cumulative or repeated exposure to trauma and is characterised by its profound impact, ‘not only [on the individual’s] range of functions[…] but the development and functioning of the self per se’.[3, 9] Childhood experiences of trauma are particularly devastating, often involving a betrayal of trust in a primary relationship. Importantly, an individual’s experience of a potentially traumatogenic stressor may vary according to a range of factors including; genetics, developmental stage, previous life experiences, cultural beliefs and available social supports.[2, 4] Therefore, what will be experienced as trauma by one person may not be experienced as such by another.
Trauma invokes protective responses within the body that may result in complex changes to the functioning and structure of the brain and other organs. Trauma may cause a range of co-morbid problems including mental and physical health conditions, suicidality and self-harming behaviours, harmful substance use and addictions, dissociation, self-esteem issues, and contact with the criminal justice system. The consequences of trauma exposure can have a cascading impact throughout families and communities, leading to ongoing relational trauma and intergenerational trauma.
Trauma survivors are also more likely to encounter problems in their interpersonal and sexual functioning due to emotional distress and distorted thinking patterns emanating from past experiences. They may be at increased risk of re-victimisation through family violence, sexual assaults, homelessness and poverty. This increased risk is experienced particularly by women and people who have been subject to community violence such as Indigenous peoples, refugees and people who identify as LGBTIQ.[8, 12]
Trauma survivors with mental illness may experience re-traumatisation due to their experience of coercive interventions or sexual and/or physical abuse in institutional settings, including psychiatric and justice environments. However, assertions that the majority of mental illness, including schizophrenia, are caused by trauma oversimplify current knowledge of the complexity of causes of mental illness. Notwithstanding the above, adverse childhood experiences, including trauma, are significant risk factors for mental illness, including schizophrenia.
Trauma across populations
The RANZCP acknowledges that some populations are more at risk of experiencing trauma than others and that psychiatrists should incorporate these considerations into their practice:
Indigenous peoples may have been exposed to a range of potentially traumatic stressors, as the result of historical trauma associated with colonisation; such as dispossession, displacement, disease, genocide, cultural assimilation and the disruption of kinship systems. Indigenous peoples may also be exposed to ongoing trauma, stemming from collective trauma, economic deprivation, social marginalisation, discrimination, incarceration and other forms of racism.[16, 17] TIP for Indigenous people requires, ‘the creation of safe places for sharing where the unspeakable can be given voice, where feelings can be felt, and where sense can be made out of what seemed previously senseless’.[18, 19] Recovery should occur within the context of relationships within communities and family/whānau, and should acknowledge the interconnected nature of spirit, body, society and the natural environment. The historical trauma of colonisation has been described as a ‘soul wound’ that can have generational impacts, so TIP must also address individual and collective healing.
Refugees and asylum seekers may also have a history of traumatic experiences including: resettlement challenges, experiences of torture and persecution, displacement and cultural bereavement. Where family violence is present and disclosed it is important to follow the patient’s lead and correctly identify supportive family members; and to not re-traumatise by seeking collateral information from identified perpetrators. Many people who identify as lesbian, gay, bisexual, transgender, intersex or queer/questioning (LGBTIQ) may have traumatic experiences associated with prolonged marginalisation and discrimination, as well as childhood bullying, puberty, and difficulties associated with ‘coming out’. Research also shows that LGBTIQ persons are at increased risk of interpersonal violence, hate crimes, homelessness and abuse in childhood. It is important to acknowledge that at-risk population groups are not discrete categories; some people are at-risk of multiple and compounding traumas – for example, refugees who have been persecuted for their LGBTIQ status.
All individuals in the workplace may be at increased risk of experiencing trauma through their engagement with the traumas of others. Some groups may also be exposed to traumatic events directly through their occupation, including emergency services personnel and first responders. This type of experience has been theorised to contribute to vicarious traumatisation and secondary traumatic stress.[23, 24] Mental health workers may also have sustained exposure to secondary, or vicarious traumatic experiences through hearing, seeing and responding to individuals and carers through their work. It is important to acknowledge that mental health workers, in particular Indigenous health workers, may come from a background of trauma exposure and may require additional support to manage trauma outcomes.
TIP and psychiatrists
In recognition of the above, the role of psychiatrists includes the provision of holistic assessment and care, taking account of a person’s ‘body, mind and soul’, which encompasses their physical, psychological, sociocultural and religious/spiritual needs and values. It is also important for traditional customs, including healing practices, to be respected and incorporated into treatment models as appropriate. The relevance and importance of religion and/or spirituality is explored further in RANZCP Position Statement 96.
A number of key studies and pilot programs have shown that TIP models can help to decrease psychiatric symptoms and substance abuse, and improve daily functioning. Integration of TIP does not necessarily require all clinicians to elicit disclosures of trauma; rather, it requires recognition of the lived experiences of individuals and awareness of triggers which can lead to re-traumatisation. In some settings, TIP may include screening for trauma-related symptoms and disorders, as well as specific trauma characteristics. Where indicated, screening should be followed up with proper assessment and trauma-specific care.
Psychiatrists should give consideration to how they can utilise TIP principles [7, 9, 31] in their own practice.[32, 33] Some identified principles include:
- recognising trauma and its impacts, including effects on affect regulation and brain physiology
- using respectful approaches to eliciting traumatic histories and responding appropriately to suicidality and disclosures of trauma
- demonstrating awareness of the transgenerational transmission of traumas and being sensitive to gender, sexual orientation, ethnicity and age dimensions of trauma
- acknowledging the impacts of trauma as adaptive, and working from a strengths-based framework to facilitate empowerment and recovery
- instilling hope, optimism and the understanding that recovery and post-traumatic growth is possible
- facilitating holistic care characterised by integration and continuity of services.[29, 34]
Psychiatrists should also consider the important role family and carers can play in TIP. This also includes the introduction of those with lived experience of mental health into the workforce (forming a peer workforce), who play an important role in providing sensitive and respectful care. As part of this, family and peer workers should have access to relevant training, education and support, and health professionals need to be aware that family and care workers may also have their own experience of trauma. In the context of family violence, the impact of trauma on all family members should always be considered.
The RANZCP acknowledges that community and mental health organisations across Australia and New Zealand have at times had a poor track record of implementing trauma-informed approaches and to supporting people with trauma. In relation to health systems, psychiatrists can play an important role in raising awareness of the relationship between trauma and mental health conditions, including complex psychosocial problems. Psychiatrists should also advocate for improvements to education around TIP practice for all members of the multidisciplinary team, including information on the prevalence of trauma, and the primacy of secure, trustworthy and collaborative relationships as the basis for establishing psychological safety.[6, 29]
The RANZCP recommends that:
- Individual psychiatrists enhance their own knowledge and skills in TIP; in order that individuals receive care that maximises recovery potential, and minimises the risk of retraumatisation for individuals, family, carers and staff.
- The development of approaches to TIP occurs using the complementary expertise of persons who have experienced trauma, carers, psychiatrists and other mental health professionals.
- Health services endorse TIP approaches in practice, incorporating the broad range of relevant TIP principles rather than one specific set of principles.
- Principles relevant to TIP are adopted into practice by all members of the multi-disciplinary team, with particularly consideration given to the impact of trauma in working with Indigenous peoples.
- The needs of people who have experienced trauma be routinely incorporated into mental health systems and processes, recruitment of staff, service funding and hospital design.