CHCMHS013 Implement Trauma Informed Care

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CHCMHS013 Implement Trauma Informed Care

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CHCMHS013 Implement Trauma Informed Care

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Course Code: CHCMHS013
University: Victoria University

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Country: Australia


Borderline Personality Disorder (BPD) and is self-harming. She has made two suicide attempts in the past. She has experienced severe physical (from infancy) and sexual (from age 4) abuse from her parents and, at the age of 8, was removed from their care by the State child protection authority.
Mary-Jane had multiple foster placements due to her aggressive and sexualised behaviour and, at the age of 13, was sexually abused by a relative of one foster carer.  She has had several admissions to a mental health in-patient facility from the age of 14 and also spent 6 months in juvenile detention at age 16 for assault.
Mary-Jane has been a polydrug user (alcohol, benzodiazepines, opiates and cannabis) since the age of 17.   She has a history of abusive relationships and her two children were removed from her care 3 years ago due to physical and emotional abuse by both Mary-Jane and several of her partners. She regularly presents at hospital emergency units after self-harming or overdosing and can be verbally aggressive towards staff.   She is currently couch-surfing with friends, but has outworn her welcome and may be homeless soon
1. How might workers in a non-trauma sensitive service respond to Mary-Jane? What knowledge systems, beliefs and attitudes might inform their behaviour?
2. If you were to work with Mary-Jane from a trauma-informed perspective, how would you:
a) Raise the issue of possible traumatic experiences with the clients?
b) Respond to a disclosure of traumatic experiences by Mary-Jane during the assessment interview?
c)E nsure that you do not re-traumatise the client in your work?
3.What issues will you need to be aware of if Mary-Jane is Aboriginal?


Task 1

Workers in the non-trauma sensitive service should work in way that realizes the widespread effect of the trauma that Mary-Jane is currently suffering from, in addition to understanding the potential pathways for her recovery. Research evidences have elaborated on the fact that a person diagnosed with borderline personality disorder (BPD) is most commonly subjected to discrimination and stigma (Chanen & McCutcheon, 2013). Workers of the non-trauma service might initially consider Mary-Jane as difficult, manipulative, untreatable and attention seeking. The workers might show a failure in recognizing the signs and symptoms of trauma related to BPD in the client. However, they are expected to address the individual needs and preference of the client, an implement a care approach accordingly. In the words of Henderson, Evans-Lacko & Thornicroft (2013) people suffering from a range of mental illnesses have often reported experiences of social stigma and the discrimination towards them often worsen the situation, thus impeding the recovery process. The non-trauma sensitive workers are likely to show similarity with the community and the society that holds stereotyped views on mental disorders and considers most person affected with such illness as dangerous and violent. Mary-Jane might be treated in a negative manner in the service centre. This can be attributed to the fact that other people often judge the patients depending on their identity and mental condition, besides the gender, sexual orientation, disability, employment and family status (Corrigan, Druss & Perlick, 2014).

Failure of the workers in delivering appropriate interventions for the disease Mary-Jane has been diagnosed with might be attributed to the fact that greater prevalence of mental disorders like anxiety and depression often make it difficult for reduced recognition of other illnesses. Some of the beliefs that might impede appropriate treatment of Mary-Jane in the non-trauma service centre are associated with prevalent myths on mental illness such as, air pollution, bad parenting, poor diet, curse of God, past sins or evil eyes (Ighodaro et al., 2015). Misconceptions and myths about mental disease might contribute to the stereotype and stigma, which will prevent the workers from responding to the presenting complaints of the client. Thus, they will not be able to completely integrate their knowledge related to trauma into the procedures or practices that are intended to be followed. These attitudes and beliefs result in a stigma that compromises social standing of the affected person and is generally perceives mental illness as a mark of discredit and/or shame. Moreover, the workers the non-trauma sensitive service might also display an intolerant attitude towards the client, thereby not forming a close rapport with her.

a) Traumatic experiences is an umbrella terms that usually applies to all kinds of incidents that are responsible for causing physical, spiritual, emotional or psychological harm to a person (Craparo, Schimmenti & Caretti, 2013). If I were to raise the issue of traumatic experiences while working with Mary-Jane, I would implement a trauma informed approach. A trauma informed approach will be implemented by me in the case scenario, where I would focus on showing adherence to realisation and recognition. Efforts will be taken to gain a deeper understanding of the trauma associated stress reactions. I would try to understand how the trauma that Mary-Jane had suffered in the course of her lifetime affected her presentation and engagement. According to Gunderson & Sabo (2013) borderline personality disorder is primarily characterised ongoing patterns of differences in self-image, mood and behaviour. These symptoms are most commonly responsible for problems in relationships and impulsive actions.

I would raise the issue of the experiences that were faced by the client by fostering trustworthiness and transparency in the treatment approach. Establishing a good rapport with the client will facilitate the development of a radical transparency, which in turn would allow Mary-Jane to disclose her fears and vulnerabilities, in addition to the problematic experiences that she had encountered in her childhood (Glueck, 2013). Herman (2015) stated that acknowledgment of the traumatic life experiences that people have often been subjected to is shrouded in denial and secrecy. The most compelling reason that governs the understanding of trauma is the link between its prevalence and post-traumatic disorders. Raising the issue of the traumatic experiences is essential since traumatic events have been found responsible for direct threats of death or psychological injury. There is mounting evidence for the fact that people diagnosed with BPD have an increased likelihood of reporting history of some kind of child abuse and distressing experiences (Bornovalova et al., 2013). Thus, I would initiate the conversation by expressing empathy towards the client, which in turn would help in the development of a good carer-servicer user relationship (Figley, 2013). Psychiatric manifestations that are realted to an exposure to trauma create an adverse impact on the cognition, normative functioning, sensation experiences and social wellbeing. Thus, I would take efforts communicate well in order to establish trust and discuss about the experiences that might have resulted in the mental illness.

b) Interacting with a client about previous or present experiences related to abuse, or trauma, has been a mainstay of the assessment and treatment phase of most mental disorders. When the client Mary-Jane finds the courage to disclose about the trauma related to abuse and sexual assault that she had experienced in her childhood, the responses will be given in a manner that displays a compassion, non-judgmental approach and helps in reducing shame in the client (Levy et al., 2014). Accepting every aspect of the trauma faced by Mary-Jane as a part of her identity will be a crucial step in this context. Health professionals hold certain personal views, beliefs and prejudices. Being non-judgmental has often been identified as a crucial professional responsibility, in regards to the obligation of bringing about a positive change in the client. Bateman, Henderson & Kezelman (2013) opined that holistic and non-judgmental care will promote her wellbeing and improve the mental and emotional health. Offering words of comfort, assurance and support will also enhance the ego-strengthening of the patient and facilitate her empowerment (Wall, Higgins & Hunter, 2016). Using statements that shows apology for the distress that the client has suffered or emphasising on the need of support are some of the sensitive responses that might help Mary-Jane.
c) Retraumatisation refers to the unconscious or conscious reminder of traumatic events that makes a sufferer re-experience the shock. Some of the major elements that must be taken into consideration to avoid retraumatisation are trustworthiness, safety, peer support, empowerment, and collaboration. Keller-Dupree (2013) stated that being proactive and informing the client about the ways by which the trauma services work will provide an occasion to make informed choices. Retraumatisation can also be prevented by fostering autonomy of Mary-Jane, to get rid of her memories related to previous violence and assault. Taking efforts to ask for suggestions from her on steps that can make the entire interaction more comfortable and using grounded techniques will also facilitate the action (Schock & Knaevelsrud, 2013). I would also try to calmly remind her that she is currently safe and not in any danger of facing abuse or assault. Moreover, restoration of a sense of control and providing the clients with the opportunity of participating in informed decision making is crucial.
The psychological assessment and mental health of Aboriginals has a contended and complex history. Thus, a culturally sensitive care must be formulated if Mary-Jane is found to be Aboriginal.  Mental health is usually holistic for the indigenous group, and is commonly related to their emotional, social, cultural and spiritual lives. Some of the issues that need to be taken into consideration in this regard are namely, rapport building, assessment, families and carer, treatment and its compliance. Indigenous clients suffering from psychiatric disorders often fail to access mainstay mental health services. Thus, it would be essential to hold the interaction/interview at a location where the client feels comfortable and protected. This might involve travelling into her community, likely her home setting and will also help in determining her self-care levels. There is a need to develop a partnership with other indigenous workers as well, while caring for Mary-Jane. Working with the diverse workforce will assist in the process of gaining knowledge on the culture. Presence of an indigenous trauma worker will make the client feel at ease (Herring et al., 2013). Discussing the rights of the client and avoiding asking questions on the illness would also prove effective. According to Atkinson (2013) the conversation must be initiated with non-threatening statements and there needs to be a caution while discussing ceremonial business, fertility, bereavement, domestic habits, and sexuality. Moreover, cultures are largely composed of personal experiences, values, concepts of shame and social rewards. Aboriginal people often hold beliefs and values that are related to ‘Dreamtime’ (Walsh, 2017). Thus, stereotyping must be avoided, while keeping an open mind. Caution should also be taken to avoid all kinds of conflict of culture with scientific rationality.

Task 2

Three reputable sources of research and information are as follows:

Trauma-Informed Care and Practice: Towards a cultural shift in policy reform across mental health and human services in Australia – a national strategic direction
Trauma-informed care in child/family welfare services
Trauma-informed services and trauma-specific care for Indigenous Australian children

Three reasons for undertaking this research are as follows:

Traumatic experiences are often unexpected and might occur in the form of direct experience, witness to an event, feelings of threat, or hearing about such incidents. Most people find that the mind returns to the upsetting and traumatising memories, on a loop. This is often experienced in the form of a feeling that the human brain tries to create a sense of the event. This results in distress among the affected individuals. Hence, the research will be imperative in defining ways of realising the immediate and long-term impacts of such incidents on the physical and emotional wellbeing of clients, thereby identifying care approaches.
The most common emotional reactions to trauma are anxiety and fear. A trigger that returns memories of the traumatic incident leads to a return of intense fear. In addition to the aforementioned emotionally overwhelming sensations, a person having experienced trauma is more vulnerable to the development of sadness, anger and guilt over past incidents (Hovens et al., 2015). Thus, the research would help in gaining a sound understanding of the ways by which an appropriate response can be given to a traumatised client, with the aim of eliminating or reducing overwhelming or numb emotions.
Implementation of certain trauma-informed services will greatly assist in the screening and assessment of individuals at-risk and will also help in reducing chances for retraumatisation. Undertaking a research on the same will also help in identifying the culturally appropriate strategies that can be put to place for reducing chances of misunderstanding the presenting complaints or underestimation of need for referrals.

Three ways by which the validity of the internet sources can be evaluated are:

Determining the credentials and affiliation of the publishers and authors and checking for the presence of a reputable organisation behind them
Determining the scope of the information such as, their usefulness, accuracy, and factual statements
Assessing whether the site is easily browsable and the target audience is clearly indicated

The three processes for analysis of information are as follows:

Defining the research question and setting the measurement priorities
Collecting data
Manipulating the data by finding correlations and interpreting the results

Thus, I would initially define the trauma-care related research question that I intend to investigate, followed by collection of relevant information from scholarly sources and medical guidelines. I will then organise the data findings into definite patterns or themes to draw a relevant conclusion.
Task 3

Two internal network connections for improvement of professional practice are peer support and guidance from supervisors. Peer support will increase the levels of self-confidence, self-esteem and inculcate a positive feeling that an appropriate work is being done in caring for patients suffering from mental illness. Moreover, being under the constant guidance of mentors and supervisors will help in the identification of personal strengths and weaknesses. A supervisor will assist in recognising effective strategies that can be put to use for overcoming the weaknesses for an effective mental practice. Moreover, upon identifying the strengths, a sound understanding of the ways by which they can be effectively utilised while interacting with patients suffering from a plethora of mental disorders, will also be gained. Two external network connections will be mass media and workshops. Mass media will exert an influence on the personal attitude about mental illness. In addition, workshops and trainings will help to learn ways to eliminate stigma and create community changes.
Two professional development opportunities that I intend to undertake in the next 12 months are:

Undertaking a training in foundation for trauma-informed practice (within next 4 months)
Enrolling in a course for TF-CBT (Trauma-focused cognitive behavioural therapy) (within next seven months)

Atkinson, J. (2013). Trauma-informed services and trauma-specific care for Indigenous Australian children. Retrieved from https://www.aihw.gov.au/getmedia/e322914f-ac63-44f1-8c2f-4d84938fcd41/ctg-rs21.pdf.aspx?inline=true 
Bateman, J., Henderson, C., & Kezelman, C. (2013). Trauma-informed care and practice: Towards a cultural shift in policy reform across mental health and human services in Australia. Mental Health Coordinating Council. Retrieved from https://www.mhcc.org.au/wp-content/uploads/2018/05/nticp_strategic_direction_journal_article__vf4_-_jan_2014_.pdf 
Bornovalova, M. A., Huibregtse, B. M., Hicks, B. M., Keyes, M., McGue, M., & Iacono, W. (2013). Tests of a direct effect of childhood abuse on adult borderline personality disorder traits: a longitudinal discordant twin design. Journal of abnormal psychology, 122(1), 180.
Chanen, A. M., & McCutcheon, L. (2013). Prevention and early intervention for borderline personality disorder: current status and recent evidence. The British Journal of Psychiatry, 202(s54), s24-s29.
Corrigan, P. W., Druss, B. G., & Perlick, D. A. (2014). The impact of mental illness stigma on seeking and participating in mental health care. Psychological Science in the Public Interest, 15(2), 37-70.
Craparo, G., Schimmenti, A., & Caretti, V. (2013). Traumatic experiences in childhood and psychopathy: a study on a sample of violent offenders from Italy. European journal of psychotraumatology, 4.
Figley, C. R. (2013). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. Routledge.
Glueck, D. (2013). Establishing therapeutic rapport in telemental health. In Telemental health (pp. 29-46).
Gunderson, J. G., & Sabo, A. N. (2013). The phenomenological and conceptual interface between borderline personality disorder and PTSD. Personality and Personality Disorders: The Science of Mental Health, 7, 49, 1-6.
Henderson, C., Evans-Lacko, S., & Thornicroft, G. (2013). Mental illness stigma, help seeking, and public health programs. American journal of public health, 103(5), 777-780.
Herman, J. L. (2015). Trauma and recovery: The aftermath of violence–from domestic abuse to political terror. Hachette UK.
Herring, S., Spangaro, J., Lauw, M., & McNamara, L. (2013). The intersection of trauma, racism, and cultural competence in effective work with aboriginal people: Waiting for trust. Australian Social Work, 66(1), 104-117.
Hovens, J. G., Giltay, E. J., Spinhoven, P., van Hemert, A. M., & Penninx, B. W. (2015). Impact of childhood life events and childhood trauma on the onset and recurrence of depressive and anxiety disorders. J Clin Psychiatry, 76(7), 931-938.
Ighodaro, A., Stefanovics, E., Makanjuola, V., & Rosenheck, R. (2015). An assessment of attitudes towards people with mental illness among medical students and physicians in Ibadan, Nigeria. Academic Psychiatry, 39(3), 280-285.
Keller-Dupree, E. (2013). Understanding childhood trauma: Ten reminders for preventing retraumatization. The Practitioner Scholar: Journal of Counseling and Professional Psychology, 2(1).
Levy, B., Celen-Demirtas, S., Surguladze, T., & Sweeney, K. K. (2014). Stigma and discrimination: A socio-cultural etiology of mental illness. The Humanistic Psychologist, 42(2), 199-214.
Muskett, C. (2014). Trauma?informed care in inpatient mental health settings: A review of the literature. International journal of mental health nursing, 23(1), 51-59.
Schock, K., & Knaevelsrud, C. (2013). Retraumatization: The vicious circle of intrusive memory. In Hurting Memories and Beneficial Forgetting (pp. 59-70).
Wall, L., Higgins, D. J., & Hunter, C. (2016). Trauma-informed care in child/family welfare services. Australian Institute of Family Studies. Retrieved from https://aifs.gov.au/cfca/publications/trauma-informed-care-child-family-welfare-services/what-trauma-informed-care 
Walsh, M. (2017). Ten postulates concerning narrative in Aboriginal Australia. Narrative Inquiry, 26(2), 193-216.

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