Trauma-informed care is critical for survivors of domestic & family violence

A trauma recovery centre is critical for survivors of domestic & family violence

Sally Stevenson
On the day I am due to speak with psychiatrist, Karen Williams, about the long term impacts of psychological trauma, especially as a consequence of sexual assault and domestic and family violence on women and children, my own medical College, the Royal Australasian College of Surgeons sends out an ad for their long-running ‘Early Management of Severe Trauma’ (EMST) course. The parallels, and consequent deficiencies in the management of psychological trauma, are striking.

In 1976, an American orthopaedic surgeon, James K. Styner, along with his wife and children, were involved in a light plane crash in a rural area. His wife was killed, and three of his four children sustained critical injuries.

Dr Styner provided first aid himself, and a passing car took the injured family to the small local hospital. Once there, he found a lack of experience and expertise in the management of acute traumatic injuries. Frustrated that he was able to provide better care in the field than he and his children received at a primary care hospital, he identified this as a systematic issue, and helped develop the course that is still taught around the world to enable doctors, nurses and other health care professionals to provide high-quality, evidence-based care to those at the point of impact of physical trauma.

I, like most Australian doctors, completed the EMST course as a very junior doctor. It was considered a pre-requisite to my own surgical training. Throughout my career, I have called on the skills learned in that course to work alongside emergency physicians and other health care professionals to help save the lives and limbs of those flung across the bitumen; caught in fire; pulled apart by machines. There is no question that the public health system must take care of these patients both in the acute period, but also in the longer term.

But my career has also involved quiet conversations in emergency bays with patients who have harmed themselves, sometimes repeatedly; who have wounds that seem defensive but are explained instead with elaborate stories involving wet floors and nearby sharp surfaces; who disclose the danger they feel but for whom there are no services to help them be safe.

As a surgeon, I have patched them up, arranged a brief conversation with an overworked hospital psychiatrist who ensures that their life is not in immediate threat and an under-resourced social worker who may or may not be able to provide much, and sent them on their way.

Too often, the woman who is self-harming comes back a week or two later; the woman with the likely defensive injury to her arm comes back with a broken face; the woman who is scared may not come back at all. I have worried about all of them.

I have not been trained in the management of psychological trauma, and I do not know what services exist to help these women. Sally Stevenson, CEO of the Illawarra Women’s Health Centre, tells me that really, there aren’t any. And she is on a mission to create the first women’s Trauma Recovery Service in the country, possibly the world.

Over several weeks, I continued to research and interview colleagues about the psychological impacts of trauma for this story, as multiple women and children were killed in heinous acts of domestic violence. As a nation grieved their loss, quietly, in cities and towns, in farms and penthouses, women across the country continue to suffer trauma, both physical and psychological, at the hands of those who they know, and often love.

These are the women who will probably never make the news, but who will suffer the consequences of their untreated trauma for their whole lifetimes.

Dr Williams works extensively with patients who have suffered psychological trauma, both men and women, and is acutely aware both of how this trauma manifests, and what resources are available to assist.

She explains that for women, trauma tends to manifest quietly and internally. It is the depression and anxiety, anger, mood swings, paranoia and emptiness that makes it hard to hold down a job or relationship, or parent effectively, leading to intergenerational trauma and violence. It is the repeated hospital admissions and self-harm that are too often misunderstood, and the financial costs of seeking such care. She tells me of a patient who, in many years of repeated admissions to hospital, was never asked what happened to her as a child.

With fewer externalising behaviours, it seems to me that traumatised women are easy to write off as innately unstable or unreliable, and their health problems easy to ignore.

It is impossible for most people to access the counselling services that they need to have a chance to overcome their trauma and lead stable, productive lives. Dr Williams explains that the recommendation for the management of psychological trauma is up to two sessions of counselling a week, and while this might be an impossible goal, one session a week would make a significant difference to the lives of many women. At present, patients are funded by Medicare for ten sessions a year, and often there are gaps of $100 or more per funded session.

Unlike a severe physical trauma, like a car accident, which is often a single and discrete event, women tend to experience trauma for extended periods of time.

Katherine Brown is a Clinical Associate Professor at the University of Wollongong and the University of Sydney, and has worked in the area of sexual health medicine for decades. Although part of her work involves managing those who have suffered sexual assault, she also has expertise in strangulation. Like many who have worked in this space for a long time, she sees domestic and family violence as being a societal issue, where somehow, some people have learnt that it is ok to beat up their wives and murder their children, or to be coercive and controlling.

Despite the violence that she has borne witness to, she remains optimistic about creating behaviour change, and points out that it is within her career that seat belts were introduced and gained widespread unquestioned acceptance, and smoking rates have plummeted. She sees the challenge as convincing people that this is an issue that is important to them, and each other.

To me, it sounds like changing the narrative about women – how the effects of trauma manifest, what is required to treat it, and even that psychological trauma requires treatment – is a key part.

In this setting, it surprises me that trauma recovery centres like the one proposed by the Illawarra Women’s Health Service do not already exist.

Stevenson explained that the idea for the centre arose around four years ago, as the strain on women’s health centres around NSW continued to increase. The effective privatisation of women’s refuges, combined with a general trend towards a demand from women who didn’t have access to suitable counselling, housing, and other support services and were struggling to cope, led them to consider what they might be able to offer to women in the Illawarra.

She acknowledged that organisations like Our Watch do an incredible job in working towards primary prevention of violence against women, and a variety of health care professionals are involved in acute care, but there is a real gap in long-term support and recovery for women.

What these women need is well known, both from specific research in the area, and from the treatment of complex PTSD in groups such as those who have served in the military.

The Illawarra Women’s Centre is hoping to offer a service where all employees, from the reception and cleaning staff to service providers, understand trauma and are knowledgeable about trauma-informed care, as detailed by the Blue Knot Foundation.

Medical services would include providers of general health services, as well as psychological and psychiatric care. Legal advice would be provided by trauma-informed lawyers, possibly avoiding the need to start at a police station. Dr Williams also highlighted the need for ‘scaffolding treatment’ – things like yoga, self-defence classes, and support groups, which don’t replace, but augment medical care. Most importantly, these services would be free and accessible to all women in the region who had experienced psychological trauma.

The likely outcomes are clear. Fewer GP visits, fewer emergency department visits, fewer episodes of self-harm, an increase in education and employment, the opportunity for stable housing, and breaking the cycle of violence. The Illawarra Women’s Centre has a relationship with the University of Newcastle and the Australian Longitudinal Study on Women’s Health in order to follow up the impact of the Trauma Recovery Centre.

To me, this is a very obvious solution to a widespread problem. Just as specific and expert management of severe physical trauma has been shown to save lives and limbs, there is evidence that specific and expert management of psychological trauma improves outcomes for those who experience it. There is a clear role for medical leadership and government to champion the idea that psychological trauma requires expert care and specific requirements for recovery, just as we have with physical trauma.

And yet, Associate Professor Brown points out that this issue is not treated as a public health emergency. As we contend with the spread of coronavirus, there is no question that the economic, social and political implications of the virus will be discussed and managed along with the health and medical concerns.

And yet, even though we know that one in four women have experienced violence at the hands of an intimate partner; that domestic assaults are rising; that hospitalisation rates to treat the consequences of domestic and family violence are rising; that 40% of victims sustain a brain injury; that trauma contributes to a host of other medical issues including heart disease and stroke; and that domestic and family violence costs the Australian economy $22 billion dollars a year – we do not treat it as the public health emergency that it is.

The Illawarra Trauma Recovery Centre is supported by the NSW branch of the Royal Australian and New Zealand College of Psychiatrists and a number of State and Federal MPs and Senators. This is no surprise to me, because the need is so obvious, and the proposed solution so logical. The working group to establish the Centre is comprised of doctors, Lord Mayors, Area Commanders of Police, and CEOs of the local health organisations – all individuals with a clear view over what effects unmanaged trauma has at a population level.

But, the clincher, as usual, is funding. The Illawarra Women’s Health Centre estimate that an investment of $10,000,000 over three years will be required to fund the service, but to further clarify this, they are seeking a mere $60,000 of initial funding to prepare a business case.

Because the impacts of domestic and family violence cross so many sections of society, the New South Wales Departments and Ministries involved in deciding upon this funding – and whose budget it might come out of – potentially include the Department of Communities and Justice; the Minister for Health; the Minister for Mental Health, Regional Youth and Women; and the Attorney General. It has been almost twelve months since the Health Centre launched the campaign to progress this cause.

In the absence of any funding initiative to date, the Illawarra Women’s Health Service is launching their community call to action campaign on April 2, at the Wollongong Art Gallery. Entitled ‘Celebrating Resistance and Resilience’, this features the work of Walkley Award winning photographer, Sylvia Liber, to show how strong and powerful women’s survival can be.

It seems very obvious that we must change how we think about what is needed for women to recover from the psychological trauma inflicted by domestic and family violence. Quietly, around the country, so many women are resisting and being resilient on their own. It is clear that there is a moral, practical and economic argument that additional, high-quality, evidence-based care is necessary.

If you want more information please contact Sally Stevenson

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