 Good evening. I'd just like to welcome everybody to MHPN webinar tonight. The topic is complex trauma, working together, working better to support adult survivors of child abuse. This is an interdisciplinary panel discussion. We have three very talented panelists with us tonight, Kathy Keselman, Ursula Benstedt and Warwick Middleton. I'm your facilitator, Michael Murray. Kathy is from Sydney, Ursula is from Melbourne, Warwick is from Brisbane, I'm from Tansel and we have over 800 people expressed an interest in coming on tonight from all over Australia and we have 250 online at the moment. You're all very welcome. The webinar, as you know, is hosted by MHPN, the Commonwealth Funded Project, supporting interdisciplinary collaboration in local primary healthcare across Australia. MHPN currently supports 450 local interdisciplinary mental health networks. The learning objectives for tonight, at the completion of this session, participants will be better equipped to consider the possibility that the next patient may have experienced complex trauma. The webinar will raise awareness of prevalence and indicators of complex trauma, identify the key principles for effective assessment and management of mental health issues for people with complex trauma and assist recognition of the challenges and opportunities that lead to disciplinary collaboration in the provision of mental health services for people with complex trauma. If you wish to apply for CPD, contact MHPN.org.au. The webinar is in two parts. Initially we will have a facilitated interdisciplinary panel discussion between Kathy, Ursula and Warwick. They will each present on the topic. They will speak for approximately 8 to 9 minutes. We will then have questions going back and forth between the panel and also questions that you type into your message box will be addressed during the webinar. As you would realise with over 250 people online, we won't be able to address all of your questions, but each question is valuable and they will be addressed later. So I will monitor the panel discussion and I will also field questions from you, so feel free to put your questions into the message box, type them in, ensure your sound is on and your volume is turned up on your computer. If you have technical problems, contact that 1-800 number. You can join the discussion post-webinar if your question hasn't been addressed. I would like to welcome you all very much. We will now turn to our first speaker, Dr Kathy Kesselman. Kathy. Thanks Michael. I'm just going to put complex trauma into perspective and then talk about the case study in relation to complex trauma. So look, trauma, you know, one can't travel through life without experience trauma. It's part of the human condition. And all trauma can invoke fear and help us has horror and overwhelm our coping mechanisms. But the trauma we're talking about tonight, which is called complex trauma, is compounded and cumulative, most often interpersonal, perpetrated by one human being on another. It's often intentional and it's often early in life, early and onset. So the child experiences multiple chronic and extreme developmentally adverse traumatic events such as sexual, emotional, physical abuse, witnessing or experiencing domestic violence, neglect community violence. And these often occur within the child's caregiving system and the disrupt the earliest of attachments. Traumatic childhood experiences are extremely common. The adverse childhood experiences study, it's called the ACE study, is one of the largest studies ever undertaken. And it's an ongoing study of the short and long term health and social outcomes of adverse childhood experiences with childhood exposure to traumatic stress. And the adverse childhood experiences included in this study include all forms of abuse and neglect, as well as the impacts of family dysfunction. Having a family member with a mental health illness, substance abuse, mother who's been subjected to domestic violence, loss of a biological parent, incarceration of a family member. The study showed that adverse childhood experiences are vastly more common than recognized. And they have a powerful impact on adult health. The more adverse childhood experiences, the greater the likelihood of adopting different coping strategies, such as smoking, alcohol and drug use, overeating. And all of these coping strategies of course are risk factors for adult health repercussions. And of course also the repercussions on mental health depression and suicide attempts. So the more adverse childhood experiences someone has, the more likelihood of developing some of the health repercussions that are listed here on the slide. So during childhood the brain grows and develops very rapidly, especially during the first three to five years, which are critical, also another growth spurt during puberty, but it continues to grow and develop into a person's 20s. During that entire period trauma can affect neurochemical processes and the development of the growth structure and function of the brain. And as a result it potentially has very pervasive long-term effects on the development of the mind and the brain. As a general rule females are subject to victimization that occurs in close relationships crimes of child sexual assault, although recent studies show that in males those are massively underreported. Males in general are at greater risk of physical abuse and assault. The reaction to traumatic exposures varies depending of course on the different socializations of males and females. But it's the combination of the ongoing trauma exposure and the developmental impact of this exposure that typifies complex trauma, and that's what we're talking about tonight. So without a safe, stable attachment abused children focus on simply surviving. They shift the resources that normally earmarks the learning and development and because the acts are often repeated the child victim is hyper-vigilant, always anticipating further harm in fight, flight and freeze mode. So the symptoms that are captured in a diagnosis of PTSD don't describe the repercussions of complex trauma because this trauma has pervasive effects as we've said on the development of the mind and the brain. Chronic trauma interferes with neurobiologic development and the capacity to integrate sensory, emotional and cognitive information into cohesive whole. It impacts a basic sense of trust and safety in the world betrayal of key relationships impacts a person's relationship both with themselves and with others and with the world and impacts the ability of people to self-regulate to self-soothe and to self-nurture and to respond to subsequent stress in a focused way. In childhood abused individuals develop extreme coping strategies as their way of coping with the overwhelming traumatic stress and these coping strategies often persist into adult life. And they present as very challenging behaviors. Suicidality, self-harm, substance abuse and addictions, dissociation and often re-enactments of abusive relationships. However, if these are understood in the context of trauma these behaviors actually make perfect sense for if you're traumatized you too may have these behaviors. So looking at Sonia, her case study, Sonia experienced multiple compounded traumas in childhood. She lost her mother at an early age and there's an implication of family violence early on. In childhood and adolescence she had a number of caregivers, little consistency and predictability in her primary relationships and disruption to her early attachment. Her history highlights her attempts to manage her traumatic stress. Drug abuse, self-medication, prostitution, self-harm, multiple suicide attempts and these are all her attempts to self-soothe, self-regulate and manage her traumatic stress. She also obviously has a tendency to repeat abusive relationships. She's in a domestic violent situation and there's a transgenerational impact of her abuse in parenting and protecting her own children. So she appears to struggle in many aspects of her functioning. To feel safe, to be safe, to trust and she obviously has difficult in sustaining intimate relationships. To seek help and to stay in a therapeutic or treatment relationship. She struggles with her self-esteem, with protecting herself and her children, with her physical health. There's reference to undiagnosed chronic pains and also with her mental health. One may assume she may be depressed, she may be dissociative and there may be impacts of ongoing substance abuse. So obviously looking after Sonia would be challenging. She's living currently in a domestic violent situation and she and her children are currently physically at risk and there's also allegations of child sexual assault and the authorities are involved. Her physical safety and that of her children is paramount but she herself is probably unable to identify the risks or certainly have the skills to change that situation. She's managed her life as best she can but her past experiences have led her to believe that people will let her down. She anticipates betrayal and hurt. Like many survivors she would readily withdraw, terminate therapy and counseling, isolate herself and draw on her past defence mechanisms. Substance abuse, self-harm, suicidality for self-protection. These are self-defeating and self-destructive behaviors but they're entrenched and that's the best she can do. Sonia has been very used to disempowering and controlling relationships so it's very important that we engage Sonia in a new sort of relationship where she feels safe relationships that are consistent collaborative and constructive but don't blame her for her attempt to manage her traumatic stress but don't shame her and that aren't violent. Supportive relationships will help her feel safe and gain her trust and keep her engaged and help to gain insight into the way her abuse continues to affect her feelings and behaviors. She needs predictable environments with clear boundaries and well defined roles and if that can be achieved she will begin to feel empowered to build on her strength and her resiliency and rebuild a sense of self-efficacy and personal control and hopefully find new ways to cope. Thank you Kathy. Kathy is a consumer advocate. She's a director of adult surviving child abuse and is a GP as well. So thank you very much Kathy. We'll be hearing from you later on in the webinar. Now we're just going to move on to Ursula. Ursula is a psychologist working in Melbourne with a special interest in complex trauma. Ursula. Hello. Thank you Michael. So Kathy's done a great job of pointing out how the complex trauma Sonia has experienced has led to very complex impacts. So to address these impacts a collaborative team approach is best but I'm going to be focusing on the role of the psychologist or the therapist across each of the three broad stages of recovery. So the three stages of recovery broadly are thought to be an establishment of safety, traumatic experience processing and then integration and reconnection. So I'm going to be spending a fair bit of time talking about the first stage because that's probably the most important. So here's some examples of interventions that are used in this first stage. So just to go into a bit of a detail to help you to get a feel for what this might look like, in my first session with Sonia I'll be working really hard to convey empathy, respect and hope to build a therapeutic alliance. Minimisation of threats to Sonia's safety including the development of clear safety plans also needs to be tackled in an empathic and respectful way in this first session. It's also likely that Sonia's ambivalent about counselling. Her drug use indicates that it's important for her to avoid feelings as she doesn't have the internal skills to regulate her feelings or tolerate the stress. I would ask Sonia what her worries and fears are about counselling. It's likely that she'll be fearful that counselling might mean retelling every detail about her traumatic past. I'm going to reassure her that she won't have to do this if she doesn't want to. I'd ask Sonia if I could get a brief sketch of her life so I can begin to understand where she's come from and what has shaped some of her beliefs about herself, others and relationships. It's always important to explain why you're asking particular questions otherwise it can just feel intrusive. I'll prompt her to say I'd rather not talk about that now to questions or subjects she doesn't want to explore right then. This is important to do as complex trauma clients may never have had the option of saying no so they may find it difficult and not actually have a language for it. I will tell her that I might ask the question again in another session but if she still doesn't want to answer it that's okay as well. I will let Sonia know that she's in the driver's seat in the counselling and she can put the brakes on any time. If I seem to be going too fast or if I seem to be on the wrong track. So again I'm modelling open communication where she can voice her opinions, feelings and needs and not be punished or get into a high conflict situation as a result. I will let her know what to expect in counselling. Basically that we will be dipping into the past to better understand what's happening in the present and to define how she wants things to be in the future. I'll talk to Sonia about counselling goals and try to break them down to concrete achievable mini goals. I'll take a history based around a genogram which will lead down to her current relationships. I'll ask direct relationships questions about abusive behaviours by her partner. If she's at a point where she acknowledges the relationships abusive and wants to leave, I'll help her develop an action and safety plan around this and make appropriate referrals. If she's evasive in her responses and unwilling to admit that her partner's abusive I'm going to only gently challenge this whilst acknowledging that the relationship is important to her. If I went into hard initially it's unlikely that she'll come back to counselling. The safety of her children is already being assessed by the appropriate services so I can afford to go a bit easy on her here. So all of these interventions to build therapeutic alliance can also have a potentially positive impact on Sonia's disrupted attachment over time. The establishment of a therapeutic alliance builds the foundation of a safe base from which Sonia can feel supported to face and explore difficult feelings and memories. Over time this can lead to new internal working models of self, other and relationships. An earned secure attachment model is possible with long term work and provides an alternative way of being to the insecure attachment model that accompanies complex trauma. In later stages of therapy this new model can be tested outside the therapy room. Other important interventions in the safety phase are psychoeducation. So psychoeducation relating to complex trauma and its impacts can help decrease Sonia's anxiety, self-blame and loathing. Presenting a complex trauma framework is a way to destigmatize impacts and symptoms by acknowledging their origin as outside of Sonia and not as being internal character flaws. Other important interventions in establishing safety are containment. So it's likely that Sonia has spent years avoiding memories and feelings because she believes that if she opens up the floodgate she'll be annihilated. To an extent there's some truth in this belief. Until she's got emotional regulation and distress tolerance skills she can become overwhelmed. Sometimes so overwhelmed that she wants to die to escape these memories. I'd have an open discussion with Sonia about this and offer to externally regulate her distress with grounding and soothing strategies in session if it seems that she's becoming overwhelmed. I might talk to Sonia about initially only talking about the impact of bad things that have happened to her rather than actually talking about the bad things in detail. I will reassure Sonia that if I see her falling back into the past and becoming distressed I'll bring her back into the present and help to ground her in her adult self. This agreement to very tentatively open up the box in which the past is kept and close it before the end of each session is very reassuring to client. With someone who seems as frightened as Sonia I might ask if it is useful if we leave five minutes at the end of each session to talk about grounding and talk about present normal day things like what she's going to have for dinner. The last or another important group of interventions to be used in the safety phase is skills training. Skills training in emotional awareness, emotional regulation, distress tolerance and relating to others is essential in attaining emotional safety. Moving on to the second stage of recovery is the traumatic experience processing and I've just put up what I think are some really important principles in this stage of recovery. I've spent a fair bit of time and gone into a lot of detail about how I'd work with Sonia in the first safety stage of healing and this is because coming to counseling will feel dangerous initially so I need to build her skills and confidence and her trust in me before suggesting we work and look at some of the unsafe past in any detail and I'll need to provide a compelling rationale to her for this work. I might give a simple explanation of how integration of implicit and explicit trauma memory can take away the power and the it's happening right now quality that makes the past problematic in the present. In this work I will titrate the intensity of Sonia's exposure to try to keep her in the therapeutic window. This means Sonia will be activated enough by the material being worked on that processing can occur but she is not overactive and activated and going into extreme hyperarousal dissociation which will inhibit processing. So here's some examples of frameworks that can be used in this second stage of healing and the third stage is integration and reconnection. So there's some examples of framework to be drawn on. Now during this stage there's an emphasis on developing a new narrative itself in which trauma is only a part of the story and no longer defines and consumes Sonia but nor does it need to be a shameful feared rid-off part of herself. Sonia will be working on new healthy connections for others in this stage to practice, consolidate and reinforce her new attachment model. Thank you. I've made it sound really simple. It's not really that simple. Oh Ursula that is just a really good summary and obviously in eight or nine minutes it's difficult to fit it all in and you and Kathy have done a marvelous job to be able to encapsulate it for the audience not. Thank you and we'll come back to you for questions later. Thank you. And we're just going to move on to Warwick now. Warwick Middleton. Hello Warwick. Hi there. Sorry we've got one slide too far now. We're both pressed at the same time. That's okay I'm sorry about that. Look thanks very much for actually chiming into this webinar. The complexities of Sonia are the thoughts of issues that I've had to be addressing in directing a trauma and association unit now for the last 15 years and a longer term in practice before actually embarking on that endeavor. We've talked about the concept of complex trauma. I just thought in terms of Sonia who's an excellent representation in all cases of that sort of presentation I thought I might just give a little bit of background to why the term complex PTSD was originally put forward. It arose out of the observation that the diagnostic criteria for post-traumatic stress disorder didn't come close to encapsulating the complex dimensions of the way in which trauma affects a person who developmentally is in a situation where they can't escape ongoing trauma. For anyone who's been involved long term in the trauma field it's very obvious that if you apply something like the DSM-4 to a very traumatized patient such as Sonia you'll probably end up legitimately using their diagnostic rules for 10 or 12 different diagnoses. They'll typically have fulfilled criteria for borderline personality disorder, past traumatic stress disorder, somatization disorder, a dissociative disorder, either a dissociative identity disorder or a dissociative disorder, not otherwise specified. They'll have problems with drugs, alcohol, sexual problems, they'll have eating problems, they'll have sleeping problems, etc. So it became apparent quite a long time ago that it might make more sense to actually assume that all of these things don't happen by random chance but they cluster and correlate highly together and hence the concept of complex PTSD which was arranged around the recognition of the multiple dimensions in which trauma affects a developing individual and it affects things like affect regulation, it affects the person's innate ability to dissociate and the more traumatized you are, the more likely you are as a child to dissociate and repeatedly dissociate and when inescapable trauma happens from an early age and is repeated and particularly where it's being perpetrated by someone who's your primary attachment object, there's a strong chance that the dissociation will actually take on, incorporate the form of alternative identity states. There's not an awful lot of difference between somebody who is traumatized repeatedly in an inescapable situation say as a Vietnam veteran as compared to a child who's being sexually and physically traumatized within their home environment except that the time that the inescapable trauma was happening for a child predates anything like full identity formation or a sense of selfhood. So the war veteran will dissociate and somatize and suffer from depression and anxiety and self-serve by use of alcohol and drugs but typically he won't switch into alternative identity states which is a way of compartmentalizing trauma. It's a way of actually putting aside things that would otherwise turn you to suicide or psychosis so that you can eke out some sort of survival by making the best of an otherwise impossible situation. Sonya's good representation of the sort of cycles of trauma where there's multi-generational trauma where there is a lot of self soothing by use of drugs or alcohol, self cutting and where you're on the marketplace of life when you have that sort of background it's really hard to find a really nice stable partner and hence a lot of people like Sonya pass underneath society's radar. They exist but when they do sort of interact with healthcare systems or police systems they may not get a very sympathetic or empathic reception and hence you have this alienation and people like Sonya have lived in a world where the world is not safe and where you don't trust people so the safest thing is not to trust people but of course as Sartre said hell is other people so you can't quite escape them. I'll move on to the next slide this just illustrates the diagnostic overlap of people with complex trauma between 1992 and 1997 myself and a colleague Jeremy Butler recorded the abuse histories and phenomenology of 62 people who fulfilled diagnostic criteria for the excessive identity disorder. Illustrating the multiple dimensions of the psychopathology that this group has is of course when you look at the prior diagnosis of people in this group most of them had prior diagnosis of depression 20% had a history so called of mania but really probably switching between different states that were misinterpreted as mania nearly 30% had previously been diagnosed with schizophrenia many with anxiety, a third with eating disorders childhood enduresis and so on. Over 70% had a diagnosis of you know would fulfill diagnostic criteria for borderline personality disorder and a similar percentage would fulfill diagnostic criteria for somatization disorder and so on. It just illustrates that these people present multiple bleeds through the mental health system and can ricochet around for years being diagnosed with multiple things usually attracting psychopsychopsychopharmacology being treated for psychosis depression, anxiety, sleep etc but in fact the typical history where it is of someone who doesn't stay long in the system, attracts multiple diagnosis but never seems to improve and these are from the same group this would slide on the abuse profiles as you can see in reality it had been sexually abused by a father or stepfather but a significant number also by a mother and then sexual abuse, there was sexual abuse obviously by multiple other people stepfathers, babysitters, uncles, aunts, brothers etc. in fact probably you know close to 90% gave a history of childhood sexual abuse a large percentage gave a history of physical abuse and then when you get to emotional abuse and neglect you know you actually have every one of them suffered from one or usually multiple forms of abuse and neglect. I mean whilst you have something like dissociative identity disorder having fairly simple criteria in that there is switching between you know enduring named identity states and between which there is a degree of anesthesia that doesn't even come close to representing the complexities of the common dissociative phenomenology associated with people with complex PDSD and in this is a study put together by Paul Dell which shows that things in this group obviously they have amnesia but things like depersonalisation derealisation feeling that the world is not real flashbacks hearing voices as having a sense of internal struggle between different parts of oneself etc etc etc having a sense of something controlling your impulses or your affects are incredibly common in fact it's rare not to have these sort of things and in fact people in this spectrum much more commonly have more schnodeurin first rank symptoms than people with schizophrenia I'm just going to finish I think probably my time is coming to an end but I just want to emphasise this is a summary of all the studies done looking at the history of sexual abuse and physical abuse in the average person who enters into the mental health system whether they're as inpatients or as outpatients. Here we have females as you can see in the average this is a multiple about 40 studies well evolving nearly 2400 people and in that group whatever the diagnostic criteria whatever the paradigm being used 69% whether it was asked for or not generally had a history of sexual and or physical abuse as a child. So there's something about having been very traumatised that draws you into having a sort of condition that lead and lends to you being in the mental health system. And with males and this is my final slide and should come up now there's slightly lower percentage of sexual abuse a slightly higher percentage of physical abuse and in this group 60% of all male mental health patients whether they're inpatients or outpatients will give a history of physical and or sexual abuse and the last point that I would make of course is that when you look at child abuse and neglect statistics that childhood physical and sexual abuse while very worrying are actually lesser reported than child neglect and then you add emotional abuse and you begin to sense that the vast majority in fact of people that enter the mental health system have experienced significant childhood physical sexual emotional abuse or neglect and at that point and Sonia's good representation of that in such slide in one individual and I'm going to leave it with you and I think we get a pretty slide if I press this yet. Thanks Michael. Thank you very much Warwick and thank you very much everybody Kathy Ursula Warwick that's really set the scene for us tonight. We will be putting some of your questions from the audience to the panel tonight but initially we're going to have the panels ask each other questions so Kathy may I ask you to ask Ursula question? Certainly. Ursula it can be very hard for adults who have experienced childhood trauma to access and afford the sustained care and support which they so often need could you please comment on the possible duration of therapy for those who have experienced complex trauma and the challenges of working within the management system. Thanks so much. Yes Kathy I think you've highlighted one of the sort of glaringly obvious glitches in this system is that there is not a lot of services available for complex clients that require long term therapy so in my experience an absolute minimum of 12 month therapy is needed for people who have experienced complex trauma and that will only get them sort of part of the way to recovery so if you think about it often the trauma has happened over many many years and whilst they're developing and it's had all sorts of impacts on brain chemistry and the way they view themselves and others attachment so it makes sense it's not going to take a long time for that person to recover so I guess recovery can be done like with continuous therapy or it can be done in like episodes of care like the centre against sexual assault that I work for we can only provide 25 sessions of counselling to people which on a fortnightly basis is about a therapy but people can come back for another episode of care after 12 months so for example a woman I'm working with at the moment we did about a year and a half work working in the safety stage and she's come back and now we've got a relationship on track and she feels emotionally safe and she's got some skills for emotional safety we'll start doing some of the trauma processing so I guess what options clients have is when Medicare when you could get up to 18 sessions that was really helpful for clients now it's cut back to 10 that's going to be much much more difficult other options are if sexual assault is one of the traumas all states have government funded sexual assault services now every sexual assault service will have different session limits so you'd need to sort of check those limits but certainly that can be a way that people can access appropriate long term care community mental health services is another option traditionally they haven't serviced this client group very well mostly due to resource constraints often massive areas and a small number of part time psychologists on the team another barrier of course is that a lot of complex trauma clients have a diagnosis of borderline personality disorder so there's a lot of stigma associated with that and often doors will close quite quickly if someone has that diagnosis so adult mental health services certainly Melbourne it's pretty hard for them to be helpful our youth mental health services seem to do a much better job another way possible way to access counselling is if they've made a police statement is to go through the victims of crime tribunal and I think it's called different things in every state but I've had some clients that have been able to get at least a couple of years of counselling funded through victims of crime now community health centres are another avenue then you need to check session limits some practitioners will have the skills for working with complex trauma and some won't but you know 20 years ago when I started out in this field I saw lots of complex trauma clients I might not have known that's what they were at the time but they did make significant progress I suppose because I prioritised developing a therapeutic alliance and I do think that is the most important the most important factor yes so there's big gaps but there's some options I suppose so what I'm hearing is that there are big gaps but things are improving we have to keep on trying well I don't know if things are improving because it's like as complex trauma is being more talked about in the community I think more people are using Medicare going to health centres applying for VOCAT so what I've seen is actually a bit of a narrowing of services in that VOCAT are now sticking to they're using the guidelines for PTSD which is an 8-12 session model which just is not appropriate for complex trauma and that was one of the comments that came through in the questions from the audience that there are people worried well who are accessing the system and people who really really need specialist care can't access it now Ursula would you like to ask Warwick a question yes Warwick I was wondering I guess I often find that psychiatrists are reluctant to prescribe medications other than perhaps antidepressants for complex trauma survivors who are struggling with issues of insomnia hyperarousal and extremely experiencing symptoms and I guess I was wondering are there medications that are useful for these types of symptoms and can enhance rather than inhibit the capacity to engage in therapy because sometimes it's like people are just so distressed it seems difficult to even get them to absorb what's happening in the counselling session yeah it's a good question probably don't see that many patients where you could say well the introduction of a medication made the difference between them having therapy or not having therapy or being able to process things or not there are a certain I mean if you look at the average complex trauma patient most of them have had a prescription for antidepressants it sort of goes with the territory because most of them presented having dysphoria if not sort of more profound depression at times as exemplified by Sonya there's a lot of them at one stage or another have used benzodiazepines related compounds and they are problematic especially they're like alcohol they're quite addictive sometimes you tolerate a small amount because it's actually in terms of supporting the therapeutic alliance they're a bigger fish to fry to get some get too self-righteous or rigorous about a small amount of benzodiazepines whilst it's not sort of in the sort of listed indication there's probably quite a lot of the newer generation antipsychotics and some of the older antipsychotics used not in the context of looking for an antipsychotic effect but in terms of ameliorating anxiety and sort of damping down the system and it's probably not uncommon for people in that spectrum to take medications such as Cerroquel you're saying it's hard to issue what psychiatrists, what their practices are and I think that when you get to complex trauma you get quite a range of responses from psychiatrists in terms of what you're talking about is someone that you can collaborate with in terms of facilitating therapy I think is that Yes I guess I'm thinking of there was one young woman I saw who came along for counselling and she would basically end up in ICU weekend she harmed herself and tried to kill herself that severely and Cerroquel helped her she got it from a GP I think and I said that in order for me to see her she needed to be linked with a mental health service and the community mental health said you can't have Cerroquel because we're not allowed to prescribe it because you don't have a body illness and so she said to me so I'm not going back so that was really difficult because I didn't feel that I could work with her when I'm a part time worker and I was finding that I was starting to think of her on the weekends is she in an ICU and yeah so that's difficult and I just felt I don't know how that's helpful sort of ripping her off all the medications which are keeping her all that stuff for the dampened down a little bit and I guess it just made me a little bit perplexed but with many patients you've probably got to try it and see and there will be some for example who feel a lot better and will take it because it doesn't resolve their long term trauma but it does make life somewhat more manageable there are others who complain of side effects you know weight gain or sorts of things where they're sensitive to that there are some who are always like to take endopresence they would never take them and I think when you're dealing with somebody as I said who you could legitimately give 12 diagnosis to you have to think a little bit outside the square the point that you're making is a very valid one is we don't spend generally speaking to spend enough time listening to the patient single sort of most profound thing you can do with someone like Sonya is to actually listen to them and if you do that may be the first time anyone ever has because they've already full of self-hate they believe that the world is to be distrusted and they don't see themselves as having highest theme or seeing themselves as valued it's actually one of the profound subliminal things about therapy is that the patient in this is treated as a legitimate human being and when they raise something like your patient that's what works for them well they have a valid point. Thank you and Warwick I think that the dilemma between psychotherapy and pharmacotherapy is one that does exercise our minds and certainly lots of questions are coming through in relation to that and I know as well many GP's are used to call off label as well so perhaps that's something that we need to think about and discuss after the webinar. Now Warwick are there any questions that you'd like to ask Kathy as our consumer advocate? Yes I do and what I was interested in I guess the issue because it's been raised tonight of borderline personality disorder and Ursula actually made a comment on the negative impact that can have on the provision of services and I was just going to ask Kathy from her experience particularly incorporating a consumer perspective you know how much does she see counter-transnce reactions on the part of the healthcare system tied in with the use of the term borderline personality disorder well obviously Warwick borderline personality disorder is a very stigmatizing diagnosis and it's one which consumers feel represents them as being beyond help and I think a lot of the healthcare community is traditionally adopted that response and obviously a lot of the behaviors, a lot of the emotional intense emotions, the overwhelming emotional pain that people bring to therapy their difficulties with stability in relationships are going to be brought into the therapeutic relationship and obviously that will engender very strong counter-transference responses and I agree with you those responses historically have undoubtedly reinforced the labelling of consumers in fact as borderlines so the term in fact goes further and labels individuals as the symptom complex and actually distances people even further so the difficulties these consumers have so labelled in relating to others they're inappropriate anger at times, distressing emotional states hypersensitive to criticism, desperate attempts to avoid abandonment, constant need for reassurance, impulsive acts elicit strong emotions in others both inside and outside the therapeutic framework but health professionals need to be alert to their own emotional responses to these behaviors and emotions and these can be enormously instructive by the same token but obviously in the health professional and you could comment much better than I can would definitely need their own supervision to guard against their own reactivity to the anger, abuse and criticism they'd often face so I suppose it's a matter of how health professionals and workers respond that's the issue and the capacity to separate one's own emotions and judgments from the feelings the consumer projects into the relationship capacity to understand these behaviors and emotions in the context of the individuals lived experience so when you're being idealized one moment and denigrated the next and constantly having to respond to suicide attempts and self-harming behaviors in the absence of suicide and good supervision you can readily be sucked into a very unhealthy relational dynamic so therefore it would be very easy for a health professional to judge, to reject, to abandon and label the consumer and for the consumer that health professional's response would undoubtedly become a self-fulfilling prophecy reinforcing their belief that people can't be trusted and that you'll be hurt and abandoned and delivered again. Can I add a comment Kathy? I just, listening to you, I just recall that John Breere quite a long time ago observed, he said he knew that the term borderline personality disorder was a majority when he began to hear colleagues describe other colleagues they didn't like by using it and it's been an unfortunate term. I think if you actually take the word borderline and apply it to any other noun it never sounds good if you said it was a borderline psychologist or a borderline psychiatrist or a borderline doctor none of those sound very good and yet you're supposed to go along and say I've got a borderline personality and you're supposed to feel good about it It implies that someone is fundamentally flawed but their very sense of self and personality is flawed and as you say it's a majority, it implies manipulation and conscious resistance to treatment and of course people's behaviors and emotions are reactions to their lived experience and that's what needs to be understood That's excellent There were so many questions that came through from the audience that were answered during that session. Thank you both very much Kathy I think we might give you a chance to ask Warrick a question Sure Warrick, question for you. Despite extensive research evidence there appears to be very much ongoing resistance amongst some health professionals to acknowledge and address the trauma underlying presentations and in fact the relevance of dissociative disorders for example What do you think will achieve greater awareness and responsiveness to complex trauma presentations other than this webinar of course is a good example of exactly what will increase awareness Speaking personally, I was just reflecting on something Ursula said earlier I think if I went back to when I first published a paper in regard to dissociative disorders which was probably just over 20 years ago, if we had a meeting of all the people in Australia that was somehow involved in the field I think we would have probably met in a tea room and over the years and find it's generally a waste of time to try to convince people of things they don't want to know it's far better to in a non-judgmental way, non-confrontational way to try and do sound research, develop treatment models take every opportunity to speak, to offer conferences, seminars, workshops to publish, to write books, to work collaboratively with other health professionals etc. etc. Someone once said never try to teach a pig to sing, it wastes your time and annoys the pig and over the years I've had a lot to do through an institute, the Canon Institute and also through the trauma and dissociation unit in developing models of research, but in putting together collaboratively with other organisations, conferences on trauma and dissociation over that period, literally many thousands of psychologists doctors, psychiatrists have attended these seminars and it's sort of interesting, we talk about where is this all going some of these seminars are the most well attended seminars you ever see in mental health field, they're literally involved in recently involved John Breyer for example and that in a four settings over Melbourne, Sydney, Brisbane and Perth, that involved the attendance of over 1600 health professionals, I don't think you get those sort of attendances virtually for somebody talking about general anxiety disorder or you know, new pharmacological treatment of schizophrenia, it's whatever it is out there there's a big number of people who have emerging awareness or a lot of awareness and a lot of experience over time so I don't preach to people, I think in fact that you know, you want to endlessly see experiences, having had professionals who sort of were skeptical or looked a scans at the idea who over time without being pressured in any way came to their own conclusions about these sort of patients and actually become very solid practitioners, quite a number of whom now regularly admit patients to the trauma and dissociation unit go back 15, 20 years and they would think that this sort of concept was from Mars, I think that organisations such as your organisation, ASCA, the mental health group run by Jenna Bateman and Corian Henderson in New South Wales, all of whom had figured out that it actually pays to make linkages to other groups professionals and consumers and finally I would say that the most powerful group at all and it's the one that probably is yet not fully mobilised is consumers because consumers are voters and if you get large blocks of consumers who actually in a professional way without appearing sort of like frightening the dogs, can put a credible case to government, particularly election time, then you're actually a very powerful lobbying group and I'm not sure, I'm sure that's occurred to multiple people but as we need to hear individual traumatised patients, we're probably moving to the stage where we need to hear them as groups. I think it is about getting a composite voice together and what I find frustrating I suppose is that there's just so much established research out there but yet it's taken a long time for that research to inform practice. It's not actually helped in many ways while research is helpful you can do yet another study that shows that the majority of people in the mental health system have been traumatised as children and just goes to the pile. In fact at this point in time we're probably in a simplistic way, we've done most of the research that kind of needs to be done to establish the case. That's right. It's not a matter of providing more proof it's about society's willingness to know. That's an excellent point Warwick. Thank you Kathy, thank you Warwick. One question that has come up that I might put to Earth is if you feel that a client has a complex trauma but you just can't you try to raise as they avoid it what's your strategy for dealing with somebody whom you feel they may have alluded to it and then retreated. Can you give our practitioners some strategies that you use to assist them in ventilating? I guess I just take it really slow at that pace because I guess if they are avoiding something they're avoiding it for a good reason and I often find this with young clients if I'm asking them about family of origin issues or their past that they'll be very they'll give me one, yep, no, yep so I guess I might talk to them about other aspects of their life and I'll try to build a relationship so that eventually when I go back to the genogram and I ask the same questions again I might just get a little bit more information or I might try something that isn't quite as confronting as the eyeball to eyeball talking. I might use like symbols and do like a sociogram sort of getting on the floor with them, you know pick an animal that's like your mum one that's like your dad, one that's like you, arrange them how close they are to you, something like that. I might use feeling cards I might use strength cards. I'd use some different things to try to get them to be able to express their internal state a little bit more but I guess I'd just be patient. Yes, well that's good thank you and you're still working within your model, I can hear you model there when you were saying yes, you know the therapeutic alliance and yes, that's great now are there any questions that you'd like to ask Kathy? Yes Kathy I guess one of the issues that I do find is that as a part-time psychologist if I do get a complex client who has those issues of serious self-parm and frequent attempts at suicide I don't feel that it's appropriate for me to be able to take on all of that care so obviously a collaborative approach is best and in ideal world I'd like to involve a GP and a psychiatrist so there's a team looking after them who can best respond but I do find that sometimes complex trauma clients are resistant to this idea and often it is because they've had very bad experiences in the mental health you know with mental health services so I understand where they're coming from but I feel a little bit like I'm between a rock and a hard place in that I feel like I need them to be in the system so that I can get them or they can get access to quick care if their life is in danger but getting them to be on board with that idea without feeling coerced or blackmailed I guess I'd just like a consumer input into that. Sure obviously challenges in trust and feeling safe that means that people have experienced complex trauma will find it very hard to engage in any sort of therapeutic relationship and to sustain that relationship readily or quickly and as you point out engaging with a number of services or practitioners brings other challenges and yes certainly many consumers that come to ASCA that ring our 1300 line have been felt very let down by a range of health professionals and services they feel that haven't inquired about trauma despite presentations that were really indicative have dismissed trauma histories as being so long ago and irrelevant minimized their concerns told them to just get over it labeled them as having a personality disorder so I mean the first step and we've just talked about that with Warwick is continuing to have much better education for health professionals around the needs of individuals who've experienced complex trauma and awareness and responsiveness to trauma across service systems so an implementation of trauma and the trauma informed approach for workers as well so that they also understand the particular sensitivities and vulnerabilities of trauma survivors so I mean as you say no doubt that collaborative care certainly would bring better outcomes for survivors and increase the opportunities for relationships of care and the responsibility for the safety of clients at risk to be shared by health professionals absolutely but you know collaborative care is also a work in progress and it demands a network of service and practitioners who you know really can work together collaboratively and communicate openly with one another understand what each one can bring to the table and that trauma informed and they're also able to collaborate with consumers to help them feel safe to feel validated to feel listened to heard and respected so with someone like Sonya yes a multi-disciplinary approach is definitely needed and it needs to involve health professionals working together as well as you know a team involving community mental health teams as you talked about before and community managed organizations, psychosocial support, housing, employment, education and so forth as to how to you know engage those relationships of trust I mean I would assume that needs to be enabled through the primary relationship because as trust is built in that primary relationship hopefully that can facilitate engagement with additional practitioners and you could probably comment better than I would on that. Thank you very much. Michael could I make a comment on that? Yes of course Warwick. I guess somewhere in the question is the issue of you know where do you actually find a liberating psychiatrist if you need one but I just say Have you got the answer to that word? That seems to be yeah well can I just say that like the smart way of doing it is to cultivate them you know if you actually want to grow a crop you know you start by planning it and cultivate the relationship so if you're going to be in this field it really is a very good idea to figure out who are the psychiatrists for example who are likely to be available with whom one can develop some sort of collegial relationship and there are multiple ways to do this it may involve attending seminars where that sort of material is available but it may involve seeking out supervision it may involve joining a peer group but it's probably a big ask to say well just on any given day I'd like to be able to ring up a psychiatrist and find one in the phone book who'll collaborate with me and feel aggrieved if they don't and I guess psychiatrists are you know a very broad spectrum group they range from people who are sort of very biologically orientated to people who are psychogeriatricians to people who are child psychiatrists to people who have a lot of interest in trauma to people who avoid trauma and we can debate about the reasons for that but if you're going to have a happy relationship seek out those that one psychiatrist who obviously have some credibility and evidence of involvement in the field who treat these patients and services the patient to give teaching supervision whatever and usually I mean usually that's not too difficult there are groups I suspect in most cities that conform to those sort of criteria. Now on that note time is marching on doesn't time go very quickly. Tempest fugitive now I'll have each of you there on the video you each have one minute to sum up. So Warwick I might ask you to go first. To sum up the reality is that something like 1.1% of the population with the field diagnostic criteria for something as severe as the status of identity disorder which is at the severe end of the spectrum of complex PTSD and yet as a society it's only really in the last 30 years that we began to even seriously recognize the reality of incest and only much more recently we began to recognize the reality that dissociative disorders and complex PTSD are not only not rare but in fact they're a common and central part of the mental health presentations of many of our patients and that if you actually look in the mental health system the majority of patients will have a history of severe childhood physical sexual and or emotional abuse in their childhood. Warwick that was excellent. You are the best psychiatrist we've ever had on a webinar. You stick to time. You're a great blog. Thank you very much. Now Ursula you have one minute to sum up. You did have two minutes but we were enjoying listening to you all talk so much. I know what to say. There is a recommended reading list that goes on this website and I think that that would be really useful and I've been noticing some questions coming through. One was talking about re-victimization so I think there's some things on that reading list that will help I guess look at that and there's an article that I wrote that's available by web link so it's a really sort of simple CBT approach to that but I guess it's on a deeper level it's to do with re-enactment of attachment and all sorts of complex stuff but yeah so it's a really interesting field and I think we are getting somewhere and webinars like this are fantastic and it's great that we've had such good attendance and it's been really good working with Warwick and Kathy and Michael with your assistance so yeah thank you all and I hope we can do things like this more often. Thank you very much. Now Kathy you have one minute in which to sum up. So a full minute I suppose my comment is going to be a bit more systemic we've seen a significant change in the approach to mental health which hopefully will continue to improve but what we haven't seen is an engagement around trauma within the mental health system and certainly around complex trauma within trauma so I suppose my comment is really around the mental health system appreciating that co-morbidity is often not co-morbidity it often represents the same response a system response to trauma and that addressing the core issues of trauma underlying people's presentations is absolutely crucial for our mental health system. So is that my minute? That was just under a minute but it was very cogent. Thank you very much. That was lovely. Now I just like to first of all thank the audience who have endured a few little glitches but not too many. I'd like to thank Kathy and Ursula and Warwick for their contributions. I think the things that come across to me from the R we've spent are is the word trauma and also the word trust which we need to have in our relationships and in our therapy, time and therapy, following a model, awareness of transference, cancer transference issues, supervision the fact that we need to lobby for our patients and clients consumer advocacy and the important role that that plays I always feel very humbled when I have specialists such as you guys talking and I feel even more humbled when we have such an eloquent consumer advocate as you Kathy. It is difficult there are workforce issues, there are resource issues we all work in different areas of Australia rural and regional areas are disadvantaged as many of our audience have pointed out in their questions but even in cities one can be quite alone if one's dealing with trauma, patients and clients. In relation to MHPN the slides will be available, transcript will be available and an audio of tonight will be available for those who through for one reason or another missed parts of it. Please go to the complex trauma online forum on MHPN online. All the recommended resources are there you'll all be sent the podcast within the next 24 hours and it is very very important that you complete the exit survey before you log out because like everyone else we need feedback, we need to send feedback back up the chain I would like to on behalf of all of our speakers tonight to thank you for your contribution and participation we look forward to having these speakers back again in the future and thank you sincerely everybody for attending tonight. That's the end of the webinar for tonight Cheerio everybody!