1. THE CHALLENGES OF CHANGE FOR
MENTAL HEALTH:
CULTURES, CONSENSUS, AND FUTURE
DEVELOPMENT
Professor Beverley Raphael
Professor, Population Mental Health & Disasters, UWS
Professor, Psychological Medicine, ANU
MHCC Conference 2011: Trauma Informed Care and Practice:
Meeting the Challenge
Four Points by Sheraton, Sydney
23-24 June 2011

2. CHALLENGES FOR CHANGE

3. HOW CAN WE ACHIEVE TRAUMA INFORMED
CARE? (i)
 Why might we need this?
 How do we know?
 Could it “Make a Difference” ?
 For whom
 How
 How do we know
 Do we “DO It” Now?
 Who would PAY for it?

4. HOW CAN WE ACHIEVE TRAUMA INFORMED
CARE? (ii)
 Why Should We “Do” it?
 What will it Involve?
 Who Wants it? Or Not?
 How Can it happen?
 How will we know if works?
How can we have what we need and when?
Our way!

5. WHAT CHALLENGES TO WE FACE FOR THE
FUTURE?
 The problems & the successes
 Lifetime Psychiatric Disorder 2007
 Current prevalence and increases
 Numbers
 More Problems
 A rich, happy, successful country
? ? ?

6. Slade, T., Johnston, A., Oakley
Browne, M.A., Andrews, G., Whiteford, H., 2007
National Survey of Mental Health and Wellbeing:
methods and key findings. Australian and New Zealand
Journal of Psychiatry 2009; 43:594605

7. SPECTRUM OF CHILD ADVERSITIES
Multiple Adversities and Measures (Jacobs et al)
Milieu of “Family”
 “Retrospective”, “Prospective”
 Independent or not
 “Validated” e.g. Legal, Medical
 Clustering of Multiple Adversities especially with
severe CSA, CPA, neglect
 Adversities: Common part of Family Life?
Milieu of “Environment”
 Multiple, external/accidents
 Disasters, disease: Acts of God/Man
Trauma, Loss Dislocation, Disruptions etc

8. CHILD ADVERSITIES: FAMILY
Multiple Studies, Consistent Findings
 Child Adversities associated with (Green NCS 2010)
 Onset of All Groups of Mental Disorders
(Mood, Anxiety, Substance, Disruptive, etc)
 44.6% of childhood Onset
 25.9-32.0% Later, Adult Onset
Severe sex, physical abuse & neglect +
maladaptive family functioning e.g. parental MI, SA
criminality, family conflict, violence
also WMH Survey: Repeats findings

10. PROSPECTIVE: ISLE OF WIGHT (1964 COHORT UK)
(COLLISHAW, RUTTER ET AL, 2007)
OR
 Adolescents
 Depression 15.5
 Suicidal ideas 8.87
 Anxiety 8.11
 Conduct/Dis 4.57 with adversities
 Peer Relations
 Mid-Life
 Major depression recurrent 8.8
 Suicidal behaviour 4.8
 1958 UK Birth Cohort (Clark et al, 2010)
Sexual abuse OR 3.4, PA OR 2.6 pathology
3 or more adversities OR 3.7
Predicts Onset and Persistence

11. PROSPECTIVELY ASCERTAINED: ABUSE &
MENTAL HEALTH IN YOUNG ADULTS (16-27)
(SCOTT ET.AL. 2010)
Child Protection Agency History
12 months & Lifetime Mental Health
PTSD 5.1
Mood 1.86 OR all
ANX2.41 when retrospective reports out
Substance 1.71
All disorder groups and 3 or more disorders
12 months & lifetime

12. CHILD ADVERSITY: ADULT “STRESS
SENSITISATION” (MCLAUGLIN ET.AL 2009)
 Child Adversity + past year life stresses
risk MD, PTSD, ANX, perceived stress
 3 or more CA’s MDD 27.3% -v- no CA’s 14.8%
PTSD also
 Cumulative adversity (Schilling)
Total CA & incremental CA – depression, drugs,
anti-social
but SEVERITY of CA’s not no’s poorer mental health

13. CHRONIC ADVERSITIES AND ONSET ALL LIFE
STAGES (BENJET 2010)
Predict psychopathlogy onset for
childhood mood; anxiety
adolescent substance
adult life disruptive (children)
Childhood family dysfunction and abuse (MFF)
Strong prediction (WMH Survey)
Old age e.g. CSA + mental Health (Draper et al 2008)

14. CHILDHOOD ADVERSITIES: SUICIDE RISK
CSA and suicide attempts (Bebbington et al 2009)
British NCS Parp 28% for women 7% men
Risk for onset and persistent risk
Childhood adversities World MH Survey
Risk suicide attempts and ideation OR 1.2 & 5.1
with number of adversities
Sexual & physical abuse est risk for adolescent
Associations still, adjusting life MH
CSA Data & Coronial Data Linkage (Cutajer et al 2010)
Suicide RR 18.09 most in 30’s
Fatal overdose RR 49.22 most mental health
women higher

15. CHILDHOOD ADVERSITY: PHYSICAL HEALTH
Child Sexual Abuse & Physical illness in (Psych pts)(Talbot et al
2009)
Severe CSA medical health burden
= 7.9 years of illness (musculo-skeletal, respiratory)
Child physical abuse (longitudinal Springer 2009)
smoking, bronchitis etc
mental health, ulcer
BMI, smoking & MH General Health
All adversities (Dube et al 2010) (PA, SA, MFF)
associated current smoking
obesity
poorer general health
premature death

16. CHILD ABUSE & NEGLECT IN AUSTRALIA 2010
Prevalence: NCPCH Price – Robinson et al (2010)
(review of studies) – estimates
Physical Abuse 5-10%
Neglect 1.6-12.2% ?estimate
Emotional Maltreatment 11%
Witnessing Family Violence 12-23%
Sexual Abuse Male Female
Non-penetrative 12-16% 23-36%
penetrative 4-8% 7-12%
(issues of reporting, substantiation)
Clustering with family functioning adversities

17. AUSTRALIAN STUDIES OF CHILD ADVERSITY
 Multiple Studies as international: retrospect;
“prospective”; longitudinal (eg MUSP)
Note: Roseman & Rodgers (2004) – PATH Project
 59.5% some adversity, 37% > 1 multiple often
domestic conflict; parental psychopathology and
substance abuse
 Severe adversities, physical & sexual abuse and
neglect – uncommon but cluster with multiple and other
severe adversities
 Average 4.8 other adversities with severe sexual
abuse, 5.9 with physical and 6.8 with neglect

18. INDIGENOUS CHILDREN TRAUMA, LOSS &
GRIEF (WAACHS) (MEIO ET AL 2005)
 Child Adversities and Social & Emotional WB:
parent taken away; parent mental/physical
illness, single parent or other care, criminal, SA, PA, etc
Maladaptive family functioning stressors
Increased risk of all disorders
 4-11 years >2 25% > 7 42% risk 5.5x
 12-17 years 19% 34%
 Protective, resilient quality of parenting
No illnesses, stressors, care, no violence
 NOTE also child sexual abuse report (Coorey 2001)

19. WHY MIGHT WE NEED THIS
People with Mental Health Problems and Mental
Illnesses
 Have more adverse experiences
 Discrimination
 Marginalisation
 Economic and social problems
 Homelessness
 Assault and other trauma
 Losses – self, dignity, family
 Negative Treatment aspects e.g.
 Seclusion, restraint, etc
 Medication, legislation etc

20. DO WE KNOW WHAT COULD MAKE A
DIFFERENCE
 What do people with illness think?
Respected studies say that consumers identify stressful
experiences as contributing to their illness.
 What do Service Providers think?
 Not known systematically
 Many would agree
 Have we Policies and Programs that address:
“Trauma”/Adversity as an aspect of Health and
Mental Health?

21. WHAT DO WE DO ABOUT THIS?

22. WHAT DO WE DO
 National Mental Health strategy
 4th National Mental Health Plan
 Multiple Developments over time
 States & Territories, collaborations, common
themes, outcomes & data reporting
 Australian Government Initiatives
 Primary Care, Better Outcomes, ATAPS etc
 Special initiatives e.g. beyondblue, depression
 Private Sector – Medicare and other rebates
 PBS (Pharmaceutical Benefits Scheme)

23. WHAT IS DONE TO ADDRESS THESE MENTAL
HEALTH VULNERABILITIES (AUSTRALIA EXAMPLE)
 Distance Resources
 Web based programs, call centres e.g.
 ACATLGN; Raising Children; COPMI;Kids Help Line; ARACY
 National Networks e.g. National Association Prevention
CAN
 Australian Institute of Family Studies
 National Child Protection Clearing House
 Multiple Agencies, Advocacy-services, state and
territory
 Care Systems
 Child protection services and counselling
 Child & adolescent mental health
 Linked programs, late programs (older adults)

24. WHAT DO WE DO (CONTINUED)
 E-Health Systems
 Information
 Interventions
 Non-Government Sector
 e.g. SANE, MHCA, States, General Specific
 e.g. advocacy, information, support services, consumer
& Carers, Housing, Employment
 COAG: Across sectors of
government, health, family, disability, indigenous etc

25. WHAT DOES THE COMMUNITY SECTOR DO
NOW

26. POPULATION HEALTH STRATEGIES
 Positive mental health & wellbeing, mental
“health”, fitness, love, work, play, relationships
 Building resilience –
individual/societal, communities of
engagement, neighbourhood, organisations (e.g.
sport, work), youth, on-line etc
 Connectedness & care & social capital
 Violence: prevention, zero tolerance, public health
education, integration for mental health
Building Health Capital/Mental Health

27. WHAT DO WE DO ABOUT IT?
 Adults
Treatments for PTSD
Trauma Focussed CBT etc
 Look after other adversities and their effects on Mental
Health?
 Cultures and trauma
 Complex, communal and multiple traumas

28. COULD IT MAKE A DIFFERENCE?
 Looking after “trauma” in Mental Health Care. In
Public, important, community, NGO’s, GP, Psych, P
rivate Sectors etc
Research is needed 
Do we assess “trauma”, what would we do? e.g.
prevention, early intervention, clinical
treatments, etc
Would it make a difference
? ? ? ?
What do we do for Those with Greatest Need?

29. AUSTRALIAN CHILDREN’S ADVERSITIES 0-14
 Children’s Mental Health (4-14) SDQ
 8% general and 13% Indigenous
 Emotional or behavioural problems: 15%/24%
 Conduct problems: 15%/24%
 Hyperactivity: 10%/16%
 Indigenous Adults:
 2 x higher psychiatric disorders
 40% life stressors in previous 12 months
 Hospital Separations – 40% higher Indigenous
 Adversity: WAACHS etc Higher > 3  risk

30. WHAT DO WE NEED TO DO: DEVELOP TRAUMA
IN FORMED CARE
 Build & Translational: Evidence base of what is
needed, what would work best, and for whom
 Who will advocate?
 How can it happen?
 How can we all be part of such an initiative

31. SCIENCE FOR MENTAL HEALTH
ADDRESSING OUR NEEDS, OUR
STRENGTHS, OUR WAY

32. TRANSLATIONAL RESEARCH FRAMEWORK
FOR TRAUMA INFORMED CARE
 Phase I: basic research – efficacy, safety RCT’s
and some clinical
 Phase II: translation to:
 Real patients / real life
 Guidelines, needs, acceptability
 Effectiveness, cost- effective
 Phase III: addresses policy for clinical and public
health and for sustainability
 “Continuous Improvement” – etc. Through R & D in
Ed & T; QI

33. TRANSLATIONAL CHALLENGES (i)
 Engaging stakeholders, consumers, carers, service
providers
 Complex and multifaceted:
 Conditions, contexts, components, and relevance for
various populations / individuals
 And, who deals with CHILDREN and their NEEDS IN
THESE CONTEXTS?
 Integrating it all to a set of cycles of RESEARCH
implementation evaluation, renewal cycles

34. TRANSLATIONAL CHALLENGES (ii)
 Develop Systems to
 Encompass research and service systems across
 Primary care; community; hospital; private etc
 Clinical, population levels
 Indigenous, culture, rural
 Cultural Diverse communities
 Workforce and professional development
 Education and Training
 Acceptability;
engagement, commitment, action, progressive
development

35. CHILDREN & ADVERSITIES/TRAUMA (an example)
 Assessing in CAMHS Services (McAndrew, 2010)
 Diagnosis & Treatment Evaluation Needed
 Research Studies
 What Family adversities could be addressed
 Can we “CLOSE THE GAP” for children with
greatest need?

36. TRANSLATIONAL CHALLENGES (iii)
 Costs, benefits, complexity and
effectiveness, governance, and outcomes over time
 Flexibility and capacity to be research
active, research valued, research development and
emerging, future need
 Politics, advocacy, resources for the change, the
good, the critically appraised. Not ideology, but
benefits, betterment for
individuals, families, children, young, old, other.
WE – THE PEOPLE

37. WHAT DO WE WANT?
 Lobbying:
 Change Barriers
 Services have ways of working
 Cultures, beliefs
 Engaging providers to explore, test, own possible
research outcomes
 Education & training positives
 Resources – cost benefits

38. WHAT CAN MAKE IT HAPPEN?
 Engagement of Leaders
 Science, need, benefits for people, systems
 Positives, risks, “Story”
 Collaborative discussion for resources, commitment
 Building program progressively and monitoring
indicators and programs
 Contributions of policy & programs to better mental
health outcomes and better systems of care

39. DOES IT HAPPEN
 Cycles of Ongoing Translational Research &
Service Development Integrated to Optimise Care
 Addressing adversities
 Identifying strengths
 Enhancing capacity for those
affected, carers, families, communities or services
 Monitoring need, processes & celebrating
achievements, hopeful & resilient trajectories

40. MENTAL HEALTH: EVERYBODY’S BUSINESS
Research and Development is Everybody’s
Business
Translating and Developing Knowledge and Skills
for Better Mental Health