Trauma-informed care is often poorly defined in Australia’s healthcare field and is even less defined when working with Aboriginal and Torres Strait Islander people. Our program, Damulgurra – the Larrakia word for ‘heart’ – seeks to address some missing elements of trauma-informed care in Australia through a process for knowing, being and doing with Aboriginal and Torres Strait Islander people. Through safety in relationship with our team of facilitators, Damulgurra seeks to support the decolonising aspect of ‘knowing’ the accurate history of Australia. The program supports learning about how systemic, intergenerational and collective trauma affects the nervous system, impacts on culture and influences the social determinants of health. Damulgurra gently encourages transformation through self-reflection on ‘being’ and action planning for ‘doing’. The hope is that trauma-informed care becomes a central practice in working with our people and is integrated at all levels of organisations and systems that service the community.
Trauma-informed care is a term often heard in the healthcare field. In general, courses aim to support health professionals to develop skills that enable better connection with clients who have a trauma background. In Australia, however, there appears to be a lack of consensus on what the definition of trauma-informed care is and how to learn and practise it.
Further, there is scarce information about trauma-informed care training for working with Aboriginal and Torres Strait Islander people. Given the overrepresentation of Aboriginal people in the healthcare system (Durey & Thompson, 2012), there is an urgent need to establish evidence-based trauma-informed practice.
Understanding the program
Born from the work of the We Al-li program (Atkinson, 2013), our program was originally named Culturally Responsive Trauma Informed Care (CRTIC). This is also the name of our research project capturing the journey from training to integration of trauma-informed care into Central Australian Aboriginal Congress (CAAC) in Alice Springs. Our program has naturally grown into a process of ongoing reflection, listening and development that honours Aboriginal wellbeing as central. Our program and process are continually evolving through our philosophy of knowing, being and doing.
The current iteration of our program has shifted from the name CRITIC to the name Damulgurra, which is the Larrakia word for Heart, given to us by elder Tony Lee. Kyleen Randall was internally commissioned to create artwork to reflect the program’s ethos.
The Damulgurra tree story represents the pathways a client navigates through the health system. Starting at the roots, the person ventures out to seek help, but finds themselves in the dark of the system, often confused by systemic ‘supports’ that aren’t a good fit for needs, values and culture. As the person goes up the tree of healing and engages with the system, there are many paths to follow and they may lose supports and go back down the tree. But with safety and good relationships, they can find their way.
The many colours represent the many parts of a person that start to heal. When the person reaches the green, new knowledge and connections that keep them healthy are made, and there is the realisation that although challenges may send them down the tree, they may never be right at the bottom again. Or, if a person does find themselves there, they have more skills, understanding and experiences to help them navigate the next cycle of the healing journey (Randall, 2020).
A participant manual was written, to accompany our training and articulate our core principles, which are to:
- support relationship building and connectedness as a means to promote healing
- understand trauma and its impacts
- understand privilege and the dynamics of power – cultural safety
- create environments in which staff, clients and community members feel physically, emotionally and spiritually safe
- empower and support clients in their journey of healing and recovery
- integrate and coordinate care to holistically meet the needs of individuals’ families and communities.
Importantly, the manual provides a view of the healthcare system through Aboriginal eyes. It is a peek into our world and how we struggle to connect with those employed to help us. Our team hopes that participants, both Aboriginal and non-Aboriginal, value the content and refer back to the information to help them operate more effectively within their roles.
Safety in relationship
Trauma happens in relationship and trauma is healed within relationship. Our facilitators make this central to our training, but even so, people can feel unsafe during the training process. This sense of unsafety can emerge for many reasons, which might include: trauma in a person’s own background, unconscious or conscious biases towards people different from oneself, unsupported or unprocessed vicarious trauma in the workplace, other difficult experiences or memories, weariness of cultural load, systemic exhaustion, or loss of hope for meaningful change. Any of these, or other challenges, can represent internal forces pushing a person outside their window of tolerance even as they seek to grow. The facilitator’s role is to support the learning cycle, even as it takes participants into this unstabilised space: the growth we need does not always feel safe, but it can feel supported.
To grow, we need to walk together into the discomfort. Facilitators hold space and create support for exploration to continue as deeply as participants are willing and able to go and allow time to sit with whatever feelings or experiences come up. It is important to note, that it is not designed to be a therapeutic program and we acknowledge that additional support may be needed afterwards to integrate what emerged in ways that support ongoing growth. However, we understand and explain to our participants that the training may feel therapeutic, as our style of training and beliefs about trauma-informed care promote transformation, even for those who consider themselves to already be ‘trauma informed’.
‘Being’ trauma informed and culturally responsive practice
Our program model, known as the Damulgurra cycles, places heart and land at the centre, along with important things that maintain integrity and strength of being. Our program philosophy focuses on the three domains of knowing, being and doing as the basis of all our learnings.
We bring ourselves, just as we are – with all our history, experiences and values – to the process of becoming trauma informed. This is the centre. This our ‘being’: the way we show up in the world.
In their guidance and advice to our program, both Larrakia elder, Tony Lee, and cultural advisor Sabella Kngwarraye Turner from Arrernte country strongly emphasise that this journey must start from the heart. The journey of becoming trauma-informed in a culturally responsive way is to honour an Aboriginal worldview of holistic identity, connection and wellbeing, and – for those who do not come with this already at their core – to embark on the transformative process of opening one’s heart to recognise these worldviews as genuine and valid: accepting their existence and truth and releasing the patterns of thought, behaviour, assumptions, power and privilege that may have been (consciously or unconsciously) diminishing the full expression, autonomy, voice and choice of Aboriginal people, in their own holistic core.
As the Damulgurra cycles suggest, this process of authentic acknowledgement, and its ripple effects of transformation, is an ongoing journey. When Larrakia elder, Tony Lee, guided the development of this diagram, he placed the boomerangs inside the two sides of this cyclical process to indicate the need to continually return, reflect on and re-evaluate what we know and how we put that into practice. He coloured the boomerangs so that they reflect their opposite sides. They represent that nothing is actually separate, we can’t have knowing without doing or doing without knowing, and all that we know and do will be affected by our sense of ‘being’, namely, how we understand the world and ourselves.
Most importantly, everything we think we know and presume to do needs to continually cycle back through the client or community themselves, who hold their own understanding about what is essential, meaningful, healing, real and important in their being. To be genuinely safe, supportive and transformative, trauma-informed care needs to be responsive to that.
Responsive ways of talking about being
Damulgurra began designing its program based strongly on the holistic model of social and emotional wellbeing as outlined in Working Together (Dudgeon et. al., 2014).
This social and emotional wellbeing (SEWB) model was developed by Indigenous psychologists Gee, Dudgeon, Schultz, Hart and Kelly (2013) to depict how health and wellbeing is interconnected and interrelated for Aboriginal people. In the development of our program, we have been grateful for this offering to describe something that is essentially indescribable with words, especially English. It’s an attempt to harness the unharnessable. Everything is actually interconnected and flowing, and it is more something that you experience and feel rather than understand intellectually or comprehend with your mind. It is felt with the heart.
SEWB will look different for each community and each client. It is important to work in a strengths-based way with an organisation, person or community. It can be re-traumatising for some Aboriginal people who have lost their cultural connections due to the process of colonisation to assume that they would, or should, have strong connections to these domains. Many people can experience a kind of complex trauma – a fracturing of developmental relationships – in relationship to any of these domains or to culture itself. To be trauma informed in a culturally responsive way, we must safely and deeply listen to people and communities as they define what wellbeing means to them.
Larrakia elder Tony Lee created the diagram of wellbeing in the centre of the cycles in the Damulgurra cycles. Sabella Kngwarraye Turner, Arrernte country, reminds us that everything comes from alhele itethe: living ground. She defined trauma as Utnenge Kwarneme Atnyeneme: hurt held in the spirit. She explained that the origin of trauma is being ‘spun away’ from the things that come from the living ground: culture, country, language, kinship, stories, clear thinking, good feelings, good friends and strong bodies. When all of this is connected and held properly, we have utnenge rlterrke: strong spirit. When we are spun away from any of these things, our spirits feel the pain of Anpernirrentye Ultakeme: kinship broken. This is trauma.
Although – out of respect for cultural intellectual property, cultural safety and extent of permissions – we can’t show the adapted SEWB wheel here or share everything about its adaptations, we can share that, significantly, we also dissolved the boundaries between the elements, to show that we are not split up into pieces, but that everything is interconnected.
Knowing
Some elements of ‘knowing’ we seek to expand during training include exploring what trauma is; how it affects our bodies, minds, nervous systems, emotional reactions and stress-based survival responses, relationships, behaviours (including risk-taking and addictive forms of coping and survival), capacity for learning (neurodevelopment), conditions of health (including trauma’s relationship with chronic disease) and, painfully, early loss of life. We discuss trauma’s history in communities and its generational embodiment. We hear stories and bear witness to some of the systemic reasons trauma can become embedded in populations due to the effects of invasion and colonisation.
When we look at the effects of colonisation, we are not just acknowledging it on an historic level. The traumas of invasion and colonisation continue today. Their precepts are systemically sustained because they have been institutionalised in organisations and political policies. And, perhaps more painfully, colonisation is sustained through an often invisible personal internalisation of its precepts, which most of us cannot escape embodying on some level. The structures we live in are predominantly mechanised by it, making it a challenge for anyone who wants to live, think, work or relate in other ways. We acknowledge, as part of the training, that the internalisation of colonisation is a kind of trauma and survival response in itself, which takes time, attention, kindness, awareness and healing to unravel and rewire. It is a kind of collective neuroplasticity that can only be addressed through growing numbers of individuals taking personal responsibility for learning and unlearning in present and healing ways.
Doing
Our program follows six important elements (known as 6Rs) to taking a trauma-informed approach, based on SAMHSA’s (2014) set of four assumptions, Atkinson’s (2002) Educating Healing Framework and the Larrakia Nation Holistic Model of Healing (2015).
The 6Rs framework acknowledges that we have to realise the trauma that has happened to Aboriginal and Torres Strait Islander people, in order to recognise the signs and symptoms of trauma. Our aim is to respond in a trauma-informed way to reduce the ongoing effects of trauma in order to revive connection to community, land, culture and ourselves. Our ultimate goal is to empower Aboriginal communities to regenerate and revive their own local healing frameworks.
Applying trauma-informed care when working with Aboriginal and Torres Strait Islander people has yet to be considered best practice among healthcare professionals. It is hoped that the roll-out of our training among member services and fee-for-service providers will gain momentum and become a core requirement of working with Aboriginal and Torres Strait Islander people in the Northern Territory.
Our main messages of safety in relationship, voice and choice, the effects of colonisation on the nervous system, and the 6Rs are embodied within the of the Damulgurra cycles as: Knowing, Being, Doing. These are practices we encourage service providers to adopt. Implementing this practice from top to bottom of organisations is important, because it paves the way for genuine relational healing for both the practitioner and the client. These ways of practising need to be reflected at the management level for trauma-informed policies to be integrated into models of care and most importantly, executives and boards need to advocate for whole organisation buy-in for being trauma informed.
Organisational change takes time. To support an organisation in the process of becoming trauma informed, Damulgurra has developed a Culturally Responsive Trauma Informed Care (CRTIC) systems assessment tool (SAT). The CRTIC SAT provides a set of measurements that assess organised systems with the intent to produce positive practice outcomes. The SAT is designed to complement a systematic reflective process in which CRTIC principles are used to review all areas of an organisation’s operation (for more information: bit.ly/3kWyzbG).
These activities in concert decolonise practices from administration to client care. In the long-term, it is hoped that through safe relationships, healing can happen across cultures from the Damulgurra – the heart.
Contact the author: [email protected]; amsant.org.au
Acknowledgements
The Damulgurra team would like to acknowledge the traditional custodians of the Larrakia country on which we develop our program. We acknowledge the facilitation team and the authors of this article: Our coordinator, Dr Carmen Cubillo, a Larrakia and Wadjigan woman, Kyleen Randall, an Anamatyerre, Yangunytjatjara and Pitjantjatjara woman; Heidi Perner, an Aboriginal woman who has connections to Gudanji, Garrawa, Wannyi and Alawa from her grandmother’s side and acknowledging grandfathers connection to Larrakia; our manager Dannielle Dyall, a Bundjalung woman; and our non-Aboriginal sisters Rosie Schubert, Jodi Smyth, Sarah Haithornthwaite, Jasmine Lyons and Alex Jordan. We are guided by strong supervisors and Aboriginal leaders in Tony Lee, a Larrakia elder; Caroline (Carlie) Atkinson a Jiman-Bundjalung woman; Sabella Kngwarraye Turner, an Arrernte woman; and Rachael Howard, a Burra Burra woman from Gundungurra country. We also acknowledge the custodians of the nations and lands upon which our content is co-created. We ask that you now close your eyes and silently acknowledge your line of ancestors, the knowledge that you carry and the innate wisdom that lives within you.
Who we are
The peak body for Aboriginal Medical Services in the Northern Territory (AMSANT) represents and serves 26 member services spanning the entire Northern Territory.
AMSANT’s Social and Emotional Wellbeing (SEWB) team have developed a trauma-informed care training program which focuses on current evidence about trauma-informed practices and infuses it with and translates it through local cultural knowledge about trauma and pathways to healing (bit.ly/3zBKT4Y).
Our vision is to empower Aboriginal people by: training those who work with our people; acknowledging the traumatic history of what happened to Aboriginal and Torres Strait Islander people; exploring how this painful history continues to be experienced and embodied today; learning how trauma affects our health, development, brain function, nervous systems, behaviour-patterns, relationships and the social determinants of health; and seeking locally led, strengths-based ways to counter the ongoing, systemic, socio-political oppression of our people. We connect trauma research with Aboriginal ways of healing. We support workers, management and services to create action plans about what they can do to integrate trauma-informed practices at all levels of their organisation.
We believe that, in working with Aboriginal people, trauma-informed care is a process whereby a person fully immerses themselves in the accurate history of colonisation, embracing an Aboriginal worldview of hurt and healing, and allows personal transformation whereby privilege, power and control is examined and released, and authentic empowerment of Aboriginal people becomes the goal in both personal and professional lives.
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