“Mr Speaker, silenced voices. Muffled cries in the darkness. Unacknowledged tears. The tyranny of invisible suffering. The never heard pleas of tortured souls bewildered by an indifference to the unthinkable theft of their innocence.”
Prime Minister Scott Morrison spoke these powerful words on the morning of Monday 22 October, 2018 as he began the Australian Government’s formal apology to survivors of institutional child sexual abuse.
The work of the Australian Psychological Society (APS) in this area began early in 2014 with the announcement of the Royal Commission into Institutional Responses to Child Sexual Abuse and culminated in 2018 when we were successful in winning a Commonwealth Department of Health tender to develop a website and directory for health professionals who could provide psychological counselling support to survivors of institutional child sexual abuse. The success of the tender was due in no small part to the contribution by the APS of 11 submissions to the Royal Commission. The APS’s proven ability to deliver on Department projects (like the Forced Adoption training project now available through the APS Institute: bit.ly/2RR1egc) was also significant, particularly given that there was only a three-month period in which the project needed to be delivered – in time for the commencement of the Redress Scheme on the 1 July, 2018. This included the establishment of an Expert Reference Group to oversee the project, consultations undertaken nationally with key stakeholders, a website developed with a searchable Trauma Support Directory (the Directory) and resources, agreed accreditation criteria for mental health professionals to enable their inclusion in the Directory and the live Directory with health professionals available and ready to undertake the work. The APS Strategic Development team kicked into action and succeeded in completing the project within the timeframe.
The consultation process
It is now well recognised by mental health professionals that listening to the voices of those with lived experience of trauma is critical to enable effective work together. This is particularly the case when those people’s voices have often not previously been heard, as highlighted by the Prime Minister. Accordingly, contact was made with more than 20 stakeholder organisations across Australia and diaries were scrutinised to find suitable times for face-to-face meetings across a two-month period.
A number of core themes quickly emerged and we found a lot of consistency in the messages across the different stakeholder groups. Some of these related to the ongoing challenges and specific needs of people who experienced childhood sexual abuse in institutions, with the impact of ageing being an area of particular concern. Importantly, other themes related to concerns about the ways in which mental health professionals, including psychologists, have worked with survivors in the past. The consultation captured many ideas about how this could be improved, including the need for better training and support for health professionals.
Survivors’ needs
The needs of survivors were often described as incredibly complex as they presented with a wide range of needs, including mental health issues, physical health concerns, financial issues, homelessness, dental health problems, family conflict and relationship breakdowns. Sometimes these issues were chronic, while other issues were emerging or precipitated by recent events. Sexuality issues were identified as common due to experiences of abuse at a young age. Many people’s stories about sexual abuse occurred within the context of other types of abuse including emotional and physical abuse. Overwhelmingly, a sense of injustice underlay the discussions, accompanied by a relief that the Royal Commission had provided an opportunity for stories to be heard and validated.
Survivors are a diverse group and their experiences of abuse occurred within a variety of contexts, including foster homes, residential care facilities, religious institutions and through schemes such as the Child Migrant Trust where young children from the age of three years were sent from England to Australia. Each of these experiences brought its own challenges. For survivors who experienced abuse in religious institutions there were often significant impacts on their sense of self in relation to spirituality, views about religion and relationships with the church and church-based organisations. For Aboriginal and Torres Strait Islanders, the intergenerational impact of abuse led to additional significant effects years later for families and young people. For many survivors, the sexual abuse remains unspoken and unacknowledged for decades due to shame and distress. For people who lived in residential facilities, their whole childhood was spent in the institution, without attending schools in the community or having contact with extended family members. Being forced to leave at the age of 15 years without an adequate education or family support often led to extreme risk and vulnerability, including homelessness or trajectories to prison. Girls often became involved in prostitution, a criminal act at the time. These experiences contributed to a pathway of further trauma and tremendous grief and loss, with lost opportunities, lack of family contact, an inability to ever feel safe and no back-up support when things went wrong.
Adding to these stories of distress and struggle from survivors and workers, there were stories of resilience, courage and strength. There are now many survivors who are active in ensuring that the doors now opened by the Royal Commission continue to remain open so that new opportunities for being heard and better understood can be discovered, along with effective redress. The survivors and advocates were very keen for the APS to assist in continuing to build awareness about their needs and ensure that mental health practitioners could be better equipped to work in ways that most effectively assist survivors.
Ways of working with survivors
There were many concerns about the way mental health professionals have worked with survivors in the past. While the role of mental health professionals was often seen as critical in supporting survivors and a key part of the Redress Scheme, there were also stories about the way that the provision of psychological support has at times been unhelpful and even damaging. Many survivors talked of the feelings of disrespect that can arise from a focus on assessment and diagnosis, rather than on validation of the person’s experiences and their uniqueness. There appeared to be confusion from survivors and workers alike around trauma-informed practice and what it means to treat trauma. There were memories of distress that survivors sometimes felt when sharing their stories with mental health professionals who found it hard to hear what they had to say, even flinching when details of stories were shared, often for the first time. For some survivors this served to silence them again, believing that their experiences were clearly too hard for anyone to hear.
While it was often confronting to hear these concerns, it was critical to be open to listening and learning. It was important to know that some survivors don’t identify the need for or seek counselling until their middle or older age, having developed a range of strategies that worked for them previously. For some, triggers relating to the Royal Commission or fears of ending up in an institution during their old age were re-traumatising and it was at that point they sought support from mental health professionals. Many people’s needs seemed to be better met by a case management, rather than a counselling, approach. This is particularly the case when they are navigating housing, health or financial support services. This means that psychologists working with survivors will need to be aware of services that are available in their community or be able to offer support in conjunction with other workers. Consultation with Aboriginal and Torres Strait Islander survivors consistently emphasised culturally safe, often community-based approaches to healing. Having a choice and opportunities to be able to make informed decisions about the services they require and how they will access them is very important.
Concerns about diagnosis of mental health conditions were raised. For many survivors, there is a fear of the mental health system and the worry of being locked up against their will if they meet the criteria for a mental health condition. Mental health professionals sometimes seemed to understand this and distinguished between the need to gather sufficient information to understand the client’s needs and conducting a formal assessment for the purposes of diagnosis. Rushing into assessment or developing treatment goals can be experienced as unhelpful and disrespectful to the survivor’s experiences. Both mental health professionals and survivors noted that many of the people affected by institutional child sexual abuse had experienced reports written by health professionals in the past which were unhelpful and damaging. We often heard about the importance of seeing the lifetime impacts of abuse as related to the injustice of the situation, i.e. their lives being disrupted because of what someone did to them, rather than a personal deficit or requiring a diagnosis to explain.
The way in which the mental health professional wrote notes and kept written records was identified as a concern for some survivors, given the negative impacts that records may have had in their lives. Some survivors are continuing to seek records or have received records with redactions and missing information. For others, the records revealed inaccurate or distressing claims made about them. Using strengths-based language and making notes with the consent and knowledge of the client were suggested as good practice for this client group.
It was noted that survivors of institutional child sexual abuse have lifetime impacts on their development, identity and attachment that may be more complex than other forms of abuse or events that were traumatic. While it may be well accepted that developing a therapeutic relationship needs to be the priority when working with people affected by trauma, both survivors and mental health professionals commented that trauma-informed principles don’t go far enough to meet the complex needs of this client group. For some it was often unclear exactly what trauma-informed principles might look like in practice.
Training and support needs of health professionals
One of the key areas of the consultation related to the training and support needs of mental health professionals. The potential risk of harm when practitioners work in unsafe ways, without sufficient training and support, was highlighted often throughout the consultations. Survivors and mental health professionals commented that given the complexities of the needs of survivors, training was required in relation to a wide range of topics, such as attachment, suicide risk, trauma-informed practice, responding to trauma, and domestic violence. For health professionals working with Aboriginal and Torres Strait Islander clients, understanding Indigenous history and the impact of intergenerational trauma were highlighted as critical. There was consistent advice that there is a lack of specific training and resources available in relation to working with people who experienced child sexual abuse in institutions. Along with training, supervision and support was noted as necessary for mental health professionals working with this client group, to both ensure safe practice but also given the risk of vicarious trauma. Organisations have a range of ways this can be provided, including both individual and peer supervision, external supervision, weekly staff meetings, regular professional development, working towards all staff training to become a Trauma-Informed Organisation, and active monitoring of the emotional states of staff.
The consultations provided a unique opportunity to engage with both survivors and mental health professionals to hear concerns and suggestions to take into account when developing the Directory and accompanying resources. They highlighted the risks in this work and the need to focus our energies towards ensuring that key messages about effective and safe ways of working could be developed. You can view the outcome of the project at the website: www.traumasupport.com.au. If you meet the criteria, we welcome your application to be included on the Directory.