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“A deep wound under my heart”: Constructions of complex trauma and implications for women’s wellbeing and safety from violence


Abstract and Figures

Responses to women who have experienced complex trauma need to be sensitive, coordinated and consistent between services and agencies to ensure women’s wellbeing and safety from violence. However, the development of shared frameworks of practice for addressing complex trauma has been forestalled by a lack of professional consensus and understanding. There is a need for holistic research into “best practice” responses to address complex trauma that place the needs and understandings of diverse women at the centre. This project sought to develop a comprehensive picture of how complex trauma is being constructed in public policy and practice and by women with experiences of complex trauma.
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ISSUE 12 | MAY 2020
A deep wound under my heart”:
Constructions of complex trauma and implications
for womens wellbeing and safety from violence
ANROWS acknowledgement
This material was produced with funding from the Australian Government and the Australian state and territor y governments.
Australia’s National Research Organisation for Women’s Safety (ANROWS) gratefully acknowledges the nancial and other
support it has received from these governments, without which this work would not have been possible. The ndings
and views reported in this paper are those of the authors and cannot be at tributed to the Australian Government, or any
Australian state or territory government.
Acknowledgement of Country
ANROWS acknowledges the Traditional Owners of the land across Australia on which we work and live. We pay our
respects to Aboriginal and Torres Strait Islander Elders past, present, and future, and we value Aboriginal and Torres Strait
Islander histories, cultures, and knowledge. We are committed to standing and working with Aboriginal and Torres Strait
Islander peoples, honouring the truths set out in theWarawarni-gu Guma Statement.
© ANROWS 2020
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“A deep wound under my heart”: Constructions of complex trauma and implications for women’s wellbeing and
safety from violence (Research Report) / Salter et al.
Sydney : ANROWS, 2020
Pages ; 30 cm. (Research repor t, Issue 12/2020)
I. Psychic trauma. II. Post-traumatic stress disorder -- Women -- Services for -- Australia. III. Women -- Violence against --
Prevention -- Australia.
I. Salter, Michael II. Conroy, Elizabeth. III. Dragiewicz, Molly. IV. Burke, Jackie. V. Ussher, Jane. VI. Middleton, Warwick. VII.
Vilenica, Sheryle. VIII. Monzon, Beatriz Martin. IX. Noack-Lundberg, Kyja.
ISBN: 978-1-925925-44-9 (print) | 978-1-925925-43-2 (online)
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Please note that there is the potential for minor revisions of this report.
Please check the online version at for any amendment.
This repor t addresses work covered in the ANROWS research project RP.17.09 Constructions of complex
trauma and implications for women’s wellbeing and safety from violence. Please consult the ANROWS website
for more information on this project.
ANROWS research contributes to the six National Outcomes of the National Plan to Reduce Violence against
Women and their Children 2010-2022. This research addresses National Plan Outcome 4 - Services meet the
needs of women and their children experiencing violence.
Suggested citation:
Salter, M., Conroy, E., Dragiewic z, M., Burke, J., Ussher, J., Middleton, W., Vilenica, S., Monzon, B. M., & Noack-
Lundberg, K. (2020). A deep wound under my heart”: Construc tions of complex trauma and implications for
women’s wellbeing and safety from violence (Research Repor t, 12/2020). Sydney: ANROWS.
School of Social Sciences, Universit y of New South Wale s
Translational Health Research Institute, Western Sydney University
School of Criminology and Criminal Jus tice, Griff ith Uni versity
Jackie Burke Psychology and Consulting
Translational Health Research Institute, Western Sydney University
Trauma & Dissociation Unit, Belmont Hospital
Translational Health Research Institute, Western Sydney University
Translational Health Research Institute, Western Sydney University
Translational Health Research Institute, Western Sydney University
A deep wound under my heart”:
Constructions of complex trauma and implications
for womens wellbeing and safety from violence
iv “A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
Author acknowledgement
We would like to acknowledge and thank all the women who shared their stories and experiences of complex
trauma with us, as well as the professionals who discussed their understandings and practices of trauma-informed
care. You provided invaluable insights into diverse experiences of violence and abuse and the response of frontline
services. We would also like to thank all the survivors, professionals and services who supported the project by
circulating recruitment information and raising the prole of the study. Finally, we would like to acknowledge the
contributions of the project advisory group members Professor Martin Dorahy, Lisa Hillan, Dr Pam Stavropolous,
Nicole McMahon, Amy Burkett and Dr Michael Daubney.
Acknowledgement of lived experiences of violence
ANROWS acknowledges the lives and experiences of the women and children affected by domestic, family and
sexual violence who are represented in this repor t. We recognise the individual stories of courage, hope and
resilience that form the basis of ANROWS research.
Caution: Some people may nd parts of this content confronting or distressing. Recommended support services
include 1800 RESPECT —1800 737 732 and Lifeline —13 11 14.
Western Sydney University
Locked Bag 1797
Penrith NSW 2751
UNSW Sydney
NSW 2052
Grifth University
170 Kessels Road
Nathan QLD 4111
“A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
List of tables 4
List of gures 4
List of abbreviations 5
Executive summary 6
Research question and aims 6
Methodology 6
Key ndings 7
Recommendations 10
Introduction 12
Our study 12
The structure of the report 14
State of knowledge review 15
Review methodology 15
Pathways and outcomes of complex trauma 16
Understandings of trauma-informed care 27
Summary 36
Methodology 38
Theoretical framework 38
Study components 38
Ethical concerns 45
Review and analysis of “complex trauma”
in Australian policy frameworks 46
Search strategy 46
2“A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
Findings 47
Summary 51
Constructions of trauma and complex trauma by women and
professionals 52
Understandings of trauma 52
Distinguishing trauma from complex trauma 57
The experience of dissociation 60
The psychosocial and embodied experience of trauma 61
How women skilfully deal with trauma 70
Summary 73
Health responses to complex trauma 74
Problematic response based on a biomedical model 74
Systemic issues that undermine an effective response 79
Best practice approaches to working with women who have experienced
complex trauma 87
Cultural considerations in service delivery 93
Summary 96
Complex trauma in criminal justice, child protection, and family law 98
Police 99
Criminal justice processes 102
Child protection services 105
Family law 106
Severely traumatised women 108
Promising practices 110
Summary 113
“A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
This work touches us at such a deep place:
Vicarious trauma and working with complex trauma 114
Prevalence and awareness of vicarious trauma impacts 114
Conceptualising vicarious trauma 115
Etiology of vicarious trauma 121
Vicarious trauma as a WHS risk 121
Management of vicarious trauma 122
Summary 125
Conclusion and recommendations 127
Further research 128
Limitations of the study 129
References 130
List of policy documents 149
Interview schedule—Professional stakeholders 153
Recruitment text for women with experiences of complex trauma 154
Interview guide—Women with experiences of complex trauma 155
Qualitative data coding matrix 156
Example of a coding summary—Survivor responses to trauma:
Physical (women) 157
4“A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
List of tables
Table 1: Availability of service documentation for analysis 40
Table 2: Participant details for the service provider interviews 41
Table 3: Participant details for interviews with women with
experiences of complex trauma 43
Table 4: Disruptions to cognitions as a result of exposure to traumatic information 116
Table 5: Transcript demonstrating lived experience of vicarious trauma impacts 120
List of gures
Figure 1: Summary of interventions and approaches helpful to
women with experiences of complex trauma 94
Figure 2: Vicarious trauma encompassing Secondary Traumatic Stress
and cognitive changes 117
Figure 3: Conuence of vicarious trauma with related but distinct constructs 119
“A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
List of abbreviations
AOD Alcohol and other drugs
CALD Culturally and linguistically diverse
CBT Cognitive Behavioural Therapy
CDCP Child Development–Community Policing
CF Compassion fatigue
CM Child maltreatment
CPA Child physical assault
CS Compassion satisfaction
cPTSD Complex post-traumatic stress disorder
CSA Child sexual assault
DID Dissociative identity disorder
D-PTSD Post-traumatic stress disorder dissociative subtype
DSM–5 Diagnostic and Statistical Manual of Mental Disorders (5th edition)
EMDR Eye Movement Desensitisation and Reprocessing
ICD–11 International Classication of Diseases (11th revision)
IPV Intimate partner violence
PTSD Post-traumatic stress disorder
STS Secondary traumatic stress
TIC Trauma-informed care
VPTG Vicarious post-traumatic growth
VR Vicarious resilience
VT Vicarious traumatisation
6“A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
Executive summary
Women with experiences of complex trauma are a signicant
but overlooked group of victims and survivors of gender-
based violence in Australia. Complex trauma refers to
multiple, repeated forms of interpersonal victimisation and
the resulting traumatic health problems and psychosocial
challenges. In Australia, one quarter of women subject to
gendered violence report at least three dierent forms of
interpersonal victimisation in their lifetime, such as child
sexual abuse, domestic violence, sexual assault and stalking
(Rees et al., 2011). is group has a high level of healthcare
utilisation linked to menta l illness, suicidality and substance
abuse. ey are in frequent contact with crisis services and
police due to domestic violence and sexual assault, with some
women reporting extreme forms of gender-based violence
that fall outside existing policy frameworks (Middleton,
2013; Salter, 2017). e health and safety needs of women
with experiences of complex trauma are interlinked, since
poor health and unmet need can increase their risk of
victimisation, while ongoing victimisation compounds
trauma-related mental illness (Salter, 2017).
e relationship between complex trauma, mental illness
and violence unfolds in diverse ways according to women’s
social position, lived experience and geographical location.
Experiences of complex trauma are not well recognised across
mental health practice or related elds, leading to inconsistent,
inappropriate and sometimes re-victimising treatment.
Complex trauma is a contested area in which the medical
model of mental illness, and the widespread stigmatisation
of distressed women as “hysterical”, malingering or simply
“mad” (Ussher, 2011), is in conict with trauma-informed
paradigms of support and treatment (Herman, 1992). is
conict is evident in the unpredictable responses faced by
women with experiences of complex trauma in a range of
settings. At the policy level, complex trauma overlaps with
frameworks on violence against women and mental health.
However, t he impact of complex trauma is not comprehensively
addressed by these frameworks, and this contributes to the
fragmented response to women in distress.
Responses to women who have experienced complex trauma
need to be sensitive, coordinated and consistent between
services and agencies to ensure women’s wellbeing and
safety from violence. However, the development of shared
frameworks of practice for addressing complex trauma has
been forestalled by a lack of professional consensus and
understanding. ere is a need for holistic research into
“best practice” responses to address complex trauma that
place the needs and understandings of diverse women at
the centre. is project sought to develop a comprehensive
picture of how complex trauma is being constructed in
public policy and practice and by women with experiences
of complex trauma.
Research question and aims
e guiding question of the study is, “How can agencies and
services improve collaboration to meet the health and safety
needs of women with experiences of complex trauma?” is
question informs four key aims:
1. Analyse how complex trauma experienced by women
is constructed in public policy at a national, state and
territory level.
2. Examine institutional responses to women’s complex
trauma in the mental health, alcohol and other drugs
(AOD) and sexual assault/domestic violence sectors in
New South Wales and Queensland.
3. Document how women wit h experienc es of complex trau ma
understand complex trauma, and their experiences and
encounters with agencies while seeking help.
4. Develop models of improved and collaborative responses
to enhance the wellbeing and safety of women with
experiences of complex trauma and their children.
e project took a psychosocial approach to complex trauma,
which recognises that traumatisation is a process that occurs
via the interaction of psychological, social and systemic
factors. Psychosocial theory makes use of select psychoanalytic
and sociological approaches in conceptualising women’s
adaptations to conditions of violence and inequality (Frosh,
20 03). We also draw on feminist understandings of the
concept of “complex trauma”, which lie in feminist clinical
practice and theorisation of the unique impacts of gendered
oppression across the lifespan (Herman, 1992; Warner,
“A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
“childhood trauma”, “early onset trauma”, “significant
trauma” and “severe trauma”. Frameworks and documents
pertaining to “trauma-informed care” are oen implicitly
focused on the impact of complex trauma, although this
is not acknowledged. Relevant psychiatric diagnoses such
as “complex post-traumatic stress disorder”, “personality
disorder” and the dissociative disorders are referred to rarely
in policy frameworks. However, “intergenerational trauma”
and related terms such as “transgenerational trauma” feature
prominently in Aboriginal and Torres Strait Islander policy
frameworks and documents, recognising the ongoing eects
of invasion, the Stolen Generations, disadvantage and racism.
e lack of shared terminology and understanding of complex
trauma raises questions about the adequacy of current policy
frameworks to address the multiple needs of people with
experiences of complex trauma and the eects that varying
understandings of the long-term impact of complex trauma
may have on program and service delivery. While an apparent
increase in services and programs engaging with complex
trauma and trauma-informed practice is promising, the
review suggests that these eorts are currently piecemeal
and in need of systemic guidance and coordination.
Understandings of trauma and complex
trauma among women and professionals
In interviews with women with experiences of complex
trauma and healthcare workers working in this sphere, the
distinction between trauma and complex trauma appeared
to be a matter of degrees. e complexity of trauma was
placed on a continuum from comparatively simple and short-
lived to more complex and enduring. Women indicated that
the vocabulary of “trauma” can assist them in articulating
dicult experiences but can also pathologise and individualise
reasonable responses to overwhelming situations. Women’s
descriptions of trauma impacts were more likely to focus on
the somatic and psychosocial implications of complex trauma,
whereas workers framed responses to complex trauma as
primarily a psychological problem. Women’s links with their
children and grandchildren are a strong motivator to seek
treatment, however they did not always feel that they had
been supported in their parenting and caring responsibilities.
Women were astute in the identication and self-management
2009). is psychosocial framework is complementary to the
prevailing social–ecological model of gendered violence, which
recognises that risk and protective factors for violence exist
at the individual, relational, community and systemic levels
(Our Watch, Australia’s National Resesarch Organisation
for Women’s Safety [ANROWS], & VicHealth, 2015), as well
as intersectional perspectives, in which categories such as
gender, race and class intersect in dynamic ways that shape
women’s experiences and responses to violence.
is was a multi-method study that combined policy and
service analysis with qualitative research with women with
experiences of complex trauma and the professionals who
work with them, via:
a policy audit of approaches to complex trauma
service documentary analysis and qualitative interviews
with 63 professionals in Queensland and New South Wales
qualitative interviews with 40 women with experiences
of complex trauma in Queensland and New South Wales
seven online workshops in which professional stakeholders
and women with experiences of complex trauma provided
feedback on the ndings of the study.
e implementation of the project methodology and the
ndings of the study were also informed by a project advisory
group. Online meetings were scheduled with the advisory
group three times during the course of the project, with the
initial meeting focused on identication of key services and
recruitment, the second meeting held to discuss the progress
of the study and initial ndings, and the nal meeting to
review key policy and practice recommendations. e project
team was also in contact with advisory group members via
email and one-to-one meetings to discuss specic challenges
or questions as they arose.
Key ndings
Policy review
The review found that references to complex trauma in
public policy are typically brief and undened. In policy
documentation, the term “complex trauma” is frequently
used interchangeably with “trauma”, “cumulative harm”,
8“A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
of their distress related to experiencing complex trauma over
time and described a wide range of self-care and coping
strategies. e ndings of Chapter 5 and 6 suggest that women
with experiences of complex trauma would benet from a
more holistic treatment paradigm, and one that builds on the
considerable strengths and skills that they have developed
in the self-management of complex trauma.
Interactions with the service system
Women with experiences of complex trauma typically have
multiple needs, however, the majority of services are funded
to address a particular issue or concern. As a result, women
with experiences of complex trauma typically needed to
navigate multiple services and agencies in order to have their
needs meet. Service systems and agencies can place unrealistic
expectations on women with experiences of complex trauma
to understand and navigate the (formal and informal) rules
governing each service system, oen simultaneously, and
oen while the woman is in crisis. A lack of support and
early intervention options predictably escalated women’s
needs until they presented in crisis, at which point they were
vulnerable to being dismissed as “crazy” and unstable. Self-
harm and suicidality are particularly stigmatised in service
settings and can attract punitive and dehumanising responses
from professionals. Women with experiences of complex
trauma frequently encountered sexist and disparaging views
about women’s mental health, encapsulated in the common
stereotype of the “crazy woman”.
Connecting with a trauma-informed professional service is
typically a matter of luck or perseverance on beha lf of women,
and where they received a supportive or eective response
in one context, this level of care was oen not maintained
across their other encounters with services and agencies.
Women diagnosed with a dissociative disorder and/or with
exposure to extreme trauma, including prolonged sexual
abuse, enslavement and tracking, experienced particular
challenges in accessing specialist services and effective
responses. e process of the service response is crucial for
women who have experienced complex trauma: how women
are treated, and t he way that they feel about the response, is just
as important as the outcome. Both women with experiences
of complex trauma and healthcare professionals pointed to
models of holistic, wrap-around and place-based service
provision that aims to meet the multiple impacts of complex
trauma as a blueprint for best practice, including specialist
providers in community health, women’s health, sexual
assault, community legal practice and the refugee sector.
Key ndings in relation to specic sectors are summarised
Health settings
Women with experiences of complex trauma attract a
range of psychiatric labels that do not result in referral
to eective treatment, but instead pathologise women as
dicult and non-compliant.
A public-health focus on highly time-limited, contractual
care is an obstacle to the safety and wellbeing of women
with experiences of complex trauma.
ere is currently a lack of trauma-specialised services
and professionals, and women’s experiences of health care
are typically segmented and uncoordinated.
Criminal justice
Successful criminal justice outcomes for women with
experiences of complex trauma are rare. All women
interviewed for the study had been extensively victimised,
however no woman reported that the full extent of
her victimisation had been prosecuted in the criminal
justice system.
Women and workers felt that police and prosecutorial
decisions about women with experiences of complex
trauma are not transparent or accountable.
Initial assessments and informal judgements by police
have a signicant impact on women with experiences of
complex trauma and their access to justice.
Child protection services
Workers and women report that the child protection
system’s understanding of trauma-informed practice
diers considerably from other service sectors.
ere is widespread concern that the impact of trauma on
parenting is not being addressed in the child protection
system, resulting in late and punitive interventions.
“A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
Family law
In family law matters, women are frequently not believed
or supported when reporting abuse by an ex-partner and
are oen worse o nancially and psychologically for
their contact with the legal process.
Best practice in complex trauma services
A picture of best practice in service provision for people
with experience of complex trauma emerged from interviews
with women and professionals. Interviewees emphasised the
eectiveness of community-based and community-controlled
services that are sensitive to the local needs, contexts and
histories of their client group. is model of service provision
was not limited to health serv ices but included child protection,
family support, legal and other areas of work. Ideally, these
services should be embedded within a broader network
of services that foster mutual learning, partnerships and
referrals of clients where necessary. To ensure cultural safety,
strength and accessibility, it was broadly seen as important
that therapeutic activities were culturally grounded and
appropriate, with the provision of well supported, trauma-
informed interpreters where necessary. Key points of best
practice are outlined below.
No wrong door with “so” and low entry points: Women
who present with experiences of complex trauma should be
able to enter into health, legal and other systems through
multiple pathways that are supportive and helpful, with
low or no barriers to entry.
Focus on self-determination and recovery: e explicit
task of services and agencies should be to support the
client to be self-determining, autonomous and thriving.
Safety first: Women’s safety needs are assessed and
addressed, including safety from perpetrators and their
housing and security needs. e service also needs to
feel safe for women, including in its physical design and
culture of clear boundaries.
Flexibility: Within those clear boundaries, services are
exible and able to accommodate the needs of women
with experiences of complex trauma, which may include
diculties attending sessions or aer-hours crises.
Continuity and predictability of care: Women are able to
establish a connection and safe relationship with a key
sta member that endures over time, and decisions about
the woman’s care are ultimately made with the woman.
A “whole of life”, “whole of person” perspective: Current
presentation and need is framed by a holistic view of
women’s experiences and selves that addresses how women’s
histories inuence their expectations and interactions
with the service.
Stepped care within ser vices: Women receive more intensive
care when/if their needs escalate and are referred back to
lower threshold care when stabilised (i.e. retained in care
rather than being dropped out of treatment because they
are no longer “acute”). Stepped care should be available
within services where possible, or else through close
collaborations between services.
Multi-disciplinary teams oering multiple modalities of
treatment: Services address physical, psychosocial and
mental health needs as well as practical life challenges,
incorporating cultural knowledge and expertise where
Psychoeducation: Women have the opportunity to learn
about the impact of trauma on their life.
Welcoming physical environments, including spaces for
recovery aer treatment: Women are oen disorientated
aer trauma-related service, and it may not be safe for
them to travel, hence it is important that the physical
environments of services are welcoming and can provide
rest spaces.
Case management and advocacy: Clients are supported to
navigate complex and challengi ng systems, including police
and the National Disability Insurance Scheme (NDIS).
Supporting parenting: Services can accommodate parenting
and also promote good parenting as part of the service.
Practical accommodation of clients’ needs: Services have
brokerage or provisions in place to address women’s
problems with childcare and transport.
Investment in sta care, support and vicarious trauma
prevention and the promotion of vicarious resilience: A
10 “A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
culture of care should be evident among and between
workers and extended to clients.
The risks and benets of working with clients
with experiences of complex trauma
There are parallels between the processes that result in
experiences of complex trauma and those that produce
vicarious or secondary trauma in professionals who work
with survivors of complex traumatic events. Risk factors
for experiencing vicarious trauma exist at the individual,
workplace and systems levels, and can produce trauma-related
cognitive changes and secondary traumatic stress in workers.
ere is considerable evidence for eective vicarious trauma
prevention at the individual and workplace level. In this study,
workers described experiencing signicant benets, including
growth in personal strength and resilience, as a result of
working with people who have experienced complex trauma.
Mainstreaming complex trauma work will require workers
and workplaces to adopt active vicarious trauma prevention
strategies. It is likely that services that are not trauma-informed
in their approach to clients are also not trauma-informed in
their approach to their employees. Formal vicarious trauma
prevention and management frameworks are critically
important, and ideally foster informal workplace cultures of
debrieng and mutual support that are optimal for worker
health and wellbeing. Workplaces have a key role in promoting
and building upon these benets.
Strengths and limitations of the study
e focus of the study was on t he narratives and understand ings
of women with experience of complex trauma and the
professionals who work with them. e study foregrounded
the voices of women and professionals at the frontline of
the response to complex trauma, drew on their insights and
expertise to recommend improvements to policy and practice,
and demonstrated how patterns of disadvantage as well as
dignity and resilience can be reproduced through multiple
systems and services. However, the study has a number of key
limitations. e policy review was limited to publicly available
information that could be ascertained via website searches
and so the research team could not gather information on
policy documentation and approaches unavailable on public-
facing websites. e interviewees were self-selecting, which
produced a cohort of a) women who all spoke English and
were predominantly (although not exclusively) heterosexual,
cisgendered Anglo–Australians; and b) professionals who were
highly trauma-literate. ere is a need for further research
into broader cohorts of women who have experienced complex
trauma, as well as with professionals who are unfamiliar with
trauma-informed practice.
Domain-specic recommendations
Public policy
Prevent and reduce the intergenerational impact of
childhood trauma via:
pre- and post-natal care and screening for abuse
and violence
trauma-informed parental and family support
early intervention for boys and girls exposed to trauma.
Embed trauma-informed care within a holistic wellbeing
framework that integ rates mental, physical a nd psychosocial
Improve access to comprehensive treatment for complex
trauma under current policy arrangements, including
Medicare and the NDIS, to minimise short-term and
disjointed interventions and treatment.
Implement acute intervention services for women being
domestically tracked, exploited and enslaved.
Ensure sustained and long-term funding for specialist
trauma programs and services.
Integrate trauma care into health and medical training,
covering psychological, physical and behavioural impacts
and implications for professionals interacting with clients.
Implement protocols for the compassionate treatment of
“A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
self-harming individuals in a range of settings, including
emergency departments.
Ensure clear pathways for clients impacted by complex
trauma to effective care, with “warm referrals” and
collaboration between services.
Mainstream the acknowledgement and treatment of
comorbidity in mental health and AOD settings and
address barriers to comprehensive mental health/substance
abuse treatment.
Invest i n vicarious trauma a nd burnout prevention among
health sta and actively promote and foster salutogenic
eects through service design and culture.
Build and promote trauma-informed cultures within
and between health services through an explicit focus
on identifying and meeting clients’ needs, and promote
the recovery, resilience and autonomy of people with
experiences of complex trauma.
Mental health
Implement mental health workforce planning to ensure
that professionals have the skills to meet demand for
services in complex trauma and dissociation.
Provide outpatient and inpatient complex trauma and
dissociation care.
Reform tertiary education and accreditation for
psychiatrists and clinical psychologists. Curricula should:
discuss the roles of trauma and complex trauma in
mental illness and distress
provide an overview of available treatment modalities
address the mental, physical and psychosocial
dimensions of trauma
include the dissociative disorders
destigmatise emotional dysregulation, psychosocial
diculties and other issues categorised as “borderline”.
Develop and implement non-traumatising models of
involuntary care.
Develop a network of trauma-informed professionals
and services.
Law enforcement and prosecution
Implement trauma-informed policing: all police need
training in trauma and complex trauma presentations.
Promote partnership models where police attend mental
health incidents with allied health.
Implement intelligence-based policing: violence and abuse
can be very complex and require careful police work.
Implement trauma-informed prosecution, including
continuity of contact and care in a case from a trusted
individual, with careful handover from police to
prosecution, and from lawyer to lawyer.
Child protection services
Conduct further research on the experience of women
who have experienced complex trauma as parents in the
child protection system. Key issues agged in this study
questions about whether assessments of parenting
reect current knowledge and practice on trauma
and attachment
a lack of access to non-stigmatising early intervention
and family support services.
Improving interagency collaboration
Encourage whole-of-government commitment to the
implementation and coordination of trauma-informed
practice across sectors.
Identify and prioritise women with experiences of complex
trauma within public policy and service frameworks.
Conduct an audit to identify barriers to serv ice cooperation
for women with experiences of complex trauma, with
participation from service consumers.
12 “A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
“someone who can listen”, whether a family member, a friend,
or a counsellor, or else “you feel you are not even loved like
and everything you do, it’s all wrong”. For Jeannette, and for
many women, the journey from the iniction of that “deep
wound” to nding “someone who can listen” was oen long
and hard. is report outlines the ndings of a study into
that journey, and the ways in which services and agencies
can improve their responses to women with experiences of
complex trauma.
Our study
e concept of complex trauma emerged in the early 1990s
from the work of pioneering feminist psychiatrist Judith
Herman (1992). In the aermath of the Holocaust and the
Vietnam War, the notion that the human mind can be injured
by overwhelming or violent events had been recognised
with the inclusion of post-traumatic stress disorder in the
1980 edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM) (the formal diagnostic tool of the
American Psychological Association). However, Herman
(1992) identied that the traumatic injuries of interpersonal
abuse, such as child abuse or domestic violence, required a
specic response. She formulated the notion of “complex
post-traumatic stress disorder” (cPTSD) to fully capture the
symptoms and experiences of those who have experienced
prolonged, entrapping and frightening abuse in interpersonal
life. Almost a generation later, cPTSD has been incorporated
into international diagnostic manuals (to be discussed further
in the State of knowledge review). However, it is broadly
recognised that current treatment and policy approaches are
not suciently attuned to the challenges of complex trauma,
and this has signicant implications for public health and
community wellbeing (Ford, 2015).
While the notion of complex trauma originates in clinical
practice and research, it is not a medical diagnosis akin
to cPTSD. Instead, it describes the diverse aereects of
experiences such as child abuse, domestic violence, sexual
assault and stalking, and recognises that these experiences are
not discrete but oen cluster and overlap (Ford & Courtois,
2009). One in four Australian women have experienced
sexual abuse as a child (Child Family Community Australia
[CFCA], 2015) and one in ve Australian women has been
So, for me, about the trauma, it’s something—it’s like—
is it a wound, like when you cut yourself? It’s like a
deep wound under your heart. It’s never healed. It can
be covered with plaster, but it will never get dry and
heal. It’s like it was still there. Unless if they take o my
brain and bring someone else’s brain, but I will never
forget it. (Jeanette)
e title of our report was inspired by the story of Jeanette,
a Rwandan woman living in Australia who survived the
genocide in her home country. She was in her early teens
at the time of the genocide, now over a quarter of a century
ago. Aer the genocide, she had to ee to another country;
she came to Australia as a refugee a decade ago. She recalls
the genocide as a real-life “horror movie” that still plays
inside her head when she is confronted with reminders of
that time. Additionally, “When I’m sad, when I feel lonely,
when I have no one talk to, it always comes back like that.”
For Jeannette, trauma was not solely an individual experience.
Trauma reverberated throughout her Rwandan–Australian
community in the absences of loved ones lost to genocide, the
presence of traumatised family and friends, the vocal grief of
public memorials, and in t he silences that can engulf women’s
experiences of conict and forced migration. While some
trauma, such as political conict, is publicly acknowledged,
those traumas that dierentially impact women, such as sexua l
violence, are oen hidden and unspoken. Jeannette said:
I wish someone can listen to me in my language, like just
listen to what I said, but because we all went through, it’s—
and we lose trust—we lost our trust in our community—
what happened because there’s some really bad thing and
no one—sometimes feel even ashamed to tell someone you
know that you’ve been raped when genocide [happened],
and there is some people who went through that, but
they need—I don’t know how they can make them talk
and—or whatever they did, but sometimes for me, I felt
like when I talk and from—even if you don’t listen—you
don’t know what I’m talking about, sometimes it really
releases me. It’s like—yeah, I feel like I’m okay now. But
hiding it, covering it, it kills people out.
For Jeannette, sharing the “deep wound” of trauma could
“release” its pain. Her advice to other women was to nd
“A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
Despite their many differences, the women we spoke to
expressed similar sentiments to Jeannette, who described
the wound of complex trauma as both deep and hidden
“under the heart”, unseen by others and sometimes unknown
to the woman, too. Women explained how the injuries of
the past endured in the present through unresolved grief,
shock and anxiety; through chronic pain and fatigue; and
through feelings of loneliness and challenges in relationships.
ese experiences oen propelled women to seek help and
understanding from many dierent sources, i ncluding ser vices
and agencies, while also drawing on their own resources. In
interviews, they described the strengths, skills and insights
they developed as they navigated through the impacts of
trauma on their lives.
We also interviewed 63 professionals from a range of services
who work with individuals with experiences of complex
trauma living in New South Wales and Queensland. We asked
workers what “trauma” and “complex trauma” meant to them,
and about their professional experience and practices with
clients who have experienced complex trauma. ey came
from many dierent sectors: mental health, community health,
homelessness, alcohol and other drugs (AOD), community
legal centres, sexual assault, domestic violence, multicultural
services, refugee services, and disability. Some were frontline
workers and others were managers and coordinators. ey
volunteered for our study because they were passionate about
the issue of complex trauma which they uniformly felt was a
crucial underlying problem for many or most of their clients.
While they were oen highly trauma-literate in their own
practice, the workers who we interviewed agreed with women
that it was very dicult to nd “someone who can listen” to
complex trauma stories in the Australian service landscape.
Across sectors, appropriate and eective responses to women
with experiences of complex trauma were grounded in a
variety of forms of “listening” and sensitivity to hidden needs
and vulnerabilities. Interestingly, listening for and to trauma
was not only positive for women with experiences of complex
trauma. Many professionals insisted, emphatically, that their
own strength and resilience had grown as they listened to and
learnt from their clients. ey also identied many systemic
obstacles across the Australian service system to these kinds
of mutually benecial interactions between professionals and
women with experiences of complex trauma.
sexually assaulted aer the age of 15 (Australian Bureau of
Statistics [ABS], 2017). One in four report physical violence
from a current or former partner, and one in six women has
been stalked (ABS, 2017). However, one quarter of women
reporting any form of gender-based violence in Australia
report experiencing at least three dierent forms, such as
child sexual abuse, sexual assault and domestic violence
(Rees et al., 2011). The experience and impacts of these
multiple forms of victimisation can be understood in terms
of complex trauma, with the recognition that not all children
and women will be impacted in the same way.
e aim of our study is to examine current responses to
women with experiences of complex trauma, and to develop
a blueprint for policy and service reform that is practical and
achievable. We did not just want to know what was wrong
with current responses. We wanted to know what was right,
too. We also wanted to know, for example:
which services and professionals are doing a good job with
women who have experienced complex trauma
the views of women with experiences of complex trauma
about the current state of service provision to them
how professionals across a range of sectors understand
complex trauma and respond to it in their practice.
We interviewed 103 people who felt passionately about these
questions. is report presents their answers.
We interviewed 40 women living in New South Wales and
Queensland who had experienced complex trauma. We did
not narrowly dene “complex trauma”. Rather, we asked
women in interviews what “trauma” and “complex trauma”
meant to them, since a key focus of the study was to examine
the various ways that trauma was understood by women and
service providers. e women who spoke to us were diverse.
ey ranged in age from their early twenties to their late
sixties, and lived in urban, regional and remote areas. ey
came from dierent cultural and social class backgrounds
and had lived through many dierent forms of trauma across
their lives: child abuse, neglect, removal from their families
of origin, sexual assault, domestic violence, trafficking,
sexual exploitation, poverty, disadvantage, and experiences
of oppression and discrimination.
14 “A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
The structure of the report
e report begins with a review of the relevant literature,
focusing on what we know about the causes and impacts of
complex trauma as well as understandings of trauma-informed
care. ere are already a range of excellent guidelines for
trauma-informed practice with clients in a range of specialist
sectors, and the intention of our study was not to attempt
to replicate or repeat their recommendations, which have
been drawn up by practitioners and scholars with in-depth
knowledge of their particular communities and sectors.
Instead, the literature review aimed to summarise this work
so that our research could build on it further. e next section
provides an overview of the research methodology, including
our theoretical approach.
e report then presents the outcomes of our multi-method
research project. e State of knowledge review presents an
overview of the existing literature on trauma impacts and
pathways, and documentation on multi-sectoral, trauma-
informed practice frameworks, and is followed by the
Methodology. Chapter 4 outlines our policy analysis related
to complex trauma in Australia, involving an analysis of
the ways in which complex trauma is addressed in policy
frameworks at Commonwealth, state and territory levels.
Chapter 5 describes how women and workers dened “trauma”
and “complex trauma” and distinguished between them,
grounded in women’s accounts of trauma as a psychosocial and
embodied experience. While trauma is oen conceptualised
as a psychological problem, women’s narratives included a
strong focus on the somatic and relational dimensions of
trauma. is chapter also discusses how women developed
unique skills and strengths in their self-management of
trauma impacts.
Chapter 6 presents qualitative data on the health response to
complex trauma from the perspectives of both women and
professionals working in this sphere, whom we refer to as
“workers”. e chapter addresses a number of systemic issues
in the health system, including the hegemony of a biomedical
model of mental illness and the widespread misdiagnosis and
maltreatment of women wit h experiences of complex t rauma.
e chapter then highlights those elements of best practice
identied by workers and women. Chapter 7 discusses the
encounters of women with experiences of complex trauma
with agencies with legal and statutory power, such as criminal
justice, child protection and family law courts. is chapter
highlights a continuity of misunderstanding and stigma
experienced by women with experiences of complex trauma
across those services and agencies ostensibly tasked with
protecting them and their children from harm. e chapter
points to promising practices that oer women a dignied
and hopeful experience of legal processes.
Chapter 8 considers the role of workplaces and service
systems in supporting professionals to support women with
experiences of complex trauma. e chapter summarises how
vicarious trauma has been conceptualised in the scholarly
literature and draws on interviews with workers and women
to illustrate the complexity of trauma in the workplace.
While emphasising the need for institutionalised support
for professionals encountering complex trauma, the chapter
acknowledges the deeply meaningful and compelling nature
of complex trauma work, and the joy that many workers
experienced in their encounters with services.
The Conclusion draws together our policy and practice
recommendations, identies models of best practice and
points to future research work.
“A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
State of knowledge review
Review methodology
Given the wide-ranging nature of this topic, we employed
a narrative scoping review methodology to survey the state
of knowledge across relevant research areas, including
psychological and psychiatric studies of trauma, patterns of
violent victimisation and psychological responses, and models
of TIC. Narrative scoping review methodologies thematise
and synthesise research ndings, support theory building
and provide scope for the identication of research strengths
and gaps (Baumeister & Leary, 1997). e multiple, exible
aims of a narrative methodology provide an appropriate
framework for literature reviews that address multiple
research areas and call for some conceptual clarication. e
terms “trauma” and “complex trauma” are routinely used in
research and professional literature without a clear denition
or apparent consensus on what they refer to, and there is a
clear need for a critical summary of conceptualisations of
complex trauma and related areas of practice that identify
points of strength and complementarity as well as points of
dierence or disagreement.
Peer-reviewed literature was initially located using a range of
databases accessed via Western Sydney University, including
Family and Society Collection, Health and Medical Collection,
PsychInfo, Proquest, PubMed, Psychology and Behavioural
Sciences Collection, Social Services Abstracts, and SocIndex.
An initial search on “complex trauma” was undertaken and
followed by further searches to explore gaps in the literature:
post-traumatic stress disorder OR posttraumatic stress
disorder OR PTSD AND dissociative subtype
complex PTSD OR complex posttraumatic stress disorder
OR complex post-traumatic stress disorder
borderline personality disorder OR BPD AND trauma
dissociative disorders OR dissociative identity disorder
AND trauma;
child sexual abuse, CSA, child physical abuse, emotional
abuse, psychological abuse, neglect, child abuse, child
maltreatment, adverse childhood events, ACEs, witnessing
domestic violence, child pornography
revictimisation OR revictimization.
e notion of “complex trauma” was rst popularised by
Judith Herman (1992) and is now widely used in a range of
professional sectors and social movements. Complex trauma
refers simultaneously to complex forms of interpersonal
victimisation, involving repeated incidents of abuse and
betrayal, and the complex traumatic and dissociative
symptomology that results from it (Ford & Courtois, 2009).
Complex trauma is distinguished from single-incident trauma,
such as a car accident or a mugging, which can induce an acute
traumatic reaction, as well as post-traumatic stress disorder
(PTSD), which was originally formulated in 1980 to describe
the symptoms of returned Vietnam servicemen. While the
sequelae of complex trauma can include symptoms of PSTD,
they also encompass chronic alterations to identity, memory
and relationships with ot hers, as well as psychosocial problems
such as self-harm, suicidality and substance abuse. Complex
trauma is associated with sustained violation and betrayal
in interpersonal relations, intersected by social inequalities
such as sexism and racism that increase the risk of trauma
and compound its harms (Herman, 1992).
is literature review draws together contemporary research
on the multiple paradigms of complex trauma before going
on to examine how treatment and support for those who have
experienced complex trauma is being operationalised and
applied in policy and practice under the rubric of trauma-
informed care (TIC). e review suggests that complex trauma
emerges through the dynamic intersection of traumatising
abuse, psychological adjustment and adaptation, and social
and systemic responses. Where appropriate, the review makes
critical comment on current strengths and weaknesses of the
empirical literature. Much of the available information on
TIC involves “grey” literature that provides recommendations
for changes to individual and organisational processes and
practices, with some consideration given to drivers of and
obstacles to system change. Building on recent Australian
literature reviews (Quadara, 2015), our review provides a
summary of TIC in health-related elds before discussing
emerging areas of TIC, including Aboriginal and Torres
Strait Islander models of trauma care and trauma-informed
policing and legal practice. e review includes discussion of
the risks and benets of working in the complex trauma eld.
Finally, the literature review proposes a multi-dimensional
and inclusive denition of complex trauma and points to
key gaps in research and knowledge.
16 “A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
child is blamed or shamed for their abuse (Ullman, 2007).
e qualitative research of Hegarty et al. (2017) with adult
survivors of sexual violence emphasised how the development
of mental illness aer sexual abuse or rape can be exacerbated
by isolation, stigma, the dismissal of disclosures or blaming
the victim for her abuse. Such experiences of powerlessness
and betrayal during or following assault are linked to social
structures of sexism, racism and other axes of oppression,
emphasising that the risk of complex trauma is heightened
for disadvantaged or marginalised groups (Salter, 2012).
e following section examines how complex trauma has been
constructed and examined in psychiatric and epidemiological
research, with a focus on the symptomatology of traumatic
response and dissociation and subsequent patterns of
developmental trauma and revictimisation. It includes
discussion of research on ext reme abuse and intergenerational
transmission of trauma. While research ndings remain
largely consistent regarding the relation of abuse and violence
to traumatic symptomatology and subsequent eects on
biopsychosocial wellbeing and vulnerabi lity to further violence,
the repetition of cross-sectional studies is notable, stymieing
the development of a more robust evidence base. In particu lar,
research ndings remain focused on associations rather than
causative attributions between violence and its impacts due to
a lack of longitudinal and cohor t methodologies. Furthermore,
the absence of an empirically sound theoretical framework of
complex trauma, elaborating upon its individual, relational,
community, systemic and transgenerational dimensions,
prevents the systematisation of research ndings in such
a way that would guide policy and practice interventions
beyond clinical settings.
Traumatic and dissociative symptomatology
In contemporary psychiatry, post-traumatic stress disorder
(PTSD) is considered the primary mental disorder arising
from exposure to potentially traumatic events. Post-traumatic
stress disorder is defined specifically in relation to the
experience of a traumatic event and involves fear-based
symptoms directly related to this exposure. PTSD, however,
is not the only mental disorder related to trauma. Rates of
trauma are elevated across a number of disorders including
dissociative, personality and substance use disorders. us, a
“Grey” literature (that is, research that has not been
commercially published, including government reports,
policy statements and issues papers) is an important source
of information on complex trauma and TIC. Key reports
and resources were identied via Google and Google Scholar
searches using the terms “complex trauma” and “developmental
Pathways and outcomes
of complex trauma
Experience of complex trauma is a dynamic process between
recurring traumatic events, physiological and psychological
sequelae, and interpersonal and relational contexts. As is well
articulated in Change the Story: Australia’s National Framework
on Preventing Violence against Women and their Children
(Our Watch, Australia’s National Research Organisation for
Women’s Safety [ANROWS], & VicHealth, 2015), abusive
relationships and individual and collective reactions to them
are mediated by institutions, structures and social norms
and values. From this socio-ecological perspective, complex
trauma occurs at the intersection of violence perpetration
and victim adaptation, within a broader context that may
enable the violence to take place while oen failing to oer
the victim a protective response. Complex trauma necessarily
implicates social inequalities along the lines of gender, race,
class and other factors that can increase the risk of violence
and abuse while also diminishing a supportive or protective
response in its aermath (Herman, 1992).
An intersectional, multi-factorial understanding of complex
traumatisation helps to explain why not all abusive or violent
experiences necessarily result in traumatisation. For example,
large-scale surveys of American adults have found that over
half the population has been exposed to at least one form of
childhood adversity (including abuse, neglect and household
dysfunction) (Felitti et al., 1998). While developmental
trauma is oen equated with complex trauma, the majority
of these children exposed to trauma will not go on to develop
problems that can be described as responses to complex
trauma. However, complex trauma is a likely outcome
where abuse is repeated and severe, occurs across multiple
domains or involves multiple perpetrators, and where the
“A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
negative self-concept and disturbed relationships (Hyland,
Shevlin, Brewin, et al., 2017).
ere is growing and consistent evidence for the separate
diagnostic category of cPTSD as dened by ICD–11. Several
studies have conrmed the distinct structure of PTSD versus
cPTSD across a range of populations with high exposure
to complex trauma, including child sexual abuse victims
and refugee populations (Ben-Ezra et al., 2017; Hyland,
Shevlin, Elklit, et al., 2017; Kazlauskas, Gegieckaite, Hyland,
Zelviene, & Cloitre, 2018; Nickerson et al., 2016; Palic et al.,
2016; Shevlin, Hyland, Karatzias, Fyvie, et al., 2017). What
is less clear is whether the type of trauma can distinguish
between the two categories, with complex trauma explicitly
linked to cPTSD and single incident trauma associated with
PTSD. For example, the ndings for child maltreatment
(CM)—commonly conceived as complex trauma—have been
inconsistent (Hyland, Murphy, et al., 2017). Some studies have
found elevated rates of CM among individuals diagnosed
with cPTSD compared to individuals diagnosed with PTSD
(Palic et al., 2016; Shevlin, Hyland, Karatzias, Fyvie, et al.,
2017); however, other studies have failed to nd a dierence
between the two groups. Such inconsistencies may be due to
dierences across studies in the measurement of CM (this
is considered in more detail in the next section). is type
of evidence would conrm a distinct aetiological pathway
associated with exposure to specic traumatic events and
also provide evidence of clinical meaningfulness (Palic &
Elklit, 2014; Resick et al., 2012).
The most recent edition of the DSM–5 chose a different
conceptualisation of PTSD. Rather than endorsing a separate
cPTSD diagnosis, the construct of PTSD was revised to
more explicitly capture traumatic sequelae. The revised
classication tightened the denition of trauma exposure
(thereby restricting the traumatic experiences on which
a diagnosis could be made) and expanded the number of
symptom clusters by including a fourth group of symptoms
related to negative cognitions (Galatzer-Levy & Bryant, 2013;
Murphy et al., 2018; Perkonigg et al., 2016). e evidence for
this conceptualisation is underwhelming. A number of studies
utilising modelling techniques to detect dierent groups or
clusters of symptoms have failed to conrm the four symptom
groups described by the DSM–5 (Armour, Mullerová, & Elhai,
number of researchers and clinicians have argued t hat trauma
is a transdiagnostic or non-specic risk factor for mental
disorder (Freedman, 2017; Lewis et al., 2019; Schore, 2003).
However, there is a distinction between mental disorders
where trauma is a precipitating factor—such as PTSD—
versus disorders where trauma is better conceptualised as
a predisposing factor (Friedman et al., 2011). With this in
mind, this section reviews the evidence related to PTSD and
recent debate regarding its conceptualisation in relation to
complex trauma.
Complex post-traumatic stress disorder
PTSD was initially conceived in relation to single-incident or
combat trauma, and it has been argued that it is inadequate
to describe the diverse presentations accompanying more
complex experiences of trauma (Taycan & Yildirim, 2015).
Complex PTSD (cPTSD) was therefore understood as a
distinct psychiatric category for responses to complex trauma,
with a focus on the experiences of women and children
subject to prolonged patterns of abuse and powerlessness.
However, there has been debate about whether responses to
complex trauma should conceive of it as a single diagnostic
category (i.e. cPTSD) or a pattern of personality and other
mental disorder comorbidities (Resick et al., 2012). Other
researchers have argued that cPTSD oers a simplied and
coherent diagnostic category and thus reduces the over-
pathologising of individuals by using multiple diagnoses to
explain a person’s presentation (Nickerson et al., 2017). at
is, in the absence of a cPTSD diagnosis, an individual might
be given multiple diagnoses covering dissociative, anxiety
and mood diagnostic categories.
The two diagnostic systems—Diagnostic and Statistical
Manual for Mental Disorders (DSM) and the International
Classication of Diseases (ICD)—have responded dierently to
these debates. While the DSM–5 retained a single diagnostic
category of PTSD and created a dissociative subty pe (Murphy
et al., 2018; Perkonigg et al., 2016), the ICD–11 described
two “sibling” disorders of PTSD and cPTSD. In the ICD–11,
PTSD was described as a fear-based response to trauma
including the traditional hyperarousal, avoidance and
re-experiencing symptoms. cPTSD additionally includes
disturbances in self-organisation (DSO) which are dened
in terms of three symptom clusters: emotion dysregulation,
18 “A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
injury and multiple suicide attempts (Carlson, Dalenberg,
& McDade-Montez, 2012).
Chronic traumatic stress of an interpersonal nature is strongly
associated with dissociative experiences. As such, dissociation
has been construed as a defence against overwhelming
experiences from which no physical escape is possible (as
is the case, for example, with CM and torture) (Lanius,
2015). Studies controlling for general psychological distress
demonstrate significant, moderate associations between
trauma exposure and dissociation, lending support to the
idea that dissociation is a traumatic response rather than a
response to general distress (Carlson et al., 2012).
PTSD-related dissociative symptoms have been described
along three dimensions (Carlson et al., 2012):
loss of continuity in subjective experience as reected in
re-experiencing symptoms
inability to access or control mental functions as reected
in gaps in awareness
experiential disconnectedness such as depersonalisation
and derealisation.
A review of studies exploring dissociation in relation to PTSD
(Carlson et al., 2012) showed that dissociative experiences
peak in the aermath of trauma and gradually decline over
time for most people. A signicant minority of individuals
exposed to trauma, however, continue to experience high
levels of dissociation. Studies comparing dissociation among
participants exposed to trauma with and without PTSD have
found a strong association between dissociation and PTSD
which persists even when dissociative PTSD symptoms
(such as re-experiencing) are removed. e studies reviewed
also showed that the severity of dissociative symptoms
was positively related to the severity of PTSD symptoms
experienced. ese ndings suggest PTSD and dissociation
are phenomenologically related in some people, however the
mechanism by which these two constructs are interrelated
is not yet fully understood (Bryant, 2007).
Given this evidence, the DSM–5 specified a dissociative
subtype of PTSD (i.e. D-PTSD) and makes a distinction
between PTSD symptoms that are conceptually related to
2016; Chen, Yoon, Harford, & Grant, 2017; Cyniak-Cieciura,
Staniaszek, Popiel, Praglowska, & Zawadzki, 2017; Murphy
et al., 2018). Instead, up to seven factors have been identied
(including symptom clusters related to anxious arousal,
dysphoric arousal and externalising behaviour), indicating
the construct of PTSD is not adequately conceptualised by
the current DSM–5 criteria.
Criticisms have also been made regarding the large number of
symptoms specied by t he DSM–5 which yield an ext raordinary
number of combinations from which a diagnosis of PTSD
could be derived (Galatzer-Levy & Bryant, 2013). Relatedly,
prevalence estimates of PTSD have varied considerably
across these different models, from 22 percent based on
the DSM–5 four-factor model to 10 percent based on the
seven-factor hybrid model (Murphy et al., 2018; Shevlin,
Hyland, Karatzias, Bison, & Roberts, 2017). Moreover, the
degree of risk attributed to CM also depended on the model
used, raising further questions about whether PTSD is being
consistently diagnosed across the dierent models (Shevlin,
Hyland, Karatzias, Bison, & Roberts, 2017).
It seems that the ICD–11 complex PTSD may be better tha n the
DSM–5 PTSD construct at capturing the diversity of trauma
experiences found in bot h community and clinica l populations.
For example, in a community sample of African–American
women, severity of CM and multi-type exposure was higher
among those classied with ICD–11 cPTSD compared to those
classied with DSM–5 PTSD. Psychiatric burden was also
higher among the women with cPTSD despite similarities
in overall trauma exposure between the two groups (Powers
et al., 2017). Other researchers have similarly argued that
the two classications are diagnostically distinct (Hyland,
Shevlin, Fyvie, & Karatzias, 2018).
Dissociation as a marker of complexity
Dissociation refers to an inability to integrate objective
experience into conscious awareness and is ref lected in
alterations in memory, emotion, identity and behaviour.
Dissociative symptoms can range from non-pathological,
transient lapses in awareness through to severe identity
dissociation. Dissociation represents signicant distress,
and is associated with high rates of suicidal ideation, self-
“A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
dissociation (e.g. ashbacks and emotional numbing) and
additional dissociative symptoms of depersonalisation and
derealisation (which refers to a state in which a person’s
thoughts and feelings seem unreal or as though they belong to
someone else) (Lanius, Brand, Vermetten, Frewen, & Spiegel,
2012). This conceptualisation assumes that dissociation
may be, but is not always, part of a traumatic response
and is consistent with commentary in the literature on
the prevalence of dissociation following trauma exposure
(Bryant, 2007; Hansen, Ross, & Armour, 2017). It can also
be implied that the presence of dissociation indicates greater
severity of post-traumatic distress. Only a few studies have
examined the structure of D-PTSD. Most of these studies
have found the severity of dissociation—rather than specic
types of dissociative symptoms—dierentiates between the
two PTSD constructs (Burton, Feeny, Connell, & Zoellner,
2018; Frewen, Brown, Steuwe, & Lanius, 2015; Hansen et al.,
2017). Further research is needed to clarify the dissociative
processes reected in the D-PTSD construct, including better
delineation and measurement of the dierent dissociative
symptoms (Bryant, 2007; Hansen et al., 2017).
The most severe dissociative disorder is diagnosed as
dissociative identity disorder (DID), characterised by the
presence of two or more distinct personality states that
recurrently take control of the individual’s behaviour,
accompanied by amnesia for everyday and life events that
cannot be explained by ordinary forgetfulness (International
Society for the Study of Trauma and Dissociation, 2011).
DID typically develops in children subject to chronic and
overwhelming abuse from early childhood, inhibiting the
development of a coherent worldview and self-identity (Spiegel
et al., 2011). Substantiated reports of CM in people with
DID include burning, mutilation and sexual exploitation
(Otnow, Yeager, Swica, Pincus, & Lewis, 1997). In addition to
a disruption of identity and memory, people diagnosed with
DID typica lly experience a range of other problems, including
depression, suicidal thoughts and self-harm, anxiety, and
vulnerability to physical and sexual victimisation. Research
in multiple countries using a variety of methodologies nds
that DID occurs in approximately 1 percent of the general
population, and up to one h of patients in inpatient and
outpatient mental health settings (Spiegel et al., 2011).
Complexity of post-traumatic
stress among marginalised populations
In the general Australian population, lifetime trauma
exposure among women has been reported to be 74 percent
(Mills, Teesson, Ross, & Peters, 2006). While this rate is
similar among men, women were found to have a higher
prevalence of specic trauma types such as physical violence
from an intimate partner, rape, sexual assault, stalking and
witnessing domestic violence. Among women with experiences
of trauma, about two thirds (63%) had experienced multiple
types of trauma and almost 75 percent had experienced
multiple episodes. e overall prevalence of PTSD (based
on DSM–IV classication)1 among Australian women was
found to be 9.7 percent (Chapman et al., 2012).
The rate of trauma exposure and PTSD is much higher,
however, among marginalised populations such as asylum
seekers and refugees, people experiencing homelessness, or
people with substance use problems. e reason for these
elevated rates is thought to relate to the complexity of the
social environment in which these people live, involving
multiple stressors.
Refugees and women seeking asylum
Refugee populations are exposed to persecution, political
imprisonment, torture, sexual exploitation, and mass trauma
or genocide (Nygaard, Sonne, & Carlsson, 2017; Palic & Elklit,
2014). Additionally, displacement experiences can mean a
loss of interpersonal connections and support; limited or no
access to eective systems of justice; uncertainty of living
situations, including perceived safety and security; and loss
of meaningful activities (such as employment) that provide
purpose and identity (Nickerson et al., 2017; Nickerson, Steel,
Bryant, Brooks, & Silove, 2011; Silove, 2013). Such factors
operating in the post-trauma environment have been found
to increase levels of post-traumatic stress (Li, Liddell, &
Nickerson, 2016; Porter & Haslam, 2005). As a result, refugees
exposed to trauma oen present with diverse symptoms that
do not necessarily t within a PTSD diagnosis.
1 Australian estimate s of ICD–11 PTSD and complex P TSD and DSM–5
PTSD and D-PTSD are not available.
20 “A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
Women experiencing homelessness
Trauma features strongly in the history of many homeless
people. Research has found the lifetime prevalence of trauma
to be almost ubiquitous among homeless persons, with
estimates of 90–100 percent reported (Buhrich, Hodder, &
Teesson, 2000; Larney, Conroy, Mills, Burns, & Teesson,
2009; Mission Australia, 2012; Taylor & Sharpe, 2008).
The rates of PTSD are similarly high and greater than
those found in general populations. For example, Taylor
and Sharpe (2008) used a structured clinical interview to
diagnose PTSD in an inner-Sydney sample of homeless
individuals and found a lifetime prevalence of 79 percent and a
12-month prevalence of 41 percent. In the only other published
Australian study to examine PTSD among homeless adults,
57 percent of participants recruited from an inner-Sydney
crisis accommodation service screened positive for past month
PTSD as measured by the Trauma Screening Questionnaire
(Larney et al., 2009). Unfortunately, neither of these studies
reported prevalence by gender; international research,
however, has found rates of trauma exposure and associated
mental health problems to be greater among homeless women
compared to homeless men (Hutchinson, Page, & Sample,
n.d.; Tinland et al., 2018). In particular, homeless women
have reported multiple and repeated experiences of physical
and sexual violence that begin in childhood and continue
into adulthood (Browne & Bassuk, 1997).
Compared to the Australian general population, homeless
persons have more experiences of interpersonal traumas
(such as sexual and physical assaults) that carry a greater
risk of developing PTSD (Buhrich et al., 2000; Conroy et al.,
2014). While there is some evidence that trauma and PTSD
precede the onset of homelessness for many people (Taylor
& Sharpe, 2008), few Australian studies have investigated
the interrelationship of trauma exposure, mental health and
homelessness over time. is is an important gap given the
high rate of violent re-victimisation that people experience
while homeless (Larney et al., 2009).
Women with substance use problems
It is fairly well established that women with substance use
problems have extensive histories of trauma, including child
maltreatment, intimate partner violence and other sexual
violence (Dore, Mills, Murray, Teesson, & Farrugia, 2012;
The extent to which the current ICD–11 and DSM–5
conceptu alisations of PTSD are relevant to refugee populat ions
has been examined by a number of studies. ese studies
suggest that additional descriptors are needed to appropriately
describe post-traumatic distress for this group, in order to
facilitate appropriate and targeted support. For example,
compared to other groups exposed to trauma (e.g. combat-
related trauma and motor vehicle accidents), refugees
demonstrate less belief in positive world assumptions (ter
Heide, Sleijpen, & van der Aa, 2017). is nding was not
explained by dierences in trauma exposure as both refugees
and individuals exposed to combat had experienced prolonged
trauma. e authors suggested that such changes in world view
may reect experiences of discrimination and post-migration
stress (including low social status) in the host country.
Similarly, other researchers have suggested that a sense of
persistent injustice is related to post-traumatic distress in
refugee populations (Tay, Rees, Chen, Kareth, & Silove, 2015).
Additionally, trauma appears to have a greater impact on
relatedness in collectivist cultures, which suggests symptoms
of diminished self (as articu lated in DSM and ICD diagnostic
categories) may be less relevant for this population. For
example, loss and grief have been found to complicate post-
traumatic distress in refugee populations at both an individual
and family level (Nickerson, Bryant, et al., 2011). Another
study identified a group of refugees who did not wholly
qualify for a PTSD diagnosis but had elevated distress and
high functional impairment related to re-experiencing and
avoidance symptoms (Minihan, Liddell, Byrow, Bryant, &
Nickerson, 2018). It was suggested that this elevated distress
reected the ongoing threat to self and family that can be
experienced in this population even aer resettlement in a
new country.
A handful of studies have confirmed that the symptom
prole of traumatised refugees is better described by the
ICD–11 cPTSD diagnosis (Nickerson et al., 2016; Tay et al.,
2015). Prevalence of PTSD and cPTSD was reported to be
20 percent and 33 percent respectively among treatment-
seeking refugees re-settled in Switzerland (Nickerson et al.,
2016), which is much higher than estimates reported for the
European general population.
“A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
PTSD symptoms were found to be interrelated over time in a
drug treatment sample (63%) (Barrett, Teesson, & Mills, 2014).
Developmental trauma
Developmental trauma refers to trauma that occurs in
childhood and adolescence. Exposure to trauma during these
developmental periods can have signicant impacts on brain
structure and functioning and create long-term vulnerabilities
for physical, psychological and social wellbeing (De Bellis &
Zi sk, 2 014). Much of the literature on developmental trauma
is concerned with child maltreatment (including witnessing
domestic violence), however it also includes other types of
trauma exposure, and it is the collective impact of repeated
or multiple exposure to trauma during key developmental
periods that contributes to a complex trauma presentation
(Bifulco and Moran, 1998).
Child maltreatment encompasses a range of related but
distinct behaviours including sexual abuse, physical abuse,
psychological/emotional abuse and neglect. Studies have
shown that child maltreatment is a common experience.
General population surveys provide good estimates for
sexual and physical abuse, as denitions of these types are
applied with relative consistency across studies (Stoltenborgh,
BakermansKranenburg, Alink, & van IJzendoorn, 2015).
Rates of psychological abuse/emotional abuse and neglect are
more dicult to estimate because measures of these forms
of child maltreatment are less well developed. us they are
rarely included in large-scale epidemiological studies, and
assessment in community samples has been inconsistent.
Additionally, prevalence estimates are not always reported
separately for males and females. Available Australian data
is presented below.
Child sexual abuse: Child sexual abuse includes the
spectrum of unwanted or harmful sexual experiences in
childhood, including sexual activity with an adult and
non-consensual sexual activity with a minor. Australian
research into the prevalence of child sexual abuse nds
that women have prevalence rates of 4–12 percent for
penetrative abuse and 14–26.8 percent for non-penetrative
abuse (CFCA, 2015).
Child physical abuse: Child physical abuse refers to any
act of intentional physical aggression by a caregiver
Mills, Lynskey, Teesson, Ross, & Darke, 2005; Roxburgh,
Degenhardt, & Copeland, 2006; Shand, Degenhardt, Slade, &
Nelson, 2011). For example, rates of trauma exposure among
street-based sex workers in Sydney found 99 percent had
experienced at least one trauma, with much of this complex
exposure: 93 percent had experienced multiple traumas with
53 percent experiencing more than six different trauma
types, 75 percent experiencing child sexual abuse (CSA),
81 percent having been raped as an adult (37 percent while
working) and 81 percent being physically assaulted as an adult
(Roxburgh et al., 2006). e most common types of trauma
reported by women in treatment for substance use problems
include serious physical assault (51–56%); being threatened
with a weapon, held captive or kidnapped (42–59%); rape
(51–54%); witnessing someone being badly injured or killed
(42–58%); and child sexual assault (51–52%) (Dore et al.,
2012; Mills, 2013).
Similarly, rates of PTSD are signicantly elevated among
women with substance use problems and have been reported
to range from 47 percent among street-based sex workers
(Roxburgh et al., 2006) to 61 percent among people with
lived experience of heroin dependence (Mills, Teesson,
Ross, Darke, & Shanahan, 2005). ese rates are higher than
comorbidity rates detected in general population samples,
possibly because the study samples reect a more complex
trauma exposure. For example, in the 2007 National Survey
of Mental Health and Wellbeing, approximately one third of
Australian women with a diagnosis of PTSD also met criteria
for a substance use disorder (Chapman et al., 2012). Trauma
exposure and post-traumatic stress symptoms, however, were
found to pre-date the development of substance use problems
in around half of all women classied with the comorbidity. It
has been suggested that self-medication for PTSD symptoms
contributes to the development of substance use disorder
following trauma exposure (Darke, 2013).
Comorbidity of substance use disorders (i.e. being dependent
on more than one drug type) has been found to be associated
with experiences of child sexual abuse and child emotional
neglect, adult victimisation, suicide attempts, mental disorder
and prison history (Shand et al., 2011). is paints a complex
picture of psychosocial problems reinforcing each other over
time. Simi larly, although ndings were not reported separately
for females, involvement in substance use, violent crime and
22 “A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
dierent combinations of child maltreatment experiences have
found dierent outcome trajectories associated with these
(Green et al., 2010; Vaughn, Salas-Wright, Underwood, &
Gochez-Kerr, 2015). For example, Vaughn et al. (2015) found
four clusters of maltreatment and family violence exposure
among adults presenting with non-suicidal self-injury:
one group with low levels of maltreatment and family
a second group with elevated levels of sexual abuse only
a third group with elevated levels of physical abuse, neglect
and family violence
a fourth group with elevated levels across all four sub-
types (sexual abuse, physical abuse, parental neglect,
family violence).
Females accounted for all of the cases in the fourth group,
with this cluster of maltreatment exposure demonstrating
the highest rate of “clinical and personality disorders”. In
comparison, group 3 had the highest rates of substance use
disorder and criminal and violent behaviour. A recent review
paper found that although there was a lack of consensus
across studies in terms of the number of clusters found (and
the maltreatment types contained within them), there was
empirical agreement for a poly-victimised group which was
associated wit h the poorest psychosocial outcomes (Debowska,
Willmott, Boduszek, & Jones, 2017).
Impact of developmental trauma
Child maltreatment occurs during development, when
neurobiological and psychological systems are maturing.
Studies of maltreated children commonly report aberrant
physiological responsiveness, dysfunctional patterns of
attachment, and decits in self-system process (e.g. self–
other relatedness, emotion regulation) (De Bellis & Zisk,
2014). Deciencies in these key developmental processes may
underlie the later expression of mental disorder such as the
dissociative and trauma-related disorders described previously
(Cicchetti & Toth, 1997; Mullen, Martin, Anderson, Romans,
& Herbison, 1996). e literature also suggests that women
who have experienced trauma in early life are more likely
to have poorer health as adults and be higher users of the
health care system (Bonomi et al., 2008; Chartier, Walker,
& Na ima rk, 2010).
towards a child. e majority of Australian studies suggest
prevalence rates of between 5–10 percent (CFCA, 2015).
Emotional and psychological abuse: Emotional abuse
includes instances i n which the child is verbally insulted and
criticised, whereas psychological abuse comprises negative
parental behaviours such as humiliation, degradation,
terrorising, cognitive disorientation, emotional blackmail,
corrupt ion/exploitation, and deprivation of valued objects
(Bifulco & Moran, 1998; Kaufman Kantor et al., 2004).
Given the varying characteristics of this form of abuse,
Australian research has identied a prevalence range of
6–17 percent, with a likely prevalence rate of between
9–14 percent (CFCA, 2015).
Neglect: Neglect encompasses inadequate supervision
and failure to provide for the physical needs of a child,
whereas emotional neglect is dened as a lack of emotional
responsiveness and support. Australian prevalence
estimates of neglec t range from 1.6–4 percent (CFCA , 2015).
Exposure to domestic violence: Violence between parents
is sometimes considered as an additional category of
child maltreatment and sometimes viewed as a subtype
of existing categories such as neglect (e.g. failure to
protect) or psychological abuse (e.g. terrorising). It is also
strongly associated with exposure to all forms of child
maltreatment. Australian prevalence estimates range
from 4–23 percent (CFCA, 2015).
Child maltreatment tends to co-occur w ith a range of childhood
adversities such as parental conict and separation, chaotic
family and poor parental supervision, parental substance
use, social isolation, poor housing and unemployment, and
bullying and social rejection by peers (Cohen et al., 2006;
Dong et al., 2004; Symes, 2011).
Multiple exposure during childhood
e research reviewed above indicates t hat while some children
may be exposed to a single incident of child maltreatment,
many experience repeated incidents of the same child
maltreatment (see e.g. Swanston et al., 2002). ere is also
strong and consistent evidence that the dierent types of child
maltreatment tend to co-occur, thus exposing children to
multiple types of child maltreatment (Conroy, Degenhardt,
Mattick, & Nelson, 2009). Some studies that have examined
“A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
why re-victimisation occurs. Longitudinal studies or those
that take a life-course or narrative perspective would be
helpful in this regard. Moreover, dierences in the type of
victimisation included in studies (sexual versus physical) and
how these are dened (broad versus narrow denitions) also
make it dicult to tease out results. e sections following
describe the research that is available, focusing on studies
that use longitudinal designs or review methodology, or
cross-sectional studies with general population samples.
Sexual re-victimisation
ere are a number of retrospective studies demonstrating
a link between CSA and sexual re-victimisation among
women (Coid et al., 2001; Desai, Arias, ompson, & Basile,
2002; Kessler & Bieschke, 1999; Kimerling, Alvarez, Pavao,
Kaminski, & Baumrind, 2007; Van Bruggen, Runtz, & Kadlec,
2006; Werner et al., 2016). Although far fewer in number,
longitudinal studies have conrmed the association between
CSA and sexual re-victimisation in late adolescence and
adulthood (Barnes, Noll, Putnam, & Trickett, 2009; Cyniak-
Cieciura et al., 2017; Fergusson, Horwood, & Lynskey, 1997;
Gidycz, Coble, Latham, & Layman, 1993; Humphrey & White,
2000). Additionally, the association has been shown to persist
even when poverty and family environment were taken into
account (Barnes et al., 2009; Kimerling et al., 2007; Nelson,
Heath, Madden, Cooper, & Dinwiddie, 2002).
In terms of the attributes of CSA that carry greatest risk for
sexual re-victimisation, a meta-analysis of studies found
more severe incidents of CSA were associated with the
greatest likelihood of sexual re-victimisation (Roodman
& Clum, 2001). ere is limited evidence on whether risk
of re-victimisation is associated with other characteristics
of CSA. In one of the few studies examining the dierent
characteristics of CSA together, severity and duration of
CSA were found to be associated with re-victimisation, but
degree of force used or type of perpetrator were not (Arata,
2000). Another study compared the perpetrators of the re-
victimisation incidents for individuals with a history of CSA
versus peer victimisation. ose with a history of CSA were
more likely to be re-victimised by a non-intimate partner
than an intimate partner (Desai et al., 2002).
e impact of developmental trauma is driven to a substantial
degree by the nature of the trauma episode. A younger age
at trauma exposure is generally associated with poorer
outcomes, possibly because older children are psychologically
more robust and have more psychological and physical
resources to draw upon in coping with traumatic events.
Manifestations of child maltreatment and other trauma may
dier, however, depending on the developmental stage at
which the maltreatment occurred (Mullen, King, & Tonge,
2000). Both the chronicity and severity of developmental
trauma are associated with poorer outcomes, likely because
of the greater disturbance to developmental processes and
systems. As previously mentioned, there is a high degree of
overlap among maltreatment types, as well as with other
childhood adversities and consistent evidence of a dose-
response relationship between multiple exposure and risk
for later psychopathology (Bifulco, Moran, Baines, Bunn,
& Stanford, 2002; Bolger & Patterson, 2001; Cohen et al.,
2006; Dvir, Denietolis, & Frazier, 2013; Higgins & McCabe,
2000). In particular, early childhood trauma is associated
with elevated rates of substance use disorder and a greater
risk of self-injurious behaviour (Cecil, Viding, Fearon, Glaser,
& McCrory, 2017; Conroy et al., 2009; Farrugia et al., 2011;
Mills et al., 2005).
Individuals who experience maltreatment or other
victimisation in childhood are at increased risk for re-
vict imisation in adulthood. Re-victimisation has been dened
as the re-experiencing of abusive behaviour in adolescence
or adulthood that was rst experienced in childhood (Clarke
& Llewelyn, 1994; Schetky, 1990). It can be distinguished
from re-traumatisation in so far as it involves interpersonal
trauma (as opposed to other trauma types such as natural
disasters or motor vehicle accidents) (Pratchett & Yehuda,
2011). Predominantly the research in this area has focused
on the link between CSA and re-exposure to sexual violence.
Some studies have also examined child physical abuse (CPA)
or a combination of maltreatment types as well as physical re-
victimisation such as intimate partner violence (IPV). Much
of the research utilises cross-sectional study designs with
lifetime estimates of trauma experience. While informative
about the types of traumas that tend to co-occur, these ty pes
of studies are limited in what they can say about how and
24 “A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
for gender, a longitudinal study found that individuals with
experiences of multiple types of child maltreatment were 11
times more likely than non-maltreated children to experience
physical re-victimisation and almost ve times more likely
to experience sexual re-victimisation (Widom et al., 2008).
Other studies have similarly found an increased likelihood
of adult re-victimisation with increasing exposure to more
severe or multiple types of maltreatment (Coid et al., 2001;
Edalati, Krausz, & Schutz, 2016; Janowski, Leithenberg,
Henning, & Coey, 2002; Mackelprang et al., 2014).
With regard to IPV, an Australian longitudinal study found
rates of IPV did not dier for women who stayed with or le
an abusive partner (Ahmadabadi et al., 2018). is suggests
that risk of IPV continued even aer women le a violent
relationship. Physical re-victimisation has been found to be
more commonly perpetrated by an intimate partner whereas
sexual re-victimisation was commonly perpetrated by a non-
intimate partner (Ahmadabadi et al., 2018; Desai et al., 2002).
Mechanism and impact of re-victimisation
Re-victimisation has been found to be associated with
an elevated risk of mental disorder, particularly PTSD
(Ahmadabadi et a l., 2018; Desai et al., 2002; Nishith, Mechanic,
& Resick, 2000; Roxburgh et al., 2006). For example, in a
general population survey of women in the United States,
women exposed to any violence were four times more likely
to experience PTSD symptoms than women not exposed
to violence; however, this risk increased to 12 times that of
women not exposed among those that had been re-victimised
(Kimerling et al., 2007), with symptoms including substance
use disorder and diculties in interpersonal, behavioural and
cognitive functioning. Some studies have also found increased
feelings of shame, blame, powerlessness and some coping
strategies among individuals that have been re-victimised.
A range of factors has been identied to explain the pathway to
re-victimisation. ese can be grouped into two main camps.
Vulnerability arising from the psychological sequelae of
child maltreatment such as PTSD symptoms of emotion
dysregulation and dissociative symptoms (Janowski et al.,
2002; Wager, 2012): this may be underpinned by changes
in the way the brain perceives and responds to threat
Multi-type re-victimisation
More limited is evidence on exposure to other forms of child
maltreatment and subsequent exposure to both sexualised
and non-sexualised forms of traumatic experience. Studies
utilising cross-sectional and quasi-experimental designs have
produced conicting results with regard to the impact of CPA
on re-victimisation (Dietrich, 2007; Gladstone et al., 2004;
Van Bruggen et al., 2006; Werner et al., 2016). ese studies
have generally involved small or specic samples (including
clinical, community, and homeless populations), varying
measures and denitions of CPA, and dierent ty pes of adult
victimisation. CPA oen co-occurs with emotional abuse, but
this CM type is only sometimes included in studies. Moreover,
CPA is dicult to classify into severity levels (unlike CSA).
e few studies that have examined this issue in the female
general population found CPA and CSA were associated with
both physical and sexual re-victimisation in adulthood (Desai
et al., 2002; Kimerling et al., 2007). However, CSA was found
to be a stronger risk factor for adult sexual victimisation
than physical victimisation; likewise, CPA was found to be
a stronger risk factor for adult physical victimisation than
sexual victimisation. is suggests that child maltreatment
confers both general and specic risk for re-victimisation
among women. This finding was confirmed in the only
longitudinal study to examine multiple CM exposure and
re-victimisation (Widom, Czaja, & Dutton, 2008).
is same study additionally found that individuals with
a history of neglect or CSA were at increased risk of being
kidnapped or stalked (Widom et al., 2008). Few studies have
examined outcomes other than sexual or physical assault.
is is an important gap to address in understanding the
complexity of violence against women over the life course.
It may be that risk of re-victimisation depends on the clustering
of exposure to dierent ty pes of trauma. Analysis of exposure
to violence among a general population sample of women in
the United Kingdom identied four clusters of victimised
women (Shevlin et al., 2013): 4 percent of women were identied
as having experienced multiple victimisation (dened as
CSA, adult sexual victimisation and IPV); 15 percent had
experienced partner violence but no sexual victimisation;
and 10 percent had experienced sexual victimisation in both
childhood and adulthood. Although not reported separately
“A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
trauma who are reporting severe and extreme interpersonal
victimisation. eir abuse histories involve deliberate and
systematic traumatisation within interpersonal relations,
including patterns of prolonged incest, oen overlapping
with organised abuse involving multiple oenders (Salter &
Richters, 2012) and the physical and sexual abuse of women
and children in the context of gangs and criminal networks
(Cooper, 2004; Salter, 2014). is group of clients typically
meets the criteria for DID and members are frequently
still entrapped in severely abusive relationships at the time
of presentation (Cooper, 2004; Middleton, 2013). Women
escaping sexually abusive family networks and criminal
gangs appear to be overrepresented in domestic violence
and sexual assault services (Cooper, 2004; Schmuttermaier
& Veno, 1999) and in mental health contexts that specialise
in treating sexual abuse and dissociation (Middleton, 2013;
Middleton & Butler, 1998).
Cooper’s (2004) research with women with complex needs
in Adelaide emphasised the presence of extremely violent
family networks who inicted “abuses that are ritualistic,
violent in the extreme and that involve a known or sometimes
amorphous chain of persons who can track, stalk and report
on the women’s movements” (p. 4). ese reports correlate
with Salter’s (2013a, 2017) research with Australian women
subject to organised sex ual abuse in childhood , and Middleton’s
(2013) clinical work and research with women diagnosed
with DID in Brisbane reporting prolonged incest and sexual
exploitation. e conuence of extreme trauma, typically
beginning in early childhood and extending into adulthood
with the development of symptoms associated with DID and
the potential for ongoing victimisation, makes this group
particularly challenging for professionals and services. In t he
United Kingdom, Sachs (2019) foregrounds the dual role of
attachment disorders and dissociation in women’s ongoing
entrapment in sexually exploitative family networks.
People diagnosed with DID typically require specialist mental
health treatment following evidence-based guidelines for
phased therapy (International Society for the Study of Trauma
and Dissociation, 2011) as well as support from a range of
other agencies including AOD services, child protection,
medical care and the police. However, due to a lack of training
and understanding, women reporting symptoms of DID and
(Pratchett & Yehuda, 2011). Cross-sectional studies that
have controlled for the eect of PTSD and depression
on the association between CSA and re-victimisation
indicate there may be a role for mental disorder, however
this needs to be veried by longitudinal research (Werner
et al., 2016).
Vulnerability arising from disturbances in self–other
relatedness: trauma involving a high level of betrayal may
lead to dysfunctional interpersonal schemas that aect
decision-making in relationships (e.g. appropriateness of
interpersonal boundaries) and reduce capacity to form
healthy social bonds (Dietrich, 2007; Mackelprang et al.,
2014; Nishith et al., 2000). At a phenomenological level, this
has been described by women as being homeless within
the self and non-existent outside the abusive relationship,
thus perpetuating “the relationship of exploitation”;
other women described a sense of confusion about their
behaviour with abusive men and feeling captive within
these relationships, and of a loss of boundaries that created
a sense of powerlessness in negotiating risky interpersonal
situations (Ben-Amitay, Buchbinder, & Toren, 2015). It has
also been suggested that early or chronic victimisation
could lead to an acceptance of violence and gender role
norms which persist across relationships ( Yod anis , 2 00 4).
Other explanations involve risky or self-destructive
behaviour such as substance misuse or problematic sexual
behaviour. CSA in part icular may aect sexual development
and the formation of intimate partner relationships
(Janowski et al., 2002). For example, a prospective birth
cohort study in New Zealand found CSA was associated
with early onset of sexual intercourse, which in turn
increased the likelihood of involvement in other sexual
behaviours such as unprotected sex and multiple partners.
ese risky sexual practices were in turn associated with
a greater risk of re-victimisation (Fergusson et al., 1997).
In another study, CSA and psychological maltreatment
were both a ssociated wit h sexual re-victimisation via their
impacts on sexual self-esteem which in turn was associated
with sexual behaviours (Van Bruggen et al., 2006).
Severe/extreme interpersonal victimisation
Research in mental health, sexual assault and domestic violence
services has documented a group of clients with complex
26 “A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
gradually result in a scenario of cultural breakdown where
trauma-coping responses are transmitted and there is a loss
of traditional cultural norms and practices.
In the Australian context, intergenerational and
transgenerational trauma have been important concepts for
Aboriginal and Torres Strait Islander scholars and clinicians
examining the contemporary eects of colonisation— linked
to a loss of social and cultural norms, values, meanings and
structures—and the subsequent imposition of an alien system
(Atkinson, 2002; Hoart & Jones, 2017; Krieg, 2009). A variety
of terms has been used to describe the legacy of colonialism
and its eects on Aboriginal and Torres Strait Islander people,
including “collective trauma” (Atkinson, 2002; Krieg, 2009),
“historical trauma” (Atkinson 2002; Treloar & Jackson, 2015),
“communal trauma” (Atkinson, 2002), “cultural trauma”
(Halloran, 2004), “transgenerational trauma” (Atkinson et
al., 2010) and simply “trauma” (Commonwealth of Australia,
1997; Funston, 2013; Herring et al., 2012). Milroy (2005, p.
xxi) describes the intergenerational and collective nature of
trauma transmission for Australian Aboriginal peoples in
the following terms:
e trans-generational eects of trauma occur via a variety
of mechanisms including the impact on the attachment
relationship with caregivers; the impact on parenting
and family functioning; the association with parental
physical and menta l illness; disconnection and a lienation
from extended family, culture and society. ese eects
are exacerbated by exposure to continuing high levels
of stress and trauma including multiple bereavements
and other losses, the process of vicarious traumatisation
where children witness the on-going eect of the original
trauma, which a parent or other family member has
experienced. Even where children are protected from
the traumatic stories of their ancestors, the eects of past
traumas still impact on children in the form of ill health,
family dysfunction, community violence, psychological
morbidity and early mortality.
In her seminal work Trauma Trails (2002), Judy Atkinson, a
Jiman and Bundjalung woman, writes that Western models
of post-traumatic stress disorder are not applicable to
Indigenous people as they are premised on an individualist
understanding of mental illness. She argues that collective
histories of extreme abuse frequently fall t hrough the cracks in
their eorts to engage mental health, police, child protection
and other agencies (Cooper, Anaf, & Bowden, 2008; Salter,
2017). Policy frameworks for prevention, intervention and
treatment of sexual violence and domestic violence rarely
acknowledge the complexities of the kind faced by women
with DID symptomatology, including traumatic attachments
to abusive families and groups and the strategic use of sexual
violence as a means to control and silence women.
Intergenerational and collective trauma
e intergenerational transmission of traumatic symptoms
and vulnerabilities from parent to child has been widely
observed across populations, including survivors of child
abuse, domestic violence and genocide. The academic
literature identies dierent pathways for the intergenerational
transmission of trauma, including through culture-wide
changes and social disorganisation (frequently associated
with colonial dispossession and genocide), parenting styles
and potential epigenetic transmission. e possibility of
intergenerational trauma transmission rst emerged in studies
of the children of Holocaust sur vivors. Psychological research
and clinical literature found that survivors and their children
responded in diverse ways to Holocaust experiences, including
a strong focus on family relationships and caregiving, however
the second generation were at increased risk of depression,
anxiety, diculties in emotional expression, feelings of guilt
and self-criticism, and somatisation (Felsen, 1998).
Research has also considered the collective and cultural
impacts of trauma (i.e. on whole communities and groups).
For example, Bezzo and Maggi (2015), in their analysis of
Ukrainian Holodomor survivors and two generations of
their descendants, described large-scale cultural changes
taking place directly after the Holodomor, resulting in
widespread mistrust, indierence and hostility to others; a
focus on surv ival and self-preservation; and increased a lcohol
and drug use as a coping mechanism. While their model
also acknowledged the roles of the individual, family and
community in trauma transmission, culture-wide changes
were presented as taking place at the time of or soon aer
the event. Historical traumas and cultural loss, and traumas
experienced by indiv iduals and transmitted within t he family,
“A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
the eects of trauma on clients and sta. e foundations of
TIC lie in the women’s movement and in social movements
for survivors of child abuse who have advocated for gender-
sensitive, client-focused models of practice since at least
the 1970s (Wilson, Pence, & Conradi, 2013). ese eorts
were bolstered by empirical ndings on trauma impacts
as research into abuse and violence burgeoned during the
1980s and 1990s. As the prevalence of trauma in the lives of
female service users in mental health and substance abuse
treatment became apparent in the mid-1990s, the central
principles of “trauma-integrated” and “trauma-informed
practice began to take shape. e core principles of trauma-
informed practice are:
safe environment for clients and service providers
promoting interpersonal relationships
cultural awareness and knowledge
supporting consumer control, choice, and autonomy
understanding trauma and its impact
sharing power, inspiring hope, and supporting recovery
integrating dierent healthcare services
sharing power and governance (Cleary & Hungerford,
ere are multiplying lists of TIC principles, and TIC has
been subject to a recent Australian literature review (Quadara,
2015). With that in mind, this section will focus rst on briey
describing the state of knowledge of TIC, particularly in
Australia, noting the growing interest in implementing TIC
beyond the levels of individual and organisational practice and
embedding TIC within and across sectors. e section will
then discuss TIC in mental health and AOD settings, before
examining the burgeoning literature on TIC in disability
care, refugee and migrant services, Aboriginal and Torres
Strait Islander community response, and trauma-informed
policing and legal practice. is comparison of TIC models
suggests that further research is necessary on the challenges
of integrating and coordinating TIC across professional
systems and sectors, rather than within them, and also in
understanding the role of community-based programs and
interventions in TIC. e TIC literature to date has been
largely concerned with the transformation of service contexts
and bureaucratic systems. However, as the following review
indicates, paradigms of TIC in Aboriginal and Torres Strait
trauma aects the whole society, rather than only aecting
people on an individual level. She claims that trauma is
“the normal human response of traumatic violations that
remain unhealed” (p. 92) and therefore should not be viewed
as a mental illness using a pathologising lens. Atkinson
(2002) views Aboriginal and Torres Strait Islander trauma
as “cumulative” or “compounding”, which distinguishes it
from a one-o traumatic event such as a natural disaster or
unique event of interpersonal victimisation. Colonisation, she
argues, “set in motion a series of disasters, one precipitating
another, to propagate trauma on trauma on trauma” (2002,
p. 59). In this model, trauma is both individual and collective
and is passed on through survivors to their descendants.
Trauma is further entrenched through policies, structures,
and systems of control that disempower Aboriginal and
Torres Strait Islander people.
e Australian practice of mass Aboriginal and Torres Strait
Islander child removals during the 20th century, in which
10–33 percent of all Aboriginal and Torres Strait Islander
children (the Stolen Generations) were forcibly removed
from their families and communities between 1910 and
1970, is recognised as a profoundly traumatic period in
Australian history (Human Rights and Equal Opportunity
Commission, 1997) and a major driver of intergenerational
trauma. A recent report by the Australian Institute of Health
and Welfare (2019) found that Indigenous children under
the age of 15 who lived in the same household as a Stolen
Generations family member had poorer school attendance
and reported more racism at school, higher levels of stress,
poorer self-assessed health and higher rates of household
poverty tha n other Indigenous children. e disproportionate
involvement of Aboriginal and Torres Strait Islander families
in the Australian child protection system, including ongoing
high rates of child removal, is linked to the intergenerational
eects of dispossession, colonisation, racism and the impact
of the Stolen Generations (Bamblett & Lewis, 2007).
Understandings of
trauma-informed care
Trauma-informed care (TIC) refers to models of professional
and organisational practice that recognise and aim to address
28 “A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
ese challenges are the subject of ongoing research and
policy innovation. In Australia, Hegarty et al.’s (2017) research
focused on how to implement trauma-informed care and
empowerment approaches within health systems for women
who had experienced sexual violence and mental health
problems. eir ndings emphasised t he need for a framework
that is simultaneously “woman-centred” (empowering
and holistic responses) as well as “practitioner-centred”
(addressing practitioner needs and providing education
and resources). Drawing on interviews and focus groups
with women who had survived sexual violence as well as
practitioners, they identied four main building blocks of
women and practitioner-centred approaches:
Relationship building: Opportunities should be provided
so that individuals and teams within services as well
as different services can develop trust and shared
Integrated coordinated care: Care coordination requires
clear roles for sta and working referral pathways within
and outside the service, with trauma-informed work
supported by policies and sta “champions”.
Reflexive systems and monitoring: Systems should
actively seek the feedback of women into system and
service improvements, and professionals should have
the opportunity to provide input into improvements in
strategy, policy and resources. Auditing and evaluation
of how women move through systems would promote
quality improvement.
Environmental and workplace scan: Regular assessments
of the adequacy of workplace and process arrangements,
including appropriate physical spaces for consultation
and counselling; reviews of workow patterns to ensure
appropriate care; assessment of workplace culture, values
and beliefs; and ongoing monitoring and evaluation.
e following two sections consider the current state of TIC in
key health sectors, namely mental health and AOD treatment.
Mental health
As discussed above, the evidence suggests that trauma is a
general but nonspecic risk factor for a host of psychiatric
disorders, and challenges prevailing medical and biological
models of mental illness. It also means that women with
Islander communities and refugee and migrant groups
frequently combine community strengthening with service
reform and collaboration.
TIC in health and human services
In the Austra lian context, there has been considerable interest
over the last ten years in promoting “trauma-informed”
health and human services to improve client outcomes,
bolster collaboration and reduce the risk of re-traumatisation
(Bateman, Henderson, & Kezelman, 2013; Kezelman &
Stavropolous, 2012). Nonetheless, interlinked trauma sequelae
such as mental illness and substance abuse remain somewhat
“siloed” within distinct response systems (Quadara, 2015).
Professionals in diverse sectors have indicated they are not
adequately trained, resourced or supported to address trauma
in their service or agency (see e.g. Salter & Breckenridge,
2014). Meanwhile, trauma-specialist agencies and workers
evince reluctance to engage with non-specialist mental health
agencies or other supports due to a lack of condence in
their trauma skills (Salter, 2017). Care following a history
of traumatic exposure continues to be fragmented and
oen involves contradictory, ineective or re-traumatising
encounters with services.
Wall, Higgins and Hunter (2016) emphasise the need for a
framework of service delivery that ensures complementarity
and consistency between t he service experiences of traumatised
people and families, and warn of the potential for “i nconsistent
or piecemeal development of trauma-informed models and
practices” in the absence of an overarching policy framework
in Australia (Wall et al., 2016, p. 2). ey identify a number
of challenges to the implementation of a trauma-informed
approach to care, including:
a lack of clearly articulated denitions (e.g. of trauma-
specic interventions vs. the concept and principles of
trauma-informed care)
translating trauma-informed care to specic practice
and service settings
consistency across service settings and systems
care coordination
a lack of guidance for facilitating complex system change
a lack of evaluation of models of trauma-informed care.
“A deep wound under my heart”:
Constructions of complex trauma and implications for women’s wellbeing and safety from violence
having private rooms and gender-specic wards. However,
a broader notion of safety goes beyond the physical
environment to include interpersonal, emotional and
spiritual safety.
ere is a need to promote the personal agency of women
in an inpatient setting that is highly regulated and
constrained and which can induce a sense of powerlessness
similar to that experienced in previous traumatisation.
is would include an appraisal of “symbols of control”
such as the demeanor and business of sta and abrupt
dismissal of clients.
ere is a recognised importance for mental health nurses
to take a lead in raising the possibility of traumatic distress
during case reviews and interdisciplinary team meetings.
e limitations of single-day awareness training and the
need to develop skills in trauma-informed practice over
a longer time period need to be addressed.
As opposed to the traditional focus on reducing symptoms,
importance should be placed on identifying the woman’s
own treatment goals and making these a priority within
treatment plans.
The authors conclude by acknowledging the significant
challenge that trauma-informed practice poses for mental
health services and the need for more coherent research “to
better inform a transmissible pedagogy for education and
research programmes in this area” (Cleary & Hungerford,
2015, p. 376). Similarly, the Mental Health Coordinating
Council (MHCC) has advocated for a National Strategy for
Trauma Informed Care (NS–TIC) (Bateman et al., 2013).
Alcohol and other drugs
Previous trauma experiences can make it dicult for women to
engage with alcohol and other drugs (AOD) treatment. is is
particularly the case where services adopt a punitive approach
aligned with an expectation that clients take responsibility
for their substance use and associated chaotic lives (Salter
& Breckenridge, 2014). is expectation is problematic for
women clients whose trauma histories have oen involved
repeated physical and sexual victimisation starting in early
childhood. Experiences of women in AOD services has
been characterised by aggression and intimidation, as well
as controlling and coercive behaviour. ese experiences
experiences of complex trauma will potentially present to
any part of the mental health system as well as to multiple
other service systems. is highlights the need for integrated
service delivery for women who have experienced complex
trauma, including support from mental health professionals
to help women navigate these multiple systems (Cleary &
Hungerford, 2015).
While there are no estimates of the number of Australian
women presenting to mental hea