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Trauma informed care and vicarious trauma in healthcare – Dr Melissa Connell

Safe Work Month and Mental Health Week 2020

Speaker: Dr Melissa Connell, Clinical psychologist.

Dr Melissa Connell shares her knowledge and experience from managing the transition of a health care agency to trauma informed care and practice.

She reflects on the challenges and key learnings of managing workers' psychological health and safety when their role involves exploring the distress and/or trauma of their clients, and how to ensure their clients are not re-traumatised during treatment.

Good afternoon everyone, and welcome to this Mental Health Week virtual event, where we are exploring the areas of Trauma Informed Care and Practice and vicarious trauma. My name is Nicole Hughes, principal advisor Psychological Health Unit, Workplace Health and Safety Queensland. And I will be the facilitator for today's virtual event. Firstly, I would like to acknowledge the traditional owners of the lands on which we are engaging in this event, and pay my respect to elders past, present and emerging. Now a quick reminder of the mentally healthy workplaces integrated approach. So we can see on the model here, we have four components, promoting positive practices, preventing, which looks at identification of psychosocial hazards and putting control measures in place, intervening early in response to early warning signs, and a supporting recovery, which involves stay at work or return to work programs. Today, our topic is going to be sitting in that prevention component of the model. It gives me great pleasure to introduce our speaker, Dr. Melissa Connell. Melissa is a clinical psychologist working in the areas of mental health and alcohol and drug treatment. She has a particular interest in Trauma Informed Care and treating PTSD and complex trauma. Melissa recently completed a project as manager Trauma Informed Care and Practice for Metro North Mental Health, Alcohol and Drug Service, where she led a team that developed Trauma Informed Care across the service. We are pleased to be joined by Melissa today, drawing on her extensive knowledge and experience of Trauma Informed Care and Practice and vicarious trauma. I'm sure that we'll learn a lot from Melissa and come away with insights to support mental health in your workplace. I'll now hand over to Melissa. Welcome Melissa.

Thanks Nicole. I'd also like to extend that acknowledgement of the traditional owners of the land to also acknowledge the intergenerational trauma that indigenous or first nations people have experienced, and indeed, I'd like to acknowledge all people who have experienced trauma and have turned to health services, seeking assistance, and haven't got the help that they needed. And before we start today, I just like to let people know that we will be talking about trauma in a general sense, but if you have an experience of trauma yourself, it could be activating for you. So if anything disturbing comes up, please do what you need to to be okay. So to begin with, I'll just give a bit of an overview of what we'll be about. We're going to be looking at what trauma is and its affects, the high prevalence of trauma effected clients in Australian health services. the rationale for Trauma Informed Care. And I'll be giving a bit of a overview of the project that we developed and implemented at Metro North Alcohol and Drug Service. And we'll talk about vicarious trauma and look at strategies to manage and reduce the risks. So what do we mean by trauma? So trauma is really a wound or an injury. It's an overwhelmingly stressful experience, it's subjective, it can be actual or threatened, it may be direct or indirectly experienced, and it has lasting adverse effects on an individual. So trauma can profoundly alter a person's beliefs about themselves, the world and others. So, there's two types of trauma. Type one is single incident trauma. This refers more to exposure to actual or threatened death, serious injury or sexual violence. This is a prerequisite for a diagnosis of post-traumatic stress disorder. And then type two is complex trauma. So this is multiple or combined traumatic events. They're typically interpersonal and they are experienced in childhood or adolescents. So let's go over what PTSD actually involves. So there are intrusion or re-experiencing symptoms, avoidance of reminders of the traumatic event, negative alterations in thoughts and feelings, and alterations and arousal reactivity. People are on edge on alert, looking out for threat. And then complex PTSD. So this includes all the symptoms of regular PTSD, but also involves emotion regulation problems, negative beliefs about self and problems and interpersonal relationships. There are overlaps with borderline personality disorder and some contention about whether it's the same or different. But this is a type of difficulty that we are highly likely to see in our health services. So what happens when we experience trauma? So most people will actually experience a traumatic event in their lifetime and the majority of people will recover without too many difficulties, but sometimes there's barriers to natural recovery, and people aren't able to go back to everyday life. There's a number of factors that can determine recovery, and things like the developmental stage that trauma occurs at. And for complex trauma occurring during a child's development, persistent exposure to traumatic stress can actually alter the developing brain and cause long lasting effects into adulthood. And there are a range of other variables how severe and prolonged the trauma is, a person's sensitivity to stress. If they experienced a traumatic event in adulthood, if they've had a healthy development and been functioning quite well, they've got to have a much higher likelihood of recovering. Childhood trauma and adversity. It's likely to have been perpetrated by family members and caregivers. So these are the people that children are dependent upon for protection and care. And when these are the people that are also harming them, it places the child in a really untenable position and has a significant and a long lasting effect. There are a range of trauma reactions that the child might experience, a hypervigilance problems with the motions, impulsivity, lack of agency, but there are a lot of problems with relationships and experiencing trust. The Adverse Childhood Experiences study was conducted in the United States, and it looked at thousands of people in the general population, and it looked at a range of adverse childhood experiences and their association with negative health outcomes and adulthood. So they found, the earlier exposure to adversity and trauma was associated with a greater magnitude of long-lasting effects. And these went across such a broad range of areas, behavioral health, physical health, social and occupational functioning, and there was a dose response effect. The more adverse childhood experiences a person had, the greater the likelihood of negative outcomes in adulthood. So this tended to a sort of compounding effect as well. So adverse childhood experiences could lead to different health risk behaviors that a person adopts to try to manage emotional pain, which then puts them at higher risk of more adversity and negative outcomes. It's also important to acknowledge vulnerable population, cultural differences and minority groups can be at higher risk of experiencing community violence and repeated victimization. So these are all determining factors and exposure to trauma and sensitivity to stress, and the meaning of traumatic experiences can differ depending on cultural groups. But when we look at the prevalence of trauma in the Australian population, it's quite alarming. These are figures from the Australian study on family domestic and sexual violence in Australia, this came out on 2018. So one in six women have experienced physical and or sexual violence by a current or previous partner. One in four women have experienced emotional abuse. One in five women have been sexually assaulted or threatened and one in six girls and one and nine boys have been sexually or physically abused before the age of 15. So we really need to acknowledge that there is a high prevalence of clients affected by trauma and health services. And the higher the rate and persistence of trauma and adversity, the greater, the likelihood of co-morbidity and complex problems. This results in reduced quality of life, life expectancy, loss productivity, but also significant increases in the utilization of medical correctional, social and mental health services. And there are flow on effects for society and the children of those who've experienced trauma, and intergenerational trauma means the cycle just goes on and on. And trauma and the failure to adequately identify and respond to trauma costs our society billions of dollars. The experience of clients and services means that we don't contribute to resolving this problem. Trauma is often unrecognized and unaddressed, these clients can be engaged in multiple services, fragmenting care, raising the risk of treatment dropout or avoidance of treatment altogether. And the attendance to be this, you know, spiral or cycle where people who experienced trauma and adversity go on to have more trauma and adversity in their life, and they end up having quite protracted and complex problems that need specialized treatment. But trauma related problems continue to be perpetuated. Our services can even retraumatize our clients, just looking broadly at a range of different services, most of practices such as seclusion and restraint are retraumatizing. The removal of children from families, the use of invasive procedures in the medical system, harsh disciplinary or punitive practices in education, and intimidating and dispatch disempowering practices in the criminal justice system. These are all ways that we perpetuate the problem. So why is Trauma Informed Care important? So unidentified and unaddressed trauma undermines health outcomes and the effectiveness of services. So we really want to be focusing on resolving problems, not exacerbating them. When clients feel recognized and that their experiences and needs being addressed, they're gonna engage more with services and be more likely to seek help. But it's really about optimizing therapeutic outcomes and minimizing adverse effects. So an organization that's trauma informed is going to realize the impact of trauma, recognize the effects of trauma in clients, families, and staff, respond by integrating knowledge about trauma into policies, procedures and practices, and resist retraumatizing clients. So what does the evidence say? Trauma Informed Care has been found to be cost-effective and it's associated with a range of benefits. So a decrease in trauma symptoms and substance use and mental health symptoms, improvements in housing stability, a decrease in crisis space services and more collaboration between services and better staff morale. And there are huge benefits for staff as well, and we'll talk more about those. But being able to have improved knowledge of different types of trauma and its effects, and understanding more about that interaction is effective in helping staff make sense of their client's presentation. Staff can be more confident working with clients, they've got more effective and sensitive ways to respond to them, and understanding vicarious trauma and the risk of secondary traumatic stress, how to prevent and minimize it is really important. So Trauma Informed Care is difficult to define, there are principles that guide it, but it's not a set of prescriptive practices. Importantly, it sits on a foundation of safety and this also involves emotional and psychological safety in addition to physical safety, but there's principles of trustworthiness, choice, empowerment, collaboration are really important for people of who have been affected by trauma. People who haven't had power, who haven't been able to trust, who haven't had control over their life, services have an opportunity to do more healing and rebuilding of clients if they're working in a trauma informed way. So it's important to think about what we can do to help people feel safe and prevent re-traumatization. So providing explanations about questions and procedures, giving an overview of what's gonna happen, offering choices, ensuring consistency and interactions and appointments, having clear boundaries and expectations, inviting clients to let us know if they've got questions or concerns, looking for opportunities to help clients feel empowered, asking for permission, "Is it okay if I get you to sit here?" Being attuned to ruptures in the relationship and how they can be repaired. So these are all things that clients who've experienced complex trauma, or who are affected by trauma aren't going to have had the opportunity to have these sorts of needs attended to. So I'll talk a bit more about the project that we did at Metro North Alcohol and Drug Service. So we recognized that there was a high prevalence of clients in AOD services. In fact, around 90% that have trauma histories, and many clients are using substances to self-medicate. In fact, the majority of these clients have experienced multiple traumas, and as many as 40 would meet the criteria for a diagnosis of PTSD. So there's a cycle of trauma and substance use, people use substances to cope with trauma related problems, but in fact those problems become worse, and substances are the only solution or coping strategy that they have. We also recognize that many of our clients were falling through the gaps. They weren't receiving treatment for their trauma symptoms, and this was perpetuating their substance use problems. So we developed a model of care, the "Trauma Informed Care and Practice for Alcohol and Drug Treatment" document. We looked at how we could structure our organization so that it could be trauma informed. We recognized it had to sit on a strong foundation of trauma informed organizational practices, and we also focused on workforce development and psychosocial treatment. But all of their sorta sat under an umbrella of trauma informed governance and Trauma Informed Care principles. So the three pillars of trauma-informed care and practice that were important were organizational practices, and in workforce development, we wanted all clinical and nonclinical staff to be supported, to develop enhanced skills and knowledge in Trauma Informed Care and Practice. And psychosocial treatment, we introduced a phase-based treatment of comorbid substances disorder and trauma related symptoms. So the steps that we took in becoming trauma informed, it really starts with leadership. And you really need to do broad consultation in the service with both staff and with consumers as well. We conducted a Trauma Informed Care service ordered or self-assessment measure. This was something that our project working group were focusing on identifying, where are we meeting the standards of Trauma Informed Care, and what did we need to improve to be able to say we were a trauma informed organization. We reviewed our policy and change some of our organizational practices, but staff training was really important. So all staff were trained in Trauma Informed Care, we introduced routine screening for PTSD and referral pathways for treatment of trauma symptoms. And then we had a sustainability model where Trauma Informed Care champions would continue to provide training, supervision and conduct an annual working group meeting. But Trauma Informed Care leadership is really integral. So you need funding for the project and for staff, you need to be able to conduct these systematic service audit reviews and be able to provide that support, to see actions taken and new steps implemented. So there's time and resources involved, you need to review all the policies and materials that the service has, and you need to be able to focus on providing a safe work environment. So there needs to be a culture of Trauma Informed Care that the organization is able to promote and sustain. So there's a range of staff capabilities. I won't go into all of them in detail now, but it really involves building staff skills and knowledge and understanding trauma and how to respond to it more effectively. But when we started the project, we identified that our staff had very low levels of training in trauma, even though the majority of staff had been there for over 10 years, working with a population that had such high exposure to trauma. We also found that there were high levels of clinician avoidance of trauma, and this is not unusual. So looking across a range of health services more broadly, clinicians who've been unlikely to assess, manage or treat their clients trauma related difficulties. And we also know that there are high rates of secondary traumatic stress that are found in health service workers. So, it's interesting to be curious about this avoidance of trauma. And sometimes trauma has this kind of mystique, people talk about not opening Pandora's box, we don't wanna open that can of worms, and there's a lot of fear and anxiety about talking about talking trauma. And I think concerns clinicians have that they're going to harm or upset their clients and that they themselves may be overwhelmed. So some of the barriers that we found in our staff were things like feeling they didn't have the institutional resources to deal with trauma, that they didn't have enough experience, they were concerned with causing further distressed clients. They didn't feel equipped to deal with trauma and adversity with their clients, and some people felt they were just too busy. But more than half of our staff endorsed these barriers prior to training. Following training, there was a significant reduction in these barriers, and these changes were maintained at six months follow up. Clinicians learned how to safely and effectively engage with trauma effected clients. And we really learned that trading and supervision is instrumental in breaking down this mistake about trauma, making it more accessible and letting staff understand that these clients who're already struggling with trauma it's leaking out, and then identifying, or being able to be more attentive and responsive in relation to these needs isn't going to harm them. And in fact, avoidance perpetuates some of the problems around trauma. So let's turn now to vicarious trauma. So this refers to the negative transformation in the helper that results from empathic engagement with trauma survivors and their trauma material, combined with that commitment or responsibility to help them. It overlaps with other concepts like secondary traumatic stress, burnout, compassion, fatigue. We'll just use the time for vicarious trauma, and it may include some of these other concepts. But it refers to negative changes over time and an enduring stress response. So vicarious trauma can mirror the effects of trauma. So all of those same PTSD symptoms can arise. So how common is vicarious trauma? There are different prevalence rates produced by different studies, but generally around 10 to 40% of health service workers or first responders may experience vicarious trauma at some time in their life. A recent study of alcohol and other drug workers found around 20% met criteria for secondary traumatic stress. It's really important to acknowledge that being affected by the vicarious trauma is not a result of personal weakness, it is a risk faced by anyone who's exposed to severe or cumulative trauma or associated with their work. So the stigma associated with the vicarious trauma, especially in first responders, organizations like the police and the military can lead to a lot of negative consequences, where people are really not well and not disclosing that they're struggling. So it's important that we're just being real and acknowledging what's going on. So looking at some of the key contributing factors. So some of the situational variables about the nature of the work indicate that of course, indirect trauma via exposure to trauma affected clients is important, relational dynamics, people that are more empathic and attuned to their clients might be at higher risk. When clinicians don't have access to support, and they're doing a high amount of trauma work or being exposed to large amounts over time, they're at higher risk. And when they perceive a lack of support from their peers and supervisors, and don't have access to clinical supervision, these are all risk factors. And then when we look at person variables, some people that are more prone to anxiety and stress can be at higher risk. If you've had a previous experience of trauma, working with trauma effected clients might trigger or activate your own experiences. If you have an avoidant coping style or a lot of stress in your life currently, you may be more effected. Other things like low job satisfaction, not being particularly committed to your job, being new to the profession, if you don't feel safe with others and perceive them as potentially harmful. And if you're trying to avoid your client's pain and your own pain, or if you're feeling powerless and guilty, these are all factors that can place you at higher risk. And the sociocultural context is interesting to consider. We can feel very overwhelmed and powerless similar to our clients that may be marginalized, not have adequate resources or support, and they might be stuck in environments where they're continuing to experience trauma and victimization, that can be really hard for clinicians to deal with. So identification of vicarious trauma, some of the markers that might indicate someone is experiencing it, having strong and emotional responses in relation to a client's disclosures, having a lot of somatic complaints, headaches, aches and pains without any kind of illness or injury, the PTSD symptoms, some people start to feel more jaded and pessimistic, and some of those are the broader mental health and stress symptoms can emerge. And then what you might see in a worker's performance, there might be increased absenteeism, they might have trouble making decisions around their care for clients, there might be decreased productivity, more work-related errors, they might have trouble feeling empathy, and they might feel a loss of enjoyment or pleasure associated with work. And a lot of people start to use drugs and alcohol as a way of coping. So there are important strategies that can prevent vicarious trauma, social support, supervisions, spiritual renewal, vicarious resilience, and self-care are all really important. But what can an organization do? So training is really important. Helping people understand what vicarious trauma is, how to recognize and how to prevent or manage it, trying to reduce the risk factors such as inadequate clinical supervision, low morale, failure to acknowledge that risk, positive policies are really helpful, flexible work hours, roster days off, opportunities for personal self-care and promoting and maintaining a healthy work environment. So fostering teamwork, encouraging collaboration, opportunities for staff to connect and also diversifying job tasks. So there are ways to work protectively, having a strong theoretical framework, realistic expectations of yourself, having a focus on strengths and process with your clients and being aware of your professional guidelines and responsibilities, managing boundaries, and try to be aware of what's going on inside you. So there are some little tips for practice, I guess these are more for clinicians. I'm trying to use progress notes as a way to gain perspective, doing something different between appointments and mindfulness, so that's really important. So this also feeds into the next topic, so ways that you can manage your own feelings when you're responding to trauma reactions or disclosures in clients. So compassion and empathy are really powerful ways to support a person, trying to normalize and validate their feelings and experiences, trying to be with the person without having to fix them, being mindful of your own reactions, and checking in with how you're feeling what's coming up in you, what's gonna help you to be okay, and it may be breathing, grounding, reassuring yourself. But if you're struggling, it's really important that you take steps to access support, checking in with your supervisor aligned manager, debriefing with the colleague, looking at getting your own therapy or EAP counseling, taking time out to really distress and attend to your needs and try and make sense of what's coming up for you and what you need to be okay. These are some of vicarious trauma screening and assessment tools that can be interesting to complete one of these or to have your staff complete them. And sometimes it can be quite disconcerting to look at ways that stress might be showing up and ways that people might be affected by the vicarious trauma without realizing it. But above all, those principles of Trauma Informed Care apply to workers and their workplace too, you really wanna promote safety in the workplace, you really want people working collaboratively, being empowered, having choice, trusting each other, those are all really important protective strategies.

We're now moving into our question answer segment. And our first question is from Haymitch. So Melissa, if I was to ask one of your staff, what the benefits and challenges were, how do you predict they would respond?

Yeah, it's interesting to reflect on, part of our project involved providing more trauma focused treatment to clients as well. So some of our staff were really apprehensive about what that might mean. They were concerned that they would be dealing with clients with more complex problems, with greater severity of trauma-related symptoms. They didn't feel that they had the expertise to be able to properly treat these clients. And I think they were concerned about becoming distressed and overwhelmed. But what we found that was as we talked through those concerns and provided more training and supervision, a lot of that resistance broke down. So we reassured staff that their clients were not going to be any different than what they were already. These were already the clients they were dealing with, but they were in fact going to be more adequately prepared to be able to treat them effectively and to have more confidence, to be able to do that. And I'm thinking of one staff member in particular, that when I spoke to her before the project, she didn't wanna talk about trauma with her clients and was very concerned about having to move in this direction of Trauma Informed Care and treatment. But by halfway through or towards the end of the project, she was one of the greatest supporters. She was trying out different kinds of trauma treatment and really advocating for the project, and things had changed so much for her. She felt this was meaningful work and she felt that she understood how to do it more effectively.

Because there's some people that be that greater job satisfaction just from changing.

Yes, yeah, definitely, yeah.

Melissa, one thing I was thinking about when you're giving a presentation was whilst we're focusing on health care, really struck me that this content is applicable to so many other workers, things like, you know, community safety or housing or education, so it has relevance across many different industries. We have another question now, which is from Sam, "Carers often see themselves as only givers of care, so struggled to ask for help or even recognize that they need help some times. How can we break down that notion of serving others to get carers to see why this is so important?"

That's a really interesting point. A lot of people that work in health services are very oriented towards caring and attending to the needs of others. And they can be quite focused on how to make other people okay, and they don't notice their own needs. And so they're more likely to experience that cumulation of stress without having awareness that they're being affected. So I think some of the ways that those people can be supported is through supervision, through prompting to, you know, be inquiring around what's going on inside them, how are they traveling, and that attention to those signs that people are being affected by secondary traumatic stress by their colleagues, the managers or supervisors, and trying to have a workplace where people talk about these problems and they feel safe to be able to share anything that they're struggling with. So those are all really important factors.

Just creating a norm, isn't it really like just shifting that culture.

Yeah, yeah.

So Melissa we have a question from Amy, "Should a Trauma Informed Care model extend beyond frontline workers, that is, should it be applied to all employees of an organization?"

Yes, definitely. We know that there are many points of service delivery that aren't clinical, where staff are goNNA be exposed to clients that may be affected by trauma. Admin workers, people working in food services, cleaners, they may encounter clients that are having problems regulating their emotions, or may have some challenging behaviors. So it's really important to provide training to them as well. The key to Trauma Informed Care is really being able to understand what's behind these difficult behaviors, that these are reactions to trauma and not people wanting to, you know, give you a hard time or make your life difficult. So I think once people have that understanding, they don't take those situations so personally, and they're able to respond more appropriately and not be as effected by them.

Just a related question. Would you be able to make some comments about how important the physical environment is too that we need to consider in our workplace?

Yes, definitely. As part of Trauma Informed Care, considering is the physical environment one that clients feel safe in is really integral to being a trauma sensitive organization. So waiting rooms, for instance, that have some sort of soft lighting or furnishings that have artifacts of different cultural groups, so they can help feel that sense of belonging or inclusion, and trying to ensure there's nothing triggering in those environments, but it's all about safety. So we noted that people who are affected by trauma are gonna be more sensitive to perceiving threat. So if you can create safety for them, when they're engaging with your services, there's going to be less likelihood of that happening, and they're going to be able to engage more effectively and any difficult behaviors may be prevented.

And I guess the safer clients feel, the less likely there's gonna be an impact on the people that are looking after them, the carers, yeah.

Yeah, exactly, that's right. That's going to mean that staff are able to do their work more effectively with less stress and disruption.

So Melissa, this is a question from Tanya, "How do you get staff members management and or stakeholders to buy in to Trauma Informed Care?"

Yes, that that can be challenging depending on what type of service we're talking about. I've mentioned before that Trauma Informed Care is that whole of service approach, but trauma treatment is the more trauma specific service. And those things are different. Of course they're related, but they're different parts of Trauma Informed Care and Practice. So I know in mental health services, for instance, they've been concerned that if they were to provide that trauma focused treatment, that they wouldn't have the resources to be able to address all the needs of clients over the length of time that might take, so they've been concerned about going down that direction. But Trauma Informed Care, I think, when you can show the evidence for its effectiveness, the benefits to staff, I think really valuable and see that it's cost-effective, there so many factors that can improve the experience of clients, of staff, of other stakeholders they may be involved with. So there's a lot of selling points.

So Melissa, we have a question from Greg, and Greg is wanting to know what our clients think about Trauma Informed Care and Practice.

Well, it really is very important for clients to feel that it's relevant to them, that it's going to have an impact on their wellbeing. And so consultation with clients is really an important part of Trauma Informed Care, but the things that we've heard from clients that they can't believe that they've been in services for such a long time and nobody has ever asked them about their trauma. So when it's recognized and addressed and responded to, they feel really validated. And for many of our clients, this is the first time they've really made a connection between what they've experienced and the problems that they're having, and that can be a really powerful point at which they develop more self-understanding. And I think self-understanding is key to be able to manage those trauma related problems, and to be able to start to move towards healing and being ready to engage in treatment that may really make a difference for them. So I think for clients it feels very validating and they have optimism that things may improve for them.

Thanks for your time today, Melissa, it's been a really interesting topic, and I think has a lot of relevance in terms of safety. You know, you've picked up on a lot of things that are quite relevant in terms of that consultation and support and clarity around role and importance of communication. There's lots of things that I think are very relevant to keeping people psychologically safe at work.

Well, thanks so much, Nicole, it's a topic that I'm really passionate about, and I think it just has so much relevance as you said to a range of different areas. And I know we've only scratched the surface here today, but I really hope that people will be inspired to go and learn more about Trauma Informed Care and see how they can look at their own workplaces and what they might be able to achieve.

Thanks again to everyone who sent through a question for Melissa. Unfortunately we have come to the end of our time. If you do have a question for Melissa that we weren't able to get to today, please email Before we conclude today's events, here are some of the key takeaway messages. There is a high prevalence of exposure to trauma and problems associated with trauma-related sequelae and clients of health services. Mental health and substance use disorder treatment outcomes are adversely affected by unrecognized and untreated trauma-related difficulties. Trauma Informed Care is a service delivery approach that's grounded in an understanding of and responsiveness to the impact of trauma. Trauma Informed Care training plays an essential role in facilitating positive in clinician's confidence, attitudes and knowledge regarding working with clients affected by trauma. Health services workers are frequently exposed to trauma vicariously when working with trauma effected clients. The risk of experiencing secondary traumatic stress symptoms is often under recognized. Training and understanding, managing and preventing vicarious trauma can assist health service workers in maintaining wellbeing and reducing the risk of conditions such as compassion, fatigue, secondary traumatic stress and burnout. If you're after some further resources on mentally healthy workplaces, this toolkit aims to help employers, managers and leaders eliminate and minimize risk to psychological health and create workplace environments that are mentally healthy. I highly recommend downloading the toolkit, the link is on the screen, it's a valuable resource that steps through the integrated model that I mentioned earlier. Thank you for joining us for this virtual event today, and I'd like to particularly thank today's speaker Dr. Melissa Connell. If you would like to access Melissa's presentation again, it will be available online after today's event. While we're nearing the end of Mental Health Week, we have a great range of free virtual events available until the end of October, including a panel discussion on peer support, which is happening tomorrow, a session exploring how cultural safety contributes to a mentally healthy workplace, which is next week, and a chat with ex-Olypian Hayley Lewis on the 30th of October, it's not too late to register for these. You can also access a full catalog industry and topics specific video case studies webinars and films to help you take action to improve your workplace health and safety and return to work outcomes. These resources are available for free for you to access any time by visiting