TRISI Executive Summary

Section 3. Executive Summary

 This is one of 24 sections that make up the proposal to form TRISI. The other sections can be found at: http://www.ptgrr.com/contents/get-involved/trisi-content

Reference: Brian Rogers. Trauma & Resilience-Informed Solutions Institute of Southern Africa – Proposal of a Trauma-Activist; PTG-RR; Sep 2015/3

While health isn’t everything, without health, nothing else matters”

CC Pollen Co-founder Royden Brown

 

TRISI – The Trauma & Resilience-Informed Solutions Institute

 

A Solution to South Africa’s Psycho-Social challenges

 

 

“If advanced countries have developed systems of resilience and trauma care that can enhance the performance of the work we are doing in community child abuse and neglect, then we certainly want to assess the impact they can make in our own communities.

It would seem ideal if we had a local Institute where we can go to both augment our care giver skills and contribute our own findings and successful Ecological Model for the benefit of others. In this way the advancement of primary care can take a collective leap forward.

I would therefore very much endorse all effort to establish such a centre and encourage the readers of this document to take the proposition seriously and contribute their own efforts to the furtherance of this objective.”

Dr Nobs Mwanda M.D., BSc, MBBCh, DCH, MSc. CEO COPESSA; ASHOKA Fellow.

 

“I am so excited to read what you’ve written. It’s fantastic and you’ve managed to put down what I’ve been dreaming about putting together myself, in a very coherent and thorough way.
Well done! “

Dr Lane Benjamin, Director CASE – Community Action towards a Safer Environment

TRISI – The Solution

“At the 2012 National Health Summit, Health Minister Aaron Motsoaledi called for greater awareness, better planning and a move away from a “Hospicentric approach” to the treatment of Mental Illness. He described South Africa’s Mental Health Services as fragmented, unfairly distributed and inadequately resourced. “We know that there continues to be over-reliance on Psychiatric Hospitals as the mode to care, treatment and rehabilitation” Motsoaledi said. South Africa has continued to follow the colonial, “Hospicentric approach”, and in doing so have neglected critical aspects of Primary Health Care. He said that it is an offence against human rights and the country’s constitution to neglect the worse off in society.

Minister Motsoaledi voiced the need to scale up investment in South Africa’s Community-Based Mental Health services and reverse the trend of institutionalised care: “We must examine how Mental Health can be integrated into General Health Care and particularly into Primary Health Care”, he stated.”

SA Federation for Mental Health Making Mental Health A South African Priority - July 2015 Awareness Campaign

The purpose of this proposal is to provide a solution to South Africa’s Psycho-Social challenges that is supported by local and global empirically based knowledge, is investable, and will positively impact on the socio-economic future of our country.

Regrettably the Minister’s challenge cannot be met by South Africa’s Mental Health resources alone. An analysis of the historic and present academic and organisational capabilities in South Africa shows that they are probably too inwardly focused (too siloed) and too independent, to make an urgent collective impact on a solution to these expressed national needs alone. (Sections 8 and 16).

TRISI: the Trauma & Resilience-Informed Solutions Institute. Formation of TRISI is the proposed Solution.

T- Trauma:              Trauma is the predominant cause of Mental Illness; it is also the primary sustaining factor in Mental Illness. In turn, Mental Illness can cause or re-enforce lack of Traumatic Health. The Traumatic Health of one person has a negative effect on others in their social circle. Trauma is the inescapable protagonist in the co-existent “Health Gang” of Substance-Abuse, Violence, HIV/Aids and Poverty. (Section 1 & Sections 5-19)

R-Resilience:        Resilience is neither the opposite nor the panacea of Trauma. Yet, correctly valued, Resilience can be both a risk-deminisher and a preventive-enabler. Resilience is not automatically positive and is equally associated with stoic negative health and social challenges. Both facts have equal solution building importance. (Sections 1, 4, 11, 14, 19)

I-Informed:             In todays world change is continuous. To be adequately informed is only momentary. In biological, neurological and social/behavioral Trauma understanding and solutions, breakthroughs are literally being made daily. To be ‘informed’ means to be able to be rapidly responsive to such change in the best interests of customers. There is an art and a science in keeping up-to-the-minute ‘Trauma-Informed’. Furthermore there is an obligation of the ‘informed’ to inform others appropriately. (Section 20)  

Solutions:                We in South Africa are very good at identifying problems and analysing them from every possible angle. We have become very poor at devising solutions and very risk averse in taking ownership of solution implementation. (Section 21)

Institute:                       Formal, legal and empirical. (Section 21)

 


“The need to identify, acknowledge and appropriately address the trauma which underpins diverse mental and physical health as well as psychosocial and intergenerational impacts is substantial. Broad-based implementation of the trauma-informed and resilience-informed principles underpinning the TRISI Institute is critical to advance the health and wellbeing of individuals and communities.”

Dr Cathy Kezelman, President ASCA - Adults Surviving Child Abuse (Australia)

 

What is at stake?

We must urgently interrupt the South African 150 year cycle of interpersonal, inter community and inter cultural abuse.  This proposal clearly demonstrates such abuse invokes negative, high-impact Behavioral and Primary Health Traumatic responses – poor Traumatic Health. There is a negative, direct and sustainable influence on Substance Abuse, Violence, HIV/Aids and Poverty. The cost to the SA Economy is at least 2.2% of GDP and probably more like 6-7.5%. (Section 6) Unless we create solutions to the now obvious problems, the social capital required to sustain the nation will decline to an irreparable deficit. (Sections 12, 13, 14)

Children: (Sections 5, 11, 14)

Education – Adverse Traumatic experiences in childhood lead to disrupted neuro-development affecting growth, structuring and development of the brain leading to inability to cope with leaning pressures;

Primary Health – Bio-physiology impairment leading to short and long term Primary Health risks;

Mental Health – Half of all diagnosable mental illness begins by age 14 and 75% by age 24. Childhood Trauma is by far the most significant determinant of poor Mental Health;

Behavioral Health – Poor conflict management skills, poor social skills, impulsivity, attention deficit, difficult temperament, delinquency, adolescent substance abuse and violence; 

Adults: (Sections 5-19)

In addition to adult traumatic experiences, social, emotional and cognitive impairmentin childhood manifests in adults: 

Employment – Unresolved Trauma regulates difficulties in pursuing continuous employment, habitual high absenteeism and employment negative behaviors (Section 6.); 

Primary Health – Unresolved Trauma  leads to adult disease, disabilityand early death (Sections 5, 6, 10, 11);

Mental Health (Sections 10, 11)

Trauma is both the cause and the consequence of Mental Health;
Poor Mental Health in early adulthood creates high epigenetic transfer risks in child rearing couples; 

Suppression and masking of Traumatic experiences in early adulthood results in delayed Mental Illness onset displaying during primary economic contribution age (40-50);

       Behavioral Health – (Sections 10, 11, 17)

                     Repetitive “learned”, and genetically transferred, negative intergenerational Behavior 
                     Substance Abuse – Trauma triggers and sustains an ever increasing spiral of substance abuse; 
                     Violence – Unresolved Trauma is the fuel for the cycle of violence in our country;
                     HIV/Aids Trauma is often the root cause of symptomatic risky sexual behaviors. 
                     Poverty – Unresolved Trauma impairs the individual’s ability to cope, be self-sustaining and socially interactive trapping the individual in poverty

 

Forward

“South Africa is a country that carries a deep and traumatic wound. This is a wound that infects the well-being of individuals and generations. It understandably continues to impact profoundly on all, across generations and chronology.

The Wound that the Rainbow Nation carries will not, and cannot, simply self-heal. It calls out for and demands attention to its pain, grief, suffering and loss. For the Nation and its people to heal, there needs to be action. Without action the deep wounding will continue to impact on all, generation after generation, as each passes their pain and grief on.

Brian Rogers understands and has lived through trauma. He speaks with the voice of experience. He feels what the Nation feels because he has been there.

I urge that attention be paid to his vision and to his willingness to sacrifice everything he has to contribute to a collective healing. I wish him well on this journey. He is a remarkable Man and Warrior.”

Barry Zworestein. Clinical Psychologist

 

At the 2012 National Health Summit, Health Minister Aaron Motsoaledi stated “Because of their condition, Mental Health Care users are often ‘voiceless’, and it is critical that we both give this group the space to voice their needs and then respond appropriately through including Mental Health in all health plans and programmes” he stated. ⁴⁶²

Ø  This is a proposal in response to that call.

Ø  The proposal is dedicated to all those who have been excluded in the past and remain discriminated against in the present.

Trauma is pervasive in Mental Health. It is historical, intergenerational, epigenetic, cultural, communal - and biological. Self-perpetuating it is highly Resilient. Poor Traumatic Mental Health is at the core of the forces that bind people to Substance Abuse and Poverty. Poor Traumatic Mental Health is the Tokolosheᶲ of HIV/AIDS and the provocateur of personal and communal violence. In a country which is painted with the 150 year old brush of deliberate and systematic moral injury and betrayal, those wounds are now festering uncontrollably. Today, unresolved Trauma is the fuel for the cycle of violence in our country.

ᶲ Tokoloshe:  essentially an African mischievous and evil spirit called upon by malevolent people to cause trouble for others. Depending on culture it has different origins, different characteristics and different means of destruction. However, what are common themes are sex and exploitation of the victim.

South Africa has made really decent legislative and strategic strides in Mental Health in the last 15 years. However, actual solutions for those in need have been very slow in forthcoming. As things stand, there are no encouraging signs of an improvement in the near future. It is typical of the current ‘culture of victimhood’ in South Africa to blame ‘them/others’, in this case the Government, for lack of progress. All psychological analysis tells us that victims are powerless to progress as they are unable, themselves, to offer reasonable solutions within given constraints. ‘Throwing money at it’ is simply not a solution in these pressing times, yet that seems to be the only voice that prevails amongst those in the Mental Health economy.  

For a Mental Health consumer activist to make a difference there are two reasonable choices: 1) be demonstrably critical and find a voice at every opportunity; or 2) be objectively critical and offer a solution – then find a voice. Both require the activist be well informed. Regrettably this is no easy task in South Africa as the required information, if it does exist, is often kept in ‘territorial silos of knowledge’.  There is no culture of Mental Health consumerism in South Africa and therefore there is very limited public dialogue with the consumer by the professions.  The first option will not overcome the sense of victimhood felt by the Mental Health consumer. Only the pursuit of solutions encourages positive resilience and healing.⁶⁰⁰

It has taken three years of research (and over 600 referenced local and international scientific papers and expert opinion) to reach a conclusion and extend a viable solution. Despite overwhelming, if somewhat previously uncoordinated, testimony supporting this proposal, it is thought unlikely that this solution will be given sufficient consideration by local existing Psychiatry (SASOP) and Psychology (PsySSA) unions (See - Section 16); and the Health Professions Council of South Africa (HPCSA) has been found by the Ministers task team to be “in a state of multi-system organisational dysfunction”³³⁹

The proposal is therefore primarily aimed at gaining support from influential individuals and organisations looking for solutions to the co-existent challenges in Mental Health, Trauma, Poverty, Substance Abuse, HIV/Aids, Violence, Education, Productivity and Absenteeism - in addition to the need to streamline our Health Care services.  It is hoped that suitably concerned people and organisations will assist in the strengthening of this proposal, supporting its presentation to Government and the formation of TRISI. 


The objective
of the document is to raise “enabling-capital” to make this solution a reality.

·         Intellectual enabling-capital; 

·         Business and Financial Expertise enabling-capital; 

·         Political-will enabling-capital; 

·         Partnership enabling-capital with existing organisations; 

·         Network enabling-capital with the right people; 

·         Marketing platform enabling-capital to bring awareness; 

·         Financial enabling-capital.

 

What is this proposal all about, really?

 Yes, it talks violence and trauma, conflict and diverse opinions, PTSD and Systems, Psycho-Social and Socio-Economic.

 Yet that is just the discourse that needs to be entertained to take the cause to reality. 

In truth it’s about giving people a better chance at a better quality of life. 

Useful lives, human connectedness and communal participation. 

It’s about school performance and childhood fulfilment. 

Jobs, productivity and reduced absenteeism. 

Cultural enrichment and nationhood. 

 Pride. 

And happiness. 

Brian Rogers  

@TraumaActivist  

Contact details: Brian Rogers; This email address is being protected from spambots. You need JavaScript enabled to view it. ;

 

Your work is very important. I have argued many times that untreated or unaddressed trauma is a serious cause of violence and aggression both here and in the Middle East”
Prof Steven Friedman, Political Scientist


TRISI – Enabling and Preventative Factors

Enabling Factors

Government – The South African Government, under the current leadership of Health Minister Aaron Motsoaledi, is strategically focused on maximising integrated Health Care, which is both a function and a primary outcome of Trauma-Informed Care;

Global Trauma-Informed Care (T-IC) progress (Sections 17, 18).  - T-IC solutions have been developing for 20 years or more and:

  • Are legitimised as the primary Behavioral Health tools in the United States, Canada, Australia and the UK (although under a different nomenclature);
  • As such it is T-IC that is recognised as having the greatest investment impact against the “Health Gang” of Mental Health, Substance Abuse, Violence, HIV/Aids and Poverty. T-IC is in third generation of implementation and empirical measurement;
  • Show rapid ‘healing’ progress in individual and intergenerational community terms;
  • Are cellular in nature and not national – reducing the risk of investment and containing failure in manageable re-generative proportions;
  • Have the appropriate cultural filters for our multi-minority society;
  • Give the necessary ‘Voice’ to Mental Health customers – individuals, institutional and community;
  • Are available to South Africa at minimal cost and maximum enthusiasm for multi-nation deployment.

Global Resilience Building progress: ‘Resilience’ is a preventative factor and a personal and community healing enabler. Whilst not quite as advanced in its progress as T-IC in Mental Health solutions, Resilience is generally accepted by the latter to be a crucial accompaniment to Trauma solution building. Additionally there is advancement in independent Resilience institutes that are not necessarily coupled to T-IC institutions and thus independent in scope, which keeps thinking fresh. The ‘science’ of personal, interpersonal and societal Resilience is highly energised and at the cusp of high impact creative solutions and empirical verification. Such progress is available to South Africa at minimal cost. (Sections 4, 11, 14, 19.)

Impact Financing: The relatively newconcept of global Impact Investment has exactly the investment philosophy that would be required for an organisation such as this. Impact Investors are inextricably linked to economic stability and or progress. They are not philanthropic donors. They are generators of economic wealth in many facets of society. Investment in social capital enables economic returns elsewhere in their portfolios. They are also interconnected and potentially able to bring both intellectual and financial capital from a variety of inter-reliant partners. (Section 21).

 

Preventative Factors

In truth, these preventative factors are primarily more ‘discouraging socio-political factors’. Predominantly the preventative factors are imbedded in organisations which either do not have the will to seek solutions to the problems, or are involved in survival struggles of their own. Either way they might see the formation of TRISI as a threat to their personal goals. It is not seen as necessary to compel the majority of these organisations to engage with TRISI. Rather, they should be encouraged to participate firstly by engaging them on the benefits to their organisations that TRISI could bring; and secondly, through progressive results, to further reassure them. However, the very subject of Trauma is the first hurdle that needs to be crossed.   

Trauma – Trauma disappeared from the public and professional psycho-social discourse in South Africa after 1997, despite the realities being made very clear by Hamber and Lewis¹⁹⁹. This is precisely the year that the United States and Canada, in particular, began to recognise the centrality of Trauma and invested heavily in developing T-IC solutions. However, many uncoordinated and uncommunicative pockets of Trauma expertise exist in the country even if somewhat lacking in modern T-IC guidance.

Academic Institutions – Currently Trauma is not a priority in Psychology and, at most, is a semesters worth of effort. Additionally there are many courses currently being run by academic institutions that are out of date and internationally unacceptable. (A prime example is Critical Incident Stress Debriefing which is still being taught despite the fact that it was globally rejected back in 2007 as ineffective and even harmful. It was replaced with Psychological First Aid. A PFA certificate is mandatory in international disaster management Trauma care.) There is considerable education of the educators to address before they will embrace TRISI.

Institutionalisation – South Africa has a dominant singular historical resource focus in care for those with Mental Illness. Institutionalisation without Trauma-Informed Care is nothing more than confinement from society. Institutionalisation in its South African form is 30 years out of date even for the market it was designed to serve – citizens of European descent. There is a vast chasm between the needs of most citizens of African and Asian descent and the methods of South African institutions. Current global opinion indicates that institutionalisation is not suitable for many of European descent either. Considerable long term donor funds have a vested interest private institutional success and represent as much of a challenge to reform as do the staff of such institutions.

PsySSA and SASOP (Psychology Society of South Africa and South African Society of Psychiatrists) – These organisations are unions/guilds which, whilst efficient in their quest, have no historical appetite for social challenges. In their present strategic display they are more part of the problem than the solution. There is no practical reason to prevent their support for TRISI, only potential politico-professional reticence. (Section 15)

SAFMH and SADAG (SA Federation of Mental Health and South African Depression and Anxiety Group.) These are South Africa’s two largest and most distinguished NGO’s. They are politically powerful and do much good work in the names of their sponsors and donors. However, the former has no history of dealing with Trauma at all and the latter has regrettably developed an entire platform on the basis that depression and anxiety is the most important Mental Health issue in the country. However, the former has no history of dealing with Trauma at all and the latter has regrettably developed an entire platform on the basis that depression and anxiety, is the most important Mental Health issue in the country. This is not supported by science or conventional wisdom.  Depression and anxiety are symptoms of health, not causes. Trauma is the primary cause of depression and anxiety, so tackling symptoms will not solve the problem.  It remains to be seen how politically defensive they would become with the entrance of TRISI into the economy. (Section 15)

Donor Power – Philanthropy has become a tightly controlled affair. Donors have specific objectives. Most Donor funds are now managed by banking agents. This has often led to NGO’s – or NPO’s as they are more likely called in today’s South African legal dispensation – adapting to deliver services to meet Donor/agent objectives rather than customer requirements. Donors and their agents are not by any means incompetent in defining needs, however the knock on effect is that employees of NPO’s are bound by Donor power and have no ‘Voice’ in the economy at all. This is a serious waste of front-line knowledge. Whilst initial reticence of Donors to accept T-IC and Resilience initiatives in their domains can be expected if it interferes with current Donor-logic, the potential for Donor/agents themselves to become customers of TRISI is quite obvious. They are looking for Social Return on Investment and the services of TRISI will enhance their professional intent.

Criminal Justice System – There are two factors to consider. Firstly, a very large contingent of the Criminal Justice human resource base is in poor Traumatic Health itself.  However, it is neither understood nor acknowledged. Secondly, there is very little appreciation of the Traumatic Health of those that pass through the system. Whilst poor Traumatic Health is no excuse for lawlessness, there is considerable evidence that Trauma-Informed CJS’s in other parts of the world are more efficient, particularly with respect to child offender rehabilitation. Initial reluctance to embrace T-IC solutions is expected. However international success (often in the toughest of neighbourhoods) will be useful leverage initially. The CJS should become a significant customer of TRISI over time.

TRISI – The Domain

TRISI in Brief

TRISI will apply both a Trauma-Informed and a Resilience-Informed lens to customer health solutions - in the co-existent environment of Primary Health, Mental Health, Poverty, Violence, Substance Abuse and HIV/Aids.

TRISI will be skilled at providing efficient solutions to South Africa’s psycho-social problems which, in turn, will positively impact on the socio-economic future of our country.

TRISI is proposed to be a solution generating organisation, for a wide range of customers. Perhaps this organisation should even be called TRICSI – Trauma & Resilience-Informed Customer Solutions Institute. There is no chance of this organisation succeeding if customer satisfaction is not the objective of the service.

TRISI will be capable of positively impacting diverse customers’ needs such as:  Individual Consumers, Home Care Givers, Primary Health, Communities, Educators, Businesses, the Criminal Justice System, Institutions, NPO’s and Government. (Section 20.)

TRISI will embrace, not replace, existing Health Care skills sets, whilst incorporating others such as Resilience, Trauma-Informed Care, Consumerism, Social Science, Innovation & Entrepreneurism, Communication, Systems, Impact Finance, and Human Resource Deployment.    

TRISI’s efficiencies will come from networks and partnerships with international organisations already advanced in the fields of Resilience and Health Care.

TRISI will be an educator and a learner, ‘hubbed’ (but not necessarily always confined) in an appropriate academic institution.

 

 

TRISI – Social Impact Statement

 

“I am truly impressed with what you are tackling here and wish you and your organisation everything of the best. It is wonderful to see a holistic, community based approach.”
Dr Lynne Derman, Managing Consultant, Goldfish Consulting.

 

TRISI Social Mission:

To directly impact the negative Primary Health Care consequences of Trauma and co-existent Behavioral Health Care challenges such as Substance Abuse, HIV/Aids and other Mental Illness; and to positively influence the consequential poverty traps and violent tendencies that accompany this “Health Gang”.

TRISI Social Vision

  • An integrated Primary Health system which minimizes re-Traumatisation and maximises positive Resilience;
  • A Criminal Justice System that respects the Human Rights of those with poor Mental Health and is relieved of the burden of current Trauma aroused interpersonal, interfamilial and community led violence;
  • An active Psycho Social network system with common purpose, education and tools;
  • Reward systems and public recognition for Social Health performance;
  • A South Africa where people are free from unnecessary institutional Traumatic influences and where hope replaces victim-mentality as the resilient social currency.

TRISI Social Strategy:

To provide effective short, medium and long term Psycho Social solutions to an extensive array of customers, using a Trauma and Resilience lens on problems and opportunities.

TRISI Social Context

  • An accessible customer service centre;
  • Disciplined, transparent Mental/Behavioral Health decision making solution centre;  
  • A shared collective resource centre for scientific research, in-field practice and independent ideas;
  • A monitoring and evaluation centre for customer projects;
  • A pro-active needs-based multi-disciplinary catalyst. 

TRISI Impact Chain:

  • Cellular solutions that are compounded customer-to-customer, geographically, culturally and by community, in targeted universes.
  • Collective cells create a ‘gestalt’ sum of component parts;
  • Failing, deviant or uniquely environmentally impacted  cells can be repaired in isolation, protecting the greater whole;
  • Knowledge transfer between ‘hive’ universes;

TRISI Impact Breadth and Depth:

  • Breadth - indirect impact on individuals and all collective sectors of society by upscaling Trauma and Resilience knowledge and competence in the entire Health Care system (Government, Private and NGO), the quasi-Healthcare systems (Disaster Management, Specialised Rescue, Fire, Police, Security Industry and neighbourhood volunteer), the Education sector, high risk business environments, religious groupings, marginalised cultures and community outreach programmes.
  • Depth - Building solutions for individuals, groups and collectives in high risk communities exposed to Poverty, Violence, Substance Abuse, HIV/Aids and Secondary Traumatic Stress.

TRISI Impact through Innovation and Change:

  • Customer culture in Mental Health Care – a South African first;
  • Interdisciplinary  community based Psycho Social programmes – a South African first;
  • Community, family and peer support programmes – a South African first;
  • Generation of Resilience-positive alternatives to  Resilience-negative preventative factors – a South African first;
  • Total solutions to needs including project Impact Financing and NGO administrative support and disciplines – a South African first;
  • Customer empowerment not control – a South African first;
  • Entrepreneurship in Mental Health solutions through a Resilience platform – a South African first.

TRISI Impact through resilient solutions

  • Localised skills development and support;
  • Localised Solution ownership – ongoing support and regenerative programmes;
  • Public acknowledgement and celebration of success.

TRISI Impact Assessment, Monitoring and Measurement

  • Financial and social risk clearly agreed between TRISI and customers;
  • Conditional participation for fee based and project financed customers which includes monitoring of skills performance, output measurement and end user assessment;
  • Internal and external social impact and financial efficacy evaluation and audit.

TRISI Impact through Learning

  • Multi-level learning facility in partnership with appropriate specialist institution/s;
  • Practical skills development in-situ for all levels of education;
  • Skills recognition and certification for practical work irrespective of academic level;
  • Academic reward system for direct project contribution;
  • Customer involvement in curricula and teaching.

TRISI Financial Model

  • Capital Finance – Source: Government/Private Health Care/local and international Impact Investment;
  • Project Finance – Impact Investment; Donor Market; Fee paying; Commercial sponsorship;
  • Customer Finance  – Non-fee paying customers to apply for “Trauma Assistance Bonds” repayable through audited performance criteria;
  • Income Generation – Fee paying customers; Sponsorship; commercial entrepreneurship; consumables.

TRISI Leadership and Staffing model

  • Multi-disciplinary network of skills;
  • Core full time employee base; project contract expertise; piece-meal expertise resources;
  • Leadership structure very flat. Key skills required: team and people management, performance management and entrepreneurship;    
  • Project management system with revolving leadership;
  • Ideal skills in all functions – solution thinking, customer satisfaction, performance driven, implementation detail, teamwork; compassionate, entrepreneurial, competitive and ambitious;
  • Customer management team – high in social, customer performance and lateral/innovation skills in limited resource environment;
  • Active, timeous and efficient Oversight and Governance.

TRISI Partners for Impact

  • Key global: WHO (World Health Organisation) ; ISTSS (International Society for Traumatic Stress Studies) UNICEF (United Nations International Children’s Emergency Fund).
  • Key Country:

USA – NCTSN (National Child Traumatic Stress network); SAMHSA (Substance Abuse and Mental Health Association) + Key States; CDC (Centres for Disease Control Prevention)

Australia – ASCA (Adults Surviving Child Abuse); MHCC (Mental Health Co-ordinating Council);

Canada – MHC (Mental Health Commission);

UK – MHSP (Mental Health Strategic Partnership);

Israel – ICTP (Israel Center for the Treatment of Psychotrauma – Note: Includes Resilience).

  • Key local – Dept. of Health; Dept. of Social Services; HSRC (Human Sciences Research Council); PHASA (Public Health Association of South Africa); HSPCA (Health Professions Council of South Africa); SAMA (South African medical Association); SAAFP (South African Association of Family Practice); RuDASA (Rural Doctors Association of Southern Africa); FPD (Foundation for Professional Development); MWASA (Medical Women Association of South Africa); TSSA (Trauma Society of South Africa): SAMRC (South African Medical Research Council); SAFMH (South African Federation for Mental Health); TAC (Treatment Action Campaign – HIV/Aids); CAPRISA (Centre for the Aids Programme of Research in South Africa); SANCA (South African National Council on Alcoholism and Drugs); SARPN (Southern African Regional Poverty Network): ISS (institute for Security Studies); The Avielle Foundation; SaferSpaces; SAPSAC (South African Professional Society on the Abuse of Children); The Trauma Centre; SADAG (South African Depression and Anxiety Group); Universities and Learning Centres – (To be investigated).

TRISI Matrix Management Model

The TRISI Matrix Model works as follows:

Fig 1. Primary axis: “Customer needs and management”  

Fig 2. Fulfilment axis “Expertise and Skills” 

Fig. 3 “Enabling Resources” axis

Fig 1. Primary axis: “Customer needs and management”  

 

Fig 2. Fulfilment axis “Expertise and Skills” 

 

Fig. 3 “Enabling Resources” axis

 

TRISI – Next Steps

Circulate the proposal to appropriate audience

Raise “enabling capital” – intellectual and financial

  •      Intellectual Psycho-Social enabling-capital;
  •      Business Expertise enabling-capital;
  •      Political will enabling-capital;
  •      Partnership enabling-capital with existing organisations;
  •      Network enabling-capital with the right people;
  •      Marketing platform enabling-capital to bring awareness;
  •      Financial enabling-capital.

Create opportunities to present the proposal one-on-one or to groups

Revise, amend and extend the proposal according to advice

Present to Government

The Backdrop to the TRISI proposal

In 2012, at the National Health Summit, Minister Motsoaledi called for ‘called for greater awareness, better planning and a move away from a “Hospicentric approach” to the treatment of Mental Illness. We know that there continues to be over-reliance on Psychiatric Hospitals as the mode to care, treatment and rehabilitation” Motsoaledi said. South Africa has continued to follow the colonial, “Hospicentric approach”, and in doing so have neglected critical aspects of Primary Health Care.” ⁴⁶³

At the conclusion of National Health Summit, theEkurhuleni Declaration on Mental Health⁵⁴³ was signed: 

The Ekurhuleni Declaration on Mental Health - April 2012; Afr J Psychiatry 2012;15:381-383

“We, the participants in the National Mental Health Summit held on 12-13 April 2012, consisting of representatives of government departments, non-governmental organizations, the World Health Organization, academic institutions, research organizations, professional bodies, traditional health practitioners, clinicians and advocacy and user organizations, gathered around the strategic theme ‘Scaling up investment in mental health for a long and healthy life for all South Africans.”

That same year, 2012, Dr Cathy Kezelman and Dr Pam Stavropoulos (supported by Prof Warwick Middleton) changed the face of Australian Mental Health services when they courageously published the ASCA (Adults Surviving Child Abuse) Trauma-Informed Care guidelines -Kezelman, C., Stavropoulos, P.  Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery.²⁸¹ These guidelines have been widely accepted and acknowledged; and formally recognised in Australia by the Royal Australian College of General Practitioners, The Mental Health Coordinating Council (MHCC), The Australian Society of Psychological Medicine (ASPM), Section of Psychotherapy, Royal Australian and New Zealand College of Psychiatrists (RANZCP) and many others.

Kezelman, C., Stavropoulos, P.  Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery. Adults Surviving Child Abuse (ASCA) 2012

‘Movement towards more decentralised models of care, community-based services, consumer participation and recovery-oriented practice have been evolving themes of successive National Mental Health Strategies [in Australia]. They are now embedded principles in mental health care, and in the National Mental Health Plan. But the gap between these goals and their implementation is also consistently reiterated. To the extent that envisaged principles and practice are not simultaneously and explicitly trauma-informed – ie embedded into both the philosophy and functioning of all levels of service-delivery – co-ordinated assistance towards client recovery will remain lacking.’


The same year The Mental Health Commission of Canada (MHCC) published their ground-breaking strategy which was based first and foremost on the needs, desires and wish lists of Mental Health consumers - “
Mental Health Commission of Canada. (2012). Changing directions, changing lives: The mental health strategy for Canada. Calgary, AB: Author.”³³⁴

Mental Health Commission of Canada. (2012). Changing directions, changing lives: The mental health strategy for Canada. Calgary, AB: Author.

‘Changing Directions, Changing Lives is the culmination of many years of hard work and advocacy by people across the country. A key driver behind its development has been the testimony of thousands of people living with mental health problems and illnesses. In increasing numbers they have found the courage to speak publicly about their personal experiences and the many obstacles they face in obtaining the help and support they need from an underfunded and fragmented mental health system. Family members have echoed this assessment while pointing to the many challenges that they also confront.’

And in 2014, following 25 years of development and practice, the most funded and supported of all Health organisations in the United States, the Substance Abuse and Mental Health Administration (SAMHSA) published Substance Abuse and Mental Health Services Administration; Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.⁴⁸³

SAMHSA; Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS PublicationNo. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

‘By recognizing that traumatic experiences and their sequelae tie closely into behavioral health problems, front-line professionals and community-based programs can begin to build a trauma-informed environment across the continuum of care. Key steps include meeting client needs in a safe, collaborative, and compassionate manner; preventing treatment practices that re-traumatize people with histories of trauma who are seeking help or receiving services; building on the strengths and resilience of clients in the context of their environments and communities; and endorsing trauma-informed principles in agencies through support, consultation, and supervision of staff.’

Resulting from the National Mental Health Summit the - Department of Health; Republic of South Africa, National Mental Health Policy Framework and Strategic Plan 2013-2020¹³⁹ - was developed and published.

Department of Health; Republic of South Africa, National Mental Health Policy Framework and Strategic Plan 2013-2020

‘There is (therefore) an urgent need to develop a national mental health policy that reflects the opinions and priorities of a wide range of mental health stakeholders; is based on sound evidence; and provides a blueprint for action on mental health in South Africa. The purpose of this policy is to give guidance to provinces for mental health promotion, prevention of mental illness, treatment and rehabilitation. The policy is intended to be comprehensive in its scope, addressing the full age range, and covering all mental disorders, including co-morbid intellectual disability and substance use disorders.’

Regrettably the ‘National Policy Framework and Strategic Plan’ fails to mention Trauma at all. In fact there are many aspects of the policy that are diametrically opposite from the work of ASCA and SAFMH as a result of not being Trauma-Informed. The reason for this is quite clear when studying the literature.

In 1997 Hamber & Lewis published their landmark - Hamber, B. & Lewis, S. (1997).An Overview of the Consequences of Violence and Trauma in South Africa.Research report written for the Centre for the Study of Violence and Reconciliation.¹⁹⁹ - This was a broadly accepted and acknowledged analysis of the State of the Nation. The hard evidence is there for all to see. 18 years on, the scenarios not only hold, they are clearly magnified. However, since that date, the social impact of Trauma has simply disappeared from our public discourse.

In fact, the entire subject of Trauma has been expunged from public discourse. A thorough examination of the press coverage of 2015 Mental Health month found not a single mention of Trauma and only a single passing mention of PTSD – the biological Psychiatric diagnostic name for Trauma. With the stand out exceptions of Lane Benjamin and Sarah Crawford Browne’s 2013 Lane Benjamin and Sarah Crawford Brown (South Africa); The psychological impact of continuous traumatic stress -- limitations of existing diagnostic frameworks²⁸⁶ and various scientific analysis conducted by Kenyan Lukoye Atwoli and UCT’s Prof Dan Stein on the rather limited South African Stress and Health Study ³⁰²'³⁰³ There has been very little public discourse around the social consequences of Trauma in the media at all, since 1997. The primary interest of SA scientists and researchers has been on single incident PTSD in individuals. 

Meanwhile, the world was going through an explosion in Trauma thinking and solution building during the exact same period.

The consequences of Single incident PTSD pales into insignificance in terms of multiple trauma exposures, known as Complex PTSD and Developmental Trauma. In fact the research focus in South Africa, influenced by global Psychiatric trends - particularly the American Psychiatry Association, on single incident PTSD vastly underestimates the number of people with PTSD type diagnostic criteria, as they are excluded from the metrics by definition.  To date this research has not been able to identify any research into Complex PTSD or Developmental Trauma in South Africa. (Sections 7 & 8).

In its defence the National Policy Framework and Strategic Plan does refer to the fact that most Mental Health issues begin in childhood. There is nevertheless no mention at all of Trauma, which is globally accepted as the primary driver of developmental Mental Health issues in children. Such issues manifest later as adult Mental Illness, Substance Abuse and other co-existing Behavioral Health problems. By ignoring the centrality of Trauma, South African interest groups, researchers and scientists have failed to recognise the importance of the US 1997 Adverse Childhood Experiences (ACE’s). 20 years later this study has been repeated over 80 times around the world, in different cultural and economic settings, with ever increasing evidence of its significance. More importantly hundreds and hundreds of shared experience field trials of resulting solution programmes have been collated and refined - and are now in second or third phase efficacy development. Aside from the cost of the surveys, this package of knowledge is available virtually free of charge to South Africa, backed by hundreds of millions of dollars invested in empirical feedback. (Sections 5 & 11).

Around the globe health economies are wrestling with costs and levels of Health Care appropriate to basic human rights. In every single advanced system of Integrated Health Care they are either in the process of realisation or already in implementation of a Trauma-Informed System of Care across Mental Illness facilities and Mental Health programmes. This means not just an internalised Trauma microscope on institutions but a magnification of the problem of Trauma in society. The impact is directly measurable against criteria in Criminal Justice Systems across Substance Abuse, serious violence and aggressive behavior, sexual misconduct and intra-family disputes. (Sections 5, 15, 16 & 18). 

  • At the core of development for treatment programmes for Mental Health of the temporarily and more permanently mentally disabled, is the movement away from the primacy of costly “Eurocentric’ Pharmacological and Cognitive Behavioral Therapies that are dominated and controlled by the professions. The break through work of van der Kolk⁵⁷¹ and others has expanded remedial options to the appreciation of the effects on brain, mind, body, ‘soul’ and ‘society connectivity’ there has been an explosion of healing solutions for consumers. Some are new but many are natural, modern extrapolations of ancient techniques – e.g. Mindfulness. Many of these are under attack by the professions for not being under regulatory control, yet it’s the psychiatric-neuroscientists like van der Kolk themselves, that are giving these self-same ‘lay’ solutions credibility. (Sections 7, 8 & 18). 
  • The biological models of Mental Illness that have led to diagnostic theory have, by definition, ignored culture. This is understandable, if not acceptable. However what is entirely unacceptable is that most of the remedial options offered by the “Eurocentric’ psychiatric and psychology bodies globally and here in South Africa. They ignore the importance of healing in a community context. Only very few of the Mentally Ill find their way to mental hospitals. The vast majority of people struggle on in everyday life. Trauma-Informed Care theorists has been adamant that both the recognition of Trauma and the treatment of people with poor Mental Health is continuously adapted for cultural and community influences. To date, Trauma-Informed Care is the only wide spread developmental theory that is actively pursuing, measuring and refining cultural and community issues in Mental Health. (Sections 6, 12, 14 & 18.) 
  • It has now been unequivocally recognised that Trauma is not a consequence of anxiety and depression. There is only a limited association. Anxiety and depression are symptoms only sometimes experienced by Traumatised people and only by some people - (In the case of depression probably less than a third of Traumatised people experience clinical depression.) The way Trauma plays out is far more complex than anxiety and depression and is the subject of the majority of the analysis in this proposal. Unfortunately this ‘error’ by the diagnosticians led to many people receiving inappropriate care and many not receiving any care at all. The dominance in South Africa of the otherwise very successful NGO, The South African Depression and Anxiety Group (SADAG), has likely contributed both to the aforementioned care issues and to the expulsion of Trauma from public discourse. (Sections 8 & 10.)  

A refreshing feature of the above influences and other Behavioral Health care philosophies and theories of Mental Health (Section 17), is the ‘collective’ effort of organisational solution activity, process and knowledge – despite the relative legal and operational independence of the caregivers. Unlike the silos that exist in the South African Mental Health economy, the driving ego force is ‘success in other markets through sharing’. The extensive empirically backed documentation, the research and training facilities, the co-operative internet connections are, in the main, free to South Africans. However, by enquiry, very few South Africans participate in this luxury.

In short, no matter where we head with our Mental Health planning and development in South Africa, it’s the global view that unless we integrate the concept of Trauma-Informed Care at the very grass roots of Mental Health and Mental Illness care, we will continue to fail. Should we integrate Trauma-Informed Care appropriately, not only will integration of health services improve the economic efficacy of Health Care in general, the Mental Health of our South African population will improve exponentially. This is a far less costly exercise than may be thought to implement. Trauma-Informed systems of Care are usually implemented on a planned, affordable step-by-step basis.

 

Key findings of the research

Trauma-Informed

  1. The “Heath Care Gang” – Mental Illness, Substance Abuse, HIV/Aids, Violence and Poverty –undoubtedly the have the largest collective negative impact on our economy, our Public Health system and our Criminal Justice System of any of the human behavior clusters. This is in line with many countries and prevails in diverse economies. It has been clearly established globally that the common denominator, the protagonist, across these Behavioral Health conditions, is Trauma. There are no dissenting voices as to the validity of this statement – only debate at solution level.
  2. In South Africa, Trauma has disappeared from the public solution discourse since 1997 despite the continuance of 150 years of moral injury and betrayal, and the rise in violent crime. There are no dissenting voices to this opinion. Trauma-Informed Systems of Care solutions have been thoroughly researched in science and practice over the last 15 – 25 years. They are seen as indispensable to both Integrated Health Care and to Institutional Mental Illness Care. There are no international dissenting voices to this principle, only debate on detail.
  3. Trauma is not Post-traumatic Stress Disorder although PTSD is one consequence of Trauma.
  4. Trauma is not an Anxiety and Depression Disorder. Trauma is far more complex. Nevertheless, anxiety and depression can result from Trauma.

Resilience-Informed

  1. The theory and practice of Resilience holds considerable promise for developing lasting solutions in Trauma Mental Health Care. However currently, both globally and locally, the understanding of Resilience in Trauma Mental Health Care is confused and misguided.
  2. The minimisation of Resilience theory to the definition of ‘to bend and not break’ is fundamentally ignorant of Trauma and other Mental Health issues, and stigmatising in the extreme.
  3. Resilience is neither the antithesis of Trauma nor the panacea for Trauma. Many people with poor Mental Health are extremely Resilient. So too are sex and substance abuse addicts, poor communities violent gangs etc. etc.
  4. Every system has Risk and Protective factors that are crucial to future Resilience. Tampering with elements and/or the mix requires both an empirical and creative construct appreciation. The consequences of change can destroy the Resilience of the system, even if the new component part is an improvement.
  5. A breakthrough in understanding ‘Resilience in the absence of a system’ is crucial to finding a solution to the global issue of stigma and to emotional health.

Solution Building

There never is a lack of passion or commitment in South Africa, and solutions to Mental Health challenges have the appropriate interest. However, a few exceptions notwithstanding, most individuals and organisations and institutes are too busy with survival procedures to contribute effectively to nationwide Mental Health solution thinking. The result is endless conferences that primarily deal with problems and endless papers that deal with symptomatic details.

  1. The only Health economy representatives of psychiatry (SASOP) and Psychology (PsySSA) are guilds/unions. As such, both their structure and outputs are part of the problem.
  2. There are only two powerful Mental Health NGO’s in South Africa – SA Federation of Mental Health (SAFMH) and the South African Depression and Anxiety Group (SADAG). The former is a conservative bastion that has been operating for over 90 years, supporting and representing the diverse micro- and small to medium size NPO’s that characterise the South African Health economy. SAFMH has recently undergone a positive management, image and operational makeover to deal with 21st century issues in Mental Health Care. SAFMH is open to, and encouraging of advocacy, human rights and ‘consumer voice’. SADAG has won many awards and is extremely brand conscious. SADAG is primarily concerned with self-perpetuation and acts as a consumer advocate for issues that further that objective.
  3. Social Workers – from Psychiatrists through lay volunteers – have no organised voice and are beholden to their employers. The majority of NGO’s – or NPO’s as they are now more commonly called – are beholden to Donor objectives. Donors primarily have short term impact in mind.
  4. The South African Government has a mountain of pressing Health Care issues to deal with. There seems to be a ‘burning platform’ at every turn. 
  5. There are very few Mental Health activists without vested interests in South Africa. The majority are beholden to those that give them funding and/or voice. Controlling advocacy organisations filter and channel customer voice. In the three countries that have pioneered Trauma-Informed Care solutions, (USA, Canada and Australia), change has only come about by the establishment being challenged by independent activists – customers, lay activists and Mental Health professionals. Fortunately in those three countries the establishment listened and responded appropriately.      

Customers (Section 20)

  1. Regrettably Mental Health in South Africa has degenerated into the singular biological diagnosis and treatment of individuals.  The concept of Behavioral Health, with its foundations in community, has not attracted any public discussion. This directly correlates with local Trauma ignorance.
  2. Global solutions to Trauma (and hence Substance Abuse, HIV/Aids, Violence and Poverty) recognise that people are social animals and as such, experience their Trauma, and in turn their healing, in the context of social environments. This has encouraged the systemisation of integrated care, the re-emergence of community based care and an emphasis on self-but-supported friends and family care.
  3. The customer is individual and collective:- community, culture, behavioral and organisational. Organisations are business, government, quasi-government; education and implementation.
  4. In terms of initially engaging customers the possibilities of Resilience are preferable to the stigma of Trauma.
  5. Although variables need to change, there is absolutely no reason why the general principles of customer centricity should not apply in a social economy – including price behavior.
  6. TRISI might be better named the Trauma & Resilience Informed Customer Solutions Institute. (TRICSI)

50 top References

Over 600 references (scientific, expert, WHO, local and international Governments, national representative organisations, business’ – papers, official documents and Acts, interviews, official and personal books and brochures) were consulted, quoted and referenced in reaching the proposal conclusions and the TRISI solution. The following are highly rated. The full list of references can be obtained here: http://www.ptgrr.com/contents/get-involved/trisi-content

 

No.

Sections

Alphabetical list of References

6

11

ACE’s Connection Network; The Roadmap to Resilience Toolkit; July, 2015; http://www.acesconnection.com/blog/the-roadmap-to-resilience-toolkit-v-1-0-is-here-1;

36

4, 11,14,19

Andrew Zolli & Ann Marie Healy; Why Things Bounce Back; Simon and Schuster; 2012

47

7, 10, 11

Anthony S. Zannas and Anne E. West; Epigenetics and the regulation of stress vulnerability and resilience; Neuroscience. 2014 April 4; 0: 157–170. doi:10.1016/j.neuroscience.2013.12.003.

48

11,17, 18

Anthony Salerno, PhD, Technical Assistance Specialist, SAMHSA-HRSA Center for Integrated Health Solutions at the National Council for Community Behavioral Healthcare; The Rest of the Story; Breaking the Silence Trauma-informed Behavioral Healthcare

72

5, 11

Bruce D. Perry, M.D., Ph.D.; INCUBATED IN TERROR: Neurodevelopmental Factors in the 'Cycle of Violence'; The ChildTrauma Academy

81

10, 17, 18

California Primary Care Association; Integrated Behavioral Health Care - An Effective and Affordable Model

100

13, 14

Christina Gamache Martin, Lisa DeMarni Cromer, Anne P. DePrince, Jennifer J. Freyd; The Role of Cumulative Trauma, Betrayal, and Appraisals in Understanding Trauma Symptomatology; Psychol Trauma. 2013 March 1; 52(2): 110–118. doi:10.1037/a0025686

111

11, 18,20

Commonwealth of Pennsylvania, Office of Mental Health and Substance Abuse Services; Strategies for Promoting Recovery and Resilience and Implementing Evidence-Based Practices; October, 2006

118

6, 12,14, 18

Dan J Stein, Soraya Seedat, Amy Iversen, Simon Wessely Post-traumatic stress disorder: medicine and politics

139

6, 10, 11, 16

Department of Health; Republic of South Africa; National Mental Health Policy Framework and Strategic Plan 2013-2020

140

5, 6,9,10, 12,19

Department of Social Development. INTEGRATED CRIME PREVENTION STRATEGY-ISCPS Building a Caring Society. Together. ISBN: 978-0-621-40570-5 2011

141

10, 12,16

Department of Social Development/Department of Women, Children and People with Disabilities/ UNICEF; Violence Against Children in South Africa

154

10, 11,12

Dr Marjorie Jobson; Crime in Post Apartheid South Africa: Communities under Threat; Khulumani Support Group

185

6, 7,12, 14,18

Galia Plotkin Amrami; Genealogy of 'national trauma', looping effect and different circles of recognition of new professional category; National Trauma Discourse in Israel; ethics.tau.ac.il/en/wp-content/uploads/…/national-trauma-gp.docx     

195

5, 11,14,18

Gordon R. Hodas MD Statewide Child Psychiatric Consultant, Pennsylvania Office of Mental Health and Substance Abuse Services ; RESPONDING TO CHILDHOOD TRAUMA: THE PROMISE AND PRACTICE OF TRAUMA INFORMED CARE; February 2006

199

5, 6,7,8, 9,12

Hamber, B. & Lewis, S. (1997).An Overview of the Consequences of Violence and Trauma in South Africa.Research report written for the Centre for the Study of Violence and Reconciliation

243

4,11,13,14,17,19

Jayasree Kalathil; Beth Collier, Renuka Bhakta, Odete Daniel, Doreen Joseph, Premila Trivedi; Recovery and resilience: African, African-Caribbean and South Asian women’s narratives of recovering from mental distress; Survivor Research. User-led perspectives in Mental Health

272

5, 6,7, 12

Karen Fleming, Lou-Marie Kruger;  “She keeps his secrets”: A gendered analysis of the impact of shame on the non-disclosure of sexual violence in one low-income South African community; African Safety Promotion Journal, Vol. 11, No. 2, 2013

281

1,5,6,7,8,9,11,1820

Kezelman, C., Stavropoulos, P.  Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery. Adults Surviving Child Abuse (ASCA) 2012

286

5, 6,7,8,12,18

Lane Benjamin and Sarah Crawford Brown (South Africa); The psychological impact of continuous traumatic stress -- limitations of existing diagnostic frameworks

296

4, 11,14

Linda C. Theron, Adam M.C. Theron;  A critical review of studies of South African youth resilience, 1990–2008; Article #252, South African Journal of Science

304

5, 6,7, 10, 12

Lukoye Atwoli, Dan J. Stein, Karestan C. Koenenc, and Katie A. McLaughlin; Epidemiology of posttraumatic stress disorder: prevalence, correlates and consequences; PubMed, 2015 July 01

313

4, 11,14

Marc T. Braverman; Applying Resilience Theory to the Prevention of Adolescent Substance Abuse; 4-H Center for Youth Development ; FOCUS; The University of California, Davis

318

5,7,10,12,14,16,18

Martha Cabrera; Essay: Living and Surviving in a Multiply Wounded Country; http://siyathanda.org.za/index.php/resources2/83-multiply-wounded-country

333

5,11,14,16,18

Mental Health Commission of Canada. (2012). Changing directions, changing lives: The mental health strategy for Canada. Calgary, AB: Author.

334

5, 6, 11, 18

Mental Health Coordinating Council (MHCC), Trauma-Informed Care and Practice: Towards a cultural shift in policy reform across mental health and human services in Australia, A National Strategic Direction,2013

345

6, 12,14

Michele Cooley-Strickland,Tanya J. Quille,Robert S. Griffin,Elizabeth A. Stuart, Catherine P. Bradshaw, Debra Furr-Holden; Community Violence and Youth: Affect, Behavior, Substance Use, and Academics; Clin Child Fam Psychol Rev (2009) 12:127–156; 27 May 2009

401

6, 12, 15

Padraig O’Malley; Consequences of Gross Violations of Human Rights; the Nelson Mandela Centre of Memory. https://www.nelsonmandela.org/omalley/index.php/site/q/03lv02167/04lv02264/05lv02335/06lv02357/07lv02398/08lv02402.htm

409

13, 19,20

Patrick Corrigan; How Stigma Interferes With Mental Health Care; University of Chicago

413

11, 13,17,19

Peter Kinderman & Sara Taiet et al ; Psychological health and well-being: A new ethos for mental health - A report of the Working Group on Psychological Health and Well-Being; The British Psychological Society; 2009; ISBN 978-1-85433-498-5

420

4, 11,12,14

Pickel, Laurel E., "The Aftermath of Intergenerational Trauma: Substance Use Risk and Resiliency" (2012). Electronic Thesis and Dissertation Repository. Paper 404.

422

5, 15

Prof Juan A. Nel, Anene. A national symbol of the tide that has turned, or…simply another, ‘bloody’ South African Statistic. PsyTalk, 2013, Issue 1.

431

4, 12,14

Rachel Davis, MSW, Danice Cook, BA, and Larry Cohen, MSW; A Community Resilience Approach to Reducing Ethnic and Racial Disparities in Health; American Journal of Public Health | December 2005, Vol 95, No. 12

461

15, 16,19,20

Rowe and Moodley ; Patients as consumers of health care in South Africa: the ethical and legal implications; BMC Medical Ethics 2013, 14:15 http://www.biomedcentral.com/1472-6939/14/15

482

6, 7,11, 12,20

SAMHSA; Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

483

1,4, 5,6,7, 8,10, 12,13,18

SAMHSA; Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS PublicationNo. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

485

7, 18

SAMHSA’s Trauma and Justice Strategic Initiative; SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach; July 2014

504

10, 13,15

Sr Silke-Andrea Mallmann;Building Resilience in Children Affected by HIV/AIDS;CPS Catholic AIDS; Catholic AIDS Action, Namibia

513

4, 11,19

Steven M. Southwick;The Science of Resilience; Huff Post Science; August 28, 2015

514

4, 7,10, 11,14,19

Steven M. Southwick, George A. Bonanno, Ann S. Masten, Catherine Panter-Brick and Rachel Yehuda; RESILIENCE AND TRAUMA; Resilience definitions, theory, and challenges: interdisciplinary perspectives; European Journal of Psychotraumatology

521

5, 6,11, 21

Stroul, B., Pires, S., Boyce, S., Krivelyova, A., & Walrath, C. (2014). Return on investment in systems of care for children with behavioral health challenges. Washington, DC: Georgetown University Center for Child and Human Development, National Technical Assistance Center for Children’s Mental Health.

556

5, 6,18

Thrive Initiative; Main, USA. System Of Care Trauma-Informed Agency Assessment (TIAA)© Overview

569

14, 18

V.S. Ramachandran,The Tell-Tale Brain: A Neuroscientist's Quest for What Makes Us Human; W. W. Norton & Company, Inc.

570

7

Van der Kolk, Bessel A. MD Robert S. Pynoos, M; Proposal to Include a Developmental Trauma Disorder Diagnosis for Children and Adolescents in DSM-V

572

5, 6,7,8, 18

Van der Kolk, M.D. The Body Keeps the Score – Brain mind and body in the healing of trauma, Viking 2014

574

6, 8,18

Vivek Datta, MD, MPHPsychiatry and the Problem of the Medical Model – Part 1; December 21, 2014; https://www.madinamerica.com/2014/12/psychiatry-problem-medical-model-part-1/

577

12, 13,17

Wegner, L. & Rhoda, A., 2015, ‘The influence of cultural beliefs on the utilisation of rehabilitation services in a rural South African context: Therapists’ perspective’, African Journal of Disability 4(1), Art. #128, 8 pages. http://dx.doi.org/10.4102/ajod.v4i1.128

581

5, 6,10,13,16

WHO Department of Mental Health and Substance Dependence, Noncommunicable Diseases and Mental Health; Investing in Mental Health; 2003

600

5, 7, 14, 18

William Steele, PsyD and Caelan Kuban, LMSW; Advancing Trauma-Informed Practices Bringing trauma-informed, resilience-focused care to children, adolescents, families, schools and communities.

 

Table of Contents – Full Proposal

Full deatails of all section content and download available here - 


 Contact details: Brian Rogers; This email address is being protected from spambots. You need JavaScript enabled to view it. ;

 Acknowledgements

 

Dr Nobs Mwanda, M.D., ASHOKA Fellow – CEO of COPESSA
It was a conversation way back in 2008 that inspired my original pursuit of solutions based advocacy in the South Africa Mental Health care world. Your passion, dedication and tenacity has been inspiring to me ever since.
Andre Bestbier (Maj.Gen Retired), Chief Executive Officer of CompreCare (HIV/Aids) Joint Venture.
Your example to me stretches many years back. You continue to teach me to be a better human being by setting standards that are hard to emulate.
Barry Zworestein - Clinical Psychologist;Head of learning support at a private school and contract counsellor for the Australian Vietnam Veterans Counselling Services and Australian Defence Force.)
Barry, we found each other on Facebook, but I’m convinced it was an act of heaven. Your guidance and support is forever a rock in my life.
Nikky Schumann, Frank Kruger and Cedrick Hedgcock
Without you I could not have survived emotionally or physically these last few years.
Penny de Vries 
My personal ‘sensibility-coach’. For someone who disagrees with me so much you have remarkably made me so agreeable to so much of your wisdom.
Ian Gross
My co-founder at PTG-RR. The best thing is to start at the beginning. I hope to see you at the finishing post.
Marion Nixon
Trustee, Editor, Trauma-Activist and professional.
Calvin, Ingrid and Kevin Rogers
Thank you for your love. This is the only way I know now.
Prof Dan Stein - Department of Psychiatry and Mental Health, Faculty of Health Sciences, Univ. of Cape Town.
Prof, I am so grateful that you have always found some time to give each and every one of this uneducated yet passionate man’s requests for opinion an honest answer. I hope this time I might have exceeded your expectations. 
Prof Steven Friedman
Thank you for your important words of support and allowing me to quote you.
The Savannah Brothers - Brothers always. You know why.
To all those Buddy Care Roadwalker’s
“I am your Roadwalker. I walk just behind you. I cannot walk your journey for you, but if you ask, I will step up and walk beside you, for as long as you wish, and I am able.”
All my kind friends who helped pay my bills whilst I completed this proposal: Rob, Gail, Choc, Tony, Louis, Stephan, Mark, Andy, Horst, Nikki, Ingrid, Jane, Gerald, Frank, Ced, Ian and those Anon’s. 
All those who had an encouraging words for me. You really don’t know how much they meant and kept me going. 

I am eternally grateful to you all. I can only hope I have done enough to get TRISI to the next steps. Brian