Introduction to case study

Lucy has experienced multiple traumas throughout her life, starting in infancy and extending into her adult life. If you compare her experiences against the Adverse Childhood Experiences study (ACES), Lucy scores incredibly highly across all three types of ACES: abuse, neglect and household dysfunction (Felitti et al., 1998). Lucy has experienced family domestic violence, sexual abuse and intimate partner violence. She is a survivor of a miscarriage during her teenage years and was separated from her biological sibling at an early age.

Scenario

Despite Lucy feeling loved by her mother, she recalls the moment she was told that her father did not want a second child, particularly not a daughter. Although she remembers affection from her father, she describes it as ‘distant’. At the time when Lucy lived with parents, her father was dependant on alcohol and socialised with many members of the community. He was well respected amongst his peers, who described him as a ‘character’ and a ‘good bloke.’ He managed the local hotel and spent much of his time drinking with his regular customers. He would often drive home drunk, smelling of stale beer. His character often altered in the privacy of his own home. Although Lucy’s father was disengaged from her and her mother, he appeared to have a strong relationship with Lucy’s brother.

Lucy recalls the arguments and yelling that were ever present in the family home. She would seek comfort and safety in the company of her brother during these times. Hearing threats of violence towards her mother was very stressful for her. Even though Lucy was young at the time, recalling memories from 5 to 7 years of age, she remembers being afraid of her father. She also remembers herself as a quiet child, interested in listening to the conversations of adults. Some of the conversations she remembers were when friends would advise her mother to leave her father, as he was often physically violent to the women with whom he was having extramarital affairs.

Lucy was aware of her father’s ‘special friends,’ some of whom were kind and caring towards her. She recalls sitting in their kitchens or playing on their swings while he privately spoke with them. This occurred often, usually after he had collected Lucy from school when her mother was working. Even at an early age (between 5 and 7), Lucy knew that something was not right. She had promised her father never to tell her mother about these meetings because he had threatened to discipline her if she did. As an adult, Lucy now understands her father was having extramarital affairs with more than one woman in town. Lucy remembers once overhearing a conversation between her mother and a neighbour, who was also the local nurse. Lucy heard the nurse tell her mother that a woman had presented to the hospital after a significant physical assault and that Lucy’s father was the perpetrator. The police had advised the patient not to pursue the issue further as Bairnsdale was a small town and everyone knew her father. Lucy recalls her mother being upset that Lucy had overheard the conversation. She told Lucy not to tell her father what she had heard as her mother was worried he would do the same to her.

Lucy recalls having mixed feelings about her dad. He was nice sometimes, often giving her chocolate and treats from work and working in the garden with her. At other times, she was afraid of his violence when he was drunk and was worried he would not approve of her. When he started to spend less time tending to the garden with Lucy, her father would exaggerate the time spent together in public. Lucy describes feeling alone and different from the relationships her peers had with their fathers.

At 7 years of age, Lucy’s parents separated after increasingly loud verbal altercations between them, which always upset Lucy. Lucy and her mother moved into the house next door, the vacant home of a family friend. Her father became increasingly volatile and would turn up drunk to the house Lucy and her mother lived in. Lucy recalls having to lock the doors and being woken at night by all the yelling. At one point her mother whispered to Lucy to go over the road to their neighbour (the nurse), and call the police, as her father was threatening to kill them. Lucy recalls feeling safe in the nurse’s home and welcomed her offer to stay there while the police attended to the call. Lucy fell asleep in the nurse’s arms and woke startled from a nightmare. She dreamt her mother had been killed. The nurse provided comfort, support and reassurance that her mother would be fine.

This was when Lucy’s mother realised they needed to find a home a safe distance from her father. Lucy recalls discussions between her mother and her close friend, where the initial plan was to relocate to a small Victorian rural town two hours away. However, there were challenges. Due to the remoteness of the village, it was too far for Lucy to get to primary school and Lucy’s mother would not be able to continue working. Fate stepped in and another option emerged. Lucy’s mother was connected through her friend to a fisherman who was looking for a housekeeper. This meant free rent in exchange for someone to attend to the house and cook meals. Lucy’s mother was very keen to take up this opportunity and the location was perfect: a large home in a seaside town. There was a good school and the town was close enough to maintain contact with Lucy’s brother, who had chosen to remain living with his father. Lucy was 8 years old when she moved to Lakes Entrance, Victoria.

After this move, life became less complicated. Lucy felt safe and liked her new school and bedroom. While she missed her brother and father, life was more stable, with no more fighting or yelling. After living there for a couple of months, her mother and the fisherman began a relationship. He had three adult children, 2 of whom were male aged 25 and 19, and one female aged 17, who moved back home around one year after the relationship started. Lucy recalls increasing conflict, as she became the target of nasty comments and later physical injuries through rough play. Lucy also recalls the oldest watching pornography loudly in the common lounge room. If her mother was home at the time, she would take Lucy out so she would not be exposed to inappropriate material. Her mother assured Lucy that the fisherman’s children just needed time to adjust to the new relationship and that things would soon settle down. As Lucy moved towards 10 years old, things got worse before they got better. Lucy recalls feeling embarrassed about her developing body, enduring early puberty with comments every day from her new step siblings. The taunts made her very self-conscious of her body and she became quieter and more withdrawn. Her mother was busy within the new relationship and Lucy felt abandoned. She longed for her brother and life with her father did not seem so bad now. She begged to return to live with her brother. This was the signal to her mother that things were not going well.

Within a day of Lucy telling her mother about her desire to return home to her father, her mother took her away on a mini holiday. They took a trip to a farm to spend time with her mother’s best friend. Lucy loved the farm and remembers how much she enjoyed spending time in the milking shed and helping with the cows. Towards the end of the holiday, her mother told Lucy that things had changed at their home in Lakes Entrance. The older children had been asked to move out and Lucy’s mother wondered how Lucy would feel about going back. Lucy recalls saying she did not want to, but also remembers the look on her mother’s face when she said this. When Lucy saw how upset her mother was, she changed her mind and told her mum she would be ok about going back. Lucy’s mother assured her that things would be better and she would be safe in the house.

Things were indeed better when they returned. After her visit to the farm, Lucy asked if she could have pets. Her mother agreed, and Lucy now had a dog, a cat and a rabbit, which she adored. Lucy was much happier and more settled now. The other children only visited the house occasionally and Lucy recalls that she did not have a great deal of interaction with them. School was going well and Lucy was now able to visit her brother, who had moved to Melbourne City for work. Then, when her mother told her they were moving to Queensland, Lucy was shocked. Her first concern was for her pets. Lucy was told they could only take their cat. Lucy recalls feeling numb and still into adulthood wonders what happened to her beloved pets.

Moving to the small coastal town of Bundaberg in Queensland was a positive experience for Lucy for the first three years, during which time she experienced no significant issues. As Lucy developed into a young woman, young men began to take interest. Lucy enjoyed the attention and began to date. When Lucy was 14, a friend of her mother and stepfather, a man in his forties, spent a lot of time complimenting Lucy on her developing body. He often commented that he wished he were younger so he could date her. One evening, as her parents sat in the lounge room, he followed her to her bedroom, claiming he needed to use the bathroom. This man then inappropriately and, uninvited, touched Lucy. Lucy remembers that she did not respond, again felt numb inside, and revisited that sense of being unsafe. He stopped when she turned away. Later, a different older male friend of the family also sexually abused her.

After this, Lucy spent more time outside the home with her friends. She started to miss school, preferred to drink with male friends and became sexually active. Her mother intervened and took her to see a counsellor where Lucy disclosed the experiences she had with her parents’ friends. While her mother was informed, she took no further action. Lucy is convinced her parents did not believe her and instead saw her as a rebellious teenager. When Lucy’s mother attempted to put firmer rules in place, Lucy pushed back and, when she turned 15, moved into a shared caravan with her boyfriend Lucas, who was 6 years older. The new relationship she had with her boyfriend was strong and it was not long after that she discovered she was pregnant. Unfortunately, it was a nonviable intrauterine pregnancy, which ended in a spontaneous abortion. Lucy felt abandoned and distressed. She did not tell anyone, apart from Lucas, about this loss. She continued for some time as though nothing had happened and that her pregnancy was progressing as normal.

Lucy experienced intimate partner violence when Lucas would drink, much like her mother had experienced. She was convinced that things would improve once they had a child together. During this time Lucy was very much isolated with minimal friends and little support from family.

Key information and links to other resources

Lucy has experienced significant trauma throughout her childhood and into adulthood. Trauma-informed care (TIC) is founded on the recognition of the impact of trauma on both physical and mental health. Speck et al. (2023) recommend six TIC principles that need to be demonstrated when providing care for a woman with past trauma. These include:

1. Safety
2. Trustworthiness and transparency
3. Peer support
4. Collaboration and mutuality
5. Empowerment
6. Cultural, historical and gender issues

There are several interventions that can support these principles. The emphasis is on ensuring the person is provided the opportunity to maintain control over their care and life decisions, as well as utilising peer support (Speck et al., 2023). The resources listed below can offer further support and assistance to developing further skills in TIC.

Organisations providing information relevant to this case study

• Centers for Disease Control and Prevention: Adverse Childhood Experiences
• Blue Knot Foundation: National centre of excellence for complex trauma
• Bravehearts
• Domestic Violence Prevention Centre

Case study 1 summary

Through this case study you have had the opportunity to learn more about Lucy’s traumatic experiences throughout her lifespan. These events have significantly affected Lucy and her relationships. You have been able to identify these events and considered how you would incorporate trauma- informed care into your practice. There are some helpful resources that are available to not only support Lucy in her recovery but also you as a health professional.

References

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventative Medicine, 14(4), 245-258. https://doi.org/10.1016/S0749-3797(98)00017-8

Morris, D., Sveticic, J., Grice, D., Turner, K., & Graham, N. (2022). Collaborative approach to supporting staff in a mental healthcare setting: “Always There” peer support program. Issues in Mental Health Nursing, 43(1), 42–50. https://doi.org/10.1080/01612840.2021.1953651

Speck, P. M., Robinson, L. S., Johnson, K., & Mays, L. (2023). Care for women with past trauma using trauma-informed care. Advances in Family Practice Nursing, 5(1), 119–135. https://doi.org/10.1016/j.yfpn.2022.11.002

Wolotira, E. A. (2022). Trauma, compassion fatigue, and burnout in nurses: The nurse leader’s response. Nurse Leader, 21(2), 202-206. https://doi.org/10.1016/j.mnl.2022.04.009

Zhou, C., Szwed, S., Wickersham, M., McDarby, M., Spellun, J., & Zonana, J. (2023). The patient population of a no-cost, student-run LGBTQ + mental health clinic: A case for equitable and trauma-informed care. Journal of Gay & Lesbian Mental Health. Advance online publication. https://doi.org/10.1080/19359705.2023.2183536