The essay that forms the basis of my forthcoming book.
April 4, 2014
We are a deeply traumatized nation. It wasn’t enough that 20 children were massacred at a school in Newtown, Conn., in 2012. It seems we are confronted with a new and devastating mass killing tragedy every few months in America, the latest being the recent shooting at Fort Hood.More soldiers have now died by suicide than by combat in Iraq and Afghanistan, and suicide now kills more Americans than car accidents.
What has been our collective answer to this appalling state of affairs? We shun serious discussions of gun control, and instead scapegoat people with mental health issuesfor the complex issue of violence in our society. But my intention is not to write about gun control. Even if by some miracle we were enlightened enough to take all guns away from people tomorrow, the fact remains that we are a traumatized nation. And the question is: what are we going to do about it?
Representative Tim Murphy is a psychologist who proposes unsatisfactory solutions to our most pressing social problems. In a “shockingly regressive” piece of legislation known as the “Helping Families in Mental Health Crisis Act of 2013” (H.R. 3717), he proposes to expand the highly controversial practice of Involuntary Outpatient Committment (IOC) for persons with serious mental illnesses. But that approach is not the answer, as documented in a fact sheetauthored by the National Coalition for Mental Health Recovery:
Proponents of IOC claim that it is effective in reducing violent behavior, incarcerations, and hospitalizations among individuals with serious mental health conditions. However, repeated studies have shown no evidence that mandating outpatient treatment through a court order is effective; to the limited extent that court-ordered outpatient treatment has shown improved outcomes, these outcomes appear to result from the intensive services that have been made available to participants in those clinical trials rather than from the existence of a court order mandating treatment. In addition, studies have shown that force and coercion drive people away from treatment. “By its very nature, outpatient commitment may undermine the treatment alliance and increase consumers’ aversion to voluntary involvement with services,” according to a study cited in “Opening Pandora’s Box: The Practical and Legal Dangers of Involuntary Outpatient Commitment,” published in Psychiatric Services.
So what is the answer? If we look across our systems, such as behavioral health (including mental health and substance use treatment), homeless services, veterans’ services, and criminal justice systems, what is the common denominator? Trauma. If we search the text of Representative Murphy’s bill, the word “trauma” only comes up four times. Conversely, “mental illness” is mentioned 83 times. This reflects a misguided lens through which we are looking at social problems. We need to flip that and look at our social problems through a trauma-informed lens.
We should be focusing on trauma, not mental illness.
Dr. Richard Mollica, of all people, should know about violence and human suffering. He is a psychiatrist who founded the Harvard Program in Refugee Trauma, and for decades he has successfully helped people who have experienced war and other kinds of severe human-to-human violence to heal. In his book Healing Invisible Wounds: Paths to Hope and Recovery in a Violent World, he points out the limits of a purely medical/individual approach:
When mass violence occurs, there is damage not only to individuals but to entire societies, indeed to the world. The victims of September 11 and their families suffered horrible losses, but even those of us who watched the television footage suffered, whether by experiencing depression, anxiety, a loss of faith in humanity, empathic overload, or emotional withdrawal. As a consequence, healing must occur not only within individuals but also within societies, with society as the healing agent…Personal and social healing are united in a reciprocal and mutually advantageous relationship.
The average person does not have a clear understanding of what “trauma” really means. It doesn’t just mean that your family physically abused you as a kid or that you witnessed a violent act, or even that you have head trauma, such as a traumatic brain injury (TBI).
Trauma should be understood as much more broadly occurring when:
An external threat overwhelms a person’s coping resources. It can result in specific signs of psychological or emotional distress, or it can affect many aspects of the person’s life over a period of time. Sometimes people aren’t even aware that the challenges they face are related to trauma that occurred earlier in life. Trauma is unique to each individual—the most violent events are not always the events that have the deepest impact. Trauma can happen to anyone, but some groups are particularly vulnerable due to their circumstances, including women and children, people with disabilities, and people who are homeless or living in institutions.[ii]
The prevalence of trauma
To understand how trauma is directly relevant to the current debates raging in America, consider the following facts and statistics:[iii]
- Men and boys of color are disproportionately affected by violence, trauma, and high rates of poverty and incarceration.[iv]
- 80% of people in psychiatric hospitals have experienced physical or sexual abuse.
- 66% of people in substance abuse treatment report childhood abuse or neglect.
- 90% of women with alcoholism were sexually abused or suffered severe violence from parents.
- Exposure to childhood trauma (physical assault and bullying) is linked to psychotic experiences, such as hearing voices.[v]
- 95% of women and 89% of men entering jail diversion programs have experienced physical or sexual abuse. [vi]
- A study of women inmates at a maximum security prison found that they had experienced physical and sexual abuse throughout their youth and adulthood.[vii]
- An individual can be “retraumatized by services, supervision, and management policies that ignore or dismiss the role of trauma.” [viii]
Take the complex problem of suicide. There is compelling research to show that early adverse childhood experiences [ACEs] dramatically increase the risk of suicidal behaviors. The ACE Study consists of a questionnaire asking people if they have experienced various ACEs, such as witnessing violence growing up, or having an alcoholic parent. ACEs have a strong, clear relationship to suicide attempts during childhood/adolescence and adulthood. Two-thirds (67%) of all suicide attempts, 64% of adult suicide attempts, and 80% of child/adolescent suicide attempts are attributable to ACEs.[ix] Dube et al. note that their estimates of population attributable fractionsfor ACEs and suicide are “of an order of magnitude that is rarely observed in epidemiology and public health data.”[x]
Or let’s look at the connections between homelessness and trauma. According to the Homelessness Resource Center:
Homelessness is traumatic. People experiencing homelessness are living with a multitude of losses. People who are homeless have lost the protection of home and community, and are marginalized, isolated, and stigmatized within the larger society. Additionally, people who are experiencing homelessness are highly vulnerable to violence and victimization.[xi]
The statistics don’t lie: we need to focus on supporting all people in healing trauma. Trauma is a huge risk factor for suicide as well as for every manner of behavioral health and physical health challenges, as well as increased risk of interpersonal violence.[xii] Yet trauma is rarely addressedin the context of legislation, community development, human service provision, jail diversion, or suicide prevention programs.
What does it mean to be “trauma-informed?”
Looking through the lens of trauma does not mean that we blame families for being in crisis. It means that we need to recognize the ways that individuals, families and communities are reeling from the effects of trauma, and to help them empower themselves to look at and address the root causes of the crises they face. As described in a 2010 report by the Center for Nonviolence and Social Justice and Department of Medicine, Drexel University:
Trauma theory represents a fundamental shift in thinking from the supposition that those who have experienced psychological trauma are either “sick” or deficient in moral character to the reframe that they are “injured” and in need of healing. Such shifts are made possible in the context of a supportive political movement. To a significant extent, “trauma theory” attained credibility because Vietnam Veterans refused to be silent about their experiences and because the antiwar movement had an air of legitimacy not previously known.[xiii]
According to the Substance Abuse and Mental Health Services Administration (SAMHSA), a federal agency that has done much to promote trauma-informed approaches:
A definition of trauma-informed approach incorporates three key elements: (1)realizing the prevalence of trauma; (2) recognizing how trauma affects all individuals involved with the program, organization, or system, including its own workforce; and (3) responding by putting this knowledge into practice.
A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for healing; recognizes the signs and symptoms of trauma in staff, clients, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, practices, and settings.[xiv]
The little Gulf Coast city of Tarpon Springs, Fla., gets it. They have undertaken an effort to be a “trauma-informed community.” The community has made a commitment to engage people in all walks of life: education, juvenile justice, welfare, housing, medical practices, and business. This is exactly the direction our country needs to take. We should read about Tarpon Springs’ initiative to train all of its systems in understanding the prevalence of trauma, and how to be more trauma-informed in the way we approach every person who interfaces with educational and human service systems. Here is one example of what they are doing to help break cycles of trauma and violence in their community:
The Pinellas Ex-Offender Re-Entry Coalition used the CDC’s Adverse Childhood Experience questionnaire to discover that the overwhelming majority of people in its substance-abuse, batterers-intervention and sex-offender groups had suffered severe trauma. The coalition counselors changed their program, with the result that the ex-offenders feel more optimistic, and that they have more tools to turn their lives around.[xv]
The solutions proposed in Representative Murphy’s legislation will never fully address the serious crises facing our communities and our nation. At best, the expansion of IOC will be a band-aid covering a horribly festering wound. H.R. 3717 represents a policy response that is not only NOT trauma-informed, but will only serve to further perpetuate trauma in our communities. We need to address our community problems within our communities, as communities. That is where the hope lies to begin to address the problem of self-inflicted and interpersonal violence in our society, and to heal our traumatized nation.
* * * * *
Mollica, Richard. Healing Invisible Wounds: Paths to Hope and Recovery in a Violent World(Vanderbilt University Press, 2006).
[ii] Blanch, A., Filson, B., Penney, D. & Cave, C. (2012). Engaging women in trauma-informed peer support: A guidebook. SAMHSA’s National Center for Trauma-Informed Care. Available at: http://www.nasmhpd.org/publications/engagingWomen.aspx
[iii] Sharp, C. and Ligenza, L. Is Your Organization Trauma Informed? http://www.thenationalcouncil.org/wp-content/uploads/2012/11/Is-Your-Organization-Trauma-Informed.pdf
[iv] Davis, L. (2009). Reparable Harm: Assessing and Addressing Disparities Faced by Boys and Men of Color in California. Santa Monica, CA, RAND Corporation.
[v] Ian Kelleher. Childhood Trauma and Psychosis in a Prospective Cohort Study: Cause, Effect, and Directionality. American Journal of Psychiatry, 2013; 170 (7): 734 DOI:10.1176/appi.ajp.2012.12091169
[vi] Policy Research Associates. (2011). Final report of the evaluation of CMHS Targeted Capacity Expansion for Jail Diversion Programs initiative. Delmar, NY: Author.
[vii] Browne, A., Miller, B., Maguin, E. (1999). Prevalence and severity of physical and sexual victimization among incarcerated women. International Journal of Law and Psychiatry, 22, 301-322.
[viii] Harris, M., & Fallot, R.D. (2001). Envisioning a trauma-informed service system: A vital paradigm shift. New Directions for Mental Health Services, 89, 3-22.
[x] Dube, et al. Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study. JAMA. 2001 Dec 26;286(24):3089-96.
[xi] Homelessness Resource Center. http://homeless.samhsa.gov/channel/trauma-29.aspx
[xiii] Center for Nonviolence and Social Justice and Department of Medicine, Drexel University. (June 2010). “Healing the Hurt: Trauma-Informed Approaches to the Health of Boys and Young Men of Color”
[xiv] Harris, M. & Fallot, R. (2001). Using trauma theory to design service systems.
[xv] “Tarpon Springs, Florida, May be the First Trauma-Informed City in the US.” (February 13, 2012). http://acestoohigh.com/2012/02/13/tarpon-springs-may-be-first-trauma-informed-city-in-u-s/