Can School Heal Children in Pain? Yes, It Can!

[This blog originally appeared on ACEs Connection.]

James Redford, director of Paper Tigers, a documentary about the journey of students and teachers at a trauma-sensitive alternative high school in Walla Walla, Washington, posed a provocative question in a recent blogcan school heal children in pain?

I believe that it can.

While trauma-sensitive schools can’t erase every source of adverse childhood experiences (ACEs), considering how many hours of their lives children spend in school, educators can do much to mitigate the effects of traumatic stress, and help students to build skills for resilience and well-being. At the very least, schools can refrain from further traumatizing children.

Children with disabilities and behavioral problems, in particular children of color, are regularly subjected to practices such as seclusion and restraint in school. The data conclusively prove that “zero tolerance policies” driving the school to prison pipeline disproportionately affect students of color and students with disabilities. Given all that we know about the devastating long-term human and economic impacts of these policies and practices, I believe that we have a moral and ethical obligation to change things.

I had the opportunity to watch Paper Tigers at a recent screening hosted by ACEs Connection and the Kennedy Forum in the Washington, DC area where I currently live. The Paper Tigers story is so compelling to me because it so closely mirrors my own experiences with trauma, disability, and education.

I am a survivor of early childhood trauma, but I am lucky in that initially, my high ACE score did not interfere with my ability to concentrate and learn. Learning was actually the only thing that brought me joy growing up. It was my sole source of self-esteem.

But around age 14-15, my unaddressed trauma began to manifest in substance use and some pretty serious mental health challenges, including suicide attempts. In one long-term residential treatment facility, I was denied permission to attend classes at the local high school because I was labeled as a “flight risk.” I was there for almost a year, and my “education” consisted of watching movies all day and writing silly essays about them. It completely set me behind academically. I had no hope of catching up with the rest of my class. This caused me enormous shame. The source of my self-esteem had evaporated.

When I got out of the residential treatment facility, I was funneled into a horrible, filthy group home, where I was told I would need to remain for life. I was on the verge of turning 18, with no job and no high school diploma — on the road to poverty, addiction, and jail. I thought about suicide every single day in that place.

I begged my family to let me come home, and they agreed—on the condition that I stay clean and finish high school. Given my troubled past and diagnosis of “serious emotional disturbance (SED),” I did not return to my previous high school, but was sent to an alternative high school—Abraxas High School in San Diego, California—much like Lincoln High School portrayed in the Paper Tigers film.

Abraxas was chaotic. I remember watching several students do lines of methamphetamine in the back of the classroom during a “study period” while the teacher read a magazine, seemingly oblivious. While I know the educators must have cared, a spirit of hopelessness and apathy pervaded the school.

One of my teachers at Abraxas, Mr. O’Leno, was different. I found myself tearing up while watching Paper Tigers, because several of the scenes portraying respectful and supportive teacher-student interactions reminded me of him. While this was the early 1990s, and Mr. O’Leno was likely not trained in trauma-sensitive approaches, he instinctively knew how to work with me.

Mr. O’Leno always saw me through the lens of my strengths. He regularly asked me about my dreams and what I wanted out of life. He took the time to establish an authentic connection, and therefore I trusted him enough to disclose how my symptoms were impacting upon my ability to learn. Together we came up with a plan where I would complete my required classes for graduation at my own pace. His collaborative, strengths-based approach was the key to my success.

I will never forget when I came to pick up my diploma on a spring day in 1993. The staff in the office played a cassette recording of “Pomp and Circumstance” on a boom box. Some of them cried as I accepted my diploma. I suspect the tears were partially for my achievement, but also because such a low percentage of kids actually graduate from Abraxas High. According to 2013 statistics, the school has a 61% graduation rate, compared with the rest of the school district, which has a 94% graduation rate. Only 55% of students with disabilities graduate from Abraxas, compared with 79% graduating district-wide.

I often wonder what might have happened to me if I didn’t have a Mr. O’Leno in my life at that critical, vulnerable time. And I think about all the kids today who don’t have a Mr. O’Leno in their lives.

It has been deeply encouraging to learn about the growing movement across the U.S. to create trauma-sensitive schools and to institute restorative justice programs. ACEs Connection has been a valuable source of information about initiatives happening in places like Cherokee Point Elementary in San Diego, several elementary schools in Spokane, WA, schools in San Francisco, a high school in Blaine, MN, and West Seattle Elementary.

I’ve also learned that Fairfax County Public Schools in Virginia have issued a restorative justice approach district-wide, as has the Oakland Unified School District. The District of Columbia City Council is holding a public hearing later this month on “the value of investing in trauma-informed public schools and support services,” hopefully a step towards adopting these approaches across DC Public Schools.

In recent years, school culture change has typically happened when individual educators, like Lincoln High School’s former principal, Jim Sporleder, learned about trauma and ACEs and decided to adopt a trauma-sensitive school model. But we shouldn’t place the full burden on individuals to be the drivers of change. We need sound policies to support all educators and administrators to move in this brave new direction.

I have been especially heartened by the landmark lawsuit filed recently in Compton, California. If this lawsuit is successful, it will mandate that all public schools in the state, including my former high school, adopt trauma-sensitive approaches. These are the kinds of policies we deeply need in every state and on the federal level.

I look forward to the day when the trauma-sensitive school/restorative justice movement ensures that every young person is empowered to realize their dreams — not as a matter of chance, as in my case – but as a matter of course.

Why We Need a Paradigm Shift in Mental Health Care: The Case for Recovery Now!

[This blog appeared originally at The Huffington Post and was re-published on ACEs Too High.]

Another “May is Mental Health Month” has come and gone, and it is time to build on years of awareness campaigns and move into action to promote whole health and recovery. People with serious mental health conditions are dying on average 25 years earlier than the general population, largely due to preventable physical health conditions, so why do we still focus on mental health separately from physical health? And when we know that people with serious mental health conditions face an 80 percent unemployment rate, why do we largely ignore the role of poverty, economic and social inequality, and other environmental factors in mainstream discussions about mental health?

Decades of public health research have clearly shown that access to the social determinants of health — affordable housing, educational and vocational opportunities, and community inclusion — are far more important to mental and physical health than access to health care alone. As one recent article explained: “For many patients, a prescription for housing or food is the most powerful one that a physician could write, with health effects far exceeding those of most medications.” Yet this wisdom does not generally guide policymaking in the U.S. Among nations in the Organization for Economic Co-operation and Development (OECD), the U.S. ranks first in health care spending, but 25th in spending on social services. Is there something wrong with our very concept of “care”?

This question is not just theoretical for me. As an adolescent, I attempted suicide several times. I found myself in the back of a police car more than once and was frequently hospitalized. At age 16, I was diagnosed with bipolar disorder. Two years later, I found myself sitting in a squalid group home, where I was told I needed to remain for life. I had no high school diploma and no job. My hopelessness and despair were all-encompassing.

I managed to get on a different path when I obtained access to safe and stable housing, education, and social support. Today, I am living life as a mother and a mental health advocate. I train human service providers in suicide prevention, recovery, trauma-informed approaches, and person-centered health care. Every day, I’m grateful that I was able to regain my life, and I want everyone to have this opportunity.

To help promote a paradigm shift in mental health care, I’ve been part of starting a new, nonpartisan public awareness campaign called Recovery Now! This campaign seeks to educate all Americans about the kinds of services and policies that promote real recovery and whole health for people affected by mental health conditions. Here are a few key messages of the Recovery Now! campaign.

Recovery is possible for all. 

The vast majority of people living with mental health conditions, even people diagnosed with serious mental illness, can enjoy a high quality of life in the community with access to the right kinds of services and supports. Dr. Richard Warner, clinical professor of psychiatry at the University of Colorado, noted: “It emerges that one of the most robust findings about schizophrenia is that a substantial proportion of those who present with the illness will recover completely or with good functional capacity.” A slew of other studies have found similar results.

An argument used against recovery is that there are some who can’t or won’t voluntarily seek treatment or services. Yet there are plenty of evidence-based ways to reach people, such as motivational interviewing, or employing peer-to-peer support or community health workers to do homeless outreach or to engage with persons with complex mental and physical health needs. But these kinds of strategies are vastly underutilized.

We must advocate for recovery-oriented policies.
Hope is essential for recovery. But hope is not enough. Too many people are still unable to access the kinds of services and supports that would help them to recover. In particular, people of color are overrepresented in our jails and prisons, and are underrepresented in community-based mental health and social services.

A prime example is in Chicago, where newly re-elected Mayor Rahm Emanuel closed six community mental health clinics in the most economically disadvantaged parts of the city, which has resulted in an increase in persons with mental health conditions being incarcerated in the Cook County Jail for low-level, nonviolent offenses related to their disabilities. While the recent appointment of a psychologist to head the jail is a step in a better direction, how will this appointment impact upon the lack of availability of community-based services in Chicago for people who desperately need them?

Yet Mayor Emanuel is not unique in his choices. Community-based services have been slashed in many state and local budgets. Any short-term “savings” accomplished by such cuts will always be offset by the devastating long-term human and economic costs that result when we deny quality services and supports to the people who are most vulnerable.

Mental health legislation has been introduced in the House and is expected in the Senate. All legislation should be evaluated through a recovery lens and should clearly address the social determinants of health. Policy should seek to end deadly cycles of poverty, homelessness and incarceration in ways that are culturally appropriate, rehabilitative rather than punitive, and community-based. We can’t talk about more hospital beds without talking about supportive housing and other programs that will actually help people to stay out of the hospital and out of prison. We need legislation that tackles disparities in access to education and employment, and funds proven programs that prevent crisis and recidivism.

We need sound policies that promote recovery for all Americans affected by mental health conditions. We don’t have the luxury of continuing to get this wrong. Too many individuals, families, and systems are in crisis, and it doesn’t have to be this way. We need recovery, and we need it now.

 

Housing Not Asylums

Originally published in Philly.com
In the January issue of the Journal of the American Medical Association (JAMA) University of Pennsylvania bioethicists argued that “prisons have become the nation’s largest mental health care facilities” — replacing the old asylums of the past, phased out since the ’60s in the process known as “deinstitutionalization.” The authors’ controversial commentary recommends a “return to the asylum,” rebuilding large psychiatric facilities.
While the bioethicists rightly point out our collective obligation to address the tragic mass imprisonment of people with mental illness, they largely fail to acknowledge that homelessness is a key component of the crisis they describe. While serious mental health conditions are highly prevalent among the incarcerated population, as the JAMA authors note, this can also be said of the population of homeless people. From a public health perspective, homelessness and incarceration are said to be “mutual risk factors” for one another.

While there isn’t much hard data, experts assert that people who are homeless and have a serious mental illness are at extremely high risk of encounters with law enforcement. About 25-50% of the homeless population has a history of incarceration. Police encounters may lead to imprisonment, largely for nonviolent offenses related to their disability or to addictions. Or they may lead to tragic outcomes associated with the use of deadly force by law enforcement, such as recent high profile shootings of homeless individuals with mental health conditions.

To address the interconnected cycle of homelessness and incarceration, what is needed is not more investment in “asylums” but in supportive housing. A 2012 report on a pilot program in Ohio showed that placing returning prisoners in such programs reduced both re-arrest and incarceration, and increased their likelihood of accessing needed treatment and services.

The JAMA authors’ call to rebuild costly “asylums” reflects our nation’s misguided spending priorities. The United States ranks first in health care spending but 25th in spending on social services among nations in the Organization for Economic Cooperation and Development. This reflects a bad set of decisions with equally poor results. Despite our high health-care spending, we have dismal health outcomes compared with similarly wealthy nations.

Instead, we should be funding community-based services that support recovery and rehabilitation. Research shows that spending on the “social determinants” of health such as permanent, affordable housing and vocational and educational services have far more impact on overall health than medical services alone.

When we fail to invest “upstream” in the social determinants of health, including supportive housing, we pay for it later: in “downstream” spending on mass incarceration, as well as in high-cost increased emergency and inpatient medical care.

Data show that people who are homeless face mortality rates three times higher than the general population and are often “super-utilizers” of emergency services. They are 10 times more likely to be hospitalized than people who are not homeless, and face longer inpatient stays. Supportive housing results in an average hospital cost savings of $3,022 per person per month, or 86% reduction in costs.

“Placing people who are homeless in supportive housing — affordable housing paired with supportive services such as on-site case management and referrals to community-based services — can lead to improved health, reduced hospital use, and decreased health care costs,” Dr. Nirav Shah, former New York State health commissioner, wrote in the New England Journal of Medicine.

Increasing federal, state, and local funding for Housing First programs is clearly the right policy direction. Housing First is an innovative supportive housing model that departs from traditional modes of thinking — namely, that people needed to be clean, sober and free of psychiatric symptoms before they could access housing. This approach resulted in homeless people with serious mental health conditions having to jump through a plethora of formidable barriers to get housing. The Housing First model removes all of these barriers, and this strategy has resulted in remarkable outcomes. Over the last 10 years, using this approach, Utah has been able to reduce homelessness by 75%.

Housing First programs exist in Philadelphia. Pathways to Housing PA and Horizon House are the city’s current providers. Chris Simiriglia, executive director of Pathways to Housing PA, says that Housing First is a critical element in addressing both homelessness and incarceration of those living with mental illness.

Simiriglia feels that what is needed in Philadelphia is to better integrate existing jail diversion programs with Housing First programs. “Currently the system is fragmented,” she said. “We can only serve returning prisoners if they are on the streets long enough to be considered ‘chronically homeless’ and if they are sick enough to be considered to be ‘seriously mentally ill.’” She added, “there are a whole lot of people going in and out of prison who are committing low-level crimes. It is costing the city a fortune to keep them stuck in this cycle.”

While current jail diversion programs in Philadelphia generally connect people with transitional housing, Simiriglia notes that “people do better with permanent, supportive housing.”

The University of Pennsylvania biothecists who recommended a return to asylums were correct in their diagnosis: The status quo is unacceptable, and unjust incarceration of people with psychiatric disabilities must end. But their prescription was wrong. It’s not more asylums we need, but more housing.

Read more at http://www.philly.com/philly/blogs/public_health/Housing-not-asylums.html#G60bjYJLmPxSMtpD.99

Rosalynn Carter Mental Health Symposium Speech

Talk given at the Rosalynn Carter Symposium on Mental Health
November 21, 2014
Atlanta, Georgia

Watch video (my presentation starts at 54:20)

Looking at the history of mental health policy in our country, it might be themed “one step forward, two steps back.” I have seen this trend play out in my own life, as the daughter of two people diagnosed with schizophenia and bipolar disorder, and someone who myself has struggled as a survivor. In 1975, when my mother became pregnant, my family pressured her to get rid of me, caught under the eugenic spell that people with serious mental health conditions shouldn’t procreate. If it wasn’t for my mother’s noncompliance, I wouldn’t be here today. I am thankful every day for her fighting spirit.

She was a beneficiary of de-institutionalization, because she was not left to rot in an institution, but she was left to rot in the community, with no support, no hope, no help. I miss her every day, because she died at the age of 46, due to the effects of overmedication and a broken spirit. The 25 year disparity in life expectancy among people with serious mental illness is not just an abstract statistic to me, it is my legacy. It means that my son will grow up never knowing his grandmother. This is why I fight this fight every day: to ensure that no one else need endure this painful legacy. The personal is the political.

Looking at the history of mental health care in America, we turned a corner of hope when the recovery model began to gain credence in the early 1990s. One could say that recovery entered the mainstream with the President’s New Freedom Commission Report in 2003, which stated, “We envision a future when everyone with a mental illness will recover.” Since then, there has been a gradual but consistent shift in orientation, in practice, to support the growth of a robust peer specialist workforce, advances in trauma-informed care, and a number of other approaches that align with the recovery model. But sadly, the promising recovery orientation has failed to have the “teeth” that it could in terms of policy.

I would actually argue that today we face a real and frightening policy backlash. We have experienced over 100 mass shootings since 2009 in this country, but Sandy Hook was a turning point. With every tragic mass shooting that occurred, we saw in the media and on the Hill an unprecedented level of scapegoating of people with mental illness for the larger problem of gun violence in our nation. As we all know, people with mental illness are more likely to kill themselves or be the victim of a violent crime than to hurt someone else, but the facts seem to matter little when the public agenda is driven by fear and misinformation.

In today’s policy realm, the backlash is best represented by Rep. Tim Murphy’s “Helping Families in Mental Health Crisis Act of 2013,” which was developed as a response to the Sandy Hook tragedy. This legislation, while well-intentioned, would set us back 20 years in terms of progress towards achieving the recovery vision that began in the early 1990s. This legislation is posited as the way to prevent more mass shootings by expanding the criteria for involuntary outpatient commitment, euphemistically referred to as “assisted outpatient treatment.” Yet as we all know, it is nearly impossible to predict who will become violent, so this is clearly a policy measure that will not prevent future mass shootings, which have been mainly perpetrated by individuals who would not have met Rep. Murphy’s expanded criteria for outpatient commitment.

The bill greatly troubles patients’ rights advocates, because it is a slippery slope when our civil rights are eroded. Forced care should not be the first line response – it should be the very last response, when numerous forms of voluntary engagement have been attempted, and in the very rare instances when a person clearly represents a danger to themselves or others. Right now we have no idea whether people would voluntarily use services, because they are so often not available, and people are turned away until they are at the crisis point, fueling our crisis based systems.

The bill would also all but decimate the Protection and Advocacy agencies, which were funded in 1986 to address individual and systemic abuses in institutional care, while increasing institutionally based care options. At the same time, the Bill is anti-Olmstead. It would partially repeal the IMD exclusion, a massively expensive proposition, in order to allow for longer periods of institutional care in public or private psychiatric hospitals at the expense of voluntary, accessible services in the community. What we know is that so often the problem is most often not a lack of hospital beds, but rather difficulty in accessing information about available beds, as well as a lack of safe affordable housing and other community options to discharge people to, causing a backlog.

The legislation is anti-privacy, as it would seek to relax HIPAA standards to allow families to gain access to protected health information. Again, the problem here is not that HIPAA needs to be reformed, but that providers do not understand the emergency exceptions to HIPAA and in many cases hide behind the law to avoid dealing with families.

Yet Rep. Murphy has some very good points to make, which we all should be extremely concerned about. The most important is the heinous way that we as a society have collectively ignored and/or punished the people with the greatest mental health needs. He rightly points out the travesty of the criminalization of the hundreds of thousands of people currently languishing in prison for nonviolent offenses related to their disability. He rightly points out that majority of persons who are homeless today also struggle with serious unmet mental health needs. This is unacceptable, and an agenda that all advocates can agree is vitally important. We have to give people opportunities to get out of jail and off the streets into the community. That means that we have to fight for supported housing and community services – the fight that has been going on for 50 years now. We have not yet won it due to discrimination, due to stigma, a pervasive apathy that has not seemed to dissipate despite all the money that has been funneled into anti-stigma campaigns to date.

What we need is social justice. We need to demand that community services are adequately funded at long last, putting into practice the vision of the Mental Health Systems Act that President and Ms. Carter so boldly championed in 1980. I cannot help but think that if the Mental Health Systems Act had not been decimated by He Who Will Not Be Named, perhaps we would not be where we are today. But we cannot dwell on the past: we must continue to move forward. I for one will be on the Hill educating legislators on where we need to go. Please join us to stand against Representative Murphy’s legislation, and to call for good, comprehensive mental health legislation that protects civil rights while expanding access to and options for voluntary treatment, which still are practically nonexistent in so many communities.

Please stand with my organization, the National Coalition for Mental Health Recovery, as we advocate in Washington in the 114th Congress for a vision of real change. We will be fighting against the Murphy bill and for a comprehensive mental health bill that provides the following:

  • Expanded outreach and support for persons with intensive needs, through assertive community treatment teams and peer engagement.
  • Supportive housing, a proven, cost-effective approach to promoting stability and self-sufficiency.
  • Citizenship initiatives to support recovery by engaging individuals in activities that enhance their sense of belonging through valued roles in their communities.
  • Specialized young adult services to provide age-appropriate interventions and supports.
  • Wellness programs that support individual health through nutrition, mindfulness training, yoga and other positive activities.
  • Jail diversion, crisis intervention trainings, alternatives to incarceration, and reentry programs to prevent inappropriate use of the correctional system.

Together – let’s find a way to move from a climate of fear to a climate of hope. Thank you.

Shifting the Paradigm: Putting Trauma-Informed Approaches at the Center of Crisis Response

Shifting the Paradigm: Putting Trauma-Informed Approaches at the Center of Crisis Response

Keynote Address, National Dialogues on Behavioral Health, 2014, New Orleans

I have a friend, in a major American city, a politically progressive city at that, who was intensely suicidal this year. She wanted help, she desperately did, but she had had traumatic prior experiences before with inpatient hospitalization, and didn’t want to have locked doors slam behind her. She had a WRAP crisis plan, and was going to therapy, and several friends who lived near her, and me, from a distance, agreed to be her supporters. We did everything we could to try to honor her wishes and help keep her out of the hospital. But there were no crisis alternatives – in this major, progressive American city – no crisis alternatives at all. We are all people who are very connected to the mental health world, and if there was something available, we would have known about it. I heard through the grapevine about two crisis respites that don’t advertise, because they simply cannot meet the demand for their services. People have to find them by word of mouth. We called them, but they wouldn’t take her insurance. Weeks went by. We took shifts to support her, but in the end she needed more support than any of us could individually or collectively give, despite our best efforts.

She did end up going inpatient, voluntarily, if you can call it that, because she felt she had no choice. Then, she attempted suicide on the ward. She was secluded and restrained for hours, further harmed, further re-traumatized, by treatment that was supposed to keep her safe.

I tell this story because I think that it is criminal that it should be that difficult to access crisis services, especially in a major American city. It is criminal when the help that does come leaves a person’s dignity bruised and scarred. Treatment should never feel like punishment.

If you look at the state of our country today, we are suffering mentally, physically, and socially. We spend the most money in the world per capita on health care, but have some of the poorest health outcomes of any developed nation. Americans comprise less than 5% of the world’s population, yet we consume 66% of the world’s psychiatric medications, and 80% of the world’s pain medications. More Americans are dying by suicide than in car accidents. More of our veterans have died by suicide than by combat in Iraq and Afghanistan. Since 2009, we have witnessed over 100 mass shootings that have devastated whole communities. We incarcerate more of our people than any other country in the world. These horrible statistics point to a shocking degree of suffering that is connected when viewed through the lens of trauma. Traumatic stress is our national hidden epidemic.

Over my 13 years of experience as an advocate, I have come to see how traumatic stress is at the heart of every single social and public health problem we face in America today. We could save countless lives and dollars by committing ourselves as a nation to addressing trauma. We spend $650 million dollars on brain research, chasing genetic cures that may be 20-30 years off, but we don’t commit anywhere near those dollars to implementing what we know works today.

I think that is the job of each of us in this room, doing the work that we do, to help to enact the culture change that will revolutionize the way we understand and prevent crisis.

Because the personal is the political, I’d like to share some of my story with you. I was born in 1975 to mother was once a bright, creative, beautiful young woman, a promising artist and a poet, who was captivated by the hippie movement. She was a bohemian artist, defying the conventions of our middle-class Jewish Midwestern family, which had carried a tradition of holding emotions inside and acting stoic. One day, soon after my grandparents’ divorce, she left. She hitched a ride to California, and from that point on, was never the same. The police picked her up on a park bench in Arizona, and she was committed for the first time at age 18.

She rotated in and out of mental hospitals, the streets, and jail until her tragic and untimely death at age 46, due to the health complications that come from extreme overmedication and a broken spirit. I live every day still with the trauma of losing my mother so young, so unnecessarily, as so many people die young and unnecessarily in our “systems of care.” The 25 year disparity in life expectancy for people with serious mental health diagnoses is not a statistic for me. It is my legacy. It means that my little boy will never know his grandmother.

I grew up with extreme trauma that came from the very unstable life my mother and I struggled to lead in Inner City Milwaukee. My mother told me that she was encouraged to abort me when she became pregnant, and my family has corroborated her story. My writing this is testament that my mother fought and won against all odds. I might as easily have not been born if she was a more compliant sort of woman. Yay for noncompliance!

But this response – get rid of it – is indicative of the attitudes of the time. The blatant fear of and discrimination against people with this thing called schizophrenia. This thing called mental illness. Things haven’t changed substantially with public attitudes since I was born, despite the money thrown at all the “anti-stigma” campaigns to date.

My mother did the best she could, and though our family tried to help her, she didn’t have enough community support to raise a baby on her own. She hated the disabling side effects of the psych meds, which made her too zonked out to chase around after a little one, and would often take herself off cold-turkey, resulting in withdrawal-induced psychotic experiences that were frightening for us all.

Trauma informed approaches are by definition collaborative and honor a person’s voice and choice. How different things would have been for us, if she had been able to get some support to keep our family together. What if my mother’s wishes to reduce, change, or even withdraw from medication were honored and respected, instead of seen as yet another sign of her “noncompliance?” Her psychiatrist could have worked collaboratively with her to help develop a care plan that would have allowed her to parent me. She could have been offered peer supports for parenting and life needs, skills for managing her overall health, and that of her family. I believe if these were present, they would have helped my mother to break out of the cycle of “noncompliance” and to find recovery.

In nearly a lifetime in and out of public systems, my mother received no emotional support, just medication stabilization and abusive interventions in the name of care. While things are getting better in many places, these kinds of abuses still go on today in many facilities, inpatient and outpatient, in this country. No one ever asked my mother what she needed or wanted out of life. That wasn’t done back then. It’s rarely done now, especially for people diagnosed with serious mental illness, who are seen more often as objects of treatment, rather than collaborators in their own healthcare.

I have an ACE score of 7, and have experienced many of the long-lasting psychological and physical effects that accompany an ACE score of 6 or higher. My memories as a girl are tinged with periodic violence – not at my mother’s hand, but at the hands of police. I remember more than one occasion when my mother was in an altered state, fighting with her voices, and the police broke down our door and dragged her away to the county mental hospital. I remember being 3,4,5 years old, cowering under the bed, terrified of the “men with the black shoes.”

After the courts removed me from my mother’s care at age 5, I went to live in another state with her mother, my maternal grandmother, and her second husband. My mother died inside the day I was taken away, and I too was traumatized by this abrupt separation. From afar, I spent the rest of my life observing her decline, as she more hopeless with every passing year. As my mother deteriorated, I went through my own crisis, multiple suicide attempts, and inpatient hospitalizations. My memories of adolescence are not of the prom, are not of acne and awkward encounters with boys, but of adolescent psych wards and residential treatment facilities where I was denied hope and education and told I was going to be broken for the rest of my life. The traumatic stress I experienced as a little girl was never addressed.

I’ll give you an example of how our systems sometimes uncannily reproduce a person’s original trauma. When I was a struggling teen, I was intensely suicidal and had locked myself in a room with knives. My family didn’t know what else to do, so they called the police. In the same exact scenario as I had experienced with my mother, the police broke down my bedroom door and dragged me off to the psych ward. More re-traumatization.

What has helped with my police trauma, in part, has been the personal connections I have developed with a few amazing CIT trained officers around the country who are trying with all their heart to do things differently. They are exceptional people. But I believe that all of the efforts to create a kinder, gentler police force, while pragmatic, are not getting to the root of the problem. Remember Bob talking about root cause analysis yesterday morning? We as a society need root cause analysis for the way we respond to crisis.

It is our collective failing that police are the first responders, have been forced to take on a role as the new “mental health workers,” in so many of our communities. And when push comes to shove, police are trained to react with violent force if they perceive any threat, no matter how much CIT training they have had, as we saw with the killing of Kajieme Powell this past August. We must collectively work towards creating the kinds of supports in communities so that police involvement with a person in crisis is minimized to the greatest extent possible, where the use of deadly force is brought down to zero everywhere.

One of the things we know about trauma is that it disconnects. It disconnects us from ourselves and from other people. And this disconnection is literally killing us. And we know that trauma is healed in the context of mutual, respectful relationships, which rebuilds trust and a sense of belonging.

We must re-define crisis care, and all care, as a way to assist a person to re-establish connections – with themselves, and with the broader community. Having the best crisis care in the world means nothing if people leave without some kind of ongoing social support. If people leave without a safe and affordable place to live.

I would not be where I am today, out of the disgusting group home where I was told I would have to be for the rest of my life, if it wasn’t for the people who believed in me. My family, who let me leave the group home at the age of 18, on the condition that I finally finish high school. The teacher at the continuation high school for “bad kids,” that I attended, who allowed me to finish my course work on a flexible schedule, and gave me not only accommodations, but endless encouragement. When I graduated from that high school, the staff and teachers were all crying, because so few kids ever earned a diploma. Most went to jail. That could have easily been me.

In community college, I learned about the power of peer support and giving back. My guidance counselor, who knew all about my mental health history, encouraged me to do a work-study program mentoring Vietnam vets who were returning to school. While I was 19 and they were men in their 50s, and on paper we had nothing in common, we connected on a human level. We connected because we were all trauma survivors, trying to figure out how to move forward with our lives and education. And we began to meet for coffee every morning, and we read the newspaper and talked about current events, and we formed an informal community of support on that campus. They will never know how much they helped me as I made the transition from institutionalized youth to student.

In America, illness and wellness are almost always depoliticized and decontextualized. Depression ceases to be an understandable reaction to poverty, marginalization, and our often dehumanizing way of life, and instead becomes a brain disease. People of privilege may feel guilty for being depressed when they “have it all,” but miss the point that regardless of privilege, none of us are immune to the distress caused by our increasingly isolated modes of being. None of us are immune to crushing hopelessness.

In this society, we have a dichotomized response to distress. Suck it up and adjust to what is, or be put somewhere where you will be made to adjust. It is possible to be so focused on individual illness and wellness that we forget the equally important need to work for collective wellness and social justice. In an ideal world, we are both taking care of one other, and working together to change the way things are.

For several years I have been part of a single moms’ support group. This has nothing to do with “mental health,” though many of the moms, myself included, have struggled with deep distress at times. It has to do with “reciprocal care.” We do everything from sharing words of encouragement in tough times; to sharing childcare; to having clothing swaps; to providing information and community resources; to having community potlucks; to organizing meals during illness or tragedy; to giving dating advice; to lending each other suits for job interviews; to accompanying one another to stressful court hearings; to organizing Moms’ Nights Out (MNOs). We also raise money to help other moms who are economically much worse off than we are. We are the village, created out of a common need. I want to say that this network prevented me from going into crisis on more than one occasion, when the burden of being a single mom living under severe stress of all kinds felt like too much to bear. This kind of network costs no money, you don’t need to bill Medicaid for it, and it’s the hope of what care can truly be. What can we do to help build these kinds of support systems in each of our communities?

A liberating notion of care would follow from the understanding that most of us need other people. We need truly safe relationships in our everyday lives where we can be vulnerable and real, and let the masks of “keeping it together” fall away. A redefined notion of care would presuppose that we as individuals are all deeply interconnected. The “burden of healing” would be spread around, rather than placed squarely on our individual shoulders.

I do believe that part of the paradigm shift is that we need peer to peer support networks everywhere, which can also be translated as “community.” Survivors have designed hearing voices networks by and for people who struggle to cope with voices and visions, as well as peer support groups for people struggling with suicide and trauma. These are hugely important, but they exist only in a handful of places. What would it look like in terms “prevention” if we had broader networks of community support than what we currently have now? Networks for people coming out of the criminal justice system, to help one another to navigate the transition? Student groups on campuses could be a safe place to share resources, skills, and support, and to advocate together to improve the availability of support for all students on campus. Teachers could form support networks to deal with the challenges of being educators in public systems with dwindling resources, and find ways together to meet their own needs, as well as the needs of the children and families they work with. Neighbors could form networks to provide emotional support to one another, while also addressing their practical community issues.

You, as crisis service providers, I am guessing, need way more support than you are currently getting doing the work that you do every day, with massive expectations and often with far too few resources to make the kind of difference you know is possible. I would encourage everyone here, if you aren’t doing this already, to think about the kinds of community that you, personally, can help build when you go home.

Here is the revolution I want to see: I want people everywhere to have access to the kind of social support and care that doesn’t require a diagnosis or insurance billing code or involve scheduling an appointment four-six weeks from now or having to take a ride in the back of a police car to get help. If we knew how much power we, everyday people, had to care with and for each other, I believe that we could prevent all manner of crises. As we all know, it is so often when people’s basic human needs for shelter, purpose, and social connections are not met, that crisis happens.

I do what I do every day because the personal is the political. And what you do is also personal and political. We must put our heads together, collectively, to better share the best ideas we have for building a range of community health alternatives to our current and all too often inadequate “systems of care.”

Change so often requires social and political will. And some of the kinds of changes I see being proposed on the federal level, working for the National Coalition for Mental Health Recovery in DC, are not the right direction for our country. Mental health legislation introduced in the last Congress, the Helping Families in Mental Health Crisis Act, introduced by Congressman Tim Murphy in December of 2013, in response to Sandy Hook, would roll back the clock 30 years. This bill would expand and provide block grant funding for more forms of coercion and outpatient commitment to the system, and aggressively create more hospital beds, while eviscerating the protection and advocacy systems that were designed to protect folks from abuse and neglect in institutional settings. It would erode our privacy rights and yank federal funding for innovative peer-run and recovery oriented programs. We don’t know the fate of this legislation, but it will likely be re-introduced in some form in the next Congress.

I know that you are all overworked and underfunded, but I ask you to take political action. Please make the time to contact your legislators and tell them that what we need is not more coercion but more voluntary forms of community support and diversion. Tell them what you think needs to be done to better promote healing and recovery for people and to prevent trauma and end criminalization, the revolving door cycle, and early mortality. Please tell them how important peer support is to the folks you work with and that it needs to be preserved and expanded. If we are going to move these systems, and our society, in the right direction, and bring the inspiring visions in this room to scale, we are going to have to fight for it – together.

We are a Society that is Dangerously out of Balance

Mad in America Film Festival Talk
October 12, 2014
Arlington, MA

According to a recent CDC report, Americans are enjoying a higher overall life expectancy, yet the suicide rate is at a 25 year high. People with serious mental health diagnoses are still dying 25 years younger than the population. And if we look at America overall, our mental and physical health outcomes really lag behind the rest of the developing world. We spend a lot of money on expensive and generally ineffective interventions, but invest little in the well-being of our people. We do shockingly little to address the issues of social, economic, and political inequality, which all impact on our mental, physical, and collective social health.

I think the rise of biological psychiatry is a symptom of a much larger problem we face in America. It’s no coincidence that innovations like Open Dialogue and the Hearing Voices Network are coming from Europe and Scandinavia. Our American brand of psychiatry doesn’t exist in a vacuum. We have a society that is organized in a way that it is driving people to madness, violence, and suicide. The sickness of our society is reflected in the disciplines and systems and the prisons and the institutions that it has created to deal with the people that it drives mad. Our way of life is killing us, and it is a way of life that I would argue is driven by the excesses of our economic system.

We are a society that is dangerously out of balance. This is reflected in our public spending priorities, our militarism, our inability to look at the root causes of the violence tearing us apart, our rising rates of suicide, mass incarceration, and increasing disability due to mental health issues. American politics suffers from a staggering lack of insight, with its desire to focus only on half-hearted, myopic responses to symptoms of the problems we face.

We, as people who have experienced trauma, distress, and psychiatric oppression, and have liberated ourselves, have an unprecedented opportunity to articulate a vision for society that is restored to balance, and must fight to see that vision implemented. That means that we have to get our hands dirty and get involved in the political process.

According to a 2013 report by the IOM and the National Research Council entitled U.S. Health in International Perspective: Shorter Lives, Poorer Health, “the largest obstacle to addressing the U.S. health disadvantage is not a lack of evidence or uncertainty about effective interventions but limited political support among both the public and policy makers to enact the policies and commit the necessary resources to implement them.”

The report goes on to say, “Meaningful initiatives to address the underlying causes of the U.S. health disadvantage may have to address the distribution of resources that are now directed to other categorical priorities—a change that is likely to engender political resistance.” This is a prescription for radical activism around our economic and political systems.

I want more people to get angry about the fact that we don’t have housing and health care and good social care in this obscenely wealthy country. I want more people to be outraged about the inequality and the injustice, the lack of public investment in our health and well-being. Because anger is a much better motivator than despair.

If we are to truly address the root causes of the problems we face, we must move beyond our narrow missions and embrace a paradigm of collaboration and solidarity. Activists have coined the term “intersectional justice,” which is defined as “the pursuit of justice emphasizing that no individual or community lives a single-issue struggle, specifically centering multiply marginalized folks.”

Being involved in the fight to defeat HR 3717, oppressive national mental health legislation over the last ten months has opened my eyes to the need for intersectional justice as never before. Because at its essence, this legislation represents a war against the marginalized, disempowered, and disenfranchised. What makes it so frightening is that it is cloaked in a form of benign paternalism, of “helping.”

We find ourselves in a climate today that is quite Orwellian. A climate where coercion is referred to as “love,” and “assistance” is a euphemism for forcing people into unwanted services and often life-threatening medications. When we demand the right to choose and direct our health care, when we demand housing and education and meaningful work, we are accused of “lacking the insight” to achieve these things. It’s a climate where we are demonized and scapegoated in all the major media as part of the problem, instead of what we know we are: perhaps the best hope for a solution to help fix our broken world.

When I first was appointed as director of the National Coalition for Mental Health Recovery six months ago, I thought about building the coalition as a true, peer-led NAMI alternative. And while I still think that is a worthy goal, I would like to go even bigger with it. I would like to see NCMHR be part of a much broader-based coalition of social justice and human rights groups, such as the National Economic and Social Rights Initiative (NESRI) working together to address the root causes of the intersecting oppressions that we face, and to galvanize the outrage necessary at the grassroots level to demand real change.

The fight before us, as I see it, is chiefly for social and economic rights, which are the essential pre-conditions of well-being. We must fight to create an America that re-distributes its resources and actually invests in the well-being of its people. And this means that we must fight against the excesses of free market capitalism, which would have us invest as little as possible in social welfare and protecting our planet, while concentrating wealth and power into the hands of an increasing few who would happily destroy it all to ensure the corporate bottom line.

I hate to end on a pessimistic note, but I wonder if we are frankly running out of time. I am reading Naomi Klein’s new book on climate change, THIS CHANGES EVERYTHING, and she points out that we are currently emitting carbon at a rate that could mean near-certain catastrophe for the planet in our very lifetimes. Klein comes to the conclusion that change will have to come from below, as the political system has been largely co-opted by the corporate agenda. She says, “either we embrace radical change ourselves or radical changes will be visited upon our physical world. The status quo is no longer an option.”

We as “mad” people, as psychiatric survivors, as people in mental health recovery, as wounded healers, can and should be an essential part of fomenting the grassroots revolution that will be needed to help save ourselves before it’s too late.

Trauma Nation: How to Truly Address the Roots of Violence, Suicide, and Suffering in America

The essay that forms the basis of my forthcoming book.

Originally published here at Mad In America.com

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.

* * * * *

References:

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.                 

[ix] http://www.ncbi.nlm.nih.gov/pubmed/11754674?dopt=Abstract

[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

[xii] Centers of Disease Prevention (CDC). Major Findings of the ACE Study.http://www.cdc.gov/ace/findings.htm

[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/