NASMHPD Position Statement on
Services and Supports to Trauma Survivors
The National Association of State Mental Health Program Directors (NASMHPD) recognizes that the psychological effects of violence and trauma in our society are pervasive, highly disabling, yet largely ignored. Recent research indicates that interpersonal violence and trauma, including sexual and/or physical abuse over the lifespan, is widespread, has a major impact on a wide range of social problems, and are costly if not addressed. The threat of terrorism is now a constant source of stress for many Americans and the sequalae to recent terrorist events have affected untold numbers of citizens. NASMHPD believes that responding to the behavioral health care needs of women, men and children who have experienced trauma is crucial to their treatment and recovery and should be a priority of state mental health programs. In addition, the prevention of traumatic experiences is a fundamental value held by NASMHPD and its individual members; state mental health authorities. Toward this goal, it is important to support the implementation of trauma-informed systems and trauma-specific services in our mental health systems and settings.1
The experience of violence and trauma can cause neurological damage and can result in serious negative consequences for an individual’s health, mental health, self-esteem, potential for misuse of substances and involvement with the criminal justice system. Indeed, trauma survivors can be among the people least well served by the mental health system as they are sometimes referred to as “difficult to treat”--they often have co-occurring mental health and substance use disorders, can be suicidal or self-injuring and are frequent users of emergency and inpatient services.
Trauma is an issue that crosses service systems and requires specialized knowledge, staff training and collaboration among policymakers, providers and survivors. Study findings2 indicate that adults in psychiatric hospitals have experienced high rates of physical and/or sexual abuse, ranging from 43% to 81%. Studies have
shown that up to 2/3 of men and women in substance abuse treatment suffer from posttraumatic stress disorder, acute stress disorder or symptoms; and up to 80% of women in prison and jails were victims of sexual and physical abuse. Children are particularly at risk as over 3.9 million adolescents have been victim of serious physical violence and almost 9 million have witnessed an act of serious violence. Adverse childhood experiences are related to health risk behaviors and adult diseases, including heart disease, cancer, chronic lung disease, skeletal fractures and liver disease. Especially significant for behavioral health care service systems are findings by the National Child Traumatic Stress Network and others that have linked serious behavioral problems to the biological, neurological and psychological effects of violence and trauma in childhood. Early abuse is now believed to create a particular vulnerability to hyper-arousal, explosiveness and/or de-personalization that results in ineffective coping strategies and difficult social relationships.
Confounding
and complicating the prevalence of trauma in public mental health service
recipients is the fact that mental health services themselves are often
experienced as traumatic. The use of coercive interventions such as seclusion
and restraint, forced involuntary medication practices, and philosophies of
care based on control and containment vs. empowerment and choice often cause
unintentional re-traumatization in already vulnerable populations.
The New Freedom Commission Report Achieving the Promise: Transforming Mental Health Care In America calls for the promise of community living for everyone and for the transformation of our mental health systems of care to meet shared goals that facilitate recovery and build resiliency. NASMHPD believes that the implementation of systems of care that are trauma informed is a cornerstone in building service systems that do not traumatize or re-traumatize service recipients or the staff that serve them. Recovery based services are sensitive to trauma issues and are never coercive. The concept of universal precautions is quite valuable when identifying and implementing the principles and characteristics of trauma informed systems of care to avoid traumatization and re-traumatization.
A set of criteria for building a trauma-informed mental health system were developed at a NASMHPD-sponsored trauma experts meeting in 2003, and a number of state mental health authorities have begun to address the these issues in the public mental health system. Trauma informed prevention strategies adopted by states and service systems include reducing and eliminating the use of seclusion and restraint; the use of prevention tools such as trauma assessments, identifying risk factors for violence or self harm, safety planning, advance directives; workforce training and development; and the full inclusion of consumers and families in formal and informal roles.
Services for trauma survivors must be based on concepts, policies, and procedures that provide safety, voice and choice, and—like all good care—must be individualized/personalized. Trauma services must focus first and foremost on an individual’s physical and psychological safety. Services to trauma survivors must also be flexible, individualized, culturally competent, promote respect and dignity, and be based on best practices. Recent research indicates that the most effective approaches for supporting recovery from trauma are well-integrated behavioral health services that also reflect the centrality of trauma in the lives and experiences of consumers[3].
NASMHPD is dedicated to better understanding of the effects of trauma and violence including physical and/or sexual abuse, neglect, terrorism; implementing emerging culturally competent best practices in trauma treatment within the public mental health system; and considering the role of prevention and early intervention programs in decreasing the prevalence of trauma-related behavioral health problems. State mental health authorities are committed to recognizing and responding to the needs of persons with mental illnesses and their families within a cultural and social context. Asking persons who enter mental health systems, at an appropriate time, if they are experiencing or have experienced trauma in their lives is becoming a standard of care. NASMHPD has taken the lead in recognizing that some policies and practices in public and private mental health systems and hospitals, including seclusion and restraint, may unintentionally result in the revictimization of trauma survivors, and therefore need to be changed.
NASMHPD is committed to working with states, consumers/survivors and experienced professionals in the trauma field to explore ways to improve services and supports for the public mental health service recipient inclusive of trauma survivors consistent with the recommendations of the New Freedom Commission Report. These efforts may include, but are not limited to developing and disseminating information and technical assistance on best practices; supporting research as recommended by the field; providing forums for national dialogues on trauma survivors; consistent advocacy in creating trauma informed and recovery based systems of care; including consumers and their families in the planning, design, implementation and monitoring of best and promising practices; and cooperating with other state and national organizations to develop treatment, prevention and education initiatives to address the issue of trauma.
Original Statement passed unanimously by the NASMHPD
Membership on
Revised Position Statement passed unanimously by the
NASMHPD Membership on
1 For purposes of this position statement Trauma
and Traumatic Events will be defined as the personal experience of
interpersonal violence including sexual abuse, physical abuse, severe neglect,
loss and/or the witnessing of violence (
Trauma Informed Care is defined as care that is grounded in and directed by a thorough understanding of the neurological, biological, psychological and social effects of trauma and violence on humans and is informed by knowledge of the prevalence of these experiences in persons who receive mental health services. Trauma Specific Services are defined as promising and evidenced based best practices and services that directly address an individual’s traumatic experience and sequalae and that facilitate effective recovery for trauma survivors (NASMHPD, 2004).
2 All statistics cited can be found in The Damaging Consequences of
Violence and Trauma, compiled by Ann Jennings, Ph.D. NTAC: 2004 and the NASMHPD
Curriculum: Six Core Strategies for the Reduction of Seclusion and Restraintã, 2004.
[3] SAMHSA citation (in press)