Compiled by: 
Ann Jennings, Ph.D. 
Prepared for: 
National Technical Assistance Center 
for State Mental Health Planning (NTAC), 
National Association of State Mental Health Program Directors (NASMHPD), 
under contract with the Center for Mental Health Services (CMHS), Substance Abuse 
and Mental Health Services Administration (SAMHSA), 
U.S. Department of Health and Human Services (HHS) 
This report was produced by the National Association of State Mental Health Program Directors (NASMHPD) and the 
National Technical Assistance Center for State Mental Health Planning (NTAC) and is supported by a Contract 
between the Division of State and Community Systems Development, Center for Mental Health Services (CMHS), 
Substance Abuse and Mental Health Services Administration (SAMHSA), and the National Association of State 
Mental Health Program Directors. Its content is solely the responsibility of the author(s) and does not necessarily 
represent the position of SAMHSA or its centers. 
Text Box: The Damaging Consequences 
of Violence and Trauma
Facts, Discussion Points, and Recommendations for 
the Behavioral Health System
2004
Text Box: NASMHPD

Table of Contents 
Acknowledgements.............................................................................................................v 
Introduction......................................................................................................................vii 
How to Use This Publication.............................................................................................xi 
The Damaging Consequences of Violence and Trauma: Facts, Discussion Points, and 
Recommendations for Behavioral Health Systems.............................................................1 
Priority Issues Selected for Their Current Public Policy Import..................................3 
Co-occurring Disorders...........................................................................................5 
Substance Abuse Treatment Capacity..................................................................13 
Seclusion and Restraint.........................................................................................17 
Prevention and Early Intervention........................................................................21 
Children and Families...........................................................................................25 
Terrorism and Bio-Terrorism................................................................................29 
Homelessness........................................................................................................37 
Mental Illness........................................................................................................41 
Serious Medical Problems and Health Risks........................................................45 
Criminal Justice....................................................................................................49 
Aging.....................................................................................................................53 
Severe Social Problems.........................................................................................55 
Cross-Cutting Principles for Each Priority Issue........................................................57 
Data and Evidence-Based Outcomes....................................................................59 
Collaboration with Public and Private Partners....................................................63 
Cultural Competency............................................................................................67 
Community and Faith-based Approaches.............................................................69 
Violence/Physical and Sexual Abuse....................................................................71 
Financing Strategies and Cost-Effectiveness........................................................77 
Workforce Development.......................................................................................81 
Peer Support and Self-Help..................................................................................83 
Appendix A: Trauma Services Implementation Toolkit 
for State Mental Health Agencies.....................................................................................87 
Other Available Resources.......................................................................................111 
Publication Contacts.................................................................................................115 
Appendix B: NTAC National Experts Meeting 
on Trauma and Violence Participants List......................................................................119 


Acknowledgements 
The National Technical Assistance Center for State Mental Health Planning (NTAC) and 
the National Association of State Mental Health Program Directors (NASMHPD) 
gratefully acknowledge the many individuals and organizations that contributed to the 
development of this comprehensive report. In particular, we would like to thank Charles 
Curie, M.A., A.C.S.W., administrator of the Substance Abuse and Mental Health 
Services Administration (SAMHSA), and A. Kathryn Power, M.Ed., Gail P. Hutchings, 
M.P.A., Joyce T. Berry, Ph.D., J.D., and Susan E. Salasin of the Center for Mental Health 
Services (CMHS) within SAMHSA for their time and effort and for continuing to 
demonstrate their commitment to this issue. We would also like to thank Michael J. 
English, J.D., formerly of SAMHSA/CMHS, for his efforts. 
Among the many individuals who contributed resources and time to this report, we would 
like to especially thank Ann Jennings, Ph.D., former director of the Office of Trauma 
Services within the Maine Department of Behavioral and Developmental Services, for 
her countless hours of work to compile and edit the information contained in this report. 
Her effort to battle the effects of trauma is inspiring. Special thanks also go to Joanie 
Stewart, who helped edit and organize this final version. 
We would like to thank the host of dedicated people who contributed to this report and its 
appendices, including Andrea Blanch, Ph.D.; Sandra Bloom, M.D.; Judy Ford, M.A.; 
Julian Ford, Ph.D.; Esther Giller; Ruta Mazelis; Shery Mead, M.S.W.; and Nan 
Stromberg, R.N., C.S. These professionals worked tremendously hard during the short 
timeframe we had to produce this report, contributing their own ideas as well as 
researching and referencing articles containing important statistics. 
The members of the State Public Systems Coalition On Trauma (a.k.a. SPSCOT—a 
dozen states that have formed a network to share ideas and support the development of 
trauma-informed systems of care) contributed a massive amount of time, energy and 
expertise to Appendix A, the “Trauma Services Implementation Toolkit for State Mental 
Health Agencies.” Many of these people responded to numerous phone calls for 
information about their state resources, contributed their own information, and helped 
edit the materials collected by others. Many SPSCOT members work for or with state 
public mental health agencies in a total of 20 states. Other SPSCOT members include 
consultants—national figures who are not connected to any one state. 
SPSCOT members, of which I am one, include Mary Jane Alexander, Ph.D.; Rene 
Andersen; Rosie Anderson-Harper, M.A.; Mary Auslander, M.S.W.; Sandy Bennett, Lyn 
Blackshaw, Ph.D.; Andrea Blanch, Ph.D.; Sandra Bloom, M.D.; Robyn Boustead, 
M.P.A.; Leticia Brockman; Celia Brown; Vivian Brown, Ph.D.; Elaine Carmen, M.D.; 
Lynn Carter; Cathy Cave; Diana Cavenaugh; Janet Chassman; Marilyn Cloud; Leslie 
Cooper, Ph.D.; Vicki Cousins; Karen Cusack, Ph.D.; Sharri Dempsey; Roger Fallot, 
Ph.D.; Judy Ford, M.A.; Julian Ford, Ph.D.; B. Christopher Frueh, Ph.D.; Joan Gillece, 
Ph.D.; Paul Gorman, Ed.D.; Dianne Greenley, J.D.; Pablo Hernandez, M.D.; Thomas 
Hiers, Ph.D.; Karlee S. Hoecker, Ph.D.; Russ Hughes, Ph.D., M.B.A.; Gail P. Hutchings, 

M.P.A.; Joe Jacobs, M.D.; d.a. johnson; Ann Jennings, Ph.D.; Margaret Joyal, M.A.; 
Andrea Karfgin, Ph.D.; Steven Karp, D.O.; David Lauterbach; Andrea Levy; Beverly 
Long, Ph.D.; Ruta Mazelis; Dan McCarthy; John Morris; Jim Overland; John Pierce; 
Kathryn Power, M.Ed.; Laura Prescott; Alan Radke, M.D.; Patricia Reed; Stan 
Rosenberg, Ph.D.; Susan E. Salasin; Kathy Sawyer; Dorn Schuffman; Karen Snyder; 
Susan Stefan, J.D.; Nan Stromberg, R.N., C.S.; Marge Tully; Carol Warshaw, M.D.; Dan 
Weisburd; and Suzanne Witterholt, M.D. 
Additional groups also made important contributions to this report, including the 
participants of NTAC’s National Experts Meeting on Trauma and Violence, held on 
August 5 and 6, 2002, in Alexandria, Virginia (Editor’s note: See Appendix B for a full 
participant list). 
Finally, many acknowledgments and thanks go to the NTAC staff members who helped 
produce, publish, and disseminate this report, including Ieshia Haynie, program associate; 
Robert Hennessy, editor and publications coordinator; and Catherine Q. Huynh, M.S.W., 
former assistant director. 
—Kevin Ann Huckshorn, R.N., M.S.N., I.C.A.D.C. Director 
NASMHPD Office of Technical Assistance 

Introduction 
The Damaging Consequences of Violence and Trauma: Facts, Discussion Points, and 
Recommendations for the Behavioral Health System is a uniquely valuable publication in 
that it combines elements of a technical report, literature review, and a de facto call-to-
action under one cover. However, the most accurate description of this document is that it 
is a collection of evidence compiled to help inform state mental health officials and the 
federal government’s Substance Abuse and Mental Health Services Administration 
(SAMHSA) about trauma and to generate interest in this daunting public health and 
public policy issue. 
Both NASMHPD and SAMHSA have longstanding commitments to the study of 
violence and to the development of effective interventions to address its consequences. 
This report builds on work stimulated by the landmark SAMHSA-sponsored Dare to 
Vision conference held in 1994; the national Women and Violence Research Project 
sponsored by CMHS, Center for Substance Abuse Treatment (CSAT) and the Center for 
Substance Abuse Prevention (CSAP); the Final Report of the President’s New Freedom 
Commission on Mental Health; and by two national trauma experts meetings convened 
by NASMHPD (held in April, 1998 and August, 2002). This report is structured to reflect 
the interests and priorities of both SAMHSA and NASMHPD/NTAC. 
In fact, the information is organized according to the programs and cross-cutting 
principles of the SAMHSA Priorities Matrix as well as the goals and recommendations 
found in the President’s New Freedom Commission Final Report, Achieving the Promise: 
Transforming Mental Health Care in America. The categories used in this document 
reflect these aforementioned guides, while also reflecting the input of the participants at 
the second NASMHPD/NTAC trauma experts meeting, held in August 2002. The 
categories are therefore based on what these experts saw as the “essential elements” of a 
trauma-informed service system. 
This document is a resource for people—at the local, state, and/or federal levels—who 
are in the process of transforming systems of care into systems that recognize and address 
trauma and for those who are trying to prove that a trauma-informed system of care is a 
priority now. The findings reported in this document demonstrate clearly that trauma 
must be addressed on policy, practice, and educational levels so that individuals who 
suffer from trauma can have a better chance at recovery, paralleling the vision presented 
in the Achieving the Promise report. 
This publication is based on the following premises: 
. The experience of trauma can be extremely damaging and often has enormous 
costs. 
. Unresolved, untreated trauma is central to the development of multiple, severe, 
and persistent health and mental health problems, substance abuse, criminal 

behavior, and social problems in our society, and should therefore be a key 
consideration for policy making in each of these fields. 
. Addressing trauma must be central and pivotal to public health and human service 
policy making including fiscal and regulatory decisions, service systems design 
and implementation, workforce development, and professional practice. Unless 
trauma is addressed, the damage to individuals and to society will continue. 
The report’s facts and discussion points are taken from published and unpublished 
services research conducted in single sites/states; epidemiological studies; qualitative and 
quantitative research; and in some cases, personal communications from individuals with 
experience and expertise in the field. Recommendations are based on the literature cited. 
This report is not intended to be an exhaustive research review, but a sampling of the 
knowledge base that exists in the field. All data sources are referenced for further 
exploration in each priority issue’s accompanying bibliography/reference list. 
Appendix A, the “Trauma Services Implementation Toolkit for State Mental Health 
Agencies,” is a detailed listing of resources that state and local policy makers have 
developed to improve trauma services within their areas. Deciding which resources to 
include was challenging, given the constantly changing nature of the field. The decision 
was made to include only completed tools that are already in use in one or more sites, 
those that are available in written form, and those that explicitly address trauma. For 
people who are already interested in systems change in support of a trauma paradigm, 
this appendix should be especially informative. 
This overall document is a product of a group of individuals, including providers, 
consumers, and policy makers, who responded to an invitation to contribute data and 
recommendations within a brief period of time. The product is the beginning of an 
ongoing effort, and should be viewed as a work-in-progress. Some sections are 
incomplete, and others may be somewhat dated before this report goes to press. If some 
sections have less information than others, it does not necessarily mean that little or no 
research has been conducted in that area. However, it does imply that findings in that area 
may not yet be widely known to people working in the field. 
The authors and publishers of The Damaging Consequences of Violence and Trauma: 
Facts, Discussion Points, and Recommendations for the Behavioral Health System 
encourage readers to cite the information contained herein as necessary, and to utilize the 
document as a technical report, a call-to-action, a body of evidence, or all of the above in 
the hopes that the document helps bring effective and appropriate trauma services to the 
forefront of today’s behavioral health care systems. 
“We now know a great deal about the impact of trauma and despite this, training 
programs, degree programs, teacher preparation courses, etc., are still woefully deficient 
in conveying the research data to the people who need to know it,” said trauma expert 
Sandra Bloom, M.D. “Trauma training is not about the seemingly simple problem of 
giving people information. The real problem is that the material is challenging, 

threatening, and it may elicit resistance to change and denial within individuals and 
within entire systems. Any effort to [improve trauma services] will have to contend with 
this resistance if efforts are to be in any way successful,” said Bloom. 
This publication is intended to encourage system transformation through the 
dissemination of data-based information, practical recommendations, and existing 
practices, while adhering to the message and spirit of the goals and recommendations 
from Achieving the Promise. 


How to Use This Publication 
The Damaging Consequences of Violence and Trauma: Facts, Discussion Points, and 
Recommendations for the Behavioral Health System is a technical report that includes a 
toolkit as an appendix. 
The report lists priority issues within the umbrella topic of trauma services systems and 
then presents a series of facts, discussion points, and recommendations for readers on 
each issue. After many of the bulleted facts, discussion points, and recommendations, the 
reader will notice superscript citation numbers that are intended to direct the reader to a 
corresponding reference located within the numbered reference list immediately 
following each section. Each priority issue is listed in the table of contents. 
Appendix A, entitled “Trauma Services Implementation Toolkit for State Mental Health 
Agencies,” lists categories of trauma service factors to be considered by policy makers. 
Within each category, the information is organized by an alphabetical listing of states that 
have relevant materials to share. The listings include underlined words and phrases 
representing documents that may aid policy makers in creating trauma-informed systems 
of care. A detailed contact list—again, organized by state—is included at the end of this 
appendix to help readers identify and locate these helpful documents. 


The Damaging Consequences 
of Violence and Trauma: 
Facts, Discussion Points, and Recommendations 
for Behavioral Health Systems 


Priority Issues Selected 
for Their Current Public Policy Import 


Co-occurring Disorders 
People who have both mental health and substance abuse problems are highly likely 
to have trauma histories; in fact, trauma is often their central problem. 
Co-occurring Disorders Facts and Discussion Points 
. Fifty-five percent of consumers and former consumers at a Maine state mental 
hospital with a dual diagnosis of mental illness and substance abuse report 
histories of physical and/or sexual abuse.1 
. In adults, the rates for co-morbid Posttraumatic Stress Disorder (PTSD) and 
substance use disorders are two to three times higher for females than males, with 
30% to 57% percent of all female substance abusers meeting the criteria for 
PTSD. Women’s increased risk for co-morbid PTSD and substance dependence is 
related to their higher incidence of childhood physical and sexual abuse.2 
. Many mental health and substance abuse providers may be under the impression 
that abuse experiences are an additional problem for their clients, rather than the 
central problem. PTSD is often the only diagnosis utilized to address abuse; in 
fact, every major diagnostic category in the Diagnostic and Statistical Manual of 
Mental Disorders, Fourth Edition (DSM-IV) can sometimes be related to trauma.3 
. Statistics on abuse history increase dramatically if respondents are questioned 
regarding emotional/mental abuses and neglect.3 
. A high prevalence of trauma exposure and PTSD exists among the dually 
diagnosed.4, 5, 6 
. It is estimated that fewer than 20% of substance abuse programs offer specialized 
trauma-related services for the dually diagnosed.7, 12 
. Among women in substance abuse treatment, rates of PTSD are double those in 
the general population, ranging from 30% to 59%.2 
. Untreated PTSD among people with co-occurring disorders often increases the 
need for more frequent hospitalizations, entitlement benefits, and supportive 
services (Rosenberg, Mueser, Friedman, Gorman, Drake, Vidaver, Torrey, & 
Jankowski, 2001).6 
. Up to two-thirds of men and women entering substance abuse treatment suffer 
PTSD or Posttraumatic Stress Symptoms (PTSS).8 

. Individuals diagnosed with substance abuse disorders and PTSD, compared with 
those without a diagnosis of PTSD, are more likely to use inpatient and outpatient 
services and often seek medical rather than mental health or substance abuse 
treatment.9, 10 
. An independent assessment of recipients of public mental health inpatient and 
outpatient services revealed 43% had a diagnosis of PTSD not previously 
assessed by any of the facilities. Mental health staff had only noted a diagnosis of 
PTSD in the charts of 2% of the consumers (Mueser et al., 1998).4 
. Both mental health and substance abuse providers may be investing significant 
effort providing services that are only partially related to their clients’ underlying 
causes of need (Switzer et al., 1999).11 
. When compared to those without PTSD, dually diagnosed individuals with 
PTSD—particularly those with psychotic disorders—report significantly greater 
needs for comprehensive services, including drug abuse treatment services, 
relapse prevention, and services related to level of functioning and health issues. 
Trauma/domestic violence counseling was rated as very important by this group.12 
. Sexual abuse and physical abuse have been identified as significant childhood risk 
factors for the development of addiction in adulthood.13 
. Survivors of early sexual abuse may use drugs and alcohol to cope with abuse-
related emotional and physical pain, abuse memories, and symptoms stemming 
from the abuse. PTSD symptoms are widely reported to become worse with initial 
abstinence. There is high probability of drug or alcohol relapse when trauma is 
not addressed and no alternative means of coping with the pain are provided.14, 15 
. In a sample of 100 male and female subjects receiving treatment for substance 
abuse, more than a third were diagnosed with some form of a dissociative disorder 
stemming from childhood sexual or physical abuse.16 
. Trauma alone is an important issue in increasing the risk of alcohol abuse. When 
combined with psychiatric disorder, risk significantly increases.17 
. Substance abuse, posttraumatic depression, or social phobia may not be 
effectively managed until the trauma-based memories have been addressed.18 
. Without trauma-informed interventions, there can exist a self-perpetuating cycle 
involving PTSD and substance abuse, where trauma (childhood or adult physical 
and/or sexual abuse, crime victimization, disaster, combat exposure) leads to the 
development of PTSD symptoms, triggering the use of alcohol and drugs, 
resulting in higher likelihood of subsequent traumatic events and retraumatization, 
leading to development of more chronic PTSD symptoms, triggering heightened 
substance use, and so on.19 

. Substance abuse consumers with PTSD are more impaired than those without 
PTSD, with more co-morbid Axis I and Axis II disorders, medical problems, 
psychological symptoms, inpatient admissions, interpersonal problems, and lower 
level of functioning, lower compliance with aftercare, and reduced motivation for 
treatment. Women with PTSD and substance abuse have numerous co-occurring 
life problems, such as homelessness, loss of custody of their children, 
maltreatment of their children, and “battered woman syndrome.”19, 20, 21, 22, 23, 24, 25, 
26, 27, 28 
. In adults, the rates for co-morbid PTSD and substance use disorders are two to 
three times higher for females than males, with 30 to 59% of all female substance 
abusers meeting the criteria for PTSD, most commonly deriving from a history of 
repetitive childhood physical and/or sexual assault.2 
. Sexual victimization in childhood and in adulthood is an important factor in dual 
diagnosis in women. Women with PTSD and alcohol abuse have a particularly 
severe level of symptoms (severe PTSD, dissociation, borderline personality 
traits) relative to women with only PTSD and controls.29 
. Neither trauma, nor alcohol and drug problems—key risk factors that complicate 
psychiatric disability and recovery—are commonly identified or addressed in 
treatment in the mental health sector. Many clinicians lack proper training on how 
and when to ask about sexual abuse and substance use, how to listen to the 
answers, or how to incorporate this information into effective treatment. 30 
. Men with dual diagnoses (severe mental disorder and significant substance abuse 
problems) frequently have histories of trauma exposure. This group of men has 
usually been excluded from trauma studies.31 
. An ethnographic study of the longitudinal course of substance abuse among 
people diagnosed with severe mental illness indicated a very close association 
between reported or experienced abuse in childhood at the hands of care-givers, 
and continuing substance use.32 
. Several studies suggest that trauma sequelae must be addressed concurrently to 
permit successful treatment of dual diagnosis.32, 33 
Co-occurring Disorders Recommendations 
. Develop and implement educational programs for educators and health care 
professionals to identify high-risk (abused) youth and offer counseling regarding 
their vulnerability to substance abuse.34 

. Develop and implement clinical training for substance abuse and mental health 
professionals that will aid in understanding co-morbidity of addiction and PTSD, 
identifying dual disorders, and treating trauma-related syndromes.34 
. Develop and implement academic curricula that train medical personnel, social 
workers, and mental health professionals to include an understanding of substance 
abuse and PTSD.34 
. Develop and implement specialized programs within inpatient and outpatient 
substance abuse facilities that offer direct treatment to trauma survivors.34 
. Train mental health and substance abuse treatment providers to assess 
clients/consumers for abuse/trauma histories and provide or refer to experienced 
trauma services. 
. Routinely assess all consumers in treatment for mental health and/or substance 
abuse for physical and/or sexual abuse, and refer to appropriate services if needed. 
. Cross train mental health and substance abuse services staff to ensure consistent 
treatment and to eliminate duplication of effort. 
Co-occurring Disorders References 
1. Maine Department of Behavioral and Developmental Services. (1998). Augusta 
Mental Health Institute consent decree class member assessment. Maine: 
Department of Behavioral and Developmental Services. 
2. Najavits, L. M., Weiss, R. D., & Shaw, S. R. (1997). The link between substance 
abuse and Posttraumatic Stress Disorder in women. A research review. American 
Journal on Addictions, 6:273-283. 
3. R. Mazelis (personal communication, April 2002). 
4. Mueser, K. T., Goodman, L. B., Trumbetta, S. L., Rosenberg, S. D., Osher, C., 
Vidaver, R., Auciello, P., & Foy, D.W. (1998). Trauma and Posttraumatic Stress 
Disorder in severe mental illness. Journal of Consulting &Clinical Psychology, 
66(3), 493-499. 
5. Mueser, K. T., Rosenberg, S. D., Goodman, L. A., & Trumbetta, S. L. (2002). 
Trauma, PTSD, and the course of severe mental illness: An interactive model. 
Schizophrenia Research, 53(1-2), 123-143. 
6. Rosenberg, S. D., Mueser, K. T., Friedman, M. J., Gorman, P. G., Drake, R. E., 
Vidaver, R. M., Torrey, W. C., & Jankowski, M. K. (2001). Developing effective 

treatments for posttraumatic disorders among people with severe mental illness. 
Psychiatric Services, 52(11), 1453-1461. 
7. Bollerud, K. (1990). A model for the treatment of trauma-related syndromes among 
chemically dependent inpatient women. Journal of Substance Abuse Treatment, 
7(2), 83-87. 
8. Center for Substance Abuse Treatment. (2000). Substance abuse treatment for 
persons with child abuse and neglect issues Treatment Improvement Protocol (TIP) 
series (DHHS Publication No. SMA 00-3357, Number 36). Washington, DC: U.S. 
Government Printing office. 
9. Kessler, R. C., Zhao, S., Katz, J., Kouzis, A. C., Frank, R. G., Edlund, M., & Leaf, 
P. (1999). Past-year use of outpatient services for psychiatric problems in the 
National Comorbidity Survey. American Journal of Psychiatry, 156(1), 115-123. 
10. Ouimette, P., Brown, P., & Najavits, L. (1998). Course and treatment of patients 
with both substance use and Posttraumatic Stress Disorders. Addictive Behaviors, 
23(6), 785-795. 
11. Switzer, G. E., Dew, M. A., Thompson, K., Goycoolea, J. M., Derricott, T., & 
Mullins, S. D. (1999). Posttraumatic Stress Disorder and service utilization among 
urban mental health center clients. Journal of Traumatic Stress, 12(1), 25-39. 
12. Cooper, L., Grella, C. E., Greenwell, L. (2002). Perceived need for treatment 
services among the dually diagnosed in drug treatment with and without 
Posttraumatic Stress Disorder. (under submission). 
13. Blankertz, L. E., Cnaan, R. A., & Freedman, E. (1993). Childhood risk factors in 
dually diagnosed homeless adults. Social Work, 38(5), 587-595. 
14. Zierler, S., Feingold, L., Laufer, D., Velentgas, P., Kantrowitz-Gordon, I., & Mayer, 
K. (1991). Adult survivors of childhood sexual abuse and subsequent risk of HIV 
infection. American Journal of Public Health, 81(5), 572-575. 
15. Anderson, C. M., & Chiocchio, K. B. (1997). Homeless, addictions and mental 
illness. In M. Harris (Ed.), Sexual Abuse in the Lives of Women (pp. 21-37). 
Harwood Academic. 
16. Ross, C. A., Kronson, J., Koensgen, S., Barkman, K., Clark, P., & Rockman, G. 
(1992). Dissociation comorbidity in 100 chemically dependent patients. In Hospital 
and Community Psychiatry, 43(8), 840-842. 
17. McFarlane, A. C. (1998). Epidemiological evidence about the relationship between 
PTSD and alcohol abuse: The nature of the association. Addictive Behaviours, 23(6), 
813-825. 

18. McFarlane, A. C. (2001). Dual Diagnosis and Treatment of PTSD. In J. P. Wilson, 
M. J. Friedman (Eds.), Treating Psychological Trauma and PTSD (pp.237-254). 
New York, NY: The Guilford Press. 
19. Najavits, L. M., Gastfriend, D. R., Barber, J. P, et al. (1998). Cocaine dependence 
with and without PTSD in the NIDA Cocaine Collaborative Study, Am J Psychiatry. 
20. Brown, P. J., Recupero, P. R., & Stout, R. (1995). PTSD substance abuse 
comorbidity and treatment utilization. Addict Behav, 20:251-254. 
21. Grice D. E., Brady K. T., Dustan L. R., et al. (1995). Sexual and physical assault 
history and Posttraumatic Stress Disorder in substance-dependent individuals. Am J 
Addict, 4:297-305. 
22. Kodoed, L., Friedman, M. J., & Peck, R. (1993). Alcoholism and drug abuse in 
inpatients with PTSD, Psychiatr Q, 64:151-171. 
23. Brady K. T., Killeen, T., Salsdin, M. E., et al. (1994). Comorbid substance abuse and 
Posttraumatic Stress Disorder: Characteristics of women in treatment. Am J Addict, 
3:160-164. 
24. Smith, E. M., North, C. D., Spitznagel, E. L. (1993). Alcohol, drugs, and psychiatric 
comorbidity among homeless women: An epidemiologic study. J Clin Psychiatry, 
54:82-87. 
25. Paone, D., Chavkin, W., Willets, I., et al. (1992). The impact of sexual abuse: 
Implications for drug treatment. Journal of Women’s Health, 1:149-153. 
26. Fullilove, M. T., Lown, A., Fullilove, R. E. (1992). Crack ‘hos’ and skeezers: 
Traumatic experiences of women crack users. Journal of Sex Research, 29:275-287. 
27. Famularo, R., Kinscherff, R., Fenton, T. (1992). Psychiatric diagnoses of abusive 
mothers: A preliminary report. J Nerv Ment Dis, 180:658-661. 
28. Levit, H. (1991). Battered women: Syndrome vs. self-defense. American Journal of 
Forensic Psychiatry, 9:29-35. 
29. Ouimette, P. C., Wolfe, J., Chrestman, K. R. (1996). Characteristics of Posttraumatic 
Stress Disorder-alcohol abuse comorbidity in women. Journal of Substance Abuse, 
8(3), 335-346. 
30. Alexander M. J., & Muenzenmaier, K. (1998). Trauma, addiction, and recovery: 
Addressing public health epidemics among women with severe mental illness. In B. 
L. Levin, A. K. Blanch, A. Jennings (Eds.), Women’s Mental Health Services: A 
Public Health Perspective (pp. 215-239). Sage. 

31. Freeman, D. W., & Fallot, R. D. (1997). Trauma and trauma recovery for dually 
diagnosed male survivors. In M. Harris (Ed.), Sexual Abuse in the Lives of Women, 
Chap 17. Harwood Academic. 
32. Alverson H., Alverson, M., Drake, R. E. (2000). Addictions services: An 
ethnographic study of the longitudinal course of substance abuse among people with 
severe mental illness. Community Mental Health Journal, Vol. 36, No. 6. pp. 557-
569. 
33. Harris, M. (1998). Trauma recovery and empowerment. New York: The Free Press. 
34. Steele, C. T. (2002). Providing clinical treatment to substance abusing trauma 
survivors. Alcoholism Treatment Quarterly, Vol.18(3). 


Substance Abuse Treatment Capacity 
Childhood physical and sexual abuse and neglect have a staggering impact on the 
prevalence of substance abuse in adulthood. Current treatment capacity is 
inadequate to meet the need. 
Substance Abuse Treatment Capacity Facts and Discussion Points 
. Up to two-thirds of both men and women in substance abuse treatment report 
childhood abuse or neglect.1 
. Seventy-five percent of women in treatment programs for drug and alcohol abuse 
report having been sexually abused.2 
. HMO adult members who had experienced multiple childhood exposures to abuse 
and violence had a 4- to 12-fold increased risk of alcoholism and drug abuse, and 
a 2- to 4-fold increase in smoking.3 
. Adults abused during childhood are more than twice as likely as those not abused 
during childhood to abuse substances.4 
. In a study of 100 adult consumers with polytoxic drug abuse, 70% of the female 
and 56% of the male drug users had been sexually abused before the age of 
sixteen. Forty percent of the male and 50% of the female participants had a 
history of severe sexual abuse with sexual intercourse. In over 50%, friends or 
relatives were the perpetrators; parents were not perpetrators in any of the cases. 
More than 40% also showed a history of physical abuse. Significantly more drug 
users than alcohol abusers had a sexual trauma. Especially severe sexual abuse 
was associated with abuse of hard illegal drugs.5 
. Nine out of ten children who need drug treatment are not getting it. One million, 
one hundred thousand American children 12- to 17-years-old have problems with 
drugs and alcohol. Only about 122,000 of them received treatment in 2000.6 
. Teenagers with alcohol and drug problems are 6 to 12 times more likely to have a 
history of being physically abused and 18 to 21 times more likely to have been 
sexually abused than those without alcohol and drug problems.7 
. About 4.7 million Americans age 12 and older are abusing or dependent on illegal 
drugs. Of that number, 3.9 million received no treatment in 2000.8 
. Nearly 8% of individuals in the U.S.—20 million people—will have full-blown 
PTSD in their lifetime. Fifty to sixty percent of consumers with PTSD (10 to 12 

million people) will develop alcohol or substance abuse. Many of these people do 
not get the help they need because the problem (PTSD) is not identified and they 
don’t receive appropriate treatment.9 
. Substance abuse (SA) treatment recovery rates are very poor for clients who have 
histories of victimization and are treated in programs where the link between 
trauma and SA is not dealt with. Money spent on treatment for SA is often lost 
due to high relapse rates from un-addressed problems.10 
. Nearly 90% of alcoholic women were sexually abused as children or suffered 
severe violence at the hands of a parent.11 
. Seventy-one to ninety percent of adolescent and teenage girls and 23% to 42% of 
adolescent and teenage boys in a Maine inpatient substance abuse treatment 
program reported histories of childhood sexual abuse.12 
Substance Abuse Treatment Capacity Recommendations 
. Address trauma in all SAMHSA policies and activities concerned with the 
substance abuse treatment gap. Thoroughly investigate and deal with unresolved 
trauma as a causative or co-occurring factor in addiction development—in all 
prevention and/or early intervention programs, all treatment approaches and 
programs, all public education campaigns, and in all related funding and 
insurance coverage programs. 
. Train substance abuse treatment providers to assess clients/consumers for 
abuse/trauma histories and to provide or refer to experienced trauma services. 
. Routinely assess all clients in treatment for substance abuse for physical and/or 
sexual abuse and refer to appropriate trauma services if needed. 
. Encourage all substance abuse services staff to integrate concept of trauma as 
direct and primary cause of a majority of substance use. 
. Clients in substance abuse programs who are assessed as having trauma histories 
should learn the direct connection between trauma and substance abuse as self-
medication. 
. All substance abuse programs should actively support and integrate the teaching 
and use of trauma symptom management skills as an alternative to substance use. 
Substance Abuse Treatment Capacity References 

1. Center for Substance Abuse Treatment. (2000). Substance abuse treatment for 
persons with child abuse and neglect issues. Treatment Improvement Protocol (TIP) 
Series. Number 36. DHHS Publication No. (SMA) 00-3357. Washington, DC: U.S. 
Printing Office. 
2. SAMHSA Center for Drug Abuse Treatment. (1994). Practical approaches in the 
treatment of women who abuse alcohol and other drugs. US Public Health Service. 
Rockville, MD: SAMHSA. 
3. 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. Am J Prev Med, 14:245-258. 
4. Stein, J. A., Golding, J. M., Siegel, J. M., Burnam, M. A., Sorenson, S. B. (1988). 
Long-term psychological sequelae of child sexual abuse: The Los Angeles 
Epidemiologic Catchment Area Study. In G. E. Wyatt, & G. J. Powell (Eds.), 
Lasting Effects of Child Sexual Abuse. Sage Focus Editions, Vol. 100 (pp.135-154). 
Newbury Park, CA: Sage Publications. 
5. Schafer, M. (February 2000). Sexual and physical abuse during early childhood or 
adolescence and later drug addiction. Psychother Psychosom Med Psychol, Vol.50 
(2), pp.38-50. 
6. SAMHSA. (August 16, 2002). National and state estimates of the drug abuse 
treatment gap. OAS Publication. See www.samhsa.gov/oas/newpubs.htm#2k2pub 
7. Clark, H. W., McClanahan, T. M., Sees, K. L. (Spring 1997). Cultural aspects of 
adolescent addiction and treatment. Valparaiso University Law Review. Vol. 31(2). 
8. SAMHSA. (2000). The National Household Survey on Drug Abuse (NHSDA). See 
www.samhsa.gov/oas/oas.html 
9. Marshall, R. (May 2001). Lead author of study presented at the 154th annual meeting 
of the American Psychiatric Association. 
10. R. Mazelis (personal communication, April 2002). 
11. Miller, B., Downs, W. (1993). Journal of Studies in Alcohol, Supplement No. 
11:109-117. 
12. Rohsenow, D. J., Corbett, R., Devine, D. (1988). Chemical Dependency Treatment 
Program, Mid-Maine Medical Center, Waterville, Maine. Molested as children: A 
hidden contribution to substance abuse? Journal of Substance Abuse Treatment, Vol. 
5, pp.13-18. 


Seclusion and Restraint 
Many people with trauma histories are routinely and unnecessarily retraumatized 
in the mental health system through the use of seclusion and restraint and other 
coercive interventions. 
Seclusion and Restraint Facts and Discussion Points 
. Consumers with trauma histories are often re-traumatized in psychiatric inpatient 
units and other settings when subjected to restraint and seclusion.1,10 
. When asked, individuals virtually always report experiencing seclusion and 
restraint as traumatic. Children, adolescents, and adults report experiencing 
vulnerability, neglect, and a sense of punishment while in seclusion.2 
. Restraint and seclusion have been responsible for consumer deaths and other 
adverse effects, and also place staff at higher risk for injury. 4, 3 
. Effective practices exist to reduce and/or eliminate restraint and seclusion.3 
. Best practice models based on collaboration, consumer empowerment, and a 
clinical approach that emphasizes the development of skills, teaching and learning 
processes, conflict resolution, and pro-active strategies exist, but they are 
inconsistently utilized.5 
. The use of restraint and seclusion among children and adolescents is particularly 
high in some states. Child-oriented best practice models demonstrating little or no 
use of restraint and seclusion include: Girls and Boys Town Psychoeducational 
Treatment Model (PEM), Teaching Family, and Ross Greene’s Collaborative 
Problem Solving Approach.5 
. For persons with histories of trauma, seclusion and restraint can cause disturbing 
behavior to increase (rather than de-escalate), thereby re-traumatizing the client 
and increasing risk to staff and other consumers.6 
. Seclusion and restraint can trigger responses to previous experiences with 
coercive control, physical abuse, isolation, bondage, etc. These responses might 
include flashbacks (hallucinations), dissociation, aggression, self-injurious 
behaviors, depression, etc.6 
. Coercive interventions involving forcible medication (whether physical, legal, or 
both) are often experienced as retraumatizing. Forced psychotropics are a form of 
chemical restraint.7 

. Conventionally accepted psychiatric practices and institutional environments may 
retraumatize consumers with histories of trauma by replicating the dynamics and 
even the specific abuses of the original childhood trauma, thus exacerbating the 
pain and sequelae of the traumatic childhood experience.8 
. Without knowledge of medications known to be helpful in treating symptoms of 
trauma, the use of psychopharmaceutical interventions can cause both physical 
and psychological damage. Forced medication violates personal boundaries, alters 
the mind, body and emotions, and may replicate the original traumatic abuse.8 
. Restraint and seclusion, which are currently accepted methods for the 
management of psychiatric consumers in this country, meet the DSM-IV 
definition of human-induced traumatic stressors. Both exert violent and absolute 
control while engendering utter helplessness and fear. 9 
. Trauma survivors may be especially vulnerable to additional traumatic and/or 
iatrogenic (physician-caused) experiences that occur within the psychiatric 
setting.11 For example, routine use of seclusion, restraints, or handcuffs may serve 
to recapitulate previous traumatic experiences, and thereby exacerbate symptoms 
of PTSD.12 
Seclusion and Restraint Recommendations 
. SAMSHA should establish clinical guidelines that reflect the most promising 
evidence-based practice models to reduce and ultimately eliminate the use of 
seclusion and restraint. 
. Consider incorporating a public health prevention model that includes the 
following: primary prevention (organizational leadership accountability, 
empowering strength-based culture, well-trained staff), secondary intervention 
(knowing triggers and using trauma-informed strategies, creative/innovative early 
interventions to de-escalate conflict) and tertiary intervention (if intervention is 
necessary), which will allow for the least traumatic treatment experience, early 
release, and active de-briefing of staff and consumers in order to minimize risk of 
harm. Feedback from each stage needs to inform the next stage and support 
ongoing prevention.3 
. Immediate post-event debriefing followed by a timely root cause analysis should 
be standard practice in all treatment settings. 
. Assessment of all service recipients for trauma histories should be routine. 
. Create (with client, upon admission) an individualized “de-escalation” plan. 

. Train staff on specific alternative, trauma-informed responses to aggressive or 
behaviorally inappropriate actions. 
. Wherever referencing “seclusion and restraint,” include the phrase “and the 
violence associated with the use of these measures” as a reinforcing step to be 
assimilated into the literature. 
. Involve survivors of forced mental health treatment in all aspects of policy and 
intervention development and practice. 
Seclusion and Restraint References 
1. Carmen, E., Crane B., Dunnicliff, M., Holochuck, S., Prescott L., Rieker, P., Stefan, 
S., Stromberg, N. (January 1996). Report and recommendations: Massachusetts 
DMH Task Force on the restraint and seclusion of persons who have been physically 
or sexually abused. Boston, MA: Massachusetts Department of Mental Health. 
2. Petti, T. A., Mohr, W. K., Somers, I. W., Sims, L. (July-September 2001). 
Perceptions of seclusion and restraint by patients and staff in an intermediate-term 
care facility. Journal of Child and Adolescent Psychiatric Nursing, Vol. 14, No 3. 
3. NASMHPD Medical Directors Council, (2000); and National Executive Training 
Institute (NETI). (2003, July). Training curriculum for the reduction of seclusion 
and restraint. Alexandria, VA: National Technical Assistance Center (NTAC), 
National Association of State Mental Health Program Directors (NASMHPD). 
4. Petti, T. A. (January/February 2002). Seclusion and restraint: A paradigm shift for 
the millennium. American Academy of Child and Adolescent Psychiatry (AACAP): 
AACAP News, Vol. 33, No. 1. 
5. N. Stromberg (personal communication, April 2002). 
6. E. Giller (personal communication, April 2002). 
7. R. Mazelis (personal communication, April 2002). 
8. Jennings A. (1998). On being invisible in the mental health system. In B. L. Levin, 
A. K. Blanch, A. Jennings (Eds.), Women’s Mental Health Services: A Public Health 
Perspective. Sage Publications. 
9. Cohen-Cole L. (Summer/Fall 2002). Restraint and seclusion: Iatrogenic trauma 
comes out of the closet. In networks. Alexandria, VA: National Technical 
Assistance Center for State Mental Health Planning, National Association of State 
Mental Health Program Directors. 

10. Bloom, S. L. (Summer/Fall 2002). Creating sanctuary. In networks. Alexandria, VA: 
National Technical Assistance Center for State Mental Health Planning, National 
Association of State Mental Health Program Directors. 
11. Cohen, L. J. (1994). Psychiatric hospitalization as an experience of trauma. Archives 
of Psychiatric Nursing, 8, 78-81. 
12. Frueh, B. C., Dalton, M. E., Johnson, M. R., Hiers, T. G., Gold, P. B., Magruder K. 
M., Santos, A. B. (November 2000). Trauma within the psychiatric setting: 
conceptual framework, research directions, and policy implications. Administration 
and Policy in Mental Health, Vol.28, No. 2. 

Prevention and Early Intervention 
Prevention and/or early intervention of childhood abuse could have a substantial 
impact on the prevalence of adult mental health and substance abuse problems. New 
biological findings suggest that prevention and early intervention may be the only 
ways to avoid enduring problems. 
Prevention and Early Intervention Facts and Discussion Points 
. Early intervention and prevention of childhood abuse are crucial 
recommendations for almost every one of the top axis items, given the link 
between unresolved childhood abuse trauma and: co-occurring disorders, 
substance abuse, seclusion and restraint, terrorism, homelessness, aging, 
HIV/AIDS, criminal justice.1 
. Nine out of ten children who need drug treatment are not receiving it. One 
million, one hundred thousand American children ages 12 to 17 have problems 
with drugs and alcohol. Approximately 122,000 got treatment in 2000.2 
. Teenagers with alcohol and drug problems are 6 to 12 times more likely to have a 
history of being physically abused and 18 to 21 times more likely to have been 
sexually abused than those without alcohol and drug problems.3 
. Primary prevention of major mental illness in adulthood (and other problems 
associated with child abuse) through prevention of severe child abuse is possible. 
This can be shown by intervention studies.4 
. Home visiting programs (HFA-Healthy Families America) are associated with 
reduced rates of child abuse. Families enrolled in HFA are two to three times less 
likely to maltreat their children than comparable families who are not enrolled.5 
. Maladaptive coping skills (dissociation, substance abuse, coercive control, etc.), 
typical of survivors of chronic abuse, can substantially interfere with successful 
parenting skills including attachment, bonding, and development of empathy 
between parent and child at developmentally critical stages. This problem is a 
primary factor contributing to the cycle of abuse and family dysfunction.6-9 
. Until recently, psychologists believed that mistreatment during childhood led to 
arrested psychosocial development and self-defeating psychic defense 
mechanisms in adults. New brain imaging surveys and other techniques have 
shown that physical, emotional, or sexual abuse in childhood (as well as stress in 
the form of exposure to violence, warfare, famine, pestilence) can cause 
permanent damage to the neural structure and function of the developing brain 

itself. These changes can permanently affect the way a child’s brain copes with 
the stress of daily life, and can result in enduring problems such as suicide, self-
destructive behavior, depression, anxiety, aggression, impulsiveness, delinquency, 
hyperactivity, and substance abuse, and conditions such as Borderline Personality 
Disorder, dissociative episodes, hallucinations, illusions, psychosis, paranoia, 
volcanic outbursts of anger, and impaired attention. These results suggest that 
much more effort is needed to prevent childhood abuse and neglect. New 
approaches to therapy may also be indicated.10 
. Stress sculpts the brain to exhibit various antisocial, though adaptive, behaviors. 
Whether in the form of physical, emotional or sexual trauma, or through exposure 
to warfare, famine, or pestilence, stress can set off a ripple of hormonal changes 
and key brain alterations that may be irreversible.10 
Prevention and Early Intervention Recommendations 
. Target the young population assessed with addiction problems (the majority of 
whom have histories of unresolved trauma) in early intervention programs. Insure 
that all federally funded early intervention and prevention programs appropriately 
address unresolved past trauma and/or ongoing trauma as a core issue in the 
development and maintenance of addictions and in the individual’s recovery. 
. Collaborate with HFA to create educational material that includes relevant 
information that links childhood trauma and violence with the onset of adult 
difficulties. The material should also identify methods of recognizing and 
responding to these difficulties. 
. Create trauma/attachment theory-informed parenting programs specifically for 
women with abuse histories. 
. Research, implement, and evaluate effectiveness of child abuse prevention 
strategies. Justify intervention based on new findings of permanent damage to the 
brain caused by child abuse and its impact on the individual, society, and human 
service fields. Justify cost of prevention strategies by a fiscal analysis that shows 
actual cost savings due to child abuse reduction. 
Prevention and Early Intervention References 
1. E. Giller (personal communication, April 2002). 
2. SAMHSA, 2002. 
3. Clark, H. W., McClanahan, T. M., Sees, K. L. (Spring 1997). Cultural aspects of 
adolescent addiction and treatment. Valparaiso University Law Review, Vol. 31(2). 

4. The Ross Institute (www.rossinst.com/Trauma.htm). 
5. Daro, D., Harding, K. (1999). Healthy Families America: Using research to enhance 
practice. The Future of Children (p. 168). 
6. Green, A. H. (1999). Patterns of violence transmission in physically and sexually 
abused children. In K. Tardiff (Ed.), Medical management of the violent patient: 
Clinical assessment and therapy (pp. 405-427). New York, NY: Marcel Dekker. 
7. DeZulueta, Felicity, I. S. (January-March 1998). Human violence: A treatable 
epidemic. In Medicine, Conflict and Survival (ISSN: 1362-3699) Vol.14, pp.46-55. 
8. Cole-Detke, H., Kobak, R. (1998). The effects of multiple abuse in interpersonal 
relationships: An attachment perspective. Journal of Aggression, Maltreatment and 
Trauma (ISSN: 1092-6771), Vol.2, No.1, pp.189-205. 
9. Sable, P. (1995). Attachment theory and Post-Traumatic Stress Disorder. Journal of 
Analytic Social Work (ISSN: 1052-9950), Vol.2, No.4, pp. 89-109. 
10. Teicher, M. H. (March 2002). Scars that won’t heal: The neurobiology of child 
abuse. Scientific American; and, Saxe, G. as excerpted in National Executive 
Training Institute (NETI). (2003, July). Training curriculum for the reduction of 
seclusion and restraint. Alexandria, VA: National Technical Assistance Center 
(NTAC), National Association of State Mental Health Program Directors 
(NASMHPD). 


Children and Families 
Violence is a significant causal factor in childhood and adolescent mental health 
problems, brain damage, substance abuse, developmental disabilities, school failure, 
and delinquency. Violence against children is a significant and inadequately 
addressed public health problem. 
Children and Families Facts and Discussion Points 
. People who are abused as children may be more prone to developing 
schizophrenia. A high rate of physical and sexual abuse is reported among 
children who were later diagnosed as schizophrenic. A particularly strong link 
exists between childhood abuse and the hearing of voices. Changes in the brain 
seen in abused children are similar to those found in adults with schizophrenia.1 
. Adolescents with alcohol dependence are 6 to 12 times more likely to have a 
childhood history of physical abuse and 18 to 21 times more likely to have a 
history of sexual abuse than those without substance abuse problems.2 
. The U.S. Department of Health and Human Services reported that almost 1 
million children were identified as victims of abuse and neglect in 1996, and more 
than 1,000 children died as a result. A survey by the National Committee to 
Prevent Child Abuse indicated that more than 3 million children were suspected 
of being victims of abuse and/or neglect in 1998. In the United States, a child is 
reported abused or neglected every ten seconds. Every two hours, a child is a 
homicide victim. And every four hours, a child commits suicide.3 
. Among juvenile girls identified by the courts as delinquent, more than 75% have 
been sexually abused.4 
. About 3.9 million adolescents have been victims of a serious physical assault, and 
almost 9 million have witnessed an act of serious violence.5 
. About 1.8 million adolescents have met diagnostic criteria for PTSD during their 
lives.6 
. The level of exposure to catastrophic violence and loss together with the resulting 
posttraumatic stress have been found to be as severe in America’s inner cities as 
in post-earthquake Armenia, war-torn Bosnia, post-invasion Kuwait and other 
trauma zones. Yet, the United States has no formal public health policy to address 
the problem.7 

. When failing adolescent students with severe PTSD symptoms were recognized 
and treated for trauma, their symptoms were markedly reduced, they required no 
further discipline, and their grade point averages went up significantly.8 
. Three to six percent of all children have some degree of permanent disability as a 
result of abuse.9 
. Between 20 and 50% of abused children suffer mild to severe brain damage.10 
. Violence is a significant causal factor in 10 to 25% of all developmental 
disabilities.9,11 
. Eighty-two percent of all adolescents and children in continuing care inpatient 
and intensive residential treatment programs in Massachusetts have histories of 
trauma as reflected by a point-in-time review of medical records.12 
. The number of children whose lives have been disrupted by war, oppression, 
terror, and other forms of conflict has grown significantly—from 1.5 million 
refugees and displaced persons following WWII, to 14 million refugees and 
displaced persons by 2001. Many of these young people experience long-term 
physical and emotional health problems, including PTSD.13 
Children and Families Recommendations 
. SAMHSA should take the lead in developing a formal public health policy to 
address the problem of PTSD in children. This policy should caution service 
providers against overlooking or misdiagnosing abuse and PTSD symptoms as 
symptoms of Attention Deficit Hyperactivity Disorder (ADD), Oppositional 
Defiance Disorder (ODD), etc. 
. Mandatory trauma assessment should be available for all children referred for 
behavior, learning, or emotional disturbances, followed by referral to appropriate 
trauma treatment.14-17 
. Trauma training should be made available for juvenile justice settings.18 
. SAMHSA should take the lead in developing and promoting a strength- and 
resiliency-based care program for children and adolescents who have immediate 
or past trauma histories. This program should be based on formal curriculum that 
includes pragmatic instruction, techniques and activities for children designed to 
promote emotional strength and to decrease vulnerability to stress, adversity and 
challenges.19 

Children and Families References 
1. Read, J. (Winter 2001). The contribution of early traumatic events to schizophrenia 
in some patients: A traumagenic neurodevelopmental model. Psychiatry; Vol. 64 (4), 
pp. 319-45. 
2. Clark, H. W., McClanahan, T. M., & Sees, K. L. (Spring 1997). Cultural aspects of 
adolescent addiction and treatment. Valparaiso University Law Review. Vol. 31(2). 
3. Mazelis, R. (Summer/Fall, 1999). SIV: The context is trauma. The Cutting Edge: A 
Newsletter for Women Living With Self-Inflicted Violence. Vol. 10, Issues 2/3 
(38/39). 
4. Calhoun, O., Jurgens, E., Chen, F. (1993). The neophyte female delinquent: A 
review of the literature. Adolescence, 28, 461-471. 
5. Kilpatrick, D. G., Saunders, B. E., Smith, D. W. (2001). Research in brief: Child 
and adolescent victimization in America: Prevalence and implications, pp.163-186. 
Washington DC: American Psychiatric Press, Inc. 
6. Kilpatrick, et al., cited in Layne, C. M., Pynoos, R. S., Cardenas, J. (2001). 
Wounded adolescence. School-based group psychotherapy for adolescents who 
sustained or witnessed violent injury. In M. Shafii, & S. L. Shafii (Eds.), School 
Violence: Assessment, Management, Prevention (pp. 163-186). Washington, DC: 
American Psychiatric Press, Inc. 
7. Pynoos, R. S. (1999). The legacy of violence and the restoration of our school 
communities. Plenary Address, National Education Association. 
8. Saltzman, W. R., Pynoos, R. S., Layne, C. M., et al. (2001). Trauma- and grief-
focused intervention for adolescents exposed to community violence: Results of a 
school-based screening and group treatment protocol. Group Dynamics: Theory, 
Research, and Practice, 5(4):291–303. 
9. Sobsey, D. (1995). Violence and abuse in the lives of people with disabilities: The 
end of silent acceptance? In D. Valenti-Hein, & L. Schwartz. The sexual abuse 
interview for those with developmental disabilities. Santa Barbara, CA: James 
Stanfield Company. 
10. Rose, E., & Hardman, M. L. (April 1981). The abused mentally retarded child. 
Education and Training of the Mentally Retarded, Vol. 16(2): 114-118. 
11. Valenti-Hein, D., & Schwartz, L. (1995). The sexual abuse interview for those with 
developmental disabilities. Santa Barbara, CA: James Stanfield Company. 
12. Heuberger. (March 2001). Massachusetts Department of Mental Health. 

13. Berman, H. (July/August 2001). Children and war: Current understandings and 
future directions. Public Health Nursing, Vol.18, Issue 4. 
14. Holaday, M. (August 2000). Rorschach protocols from children and adolescents 
diagnosed with Posttraumatic Stress Disorder. Journal of Personality Assessment 
(ISSN: 0022-3891), Vol. 75, No. 1, pp.143-157. 
15. Ford, J. D., Racusin, R., Ellis, C. A., Davis, William, B., Reiser, J., Fleischer, A., & 
Thomas, J. (August 2000). Child maltreatment, other trauma exposure, and 
posttraumatic symptomatology among children with oppositional defiant and 
Attention Deficit Hyperactivity Disorders. Child Maltreatment (ISSN: 1077-5595), 
Vol. 5, No. 3, pp. 205-217. 
16. Ford, J. D., Racusin, R., Davis, William, B., Ellis, C. A, Thomas, J., Rogers, K., 
Reiser, J., Schiffman, J., & Sengupta, A. (October, 1999). Trauma exposure among 
children with oppositional defiant disorder and Attention Deficit-Hyperactivity 
Disorder. Journal of Consulting and Clinical Psychology (ISSN: 0022-006X), Vol. 
67, No. 5, pp. 786-789. 
17. Brown, R. W. (1999). An examination of the relationship between Posttraumatic 
Stress Disorder symptoms and conduct disordered behaviors (Dissertation, ISBN: 
0-599-39945-7). Temple University. 
18. King, S. A. (2000). PTSD: An overlooked diagnosis among adjudicated juvenile 
delinquents (Dissertation, ISBN: 0-599-68845-9). University of Hartford. 
19. N. Stromberg (personal communication, April 2002). 

Terrorism and Bio-Terrorism 
Community disasters (including terrorism) have a particularly devastating impact 
on people who have previously experienced trauma, increasing the length and 
severity of Posttraumatic Stress Disorder (PTSD), interrupting recovery, and 
leading to high rates of hospitalization. In the event of continued terrorism or 
disasters, the mental health system is ill-prepared to offer effective help to victims. 
Many mental health professionals have received little or no training in trauma. 
There are also some groups who are at higher risk for developing severe, lasting, 
and pervasive psychological effects after a disaster. In addition, a shortage of mental 
health workers with knowledge of trauma is widely reported. 
Terrorism and Bio-Terrorism Facts and Discussion Points 
. The majority of people recover from grief and shock after a few months. 
However, 25% to 30% of people directly affected by terrorist attacks or other 
disasters may eventually develop full-blown PTSD or other debilitating 
psychological conditions such as major depression.1, 2, 3, 4, 5 
. Five to eight weeks following the 9-11-01 terrorist attacks, almost 10% of adults 
living below 110th Street in Manhattan reported symptoms of PTSD or clinical 
depression, and 3.7% met criteria for both diagnoses. These rates are 2 to 3 times 
higher than those normally reported in any given year.6 
. Some traumatized individuals may take months or years to notice troubling 
symptoms or to seek help. Using formulas derived by the federal government 
following disasters such as the 1995 Oklahoma City bombing, the New York 
OMH estimates that as many as 1.5 million New Yorkers may eventually need 
some kind of mental health help as a result of 9-11-01.7, 8 
. Almost 6% of Americans across the country, including children, had substantial 
symptoms of stress following the 9-11-01 terrorist attacks.9, 10 
. Nearly 90% of the 710,000 New York City schoolchildren in grades 4 through 12 
showed at least one symptom of posttraumatic stress six months after 9-11-01. An 
estimated 10%, or 75,000 children, are suffering six or more symptoms of post-
traumatic stress.11 
. New York City schoolchildren with PTSD, at least two-thirds of whom have not 
received mental health services, are at high risk of suicide and substance abuse 
and may find their symptoms worsen if ignored.11, 12 
. Survivors of previous traumatic experiences who have not successfully resolved 
their trauma are at particular risk for developing symptoms severe enough to 

interfere with normal life. They may re-experience thoughts, emotions, 
symptoms, and arousal levels associated with their original experiences, and are at 
high risk for developing chronic PTSD.13, 14, 15 
. Abuse survivors with prior exposure to interpersonal violence (physical, sexual 
abuse or neglect) in childhood or adulthood, have significantly heightened 
susceptibility to severe and chronic PTSD, anxiety, and clinical depression 
following exposure to any type of traumatic event.6, 16, 17, 18, 19 
. Women or girls in 42 of 45 studies (93%) were affected more adversely by 
disasters than were men or boys; the effects lasted longer, and the strongest 
adverse effects were noted in cases of PTSD for which women’s rates often 
exceeded men’s by a ratio of 2:1.6, 21, 22 
. The number of women victimized by domestic violence increases significantly 
(46% in one study) following major disasters. Thirty-nine percent of abused 
women develop post-disaster PTSD compared to 17% of other women, and 57% 
of abused women develop post-disaster depression, compared to 28% of other 
women.23 
. People diagnosed with severe mental illness (SMI) may have an increased risk for 
distress, especially posttraumatic stress symptoms, after a disaster. More than 
90% of people with SMI report exposure to previous trauma. Most experienced 
multiple traumatic events of an interpersonal nature including sexual and physical 
assault in childhood and adulthood. Approximately 30% to 40% of these people 
currently have PTSD. This rate is 20 to 30 times greater than that of people 
without SMI. Events such as a terrorist attack can exacerbate pre-existing PTSD 
symptoms and may cause people with SMI to be at increased risk for developing 
PTSD over time.22, 24 
. Children and adults with prior psychiatric disorders or with family histories 
(especially parental) of psychiatric or addictive disorders are at high risk for 
psychosocial impairment when exposed to trauma (including disasters and 
community or domestic violence).18, 22 
. Individuals whose parents have been previously traumatized are at risk of 
experiencing increased symptoms when exposed to a violent event.25 
. Significantly higher rates of both PTSD and clinical depression following the 9-
11-01 terrorist attacks were found among people who lived close to ground zero, 
who suffered personal losses as a result of the attacks, who had endured other 
stressful events, who experienced extreme panic during or shortly after the 
attacks, or who had disengaged from coping efforts early on (e.g., giving up, 
denial, self distraction).6, 10, 22 

. Rates of PTSD and clinical depression were higher among New York City 
Hispanic respondents than among Whites, Blacks or Asians. Hispanics were 2.6 
times more likely to have experienced posttraumatic stress and 3.2 times more 
likely to experience depression than were Whites.6 
. Refugee clients who had been previously traumatized in their native war-torn 
countries and who were diagnosed with PTSD reacted intensely to televised 
images of 9-11-01. Cross–cultural reactivation of trauma has a significant clinical 
impact. It is essential that clinicians anticipate PTSD symptom reactivation 
among refugees when they are re-exposed to significant traumatic stimuli.26 
. As more time elapses after a trauma, PTSD symptoms and co-morbidity increase. 
This finding implies that PTSD is a chronic disorder with a downward course, and 
suggests the necessity for early recognition and intervention.27 
. Before severe, lasting, and pervasive psychological effects appear, professional 
help from providers trained in the early identification, recognition, and treatment 
of stress disorders is recommended.28 
. Existing mental health systems are not designed for the scope and the nature of 
the needs created by terrorism acts such as those seen on 9-11-01.13 
. Few New York-based mental health clinicians were trained to treat the level of 
trauma or the profound psychological impact incurred by the World Trade Center 
attack. Left untreated, the most serious mental health disorders brought on by 
trauma can lead to suicide.29, 30 
. Across the country, few universities offer comprehensive trauma programs that 
prepare their graduates to address trauma. As a result, mental health clinicians are 
often scared, uncomfortable and uncertain about whether they have the skills they 
need to help victims of traumatic events.29, 30 
. Without sufficient training in techniques to treat trauma, clinicians may: 1) offer 
untested therapies; 2) fail to recognize and treat symptoms ranging from 
flashbacks to anxiety to physical effects; or 3) provide treatment that is harmful.13, 
29 
. Individuals who have successfully resolved previous traumatic reactions have 
been shown to be more resilient to disasters, and should be viewed as a resource 
for disaster-stricken communities.14 
. A program in Hawaii successfully identified and treated children with 
posttraumatic stress symptoms following a 1977 disaster and noted a gulf between 
children who had received counseling for PTSD and those who had not. Children 
who were treated reported fewer trauma-related symptoms, and the positive 
effects were maintained a year later.8, 31 

. The development of a meaningful narrative of trauma experience is an important 
factor in recovery. Religious beliefs may provide meaning for trauma survivors 
and may be a useful focus for intervention with trauma survivors.32, 33 
Terrorism and Bio-Terrorism Recommendations 
. Invest in training to enable the mental health system to address trauma 
specifically. Collaborate with academia, professional organizations and policy 
makers to develop comprehensive trauma programs and curricula that teach best 
practices in the treatment of trauma.30 
. Develop mental health system capacity to provide early diagnosis, trauma 
assessment and intervention. Evaluate trauma history to aid in early intervention 
efforts. Interventions addressing initial reactions to a disaster, such as panic 
attacks, may help prevent the development of long-lasting psychological 
sequelae.6, 27, 28 
. Mental health providers should make additional support and services available 
including routine assessment for PTSD and consultation with trauma specialists 
when a client experiences symptom exacerbation following recent trauma.3, 24, 27 
. Mental health workers should collaborate with primary care physicians, family 
practice physicians and health care personnel to ensure prompt recognition of 
signs of PTSD and early intervention. 
. Health care workers can prepare for the effects of disaster and terrorism by 
establishing tertiary prevention initiatives to reduce the impact of retraumatization 
on vulnerable groups. 
. A national volunteer agency has been created called Citizen Corps, which among 
other activities will aid in recruiting and training retired doctors and health care 
workers for emergencies, and increase training for disaster preparedness in local 
communities. As part of the new USA Freedom Corps (which includes Peace 
Corps, Senior Corps and AmeriCorps), Citizen Corps will include trauma experts, 
training, and educational materials on how to respond to people who are most at 
risk of developing PTSD following a catastrophe. This educational initiative 
should also be included in ongoing disaster preparedness work in local 
communities. 
. Collaborate with the National Disaster Team program to address 9-11-01 and 
other community disasters and the continuing impacts of terrorism. Create basic, 
easy-to-read educational material on: 1) how prior trauma (childhood abuse or 
other events) can put people at risk for developing chronic or severe PTSD 

symptoms when exposed to subsequent trauma; and 2) how to recognize and 
respond to those who are at-risk. 
. Implement programs of self-care for volunteers, crisis workers, first responders, 
and clergy, etc. who are at increased risk of developing secondary stress reactions 
following a disaster. 
. Develop peer-professional alliances in support of a trauma-preparedness support 
system. One such example in Connecticut is a systematic, comprehensive, and 
relatively inexpensive statewide network of professionally guided, peer-conducted 
trauma education and support programs for people in recovery. 
. Develop partnerships between women in recovery and providers around the issue 
of community safety and preparedness, which could lead to consumer-driven 
support services linked with gender-specific treatment. 
. Educate teachers, school administrators, and parents about how to recognize 
children in distress. All schoolchildren impacted by a disaster should be screened, 
childcare professionals should be trained on handling traumatized children, and 
more funding should be directed toward treatment. 
. Develop collaborations with faith-based organizations. Combine spiritual support 
with a basic framework for understanding and responding to traumatized 
individuals (such as the Risking Connections curriculum). 
. Train clinicians to anticipate PTSD symptom reactivation among refugees when 
they are re-exposed to significant traumatic stimuli.26 
Terrorism and Bio-Terrorism References 
1. Marshall, S. (March 4, 2002). Mental health system failing 9/11 victims: 
Traumatized counselors lack skills, funds. Crains New York Business. 
2. Eig, J. (October 23, 2001). Flood site holds key to trauma recovery. Dr. Honig 
Studies, Wall Street Journal. 
3. North, C. S. (December 2001). The course of post traumatic stress disorder after the 
Oklahoma City bombing. Mil Med, 166(12 Suppl): 51-2. 
4. Abenhaim, L., Dab, W., & Salmi, L. R. (February 1992). Study of civilian victims of 
terrorist attacks (France 1982-1987). Journal of Clinical Epidemiol, 45(2);103-9. 
5. Jehel, L., Duchet, C., Paterniti, S., Consoli, S. M., Guelfi, J. D. (September-October 
2001). Prospective study of post traumatic stress in victims of terrorist attacks. 
Encephale, 27(5):393-400. 

6. Galea, S., Ahern, J., Resnick, H., Kilpatrick, D., Bucuvalas, M., Gold, J., & Vlahov, 
D. (March 28, 2002). Psychological sequelae of the September 11 terrorist attacks in 
New York City. New England Journal of Medicine, Vol. 346, No. 13, pp. 982-987. 
7. Kluger, J., Dorfman., A., Gorman, C., Horowitz, J. M., Park, A., Ellin, H., & 
McDowell, J. (September 24, 2001). Attack on the spirit. Time Atlantic, Vol. 158 
Issue 13, p. 90. 
8. Sealey, G. (November 5, 2001). Fragile psyches: Mental health counselors gear up 
for potential crisis in NY. ABC News.com. New York, NY. 
9. Schuster, M. A., Stein, B. D., Jaycox, L., Collins, R. L., Marshall, G. N., Elliott, M. 
H., Zhou, A. J., Kanouse, D. E., Morrison, J. L., & Berry, S. H. (November 15, 
2001). A national survey of stress reactions after the September 11, 2001 terrorist 
attacks. New England Journal of Medicine, 345(20), pp.1507-12. 
10. Silver, R. C., Holman, E. A., McIntosh, D. N., Poulin, M., & Gil-Rivas, V. (2002, 
September 11). Nationwide longitudinal study of psychological responses to 
September 11. JAMA: the Journal of the American Medical Association, 288(10), 
pp.1235-44. 
11. Kugler, S. (June 10, 2002). Children affected by World Trade Center attack need 
better mental health care. Report on Congressional hearing in lower Manhattan to 
address children’s mental health needs. Associated Press. 
12. Effects of the World Trade Center attack on NYC: Initial report to the New York 
City Board of Education. May 6, 2002. 
13. Goode E. (November 20, 2001). Treatment can ease lingering trauma of September 
11. Science Times, The New York Times. 
14. Nader, K. (1998). Violence: Effects of a parents’ previous trauma on currently 
traumatized children. In Y. Danieli (Ed.), An international handbook of 
multigenerational legacies of trauma (pp. 571-583), New York, NY: Plenum Press. 
15. Brewin, C. R., Andrews, B., Valentine, J. D. (2000). Meta-analysis of risk factors for 
Posttraumatic Stress Disorder in trauma-exposed adults. J of Consulting and Clinical 
Psychology, 68:748-766. 
16. Chambers, S. (Oct 19, 2001). As tragedy begins to hit home, mental health providers 
worry. New Jersey Star-Ledger. 
17. Widom, D. C. (1999). Childhood victimization and the development of personality 
disorders: Unanswered questions remain. Archives of General Psychiatry, 56(7), 
607-608. 

18. Breslau, N., Chilcoat, H. D., Kessler, R. C., Davis, G. C. (1999). Previous exposure 
to trauma and PTSD effects of subsequent trauma: Results from the Detroit Area 
Survey of Trauma. American Journal of Psychiatry, 156:902-907. 
19. King et al. (1999). Stretch, Knudson, & Durand (1998). Bremner, Southwick, Brett, 
& Fontant (1992). Breslau et al. (1998). Green et al. (2000). Nishith, Mechanic, & 
Resnick (2000). In B. Litz, M. Gray, R. Bryant, & A. Adler. Early intervention for 
trauma: Current status and future directions. A National Center for PTSD Fact Sheet. 
See www.ncptsd.org/facts/disasters/fs_earlyint_disaster.html 
20. Breslau, N. (January-February 2002). Gender differences in trauma and 
Posttraumatic Stress Disorder. Journal of Gender-specific Medicine, 5(1), pp.34-40. 
21. Norris, F. H., Byrne, C. M., Diaz, E., & Kaniasty, K. (2002). Risk factors for adverse 
outcomes in natural and human-caused disasters: A review of the empirical 
literature. A National Center for PTSD Fact Sheet. See www.ncptsd.org 
22. North, C., Nixon, S., Shariat, S., Mallonee, S., McMillen, J., Spitzanagel, E., & 
Smith, E. (1999). Psychiatric disorders among survivors of the Oklahoma City 
bombing. Journal of the American Medical Association, 282, 755-762. 
23. Norris, F. H. Prevalence and impact of domestic violence in the wake of disasters. A 
National Center for PTSD Fact Sheet. See 
www.ncptsd.org/facts/disasters/fs_domestic.html 
24. Mueser, K. T., Trumbetta, S. L., Rosenberg, S. D., Vidaver, R. M., Goodman, L. B., 
Osher, F. C., Auciello, P., Foy, D. W. (1998). Trauma and Posttraumatic Stress 
Disorder in severe mental illness. Journal of Consulting and Clinical Psychology, 
66(3), 493-499. 
25. Nader, K. (October 9, 2001). Terrorism: September 11, 2001: Trauma, grief, and 
recovery. Published by www.GiftFromWithin.com 
26. Kinzie, J. D., Boehnlein, J. K., Riley, C., Sparr, L. (July 2002). The effects of 
September 11 on traumatized refugees: Reactivation of Post Traumatic Stress 
Disorder. J Nerv Ment Dis, 190(7):437-41. 
27. Amir, M., & Kaplan, Z. (October 1996). Type of trauma, severity of Posttraumatic 
Stress Disorder core symptoms, and associated features. J of General Psychology, 
Vol.123, Issue 4, p. 341. 
28. Norris, F. H., Byrne, C. M., Diaz, E., & Kaniasty, K. (September 2002). The range, 
magnitude, and duration of effects of natural and human-caused disasters: A review 
of the empirical literature. A National Center for PTSD Fact Sheet. See 
www.ncptsd.org/facts/disasters 

29. Marshall, S. (March 4, 2002). Mental health system failing 9/11 victims: 
Traumatized counselors lack skills, funds. Crain’s New York Business. 
30. Strom, S. (July 22, 2002). Mending the hearts broken on September 11 is as difficult 
as explaining the cost. The New York Times. 
31. Chemtob, C. (2002). School based trauma program helps children cope. Archives of 
Pediatrics and Adolescent Medicine, 156:208, 211-216. 
32. Ogden, C. J., Kaminer, D., Van Kradenburg, J., Seedat, S., Stein, D. J. (July 2000). 
Narrative themes in responses to trauma in a religious community. Central African 
Journal of Medicine, 46(7), pp.178-84. 
33. Niles, D. P. (November 1991). War trauma and Post-Traumatic Stress Disorder. 
American Family Physician, 44(5), pp.1663-9. 

Homelessness 
A high percentage of homeless women and girls have experienced physical or sexual 
violence as children and/or adults, and have experienced substance abuse or mental 
health problems (including attempted suicide) as a result. 
Homelessness Facts and Discussion Points 
. Ninety-two percent of homeless mothers have experienced physical and/or sexual 
assault.1 
. More than 66% of homeless mothers have experienced severe physical violence 
by a caretaker and 43% were sexually molested during childhood. Sixty percent 
of homeless mothers were abused by the age of 12.2 
. Abuse often continues into adulthood. Sixty-three percent of homeless mothers 
have been victims of intimate partner violence and 32% are current or recent 
victims of domestic violence.2 
. More than half of homeless mothers who have been abused by an intimate partner 
were physically injured as a result of the abuse, and 27% required medical 
treatment.2 
. Over 39% of homeless women who have been abused have experienced PTSD, 
more than three times the level of the general female population. Forty-seven 
percent have had a major depressive disorder, more than twice the rate of the 
general female population.3 
. One-third of homeless women who have experienced violence have attempted 
suicide at least once.3 
. Forty-five percent of homeless women who have experienced abuse during their 
lives have subsequently been alcohol or drug dependent at some time.3 
. Seventy percent of women living on the streets or in shelters report abuse in 
childhood. Over 70% of girls on the streets have run away from violence in their 
homes.4, 5 
. Ninety-seven percent of mentally ill homeless women have experienced severe 
physical and/or sexual abuse, and 87% experienced this abuse both as children 
and as adults.6 

. Childhood abuse has been correlated with increased adolescent and young adult 
truancy, running away, and risky sexual behavior. Many of these children are 
homeless or living in shelters.7 
. More than 40% of women on welfare with repeated incidence of leaving the 
welfare rolls were sexually abused as children. These women often become 
homeless along with their children.8 
Homelessness Recommendations 
. Violence is pervasive in the lives of homeless and other extremely poor women. 
SAMHSA should examine its current and future programs to ensure that they 
respond to the impact of trauma on women. In addition, SAMHSA should work 
with other Department of Health & Human Services (HHS) agencies and other 
departments providing services to homeless women (U.S. Department of Housing 
and Urban Development [HUD], U.S. Department of Labor, etc.) to ensure the 
same response. 
. Many homeless and homeless-related service programs serving women do not 
address the impact of trauma on the lives of homeless women and are sometimes 
retraumatizing. Service providers and program administrators should make their 
services and programs more responsive to the needs of women. Such efforts 
might include: 
. Education/training on the pervasiveness of violence on homeless and other 
poor women for providers (such as health and mental health clinicians, 
substance abuse treatment providers, shelter workers, welfare case 
workers, etc.) who work with women and their children. 
. Development and broad dissemination of sensitive violence screening and 
referral processes to be used in a variety of social service settings. 
Training should be provided to ensure proper use. 
. SAMSHA should support a knowledge development and application effort 
designed to integrate and coordinate violence and homeless related services and 
delivery systems for women at the community level. 
. Many shelters and programs for the homeless receive federal money; all perform 
substance abuse and mental health assessments. Trauma/violence should be added 
to these assessments. 
. Homeless shelters and programs should be assessed for safety and to uncover any 
policies/practices that might re-victimize homeless persons. Persons seeking 
shelter should be assessed for histories of trauma. 

. Homeless and formerly homeless persons should be involved in every aspect of 
program design and management. 
Homelessness References 
1. Bassuk, E. L., Weinreb, L. F., Buckner, J. C., et al. (August 28, 1996). The 
characteristics and needs of sheltered homeless and low-income housed mothers. 
JAMA, The Journal of the American Medical Association, 276(8), pp. 640-6. 
2. Browne, A., & Bassuk, S. S. (April 1997). Intimate violence in the lives of homeless 
and poor housed women: Prevalence and patterns in an ethnically diverse sample. 
American Journal of Orthopsychiatry, 67(2), pp. 261-78. 
3. Bassuk, E. L., Buckner, J.C., Perloff, J. N., Bassuk, S. S. (November 1998). 
Prevalence of mental health and substance use disorders among homeless and low-
income housed mothers. American Journal of Psychiatry, Vol. 155(11). 
4. Goodman, L. A. (October 1991). The prevalence of abuse among homeless and 
housed poor mothers: A comparison study. American Journal of Orthopsychiatry, 
Vol. 61(4): 489-500. 
5. Chesney-Lind, & Shelden. (December, 1998). What to do about girls? Promising 
perspectives and effective programs. ICCA Journal. 
6. Goodman, L. A., Dutton, M. A., & Harris, M. (January 1997). The relationship 
between violence dimensions and symptom severity among homeless, mentally ill 
women. Journal of Traumatic Stress, 10(1), pp. 51-70. 
7. Briere, J. (1992). Child abuse trauma: Theory and treatment of the lasting effects. 
CA: Sage Publications. 
8. DeParle, J. (November 28, 1999). Life after welfare. The New York Times. 


Mental Illness 
(includes Suicide, Self-Injury) 
The relationship between childhood physical and sexual abuse and the development 
of psychiatric symptomatology in adulthood is well documented. Childhood abuse is 
a significant causal factor in suicide and self-injury. 
Mental Illness Facts and Discussion Points 
. Fifty to seventy percent of all women and a substantial number of men treated in 
psychiatric settings have histories of sexual or physical abuse, or both.1-3 
. Up to 81% of men and women in psychiatric hospitals who are diagnosed with a 
variety of major mental illnesses have experienced physical and/or sexual abuse. 
Sixty-seven percent of these men and women were abused as children.4 
. Seventy-four percent of Maine’s Augusta Mental Health Institute consumers, 
interviewed as class members, reported histories of sexual and physical abuse.5 
. The majority of adults diagnosed with Borderline Personality Disorder (81%) or 
dissociative identity disorder (90%) were sexually and/or physically abused as 
children.6-7 
. Women who were molested as children are at four times greater risk for Major 
Depression than those with no such history. They are significantly more likely to 
develop bulimia and chronic PTSD.8-11 
. Childhood abuse can result in adult experiences of shame, flashbacks, nightmares, 
severe anxiety, depression, alcohol and drug use, feelings of humiliation and 
unworthiness, ugliness, and profound terror.12-18 
. Adults who were abused during childhood are: 
o more than twice as likely to have at least one lifetime psychiatric 
diagnosis; 
o almost three times as likely to have an affective disorder; 
o almost three times as likely to have an anxiety disorder; 
o almost 2 1/2 times as likely to have phobias; 
o more than 10 times as likely to have a panic disorder; and 
o almost 4 times as likely to have an antisocial personality disorder.19 

. Ninety-seven percent of mentally ill homeless women have experienced severe 
physical and/or sexual abuse. Eighty-seven percent experienced this abuse both as 
children and as adults.20 
. Adults who were abused as children may be more prone to developing 
schizophrenia. A high rate of childhood physical and sexual abuse is evident 
among children later diagnosed as schizophrenic, with a strong link between 
childhood abuse and hearing voices. In addition, changes in the brain seen in 
abused children were similar to those found in adults with schizophrenia.21 
. There is a significant relationship between childhood sexual abuse and various 
forms of self-harm later in life, i.e. suicide attempts, cutting, and self-starving.22 
. For adults and adolescents with childhood abuse histories, the risk of suicide 
increases 4- to 12-fold.23 
. Most self-injurers have a history of childhood physical or sexual abuse. Forty 
percent of persons who self-injure are men.24–26 
. Approximately 8% of individuals in the U.S.—20 million people—will be 
diagnosed with full-blown PTSD in their lifetime. As many as 20 million more 
people may experience PTSD-related symptoms. In many cases, problems are not 
identified, or consumers do not receive appropriate treatment.27 
Mental Illness References 
1. Carmen, E., Rieker, P., & Mills, T. (March, 1984). Victims of violence and 
psychiatric illness. Am J Psychiatry, 141:3. 
2. Bryer, J. B., Nelson, B., Miller, J. B., & Krol, P. (November 1987). Childhood sexual 
and physical abuse as factors in adult psychiatric illness. Am J Psychiatry, 144:1426-
1430. 
3. Craine, L. S., Henson, C. E., Colliver, J.A., et al. (1988). Prevalence of a history of 
sexual abuse among female psychiatric patients in a state hospital system. Hospital 
and Community Psychiatry, 39, 300-304. 
4. Jacobson, A., & Richardson, B. (1987). Assault experiences of 100 psychiatric 
inpatients: Evidence of the need for routine inquiry. American Journal of Psychiatry, 
144, 908-913. 
5. Maine Department of Mental Health, Mental Retardation and Substance Abuse 
Services. (1998). Augusta Mental Health Institute consent decree class member 
assessment. 

6. Herman, J., Perry, C., & van der Kolk, B. (April 1989). Childhood trauma in 
Borderline Personality Disorder. Am J Psychiatry, 164:4, 490-495. 
7. Ross, C., Miller, S., Reagor, P., Bjornson, L., Fraser, G., & Anderson, G. (1990). 
Structured interview data on 102 cases of Multiple Personality Disorder from four 
centers. J Psychiatry, 147, 596-601. 
8. Stein, J. A., Golding, J. M., Siegel, J. M., Burnam, M. A., Sorenson, S. B. (1988). 
Long-term psychological sequelae of child sexual abuse: The Los Angeles 
Epidemiologic Catchment Area Study. In G. E. Wyatt, & G. J. Powell (Eds.), Lasting 
effects of child sexual abuse. Sage Focus Editions, Vol. 100 (pp. 135-154). Newbury 
Park, CA: Sage Publications. 
9. Root, M., & Fallon. (1989). The incidence of victimization experiences in a bulimic 
sample. J. of Interpersonal Violence, 4, 90-100. 
10. Sloane, G., & Leichner, P. (1986). Is there a relationship between sexual abuse or 
incest and eating disorders? Canadian J. of Psychiatry, 31, 656-660. 
11. Craine, P. (1990). Cited by Gondolf, E. W. Psychiatric responses to family violence: 
Identifying and confronting neglected danger. Lexington, MA: Lexington Books. 
12. M. Harris, & Landis (Eds.), (1997). Sexual abuse in the lives of women diagnosed 
with serious mental illness. Netherlands: Harwood Academic Publishers. 
13. Rieker, P. P., & Carmen, E. H. (July 1986). The victim-to-patient process: The 
disconfirmation and transformation of abuse. American Journal of Orthopsychiatry, 
Vol. 56(3). 
14. Herman, J. (1992). Trauma and recovery: The aftermath of violence – from domestic 
abuse to political terror. New York, NY: Basic Books. 
15. Janoff-Bulman, R., & Frieze, I. H. (Summer 1983). A theoretical perspective for 
understanding reactions to victimization. Journal of Social Issues, Vol. 39(2): 1-17. 
16. B. A. van der Kolk (Ed.), (1987). Psychological trauma. Washington, DC: American 
Psychiatric Press. 
17. Brown, A., & Finkeihor, D. (1986). Impact of child sexual abuse: A review of the 
literature. Psychological Bulletin, 99:66-77. 
18. Rimsza, M. E., Berg, R. A., & Locke, C. (1988). Sexual abuse: Somatic and 
emotional reactions. Child Abuse and Neglect, 12(2):201-8. 

19. Stein, J. A., Golding, J. M., Siegel, J. M., Burnam, M. A., Sorenson, S. B. (1988). 
Long-term psychological sequelae of child sexual abuse: The Los Angeles 
Epidemiologic Catchment Area Study. In G. E. Wyatt, & G. J. Powell (Eds.), Lasting 
effects of child sexual abuse. Sage Focus Editions, Vol. 100 (pp.135-154). Newbury 
Park, CA: Sage Publications. 
20. Goodman, L., Johnson, M., Dutton, M. A., & Harris, M. (1997). Prevalence and 
impact of sexual and physical abuse. In M. Harris, & C. L. Landis (Eds.), Sexual 
abuse in the lives of women diagnosed with serious mental illness (pp.277-299). 
Netherlands: Harwood Academic Publishers. 
21. Read, J. (2002). Interpersonal and biological processes. Journal Psychiatry. 
22. van der Kolk, B. A., Perry, J. C., & Herman, J. L. (1991). Childhood origins of self-
destructive behavior. American Journal of Psychiatry, 148:1665-1671. 
23. 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. Am J Prev Med, 14:245-258. 
24. Graff, H., & Mallin, R. (1967). The syndrome of the wrist cutter. American Journal 
of Psychiatry. 12A(1):36-42. 
25. Pattison, E. M., & Kahan, J. (July, 1983). The deliberate self-harm syndrome. Am J of 
Psychiatry, Vol. 140(7): 867-872. 
26. Briere, J., & Runtz, M. (1988). Post sexual abuse trauma. In G. E. Wyatt, G. J. Powell 
(Eds.), Lasting Effects of Child Sexual Abuse. CA: Sage Publications. 
27. Marshall, R. (May 9, 2002). The prevalence of problems related to PTSD. Study 
presented at the 154th Annual Meeting of the American Psychiatric Association. 

Serious Medical Problems and Health Risks 
(Includes HIV and Developmental Disabilities) 
Maltreatment at an early age can have enduring negative effects on the brain and 
can cause multiple risk factors for several of the leading causes of death in adults. 
Both adults and children with trauma histories are at high risk for HIV/AIDS. A 
significant percentage of developmental disabilities are the result of child abuse. 
Serious Medical Problems and Health Risks Facts and Discussion Points 
. Medical impacts of childhood abuse include: head trauma, brain injury, sexually 
transmitted diseases, unwanted pregnancy, HIV infection, physical disabilities 
(back, orthopedic, neck, etc.) chronic pelvic pain, headaches, stomach pain, 
nausea, sleep disturbance, eating disorder, asthma, shortness of breath, chronic 
muscle tension, muscle spasms, and elevated blood pressure.1-5 
. Adults who experience multiple types of abuse and violence in childhood 
(compared to those who do not) are found to have a 2- to 4-fold increase in 
smoking, poor self-rated health, more than 50 sexual intercourse partners, 
sexually transmitted disease, a higher rate of physical inactivity, and severe 
obesity.6 
. Adverse childhood exposures show a relationship to the presence of adult 
diseases, including ischemic heart disease, cancer, chronic lung disease, skeletal 
fractures, and liver disease.6 
. Severe and prolonged childhood sexual abuse causes damage to the brain 
structure, resulting in impaired memory, dissociation, and symptoms of PTSD.7-9 
. Women with histories of sexual abuse are at higher risk for unprotected sex, 
increased number of sexual partners, prostitution, drug and alcohol addiction—all 
of which are risk factors for HIV/AIDS.10 
. Homeless women, especially homeless mentally ill women, are at high risk for 
sexual abuse, sexual assault, and “sex for barter” activities that increase their risk 
for HIV/AIDS.11 
. Promiscuity and prostitution (as a means of supporting substance abuse/addiction) 
often correlate to prior sexual abuse, and result in increased risk of HIV 
infection.12 
. Childhood violence is a significant causal factor in 10 to 25% of all 
developmental disabilities.13, 14 

. Three to six percent of all children will have some degree of permanent disability 
as a result of abuse.13, 14 
. Between 20% and 50% of abused children suffer mild to severe brain damage.15 
Serious Medical Problems and Health Risks References 
1. Prescott, L. (1998). Women emerging in the wake of violence. Los Angeles, CA: 
Prototype Systems Change Center. 
2. Cunningham, J., Pearce, T., & Pearce, P. (1988). Childhood sexual abuse and medical 
complaints in adult women, Journal of Interpersonal Violence, 3,131-144. 
3. Morrison, J. (1989). Childhood sexual histories of women with somatization disorder. 
American Journal of Psychiatry, 146, 239-241. 
4. Springs, F., & Friedrich, W. (1993). Health risk behaviors and medical sequelae of 
childhood sexual abuse. Mayo Clinic Proceedings. 
5. Walker, E., Katon, W., Harrop-Griffiths, J., Holm, I., Russo, J., & Hickok, L. (1988). 
Relationship of chronic pelvic pain to psychiatric diagnosis and childhood sexual 
abuse. American J. of Psychiatry, 145, 75-80. 
6. 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. Am J Prev Med, 14:245-258. 
7. Briere, J. (1997). Child abuse trauma: Theory and treatment of the lasting effects. 
Sage Publications. 
8. van der Kolk, B. (1996). The body keeps the score: Approaches to the psychobiology 
of Posttraumatic Stress Disorder. In van der Kolk et al. (Eds.), Traumatic stress: The 
effects of overwhelming experience on mind, body, and society. Guilford Press. 
9. Perry. (1994). Biological and neurobehavioral studies of borderline personality 
disorder. In K. Silk (Ed.), Progress In Psychiatry, No. 45. American Psychiatric 
Press. 
10. Brady et al. (2002). Physical and sexual abuse in the lives of HIV-infected women. 
Journal of AIDS/HIV. 
11. Brady et al. (2000). Aids risk and knowledge. Journal of Health Care Safety. 
Compliance and Infection Control. 

12. R. Mazelis (personal communication, April 2002). 
13. Sobsey, D. (1994). Violence and abuse in the lives of people with disabilities: The 
end of silent acceptance? Baltimore, MD: Paul Brookes. 
14. Valenti-Hein, D., & Schwartz, L. (1995). The sexual abuse interview for those with 
developmental disabilities. Santa Barbara, CA: James Stanfield Company. 
15. Rose, E., & Hardman, M. L. (April 1981). The abused mentally retarded child. 
Education and Training of the Mentally Retarded, Vol. 16(2):114-118. 


Criminal Justice 
(Includes Delinquency, Violence, and Criminal Behavior) 
Women and children in the criminal justice system show rates of childhood physical 
or sexual abuse that are comparable to rates in the mental health and substance 
abuse systems. Almost all murderers and sex offenders (male or female) have a 
history of childhood maltreatment. 
Criminal Justice Facts and Discussion Points 
. Victims of child sexual abuse are at increased risk of becoming prostitutes.1-3 
. Childhood abuse or neglect increases the likelihood of arrest as a juvenile by 
53%, as a young adult by 38%, and for violent crime by 38%.4 
. Eighty percent of women in prison and jails have been victims of sexual and 
physical abuse.5 
. Reenactment of victimization is a major cause of violence in society. Many 
violent adult criminals were physically or sexually abused as children.6-7 
. The majority of murderers and sex offenders have a history of childhood 
maltreatment. The majority of women and men in the criminal justice system 
were abused as children.8 
. One-third of individuals abused in childhood may abuse or neglect their own 
children. 9 
. Of 16 men sentenced to death in California, a history of family violence was 
found in all cases. Fourteen were victims of severe childhood physical and/or 
sexual abuse. Individual impairments were found in 16 cases, including 14 with 
Posttraumatic Stress Disorder, 13 with severe depression, and 12 with histories of 
traumatic brain injury; community isolation and violence occurred in 12 cases; 
and institutional failure in 15, including 13 cases of severe physical and/or sexual 
abuse while in foster care or under state youth authority jurisdiction. Interventions 
may have made a difference in reducing lethal violence and its precursor 
conditions.10 
. Boys who experience or witness violence are 1,000 times more likely to commit 
violence than those who do not.11 
. In 1998, 92% of incarcerated girls reported sexual, physical or severe emotional 
abuse in childhood.12 

. A Maine study of 15 girls at Long Creek Youth Development Center (formerly 
Maine Youth Center), found 12 out of 15 girls to have a known history of early 
childhood trauma.13 
Criminal Justice Recommendations 
. Teach trauma theory and tools in corrections settings. 
. Empower corrections staff to use tools other than coercive control (which can 
increase reactivity among inmates)—see Seclusion and Restraint section. 
Criminal Justice References 
1. Browne, A., & Finkelhor, D. (1986). Impact of child sexual abuse: A review of the 
literature. Psychological Bulletin, 99:66-77. 
2. Silbert, M. H., & Pines, A. M. (1991). Sexual child abuse as an antecedent to 
prostitution. Child Abuse and Neglect, Vol. 5(4): 407-411. 
3. Prescott, L. (1998). Women emerging in the wake of violence. Los Angeles, CA: 
Prototype Systems Change Center. 
4. Widom, C. S. (1995). Research in brief: Victims of childhood sexual abuse – later 
criminal consequences. 
5. Smith, B. (April 1998). An end to silence: Women prisoners’ handbook on identifying 
and addressing sexual misconduct. National Women’s Law Center. 
6. Groth, A. N. (1979). Men who rape: The psychology of the offender. New York, NY: 
Plenum publishers. 
7. Seghorn, T. K., Boucher, R. J., & Prentky, R. A. (March 1987). Childhood sexual 
abuse in the lives of sexually aggressive offenders. American Academy of Child 
Adolescent Psychiatry, Vol. 26(2), pp. 262-7. 
8. National Commission to Prevent Child Abuse. (2000). 
9. Kaufman, J., & Zigler, E. (April 1987). Do abused children become abusive parents? 
American Journal of Orthopsychiatry. Vol. 57(2), pp. 186-92. 
10. Freedman, D., & Hemenway, D. (2000). Precursors of lethal violence: A death row 
sample. Social Science and Medicine, pp. 1757-1770. 

11. van der Kolk, B. A. (January 1998). Psychology and psychobiology of childhood 
trauma. Prax Kinderpsychol Kinderpsychiatr. Vol. 47(1), pp. 19-35. 
12. DOC Juvenile Justice Recidivism Baseline Report for 1998. 
13. Salisbury, N. (April 9, 2002). Report to the Children’s Cabinet: Girl’s Project. 


Aging 
If untreated, the psychological impact of violence can remain throughout one's life. 
Elderly populations display high levels of symptomatology related to early trauma. 
Aging Facts and Discussion Points 
. Approximately 818,000 elderly Americans were victims of domestic abuse in 
1994. Two thirds of the victims were women.1 
. Negative life events in childhood lead to a strong association between the number 
of negative life events experienced in adulthood and depressive symptoms in later 
life.2 
. In a study of 14 elderly women (ages 68-83) with a history of severe depression, 
most were shown to have experienced significant childhood trauma.3 
. Unresolved childhood sexual abuse in elderly women is characterized by chronic 
depression, re-victimization, and misdiagnosis of residual abuse trauma as 
dementia or mental illness.4 
. Posttraumatic Stress Disorder may present many years after the original trauma. 
Elderly PTSD consumers often avoid talking about traumatic experiences due to 
associated distress. Without taking a military and trauma history from elderly 
consumers, a diagnosis of PTSD may be missed.5 
. As external and internal resources diminish in the elderly population, 
psychological effects of trauma may reappear.6 
. Elderly consumers who encounter psychological trauma earlier in life may have 
persisting symptoms including: marked disruptions of sleep and dreaming, 
intrusive memories, impairment of trust, avoidance of stressors, and heightened 
vulnerability to various types of age-associated retraumatization.7 
Aging Recommendations 
. Health care and mental health care providers should take a comprehensive trauma 
history from elderly consumers, including military and interpersonal violence, and 
abuse experiences in childhood and adulthood. A diagnosis of PTSD should be 
followed by treatments known to be effective with elderly persons. 

. Statistics should be obtained (possibly through Medicare records) regarding the 
very high incidence of older women who are subjected to electroconvulsive 
therapy (ECT).8 
Aging References 
1. Tatara, T., & Blumerman, L. (1996). Summaries of the statistical data on elder abuse 
in domestic settings: An exploratory study of state statistics for FY 95 and 96. 
Washington, DC: NCEA. 
2. Kraaif, V., & de Wilde, E. J. (February 2001). Negative life events and depressive 
symptoms in the elderly: A life span perspective. Aging and Mental Health. Vol. 5(1). 
3. Mullan, E., & Orrell, M. (March 1996). Early life experience in elderly women with a 
history of depression: A pilot study using the brief parenting interview. Irish Journal 
of Psychological Medicine, Vol. 13(1). 
4. Allers, C. T., Benjack, K. J., Allers, N. T. (September-October 1992). Unresolved 
childhood sexual abuse: Are older adults affected? Journal of Counseling & 
Development, Vol. 71, Issue 1, p. 14. 
5. Hilton, C. (August 1997). Media triggers of post-traumatic stress disorder 50 years 
after the Second World War. International Journal of Geriatric Psychiatry, Vol. 12, 
(8), pp. 862-7. 
6. van der Kolk, B. A. (July 1996). Dissociation, somatization, and affect dysregulation: 
The complexity of adaptation of trauma. American Journal of Psychiatry, Vol. 153, (7 
Suppl), pp. 83-93. 
7. Sadavoy, J. (Fall 1997). Survivors. A review of the late-life effects of prior 
psychological trauma. American Journal of Geriatric Psychiatry, Vol. 5 (4), pp. 287-
301. 
8. R. Mazelis (personal communication, April 2002). 

Severe Social Problems 
The long-term impacts of childhood sexual and physical abuse may significantly 
impair a person’s life and lead to serious social difficulties. Predators look for 
victims who have been abused as children, especially victims of sexual abuse who 
are vulnerable to re-victimization. 
Severe Social Problems Facts and Discussion Points 
. More than 40% of women on welfare were sexually abused as children. These 
women are often unable to keep a job and become homeless along with their 
children.1 
. Sixty percent of housed, low-income mothers on Aid For Dependent Children 
(AFDC) experienced severe childhood physical abuse and 42% were sexually 
molested as children.2 
. Victims of father-daughter incest are four times more likely than non-incest 
victims to be asked to pose for pornography.3 
. Children who experience multiple exposures to abuse and violence (compared to 
those who do not) may experience multiple (sometimes 50 or more) sexual 
intercourse partners and sexually transmitted disease.4 
. Promiscuity and prostitution (as a means of supporting substance abuse/addiction) 
have a correlation with prior sexual abuse, and result in increased risk of HIV 
infection.5 
. Women with a history of sexual abuse are at higher risk for unprotected sex, 
increased number of sexual partners, prostitution, and drug and alcohol 
addiction—all of which are risk factors for HIV/AIDS.6 
. Among juvenile girls identified as delinquent by a court system, more than 75% 
were sexually abused.7 
. Childhood abuse has a correlation with increased adolescent and young adult 
truancy, running away, homelessness, and risky sexual behavior.8 
. Women who were sexually abused during childhood are 2.4 times more likely to 
be re-victimized as adults than women who were not sexually abused.9 

. Sixty-eight percent of women with a history of childhood incest report incidents 
of rape or attempted rape after age 14, compared to 38% of women in a random 
sample.3 
. Girls who experience violence in childhood are three to four times more likely to 
be victims of rape than those who do not.10 
. Twice as many women with a history of incest become victims of domestic 
violence as women without such a history. Twice as many also report unwanted 
sexual advances by an unrelated authority figure.3 
Severe Social Problems References 
1. DeParle, J. (November 28, 1999). Life after welfare. The New York Times. 
2. Bassuk, E. L., Buckner, J. C., Perloff, J. N., & Bassuk, S. S. (1998). Prevalence of 
mental health and substance use disorders among homeless and low-income housed 
mothers. American Journal of Psychiatry, Vol. 155(11), 11. 
3. Russell, D. E. H. (1986). The secret trauma: Incest in the lives of girls and women. 
New York, NY: Basic Books Inc. 
4. 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. Am J Prev Med, 14:245-258. 
5. R. Mazelis (personal communication, April 2002). 
6. Brady et al. (2002). Physical and sexual abuse in the lives of HIV-infected women. 
Journal of AIDS/HIV. 
7. Calhoun, O., Jurgens, E., & Chen, F. (1993). The neophyte female delinquent: A 
review of the literature. Adolescence, 28, 461-471. 
8. Briere, J. (1992). Child abuse trauma: Theory and treatment of the lasting effects. 
CA: Sage Publications. 
9. Wyatt, G. E., Guthrie, D., & Notgrass, C. M. (April, 1992). Differential effects of 
women’s child sexual abuse and subsequent sexual revictimization. Journal of 
Consulting and Clinical Psychology, 60:167-173. 
10. Browne, A. (June 17, 1992). Violence against women: Relevance/or medical 
practitioners. Council on Scientific Affairs, American Medical Association Report. 
JAMA, Vol. 257, No. 23. 

Cross-Cutting Principles 
for Each Priority Issue 
The following section details principles that “cut across” the issues that are itemized 
in the first part of this report. From evidence-based practices to culturally 
competent services, these cross-cutting principles affect each priority issue facing 
behavioral health providers, administrators, and consumers. 


Data and Evidence-Based Outcomes 
Many promising treatment interventions for the consequences of trauma exist; 
further work in this area will help to establish an evidence-based approach to 
trauma treatment. 
Data and Evidence-Based Outcomes Facts and Discussion Points 
. A wide variety of treatments are available for Posttraumatic Stress Disorder. 
Some have been proven effective. Others may work, but have not yet been studied 
extensively (among these treatments are Cognitive Behavioral Therapies [CBT], 
Drug Therapies, Eye Movement Desensitization and Reprocessing [EMDR], 
Group and Individual Therapy).1 
. To date, CBT (but not EMDR) has shown promise in controlled studies that 
exclude or simply fail to include people with chronic and persistent mental illness 
or addictions. Recent studies of Rosenberg et al.’s use of a Cognitive 
Restructuring Approach—combined with individual therapy—is showing promise 
with people hospitalized and diagnosed with schizophrenia who also have PTSD 
symptoms.2 
. Alternative approaches emphasizing skills and support for managing trauma-
related symptoms in the “here-and-now” are showing promise.2 
. Dialectical Behavioral Treatment, though not designed specifically for treatment 
of PTSD, is a helpful treatment approach for some survivors.3 
. Practitioners trained in evidence-based treatment, such as cognitive behavioral 
approaches, may be hard to find. Locating effective treatment for consumers with 
traumatic stress symptoms can be difficult, as many therapists have no training in 
treating stress disorders.1, 4, 5 
. There is currently a shortage of health and mental health professionals who are 
educated and trained to work with trauma. Most clinical education programs lack 
formal courses or educational opportunities in trauma. American universities have 
been slow to contribute to advances in the study and treatment of trauma.1, 4, 5 
. Research monies are being spent on techniques directed at symptom management 
of PTSD as well as other mental health categories. Managed care often overlooks 
trauma-focused relational psychotherapy. CBT, meds, and EMDR target 
symptoms and do not address the core of trauma work, which is relational.6 

Data and Evidence-Based Outcomes Recommendations 
. SAMHSA should integrate comprehensive trauma programs into the academic 
mainstream, and should require trauma education to be required for key 
professional groups (psychologists, nurses, social workers, neurobiologists, public 
health workers, medical researchers, etc.). SAMHSA should convene key 
professionals from universities, guilds, and licensing and accrediting bodies to 
organize practical programs in traumatology that draw from existing models and 
facilitate cross-fertilization between fieldwork, university research, and curricula. 
. SAMHSA should encourage professional accrediting bodies to include some form 
of trauma training in their programs. 
. Develop a “Certificate of Proficiency in the Treatment of Trauma Disorders.” 
. Collaborate with the National Area Health and Education Center Program 
(AHEC) to bring trauma training programs and educational opportunities to 
professionals and communities served by AHEC Centers across the country. 
. Foster and fund increased training in trauma theory and application to all service 
providers. 
. Foster and fund treatment outcome research for existing models. 
. Promote funding for trauma-specific psychotherapy, and trauma-informed 
services in general. 
. Trauma survivors should be involved in every aspect of research design, 
development, practice, and analysis of trauma education programs. 
. Assist evaluators in developing research practices that identify the relational 
components of trauma work in the assessment of interventions for trauma 
survivors. 
Data and Evidence-Based Outcomes References 
1. Goode, E. (November 20, 2001). Treatment can ease lingering trauma of September 
11. Science Times, The New York Times. 
2. J. Ford, Ph.D. (personal communication, April 2002). 
3. S. Witterholt, M.D. (personal communication, August, 2002). 
4. Marshall, S. (March 4, 2002). Mental health system failing 9/11 victims: 
Traumatized counselors lack skills, funds. Crain’s New York Business. 

5. Strom, S. (July 22, 2002). Mending the hearts broken on September 11 is as difficult 
as explaining the cost. The New York Times. 
6. R. Mazelis (personal communication, April 2002). 


Collaboration with Public and Private Partners 
Due to the multiple severe consequences of trauma, including physical, 
psychological and social problems, trauma treatment and services should be 
developed and implemented through integrated systems of care. 
Collaboration with Public and Private Partners 
Facts and Discussion Points 
. Systems that duplicate efforts may waste time and money.1 
. Medical impacts of childhood abuse include: head trauma, brain injury, sexually 
transmitted diseases, unwanted pregnancy, HIV infection, physical disabilities 
(back injury, orthopedic, neck, etc.), chronic pelvic pain, headaches, stomach 
pain, nausea, sleep disturbance, eating disorder, asthma, shortness of breath, 
chronic muscle tension, muscle spasms, elevated blood pressure.2-6 
. Among the physical sequelae of trauma are autoimmune disorders.7 
. Adults who experience multiple types of abuse and violence in childhood, 
compared to those who do not, have a 2- to 4-fold increase in smoking, poor self-
rated health, a higher rate of physical inactivity, and severe obesity.8 
. A study of adverse childhood exposures shows a relationship to the presence of 
adult diseases, including ischemic heart disease, cancer, chronic lung disease, 
skeletal fractures, and liver disease.8 
. Severe and prolonged childhood sexual abuse causes damage to the brain 
structure, resulting in dysregulated emotional systems, dissociation, and 
symptoms of PTSD.9-11 
. Primary care physicians are often the sole or first professional seen by abused 
children and adults who present with medical or physical problems and/or 
behavioral problems.12 
. Some primary care physicians prescribe as many anti-psychotic medications to 
asymptomatic children as they prescribe to symptomatic children.12 
. Drugs are often prescribed for children misdiagnosed with Attention Deficit 
Hyperactivity Disorder (ADD), Oppositional Defiance Disorder (ODD), etc., 
whereas these children’s symptoms are indicative of trauma (chronic 
community/gun violence as well as sexual/physical abuse).12 

. Theories and interventions on traumatic stress issues have been generated in the 
private sector for decades (Eye Movement Desensitization and Reprocessing 
[EMDR], Dialectical Behavior Therapy [DBT], Risking connection, Sanctuary, 
etc.).13 
. Due to perceived high cost of individual treatment, existing approaches have not 
been widely implemented in public sector settings.13 
. Many private practice trauma specialists are not aware of growing interest in the 
public sector to address trauma issues in public settings.13 
. Unless affiliated with a research university, private sector trauma specialists 
generally cannot afford to conduct outcome studies that prove anecdotally 
successful approaches.13 
. The lack of a shared language or a shared conceptual framework (e.g., mental 
health and criminal justice, or mental health and public health) significantly 
impairs the capacity of systems to collaborate effectively.14 
Collaboration with Public and Private Partners Recommendations 
. Launch an educational campaign targeting health care professionals (psychiatrists, 
primary care physicians, physician assistants, nurses, health clinicians, and other 
organizations and associations), which focuses on recognizing the signs and 
symptoms of trauma, and assisting children and adults via appropriate referrals 
and interventions. 
. Collaborate with the Department of Health & Human Services Bureau of Primary 
Health Care (BPHC), which provides medical and mental health care in 
underserved urban areas through schools and community clinics. 
. Collaborate with existing non-profit organizations that educate about trauma, 
abuse, domestic violence, etc., to provide widespread information and referral 
services. 
. Collaborate with American Nurses Association, International Association of 
Psychiatric Nurses, and American Psychiatric Nurses Association, a professional 
population with people who are familiar with the incidence of violence and 
trauma, sympathetic to the cause, and who may hold influential positions. 
. Foster and fund adaptation of existing models for public education settings. 
. Create venues for teaching partnerships between private sector teachers and 
public sector learners. 

. Foster models for group clinical supervision, in which experienced trauma 
therapists can supervise novice clinicians in both the public and private sector. 
. Create and/or increase funding for outcome studies on the most successful trauma 
treatment approaches. 
. Educate both public and private systems on the existing literature of trauma-
informed system of care practices. 
Collaboration with Public and Private Partners References 
1. E. Giller (personal communication, April 2002). 
2. Prescott, L. (1998). Women emerging in the wake of violence. Los Angeles, CA: 
Prototype Systems Change Center. 
3. Cunningham, J., Pearce, T., & Pearce, P. (1988). Childhood sexual abuse and medical 
complaints in adult women. Journal of Interpersonal Violence, 3,131-144. 
4. Morrison, J. (1989). Childhood sexual histories of women with somatization disorder. 
American Journal of Psychiatry, 146,239-241. 
5. Springs, F., & Friedrich, W. (1993). Health risk behaviors and medical sequelae of 
childhood sexual abuse. Mayo Clinic Proceedings. 
6. Walker, E., Katon, W., Harrop-Griffiths, J., Holm, L., Russo, J., & Hickok, L. R. 
(1988). Relationship of chronic pelvic pain to psychiatric diagnoses and childhood 
sexual abuse. American Journal of Psychiatry, 145, 75-80. 
7. R. Mazelis (personal communication, April 2002). 
8. Felitti, V. J. (May 1998). Relationship of childhood abuse and household dysfunction 
to many of the leading causes of death in adults. The Adverse Childhood Experiences 
(ACE) Study. Am J Prev Med; Vol. 14 (4), pp. 245-58. 
9. Lindsey, D., Stephen, Briere, J. (October 1997). The controversy regarding recovered 
memories of childhood. Journal of Interpersonal Violence, Vol. 12, Issue 5, p. 631, 
17 p. 
10. van der Kolk, B. A., (July 1996). Dissociation, somatization, and affect dysregulation: 
The complexity of adaptation of trauma. Am J Psychiatry, Vol. 153, (7 Suppl), pp. 83-
93. 

11. Perry. (1994). Biological and neurobehavioral studies of borderline personality 
disorder. In K. Silk (Ed.), Progress in Psychiatry, No. 45, American Psychiatric 
Press. 
12. J. B. Harrod, Ph.D. (personal communication, based upon Maine epidemiological 
study conducted by Gwen Zahner Ph.D., Research Triangle Institute, 2002). 
13. E. Giller (personal communication, April 2002). 
14. S. Bloom (personal communication, April 2002). 

Cultural Competency 
The treatment needs of one cultural/age/gender group may be different than those 
of another. Trauma services must be specific and sensitive if they are to be of value 
to the recipient. 
Cultural Competency Facts and Discussion Points 
. In the state of Connecticut, only 1% of women in substance abuse treatment are in 
gender-specific residential or intensive outpatient programs. There are very few 
gender-specific programs for women in mental health treatment.1 
. The number of children whose lives have been disrupted by war, oppression, 
terror, and other forms of conflict has grown from 1.5 million refugees and 
displaced persons following WWII, to 14 million refugees and displaced persons 
by 2001. Many of these young people experience long-term physical and 
emotional health problems, including PTSD.2 
. The use of traumatizing, restrictive measures is used disproportionately in 
minority populations.3 Research is needed in this area. 
Cultural Competency Recommendations 
. Leadership is needed at the federal level to bring the message to states about the 
importance of delivering culturally competent services to better meet the needs of 
all persons requiring such services. 
Cultural Competency References 
1. J. Ford (personal communication, April, 2002). 
2. Berman, H. (July/August 2001). Children and war: Current understandings and future 
directions. Public Health Nursing, Vol.18, Issue 4. 
3. Brooks, K., Mulaik, J., Gilead, M. & Daniels, B. (1994). Patient overcrowding in 
psychiatric hospital units: Effects on seclusion and restraint. Administrative Policy in 
Mental Health, 22, 133-144. 


Community and Faith-based Approaches 
Faith and spirituality are frequently cited by trauma survivors as a primary support 
and a key to their healing. 
Community and Faith-based Approaches Facts and Discussion Points 
. Many survivors of abuse and trauma look to their spiritual leaders for guidance 
and healing.1 
. Faith communities, prayer circles, and clergy are the primary source of support 
for trauma survivors in communities of color.2 
. In addition to physical and psychological crises, traumatic experiences may 
generate spiritual crises, loss of faith, and questions of identity, meaning, and 
world-view.2 
. For people who have strong religious belief systems, trauma-informed, faith-
based responses are critical to successful recovery from trauma.2 
. Spiritual leaders may lack knowledge in the area of trauma.2 
. Some religious/spiritual leaders are actual perpetrators of trauma or they may 
protect perpetrators. This should be recognized and addressed.2 
. A religious belief system may provide a framework by which survivors of 
traumatic events can construct a meaningful account of their experience, and may 
be a useful focus for intervention with trauma survivors.3 
. Consumers suffering from Posttraumatic Stress Disorder appear to benefit from 
psychosocial therapy and spiritual support, in conjunction with medication.4 
Community and Faith-based Approaches Recommendations 
. Work with Catholic leaders to fund and collaborate with trauma experts in a 
public education campaign about interpersonal violence/abuse trauma, its long-
term impacts, the consequences of unresolved trauma, the need to prevent child 
abuse, the need to intervene early, and the need to help adult trauma and abuse 
survivors get treatment. 
. Support education of clergy and lay leaders in all faiths regarding their role in 
responding to traumatized congregants, i.e. to recognize, counsel, and refer to 
trauma treatment, when appropriate. 

. Foster collaboration between clergy/denominational leaders and mental health 
service providers to de-stigmatize the acknowledgement of trauma, and to bring 
appropriate trauma services to the churches and faith-based service providers. 
Community and Faith-Based Approaches References 
1. Blanch, Ph.D. (personal communication, April 2002). 
2. E. Giller (personal communication, April 2002). 
3. Ogden, C. J., Kaminer, D., Van Kradenburg, J., Seedat, S., & Stein, D. J. (July 2000). 
Narrative themes in responses to trauma in a religious community. Central African 
Journal of Medicine, 46(7), pp. 178-84. 
4. Niles, D. P. (November 1991). War trauma and post-traumatic stress disorder. 
American Family Physician, 44(5), pp.1663-9. 

Violence/Physical and Sexual Abuse 
Along with childhood neglect, emotional abuse, and the witnessing of violence, 
childhood physical abuse and sexual abuse are key causal factors in many of the 
most debilitating and persistent social, medical, and mental health problems 
experienced by adults. If not recognized and addressed, these childhood experiences 
lead to a cycle of violence and victimization in adulthood. The traumatization of 
children in our society remains highly prevalent, underreported, and ignored. 
Violence/Physical and Sexual Abuse Facts and Discussion Points 
. The number of children traumatized in the United States in a single year equals 
the number of combat veterans who served in Vietnam for a decade.1 
. The United States has the highest rate of rape of any country that publishes such 
statistics: 13 times higher than Great Britain and 20 times higher than Japan.2 
. Approximately 20% of children are sexually abused in some way before they 
reach adulthood, with this figure cumulating at a rate of about 1% each year.4 The 
sexual victimization rate is generally considered to be between 20% to 30% for 
females and between 10% to 20% for males.3-6 
. Girls are about 2.5 to 3 times at higher risk for sexual abuse than boys, although 
approximately 22% to 29% of all child sexual abuse victims are male.4,7-10 
. Thirty-eight percent of women report at least one experience of incest or extra-
familial sexual abuse before age 18; 28% report at least one such experience 
before age 14. Of these women, 16% were sexually abused by a relative and 4.5% 
by their fathers.4 
. Girls in high-income families are more frequently victims of incest than girls in 
lower-income families.4 
. A 1994 survey found 44.8% of African American women, 38% of white women, 
25.6% of Latina women, and 21.1% of Asian American women had histories of 
child sexual abuse.11 
. Persons with disabilities are at 1.5 to 5 times greater risk of sexual abuse and 
assault than are members of the general population.9 Of the most frequent crimes 
against people with disabilities, more than 90% are sexual offenses.12,13 
. Three to 10 children per 100 children under the age of 18 experience severe 
physical abuse.14 

. In 1992, 2.94 million cases of child abuse and neglect were reported in the United 
States. In the same year, an estimated 1,261 children died from abuse and neglect. 
An estimated rate of child neglect is 14.6 per 10,000 children.15 
. An estimated 2,000 children (90% under the age of 5) die annually in the United 
States from maltreatment, the leading cause of injury fatality in this age group.16,17 
. Over 90% of American parents have performed corporal punishment on their 
children by spanking, slapping, or other physical discipline. The same behavior 
between adults would be grounds for criminal proceeding.18 
. Twenty-five percent of infants one to six months are hit. This figure rises to 50% 
of all infants by six months to a year.20 
. In the United States, about 4 million adolescents are victims of serious physical 
assault, and 9 million have witnessed serious violence during their lifetime.19 
. Each year, at least 3.3 million children in the U.S. witness physical and verbal 
abuse among adults in their homes—behaviors ranging from insults and hitting, to 
fatal assaults with guns and knives.20 
. Each year, between 3.5 and 10 million children witness the abuse of their mother. 
Up to half are victims of abuse themselves.21 
. The number of seriously injured children who are victims of abuse and neglect 
quadrupled between 1986 and 1993.12 This is not thought to be due to increased 
reporting but to an actual real rise in incidence.22 
. Between 1986 and 1993 and under a restrictive standard of harm, the following 
estimates were reported: the number of sexually abused children rose by 83%, the 
number of physically neglected children rose by 102%, the number of emotionally 
neglected children rose by 333%, and the number of physically abused children 
increased by 42%.25 
. Homicide is the third leading cause of death for girls ages 11 to 14 and the second 
leading cause of death for girls ages 15 to 18.23 
. In inner-city neighborhoods, homicide is the fourth leading cause of death for all 
children ages 1 through 4, third for youth ages 5 through 14, and second for 
persons ages 15 through 24.22 
. Child neglect is more commonly reported than physical or sexual abuse and has 
profound consequences. Research sometimes fragments abuse experiences into 
distinct categories that do not distinguish the impacts of trauma such as poverty 
and neglect.24 

. Social discrimination, racism, sexism, and war may be considered culturally 
supported child maltreatment.25-28 
. One in five school-age children and 1 in 4 preschoolers live in poverty. Extreme 
poverty and homelessness may indicate ways in which American society 
withholds support for many of its citizens and indirectly maltreats large numbers 
of children.29 
. Reports of physical and sexual abuse are significantly lower than actual incidence 
due to repression, cultural shame, reporter unwillingness or inability to disclose or 
identify experiences as abusive, and other factors.29,30 
Violence/Physical and Sexual Abuse Recommendations 
. Public policy for the prevention and early intervention of child abuse and neglect 
in the United States is necessary to prevent the often severe and disabling 
neurological, psychological, physiological, and social effects of such abuse. 
. The prevention and/or treatment of interpersonal violence, especially childhood 
abuse, should be considered an extremely high priority for the behavioral health 
system as well as other public systems. 
Violence/Physical and Sexual Abuse References 
1. Perry, B.D., & Pate, J. E. (1994). Neurodevelopment and the psychobiological roots 
of post-traumatic stress disorder. In L. F. Koziol, & C. E. Stout (Eds.), The 
Neuropsychology of Mental Disorders: A Practical Guide. Springfield: Charles C. 
Thomas. 
2. Finkelhor, D., et al. (1990). Sexual abuse in a national survey of adult men and 
women: Prevalence, characteristics and risk factors. Child Abuse and Neglect: The 
International Journal, Vol.14(1), pp.19-28. 
3. Finkelhor, D., Hotaling, G., Lewis, I. A., & Smith, C. (1989). Sexual abuse and its 
relationship to later sexual satisfaction, marital status, religion, and attitudes. Journal 
of Interpersonal Violence, 4,279-399. 
4. Russell, D. D. H. (1986). The secret trauma: Incest in the lives of girls and women. 
New York, NY: Basic Books. 
5. Wyatt, G. E. (1985). The sexual abuse of Afro-American and White American 
women in childhood. Child Abuse and Neglect, 9, 231-240. 

6. Henschel, D., Briere, J., Magallanes, M., & Smiljanich, K. (1990, April). Sexual 
abuse related attributions: Probing the role of “traumagenic factors.” Paper 
presented at the annual meeting of the Western Psychological Association, Los 
Angeles, CA. 
7. Fergusson, D., Lynskey, M., & Horwood, L. (1996). Childhood sexual abuse and 
psychiatric disorder in young adulthood, I: Prevalence of sexual abuse and factors 
associated with sexual abuse. J Am Acad Child Adolesc Psychiatry 35:1355-1364. 
8. Finkelhor, D. (1993). Epidemiological factors in the clinical identification of child 
sexual abuse. Child Abuse Negl 17:67-70. 
9. Sobsey, D., Randall, W., & Parrila, R. (1997). Gender differences in abused children 
with and without disabilities. Child Abuse Negl, 21:707-720. 
10. U.S. Department of Health & Human Services. (1998). Child maltreatment 1996: 
Reports from the states to the National Child Abuse and Neglect Data System. 
Washington, DC: U.S. Government Printing Office. 
11. Urquiza, A. J., & Goodlin-Jones, B. L. (1994). Child sexual abuse and adult 
revictimization with women of color. Violence and Victims, 9(3):223-232. 
12. Sobsey, D. (1994). Violence and abuse in the lives of people with disabilities: The 
end of silent acceptance? p.52. 
13. Carmody, M. (1991). Invisible victims: Sexual assault of people with an intellectual 
disability. Australia and New Zealand Journal of Developmental Disabilities, 17, pp. 
229-236. 
14. AMA. (1993). Report of the Council on Scientific Affairs. 
15. National Victim Center. (1993). Crime and victimization in America: Statistical 
overview. Arlington, VA: National Victim Center. 
16. McClain, P. W., Sacks, J. J., Froehlke, R. G., & Ewigman, B. G. (1993). Estimates of 
fatal child abuse and neglect, US, 1979 through 1988. Pediatrics, 91:338-343. 
17. Ewigman, B., Kivlahan, C., & Land, G. (1993). The Missouri Child Fatality Study: 
Underreporting of maltreatment fatalities among children younger than five years of 
age, 1983 through 1986. Pediatrics, 91:330-337. 
18. Straus, M. A. (1994). Beating the devil out of them: Corporal punishment in 
American families. New York, NY: Lexington Book. 

19. From studies cited by Future of the Children. In World Mental Health Day: Faces of 
Violence and Trauma, 2002. Source: 
http://www.wfmh.org/wmhday/wmhd2002/seclfvt_violence.htm 
20. Jaffe, P., Wolfe, D., & Wilson, S. K. (1990). Children of battered women. Newbury 
Park, CA: Sage Publications. 
21. Edleson, J. (1999). Children’s witnessing of adult domestic violence. Journal of 
Interpersonal Violence, 14(8), 845. 
22. Sedlak, A. J., & Broadhurst, D. D. (1996). Executive summary of the Third National 
Incidence Study of Child Abuse and Neglect. U.S. Department of National Incidence 
Study of Child Abuse and Neglect. U.S. Department of Health and Human Service, 
Administration for Children and Families, Administration on Children, Youth and 
Families, and National Center on Child Abuse and Neglect. 
23. Coyne-Beasley, T., Moracco, K., & Casteel, M. (2003). Adolescent femicide: A 
population-based study. Arch Pediatr Adolesc Med, 157:355-360. 
24. R. Mazelis (personal communication). 
25. Ayalon, O., & Van Tassel, E. (1987). Living in dangerous environments. In M. R. 
Brassard, R. Germain, & S. N. Hart (Eds.), Psychological Maltreatment of Children 
and Youth (pp. 171-182). New York, NY: Pergamon. 
26. Gil, D. G. (1987). Maltreatment as a function of the structure of social systems. In M. 
R. Brassard, R. Germain, & S. N. Hart (Eds.), Psychological Maltreatment of 
Children and Youth (pp. 159-170). New York, NY: Pergamon. 
27. Jones, R. L., & Jones, J. M. (1987). In M. R. Brassard, R. Germain, & S. N. Hart 
(Eds.), Psychological Maltreatment of Children and Youth (pp.146-158). New York, 
NY: Pergamon. 
28. Reschly, D. J., & Graham-Clay, S. (1987). Psychological abuse from prejudice and 
cultural bias. In M. R. Brassard, R. Germain, & S. N. Hart (Eds.), Psychological 
Maltreatment of Children and Youth (pp. 137-145). New York, NY: Pergamon. 
29. Molnar, J. M., Rath, W. R., & Klein, T. P. (1990). Constantly compromised: The 
impact of homelessness on children. Journal of Social Issues, 46, 109-211. 
30. Russell, D., Bolen, R. (2000). The epidemic of rape and child sexual abuse in the 
United States. Sage Publications, Inc. 


Financing Strategies and Cost-Effectiveness 
There are significant social and economic costs to ignoring trauma. Numerous 
reputable studies have documented the link between the abuse and neglect of 
children and a wide range of medical, emotional, psychological, and behavioral 
disorders in adulthood. 
Financing Strategies and Cost-Effectiveness Facts and Discussion Points 
. Child abuse and neglect cost the United States almost $94 billion per year, or 
$258 million per day ($1,462 annually for every American family). The annual 
cost is conservatively estimated to be $94,076,882,529 per year in a 2001 report. 
Direct costs associated with the immediate needs of abused or neglected children 
total $24,384,347,302. They include: hospitalization, $6,205,395,000; chronic 
health problems, $2,987,957,400; mental health care system, $425,110,400; child 
welfare system, $14,400,000,000; law enforcement, $24,709,800; judicial system, 
$341,174,702. Indirect costs associated with the long-term and/or secondary 
effects of child abuse and neglect total $69,692,535,227. They include: special 
education, $223,607,830; mental health and health care, $4,627,636,025; juvenile 
delinquency, $8,805,291,372; lost productivity to society, $656,000,000; adult 
criminality, $55,380,000,000.1 
. Clients with a history of sexual abuse (with or without physical abuse) utilize 
significantly more crisis, inpatient, and restrictive residential setting services than 
those with a history of physical abuse alone.2 
. Long-term sequelae of severe child abuse generate over $100 billion in 
psychiatric and medical health care costs per year in North America. The majority 
of these costs are unrecognized and misattributed.3 
. In psychiatry, trauma-specific psychotherapy is the most financially cost-effective 
intervention.3 
. Annual cost of mental health care for victims of attempted or completed rape is 
$863 million. Total annual mental health care costs for adult survivors of child 
sexual abuse is $2.l billion.4 
. In Massachusetts, PTSD that is caused primarily by physical or sexual abuse in 
childhood costs the mental health care system about $47 million per year.5 
. Money is often spent in vain on treatment for substance abuse due to high relapse 
rates from unaddressed trauma-related problems.6 

. According to the National Mental Health Association (NMHA), American 
businesses, governments, and families contribute $113 billion per year to the cost 
of untreated and mistreated mental illness. Between 50% and 75% of these 
untreated and mistreated people have a history of trauma that either caused or is 
contributing to their mental illness. Based on the above figures, the cost of 
untreated trauma is between $65,500,000,000 and $84,750,000,000 per year.7 
. Seventy-five percent of adults in substance abuse treatment have a history of 
childhood abuse and neglect.7 The cost of unaddressed childhood trauma, based 
on public health care costs related to substance abuse treatment provided through 
Medicaid, is: 
o $582 million for addictive disorders; 
o $84 million for diseases attributable to substance abuse; 
o over $2 billion for disease for which substance abuse is a risk factor; and 
o $252 million for consumers with a secondary diagnosis of substance abuse 
(estimated % applied to figures from MIMH Policy Brief, June 2002).7, 8 
. The total cost of substance abuse and mental illness per year is more than $300 
billion. Of this amount, 75% or $225 billion may be attributable to unaddressed 
childhood trauma (estimated percentage applied to figures from MIMH Policy 
Brief, June 2002).8 
. Trauma caused by the Oklahoma City bombing resulted in long-term mental 
health problems for many people. The average costs of mental health services not 
covered by insurance were: 
o $2.8 million in treatment of direct victims; 
o $1.15 million out-of-pocket cost for rescuers; 
o $2.2 million for others in community with depression or PTSD; and 
o $3.2 million for substance abuse treatment. 9 
Financing Strategies and Cost-Effectiveness Recommendations 
. Increase collaboration between systems (substance abuse, mental health, 
correctional, etc.), and include trauma assessment and treatment to reduce costs. 

. Advocate routine intake assessment and screening for consumers with abuse 
history and trauma symptoms, as well as referral to trauma services as needed. 
Early treatment will help reduce the cost of care. 
. Incentivize private sector entities to join the initiative by articulating actions they 
can take that will decrease costs. 
Financing Strategies and Cost-Effectiveness References 
1. Prevent Child Abuse America. (2001). Total estimated cost of child abuse and neglect 
in the United States: Statistical evidence. Report funded by the Edna McConnell 
Clark Foundation. 
2. Newmann, J. P., Greenley, D., Sweeney, J. K., & Van Dien, G. (1998). Abuse 
histories, severe mental illness, and the cost of care. In B. L. Levin, A. K. Blanch, A. 
Jennings, Women’s Mental Health Services: A Public Health Perspective. pp. 279-
308. Sage. 
3. The Ross Institute (http://www.rossinst.com/TRAUMA.htm). 
4. Miller, T. R., Cohen, M. A., & Wiersama, B. (1996). Victim costs and consequences: 
A new look. U. S. Department of Justice, Office of Justice Programs, National 
Institute of Justice. 
5. van der Kolk, B. A. (January 1998). Psychology and psychobiology of childhood 
trauma. Prax Kinderpsychol Kinderpsychiatr, Vol. 47(1), pp. 19-35. 
6. R. Mazelis (personal communication, April 2002). 
7. Substance abuse treatment for persons with child abuse and neglect issues: Treatment 
Improvement Protocol (TIP) Series 36. (2000). Substance Abuse and Mental Health 
Services Administration, Center for Substance Abuse Treatment. 
8. University of Missouri Columbia School of Medicine. (April 2002). Missouri 
Institute of Mental Health policy brief. 
9. Healing the future: The long-term mental health needs of Okalahoma City. 
Department of Psychiatry and Behavioral Sciences, College of Public Health, 
University of Oklahoma. (limited public release). 


Workforce Development 
The public mental health workforce is largely unprepared to recognize and address 
the serious psychological impacts of unresolved trauma in the lives of the majority 
of children, adolescents, and adult consumers of mental health services. 
Workforce Development Facts and Discussion Points 
. Newly graduated mental health professionals across the country are unprepared to 
treat individuals with symptoms related to trauma. Almost no universities offer 
comprehensive trauma programs that prepare their graduates to address this 
complex disorder. As a result, clinicians may be scared, uncomfortable, and 
uncertain about their readiness to help survivors of trauma.1, 2 
. Without adequate training in evidence-based techniques to treat trauma, clinicians 
may: 1) offer untested therapies; 2) fail to recognize and treat symptoms ranging 
from flashbacks to anxiety to physical effects; or 3) provide treatment that is 
harmful.1, 3 
. Because few clinicians are trained to treat trauma, the mental health system was 
unprepared to help people—adults or children—deal with the profound 
psychological impact of the World Trade Center attack. Left untreated, the most 
serious mental health disorders brought on by trauma can lead to suicide.1 
. Traditionally the domain of psychology, the effects of trauma are more recently 
being examined by nurses, social workers, neurobiologists, public health workers, 
medical researchers, and others. Universities have been slower to combine these 
disciplines and create comprehensive study and research programs.4 
. Because of the multi-disciplinary approach needed to treat the impact of trauma, 
the study of trauma disorders does not easily fit into the existing structure of 
universities. It may take years before comprehensive trauma programs that 
incorporate current scholarly and professional work in trauma are included in the 
academic mainstream.4 
. There is a shortage of skilled medical or other professionals who have the 
expertise to treat or provide services to sexually abused children. Nor are there 
training programs which are standardized across disciplines and easily 
accessible.5 
. Much is known now about the impact of trauma. Training programs, degree 
programs, teacher preparation courses, etc., are deficient in conveying the 
research data to service providers.6 

. Material presented in trauma training may be challenging or threatening, and may 
elicit resistance to change and denial within some individuals and within entire 
systems. This resistance should be confronted and reduced.6 
Workforce Development References 
1. Marshall, S. (March 4, 2002). Mental health system failing 9/11 victims: Traumatized 
counselors lack skills, funds. Crain’s New York Business. 
2. Strom, S. (July 22, 2002). Mending the hearts broken on September 11 is as difficult 
as explaining the cost. The New York Times. 
3. Goode, E. (November 20, 2001). Treatment can ease lingering trauma of September 
11. Science Times, The New York Times. 
4. Cohen, P. (May 8, 1999). The study of trauma graduates at last. The New York Times. 
5. Gaffney, D. (March/April 2000). Child sexual abuse and assault: Different training 
standards for clinicians. Sexual Assault Report, Vol. 3, No. 4. 
6. S. Bloom (personal communication, April 2002). 

Peer Support and Self-Help 
Peer support, mutual support groups, and self-help approaches contribute greatly 
to recovery from abuse and trauma. These approaches are recognized as promising 
and/or evidence-based practices. 
Peer Support and Self-Help Facts and Discussion Points 
. Individuals who have resolved previous traumatic reactions are more resilient to 
disasters and should be viewed as valuable resources for disaster-stricken 
communities.1 
. By joining together, consumers have power and a voice that not only impact their 
individual treatment but attitudes toward and treatment of all consumers. This 
power has increased under the motto “Nothing About Us Without Us.”2 
. In its priority set of evidence-based practices for adults, New York State includes 
self-help and peer-support education and treatment for Posttraumatic Stress 
Disorder. As an example of evidence-based practice,3,4 self-help is a lifelong 
support that is beneficial to the sustained management of many health 
conditions.5,6,7 In response to the catastrophic events of 9-11-01, New York 
utilizes current research for the most effective treatments.8 
. The role of peer support and mutual support groups is of fundamental importance 
for many women survivors. Resources such as transportation, meeting space, 
funding for information resources, drop-in centers, and alternative peer-run crisis 
support centers are necessary for such “informal” networks to thrive. These 
networks provide a larger community of peers, and also greatly enhance healing.9 
. Many communities lack adequate peer advocacy services or peer support systems 
that can assist a trauma survivor in obtaining the necessary information or help to 
avert crisis or hospitalization. Without information as to which therapeutic 
approaches work best, it is difficult to advocate for trauma survivors or to control 
the therapeutic process.10 
. Peer support and self-help are useful and cost-effective tools in helping survivors 
overcome the shame that often accompanies trauma, and these tools also provide 
leadership, motivation and guidance. 
. Peer support and self-help are characterized by the following: 
o People experience themselves and their relationships across multiple roles. 

o People have the opportunity to de-construct and re-construct their mental 
health story within the context of these multiple roles and relationships. 
o People can express concern about coercive mental health practices without 
fear of retaliation. 
o As rights issues emerge, they may be viewed as political rather than 
personally pathologized (e.g., the effects of trauma and abuse). 
o People can practice “help” as both the receiver and the giver. 
o As peer support becomes an adjunct/alternative to traditional practice, 
people find they need less intensive professional treatment. 
o As people feel confident in their ability to help others, their sense of self-
efficacy strengthens (many go back to work). 
o People begin to make meaning of their experience outside the traditional 
rubric of mental health/mental illness (i.e. symptoms of trauma and abuse 
are no longer seen as personal pathology but rather as understandable 
reactions to the trauma). 
o People build relationships that establish new ways of understanding their 
experiences. 
o Peer communities develop norms, rituals, language, and outcomes from 
these new practices that may ultimately inform future direction for mental 
health services.11 
Peer Support and Self-Help Recommendations 
. Teach trauma survivors how to support each other. They can often be more 
helpful to each other than professional helpers through mutual understanding of 
their experience.10 
. Create means for consumers to feel supported through support groups, 
newsletters, conferences, warmlines (a support phone line). Train volunteers who 
are survivors to coordinate peer support services.10 
. Provide training for survivors that includes understanding of their own illness, 
better control of the therapeutic process, creating a positive attitude, meditation, 
and ways of managing symptoms. Teach techniques that deal with PTSD (i.e. 
focusing on something other than the trauma or flashbacks, using imagery, 
keeping a journal, listening to tapes, reading materials, enjoying self, and 
experiencing pleasure).10 

. Create support groups for sharing and discussing ways survivors have found to 
help themselves. Topics could include work, school, volunteering, supportive 
friends and family, participation in treatment programs.10 
. Develop a Web site in each state to provide information and education about 
trauma. This could be a project for graduate students.10 
. Develop “Trauma Information Centers.” Make materials available for self-
education, including books and other materials that provide survivors with tools to 
manage their own symptoms in non-traditional ways and in ways others have 
found helpful.10 
. Develop cost-effective, comprehensive peer-professional alliances in support of a 
trauma-preparedness support system. Such alliances provide a “surge buffer” to 
prevent relapse/crises among vulnerable people in the event of subsequent local 
traumas or mass disasters. 
. The facts on peer support fit with new ways of thinking about crisis, elimination 
of seclusion and restraint, minimizing the need for professional intervention with 
substance abuse, the Olmstead Act (in terms of least restrictive environment), and 
awareness of the effects of violence in relation to mental health. 
Peer Support and Self Help References 
1. Goode, E. (November 20, 2001). Treatment can ease lingering trauma of September 
11. Science Times, The New York Times. 
2. Greenley, D., Barton, J., Hennings, B., Marquez, L. B., & Michaelis, P. (March 31, 
2001). Promoting partnerships with consumers: An experiential report and “how to” 
guide. The Women and Mental Health Study Site of Dane County School of Social 
Work, University of Wisconsin-Madison. 
3. Carpinello, S. E., Knight, E. L., Markowitz, F. E., et al. (2000). The development of 
the mental health confidence sale: A measure of self-efficacy in individuals 
diagnosed with mental disorders. Psychiatric Rehabilitation Journal, 23:236-242. 
4. Segal, S. P., Silverman, C., & Temkin, T. (1995). Measuring empowerment in client-
run self-help agencies. Community Mental Health Journal, 31:215-227. 
5. Borkman, T. J. (1997). A selected look at self-help groups in the United States. 
Health and Social Care in the Community, 5:357-364. 
6. Kurtz, L. F. (1997). Self-help and support groups: A handbook for practitioners. 
Thousand Oaks, California: Sage. 

7. Vogel, H. S., Knight, E., Laudet, A. B., et al. (1998). Double trouble in recovery: 
Self-help for people with dual diagnoses. Psychiatric Rehabilitation Journal, 21:356-
362. 
8. Carpinello, S. E., Rosenberg, L., Stone, J., Schwager, M., & Felton, C. J. (February 
2002). New York State’s campaign to implement evidence-based practices for people 
with serious mental disorders. Psychiatric Services. 
9. Deegan, P. E. (July 13-16, 1994). Dare to vision: Shaping the national mental health 
agenda on abuse in the lives of women labeled with mental illness: A keynote 
address. Center for Mental Health Services Conference on Women, Abuse and Mental 
Health. Washington, DC. 
10. Jennings, A., Ralph, R. O. (June 1997). In their own words: Trauma survivors and 
professionals they trust tell what hurts, what helps, and what is needed for trauma 
services. Maine Trauma Advisory Groups Report. Maine Department of Behavioral 
and Developmental Services. Augusta, ME. 
11. S. Mead (personal communication, April 2002). 

Appendix A: 
Trauma Services Implementation Toolkit 
for State Mental Health Agencies 
This toolkit identifies written documents and products (the underlined words and phrases) 
providing examples of state systems activities contributing to the development of trauma-
informed mental health systems and trauma-specific mental health services. The 
documents and products are listed by state within a series of Trauma Services Categories. 
Although there are many other resources that may be helpful to recipients of mental 
health services who have histories of trauma, only those that specifically and explicitly 
address trauma will be listed in this appendix. 
The majority of these materials are available electronically and many of them can be 
obtained by contacting the individuals listed at the end of this appendix in the Publication 
Contacts section. Other publications used by states may need to be obtained from 
publishers or authors. 
This is a continually updated, working document. Last update: Fall 2002. 


Trauma Services Categories 
1. State trauma policy or position paper and/or definition of trauma 
Connecticut: 
. Department of Mental Health and Addiction Services Policy on Trauma-
Sensitive Services. Includes mission statement, definition and effects of 
trauma, meaning of recovery, value statement, value base, governing 
principles. 
Maine: 
. Definition of Trauma included in Department of Behavioral and 
Developmental Services Plan for Improving Behavioral Health Services for 
Persons with Histories of Trauma, August 2001. 
Maryland: 
. Department of Health and Mental Hygiene, Mental Hygiene Administration’s 
Division of Special Populations Trauma Addictions, Mental Health And 
Recovery (TAMAR) project Definition of Trauma for all Department 
programs in jails. 
Massachusetts: 
. Commissioner Monograph of March 10, 1999, summarizing key policy points 
and providing guidelines regarding treatment of Department of Mental Health 
clients with a history of trauma. 
Oregon: 
. Department of Human Services, Health Services, Mental Health and 
Addiction Services Trauma Policy (7/01/02). Includes Policy statement, 
definition of psychological trauma, background information and 
implementation plan. 
South Carolina: 
. Department of Mental Health Position Statement on Services for Trauma 
Victims. 
. DMH Definition Document on Trauma, Sanctuary Trauma, and Sanctuary 
Harm. 
Wisconsin: 
. Definition of Trauma by Bureau of Community Mental Health. 
Wyoming: 
. Policy regarding trauma is imbedded in Consumer Rights Policy Statement. 

2. Trauma assessment 
Connecticut: 
. Clinical staff in 2 hospitals and 25 state-operated and private non-profit 
agencies are being trained to conduct brief screens for trauma history and 
PTSD. Screening forms available. 
. Trauma screening is being done in connection with a statewide program, 
Project SAFE, to screen parents involved in the child welfare system who are 
suspected of having substance abuse problems. Screening forms available. 
Illinois: 
. Chicago’s Domestic Violence and Mental Health Policy Initiative’s Trauma 
Assessment Committee, in collaboration with the Office of Mental Health 
Chicago Bureau of Network Operations (CBNO), is developing domestic 
violence, trauma and safety assessment questions for 18 state-funded mental 
health and domestic violence agencies participating in an Intensive Trauma 
Training and Implementation Program. Questions will be reviewed by the 
DV/Trauma committee of the Greater Chicago Area Mental Health Planning 
Council and will be made available to all OMH-funded agencies. 
Maine: 
. Uniform Assessment Tools for Adult Mental Health incorporating brief 
assessment for trauma has been completed. These tools are designed for 
implementation throughout Maine’s adult mental health system including state 
operated and contract agencies, community hospitals and state institutions. 
. Uniform Assessment Tools for Children/Adolescent Mental Health 
incorporate trauma. 
. Trauma Screening Questionnaire, Introductory Information and Guidelines for 
Administration created by clinicians and consumers as part of Department of 
Behavioral and Development Services pilot project to develop trauma-
informed systems of services within local Community Mental Health Centers. 
Maryland: 
. All individuals coming into jails in eight Maryland counties are assessed for 
trauma through the Mental Hygiene Administration’s TAMAR project. Two 
assessment instruments are used: a brief intake form, and if indicated, a 
comprehensive trauma assessment form. 
Massachusetts: 
. Universal Trauma Assessment (computerized medical record) applicable to all 
DMH-operated programs. 

. Requirement that all licensed and contracted inpatient programs assess 
consumers for trauma on admission (by regulation). 
New York: 
. Brief Trauma Screening and Assessment forms for adults and for children will 
be incorporated into New York State Automated Medical Records. These 
forms are in development and will be pilot tested prior to final draft. The 
tested trauma screening and assessment instruments will be finalized within 
one year and implemented in all 28 New York State Hospitals. Adult 
assessments use PTSD checklist from the National Center for PTSD, adding 4 
questions and treatment recommendations. 
Rhode Island: 
. Kent County Mental Health Center intake package includes several questions 
regarding trauma histories. 
South Carolina: 
. Detailed trauma & PTSD screening instruments implemented for adults and 
children. Assessment in place for 2 Mental Health Centers and 2 hospitals. Six 
additional Mental Health Centers have begun assessments. 
. Adult Intake Packet includes SF-12v2 TM Health Survey, a Trauma 
Assessment, and PCL-C an assessment for trauma symptoms, National Center 
for PTSD. 
. An Interview for Children: Traumatic Events Screening Inventory (TESI-C) 
includes 16 items that survey the domains of potential traumatic experiences. 
The National Center for PTSD. Dartmouth Child Trauma Research Group. 
. Parent Questionnaire, includes questions about child and about self. 
. Trauma Symptom Checklist for Children, by John Briere, Ph.D. and 
Psychological Assessment Resources, Inc. 
Vermont: 
. Universal screening for trauma: Draft set of questions addressing trauma as 
part of intake for all Departments within the Vermont Agency of Human 
Services. Questions are incorporated into existing standard intakes. 
Wisconsin: 
. Guidelines for Assessment of Trauma: an approach to doing an assessment 
with referrals to various kinds of instruments. 
Wyoming: 
. Existing assessment tools incorporate questions about trauma issues. 

3. Clinical practice guidelines for working with trauma survivors 
Illinois (Chicago): 
. State of Illinois Office of Mental Health Chicago Bureau of Network 
Operations’ (CBNO) Greater Chicago Area Mental Health Planning Council 
has a Domestic Violence/Trauma Committee to develop practice and policy 
guidelines on trauma and domestic violence for State Office of Mental Health-
funded clinics and State Operated Facilities. 
. The Domestic Violence and Mental Health Policy Initiative is completing its 
Recommendations for Addressing Domestic Violence in Mental Health 
Settings. 
Maryland: 
. Clinical guidelines for working with trauma survivors in jail have been 
developed and implemented through the TAMAR project. 
Massachusetts: 
. Clinical Guidelines – 8/6/96 for DMH Clients with a History of Trauma. 
New York: 
. Evidence-Based and Promising Practice Initiative mandates NY State’s entire 
outpatient service system to make eight proven or promising practices 
available to clients. Trauma has been designated a promising practice. 
Technical Assistance Documents to the Field are being developed for each of 
eight practices, including guidelines, minimum standards and core 
competencies. Compliance will be tied to certification of agencies under 
contract with NYOMH, affecting mental health clinics, day programs, partial 
hospitalization and rehabilitation programs across the state. 
Oregon: 
. Draft Guidelines: Chemical Dependency and Mental Health Services for Co-
occurring Mental and Substance Use Disorders. Incorporates trauma in 
program policy and procedures, service delivery criteria, documentation, and 
staff competencies and training. Used and available in draft form. 
Rhode Island: 
. Kent County Mental Health Center worked with consumers and providers in 
the Coalition for Abuse Recognition and Recovery (CARR) to establish 
guidelines for working with trauma survivors. 
4. Specialized trauma treatment and/or support programs, including both trauma-
informed services and trauma-specific services 

Connecticut: 
. Statewide trauma treatment services are currently being developed. Two state 
hospitals and 25 state-operated and private non-profit mental health and 
addiction treatment agencies are participating in year-long, on-site training 
and consultation in identification and treatment of trauma. State/agency 
agreement, information and manuals on the treatment models, and information 
on the training model are available. 
. Each agency can choose one of the three following treatment models: 
o Seeking Safety: Designed to treat trauma and substance abuse at the same 
time. Focuses on coping skills to help clients achieve safety in their 
behavior, thinking, and relationships. Twenty-five topics, with client 
handouts, can be flexibly conducted in any order, including: Compassion, 
Asking for Help, Setting Boundaries in Relationships, Detaching From 
Emotional Pain (Grounding), Taking Good Care of Yourself, and 
Creating Meaning. It is present-focused, and can be used for group or 
individual treatment. Has achieved positive results in four outcome trials 
with women, men, women in prison, and minority women. Model, manual 
and materials developed by Lisa Najavits. See www.seekingsafety.org 
o Trauma Adaptive Recovery Group Education and Therapy (TARGET): A 
strengths-based model, explaining PTSD in terms of the body’s 
survival/alarm system and teaching a set of practical skills to enable 
participants to gain control of PTSD symptoms. Uses self-regulatory skills 
approach and experiential exercises to address topics including self-
esteem, anger, grief, shame, re-victimization, and spirituality. TARGET 
has versions of different lengths: 3-5 sessions, 9 sessions, and 26 sessions. 
Model, manual and materials developed by Julian Ford. 
o TREM (Trauma Recovery and Empowerment Model): A three-part 
psychoeducational model focusing on skill-building, trauma education, 
development of understanding of responses to trauma, and group cohesion 
and support. Each session is built around one of 33 topics and includes 
experiential and culturally diverse exercises. The model has achieved an 
80% retention rate with women who attend at least 75% of the sessions. 
There are separate versions of TREM that are highly gender specific for 
men and women. TREM is appropriate for consumers with mental health, 
co-occurring, or addictive disorders. Model and published manuals 
developed by Community Connections D.C. 
Illinois (Chicago): 
. The Domestic Violence and Mental Health Policy Initiative is working with 
nine state-funded community mental health agencies to pilot the development 
of trauma-informed and trauma-specific services utilizing the Trauma 
Recovery and Empowerment Model (TREM), the Sanctuary model (S. 

Bloom) and Risking Connection model (Sidran Foundation and Traumatic 
Stress Institute) and Harris and Fallot’s work on Trauma Informed Systems, 
Using Trauma Theory to Design Service Systems. This work is undertaken in 
conjunction with the authors of each model to address lifetime trauma in the 
context of ongoing abuse. Three hundred representatives from over 55 
domestic violence and mental health agencies participated in an introductory 
training on these issues in November 2001. Documents describing the 
Initiative are available. 
Maine: 
. Pilot project to develop a model trauma-informed system of services, initially 
in one unit of a major mental health agency, based on criteria outlined by 
Maxine Harris and Roger Fallot in monograph Using Trauma Theory to 
Design Service Systems. Project described in Department’s Plan for Improving 
Behavioral Health Services for Persons with Histories of Trauma. Evaluation 
pre- and post- implementation. Outcomes will determine replication of model 
in larger agency and across the BDS service system. Documents available 
include Plan, Evaluation Package, Screening Tools, Consumer Satisfaction 
Questionnaire. 
. Statewide Trauma Telephone Support Line provides 24-hour, 365-days-per-
year coverage to adults and adolescents with histories of sexual abuse trauma 
who have serious mental health or addiction problems. Special training for 
these Level 2 Calls. Service supported by BDS in collaboration with the 
Maine Coalition Against Sexual Assault. Description Document, Program 
Standards, RFP available. 
. Trauma Clinical Consultation Service. Department funds available regionally 
to all providers serving public mental health clients, to purchase trauma 
clinical consultation service on an as needed, fee-for-service basis. 
Description Document available. 
. Trauma Recovery and Empowerment Model (TREM) Psychoeducational 
Groups for Women offered through local centers of Maine Coalition Against 
Sexual Assault, and a variety of agencies for women with histories of sexual 
abuse and other trauma who have serious mental health and/or addiction 
problems. Model developed by Community Connections D.C. Published 
facilitator and participants manuals (See CT). 
. Trauma Recovery and Empowerment Model (M-TREM) Psychoeducational 
Groups for Men who have serious mental health and/or addiction problems. 
Offered through local centers of Maine Coalition Against Sexual Assault and 
a variety of community mental health agencies. Model and materials 
developed by Community Connections D.C. (See CT). 

. Maine Trauma Providers Listserve: a vehicle for dialogue between and among 
providers, educators, researchers, and others involved in trauma treatment 
and/or training in the state of Maine. Sponsored by Counseling Services Inc. 
in collaboration with the Department. Purpose, directions and guidelines 
available. 
Maryland: 
. Risking Connection Model, a framework for understanding and working with 
individuals with mental health and/or substance abuse problems who are 
survivors of childhood abuse, is implemented for both women and men in the 
correctional system including eight county jails, and in the agencies serving 
these individuals after their release. Model developed by the Sidran 
Foundation in collaboration with the states of Maine and New York. 
Published Curriculum and Manual. 
Minnesota: 
. Ananda Project/Dialectical Behavior Therapy: for multi-diagnosed, difficult-
to-treat clients, usually with histories of severe trauma; used to treat clients 
who are demonstrating out-of-control behaviors that interfere with standard 
treatments for individuals with trauma histories. Intensively trained team that 
teaches and consults with both state-operated and community-based agencies 
to treat clients with Borderline Personality Disorder and other trauma-related 
disorders within their home counties/cities. Service delivery plan and updated 
work plan now available. 
New Hampshire: 
. Trauma Recovery Group offered at the Greater Manchester Mental Health 
Center and West Central Services in Claremont. Twenty to twenty-one weeks 
long. Candidates are screened for referral via PTSD screening tool (PCLS). A 
cognitive restructuring approach combined with individual therapy. This is a 
pilot study, headed by Dartmouth Psychiatric Research Center (PRC). 
Description of study. 
New York: 
. Trauma Drop-In Groups: Low intensity groups facilitated by clinicians as a 
first step toward addressing trauma in treatment. Facilitators Manual: The 
Trauma Safety Drop-In Group: A Clinical Model of Group Treatment for 
Survivors of Trauma. 
Oregon: 
. Trauma-based Sanctuary Model (Sandra Bloom, M.D.) implemented at Salem 
General Hospital Psychiatric Inpatient Unit. Model universally applicable for 
all consumers. Has almost eliminated use of seclusion and restraint and other 
coercive measures. Articles available describing Sanctuary Model. 
Rhode Island: 

. Kent County Mental Health Center services are trauma informed. For 6 years 
staff have regularly attended agency sponsored trauma conferences with 
national trauma experts. They receive monthly staff training from the Sexual 
Assault and Trauma Resource Center. Description of training and conference 
brochures. 
. A Victims of Crime Program and a Victims of Trauma Program are 
implemented at Kent County Mental Health Center. Description of Programs. 
Vermont: 
. Statewide Trauma-Informed Service System is being implemented through the 
Vermont Agency for Human Services, based on model and criteria outlined in 
monograph Using Trauma Theory to Design Service Systems developed by 
Community Connections D.C. Overall implementation plan and plans for each 
Department (Mental Health, Social Welfare, Aging and Disabilities, Health, 
Corrections, Vocational Rehabilitation, Social Services and Child Welfare) 
are being developed. 
Wisconsin: 
. New Partnership for Women: a state-supported collaborative 
consumer/provider project operated out of the Madison YWCA is developing 
a consumer curriculum on trauma to be co-taught by consumers and providers 
for groups of consumers with histories of trauma across the state. This service 
includes working with groups on 1) understanding effects of trauma, 2) 
symptom self-management, 3) meeting basic needs, and 4) self-advocacy. The 
Consumer Curriculum and Manual is available. 
Wyoming: 
. Existing programs such as DBT and other groups incorporate trauma. Written 
materials. 
5. Procedures to avoid re-traumatization, including but not limited to seclusion and 
restraint reduction policies 
Maine: 
. Department of Behavioral and Developmental Services (BDS): Policy 
Regarding the Prevention of Seclusion and/or Restraint Informed by the 
Client’s Possible History of Trauma. Applies to all clients (adults, adolescents 
and children) supported directly by BDS staff and institutions (Mental Health, 
Mental Retardation, Substance Abuse). 
. Personal Safety Form for BDS Facilities/Staff: Guide to gathering information 
with clients for development of strategies to de-escalate agitation and distress. 
Used in conjunction with Trauma Assessment Form. 

. Trauma Assessment form for BDS Facilities/Staff. 
Maryland: 
. Procedures for avoiding retraumatization developed by the Department’s 
TAMAR project are implemented in jails and in community follow-up 
agencies. New procedures are being drafted with special application for 
women in jails who are pregnant. 
Massachusetts: 
. Massachusetts DMH Task Force on Restraint & Seclusion of Persons with 
Histories of Physical and Sexual Abuse: Report and Recommendations 
(1996). 
. DMH 8/6/96 Clinical Guidelines regarding DMH Clients with a History of 
Trauma, De-Escalation Form and Trauma Assessment. 
. The Safety Tool: a crisis prevention tool developed by clients and clinicians to 
address de-escalation planning and to identify triggers and behavioral 
strategies. 
. The Adolescent Safety Zone Tool. 
. Safety Tool Development for the Younger Child: An individual child-friendly 
(using pictures) de-escalation planning tool is being developed by DMH with 
experts Glenn Saxe, M.D., and Beth Caldwell, M.A., and members of the 
provider community. 
. Dr. Solomon Carter Fuller Mental Health Center Admission Assessment 
incorporating trauma. 
Minnesota: 
. Guidelines for assignment to intensive behavior care units in the Anoka-Metro 
Regional Treatment Center and the Willmar Regional Treatment Center 
intentionally separate individuals with known histories of trauma from those 
with known histories of perpetration. 
Missouri: 
. Form used at state facility modeled after language from Massachusetts 
Department of Mental Health Task Force on the Restraint and Seclusion of 
Persons who have been Physically or Sexually Abused, as presented at the 
first NASMHPD Summit of State Psychiatric Hospitals. All Missouri’s acute 
and psychiatric facilities have incorporated prompts/forms to assist in 
determining triggers. Provides a tool—when coupled with JCAHO required 
questions regarding histories of abuse—for clinicians to explore trauma-
related issues. 

New Hampshire: 
. New Hampshire Hospital: Restraint and Seclusion guidelines. 
. Nursing Database Assessment (trauma-informed). 
New York: 
. Trauma-Informed Seclusion and Restraint Policy mandated at all state 
facilities. 
Wisconsin: 
. Recommendations regarding seclusion and restraint of individuals with 
histories of trauma are included in Wisconsin Workgroup on Trauma’s Draft 
Recommendations to Bureau of Community Mental Health. 
Wyoming: 
. Sensitivity to past and recent trauma is built into all practices and procedures 
including physical examinations, dressing and undressing, transporting 
consumers, seclusion and restraint. Written documents available. 
6. Staff training, support, core competencies and job standards related to trauma 
California (Los Angeles): 
. Psychological Trauma Among People with Mental Illness and Substance Use 
Disorders: half-day, one-day, or two-day trainings offered once per year 
through the Los Angeles County Department of Mental Health Training and 
Cultural Competency Bureau in collaboration with UCLA Integrated 
Substance Abuse Programs Dual Diagnosis Study. Training is offered to 
mental health and substance abuse providers and reviews the background 
events and the conceptual basis for the development of the diagnosis of PTSD. 
Training materials available. Topics covered include prevalence rates, the 
neurobiology of trauma exposure, risk and resiliency factors, issues related to 
assessment and diagnosis, a trauma framework, and treatment approaches. 
This training incorporates several models: 1) The Risking Connection 
Curriculum (Sidran Foundation and Traumatic Stress Institute) provides 
training infrastructure; 2) Seeking Safety Model (developed by Lisa Najavitz); 
3) TREM - Trauma Recovery and Empowerment Model (developed by 
Maxine Harris); 4) The Body Remembers (Rothschild). 
Connecticut: 
. Statewide Meeting: Psychological Trauma: Myths and Realities (May 10, 
2002). Brochure. 
. Statewide Meeting: CT 2001 Women’s Conference: Defining a Vision for 
Behavioral Health Care (Oct 2-23, 2001). Brochure. 

. Three-day training offered once per year emphasizes cultural sensitivity and 
consumer perspective in treatment of trauma. Brochure. 
. Behavioral Management Strategies (BMS) training program has incorporated 
a unit on trauma. This is provided annually to all employees who participate in 
consumer care. 
Maine: 
. BDS Competency Model: Trauma identified as a Core Competency area 
required of all BDS employees. Describes learning objectives that must be 
met under seven competency areas of trauma. Used in supervision to identify 
training needs, and in design of training programs and curriculums. 
. Risking Connection Training Program: A 5-module trauma curriculum for use 
in public mental health, substance abuse and human service fields is offered 
regularly across the state to all levels of direct care staff in a variety of 
disciplines and treatment and support settings. It provides a basic framework 
and context for understanding and responding helpfully to clients with 
histories of trauma. Current trainings include: 
o Train-The-Trainer program for selected clinicians to provide in-service 
and other Risking Connection trainings throughout the state 
o Risking Connection (RC) training for Intensive Case Managers statewide 
o RC trainings for middle management and supervisory personnel in mental 
health and mental retardation fields 
o RC training for service providers working with clients with co-occurring 
disorders 
o RC training for clinical supervisors statewide 
o RC training on vicarious traumatization and burnout issues 
o RC training for providers in inpatient and residential settings 
o RC training for providers in partial hospital/day program settings 
. Crisis System Training and Case Consultation: Use of Dusty Miller’s 
ATRIUM model (an assessment and treatment recovery model for women, 
men and adolescents with addictions and trauma-generated co-occurring 
disorders) in training program for crisis system staff statewide. Training focus 
on responses to individuals in crisis who self-injure, are suicidal, or are 
otherwise at risk. Model published in Addictions and Trauma Recovery: 
Healing the Body, Mind and Spirit, by Miller and Guidry. 
. Six Annual Two-day Statewide Trauma Clinical Training Conferences: 
Summer 2000 Trauma in Childhood and Adolescence; fall 2001 Trauma, 
Substance Abuse and Mental Health; spring 2003 Trauma, Substance Abuse 
and Mental Health. National keynotes and multiple workshops. Conference 
brochures, all topics and presenter information. 

. TREM (Trauma Recovery and Empowerment Model) Training Programs 
conducted by Community Connection staff in all Regions of the state. Three-
day trainings of clinicians to facilitate psychoeducational groups for women 
trauma survivors with serious persistent mental health and/or substance abuse 
problems. Published facilitators manual and materials, by Maxine Harris, 
Ph.D. 
. MTREM (Men’s Trauma Recovery and Empowerment Model) Training 
Programs. Conducted by Community Connection staff statewide. Two-day 
trainings of clinicians to facilitate psychoeducational groups for male trauma 
survivors with serious persistent mental health and/or substance abuse 
problems. Published facilitators manual and materials, by Roger Fallot, Ph.D. 
Maryland: 
. Mental Hygiene Administration and local detention centers in-service training 
for all jail personnel, related community agencies and state hospitals, using 
varied adaptations of the Sidran Risking Connections model. 
. Conference April 12, 2000, Trauma and It’s Impact on Parenting presented by 
Sharon Melnick, Ph.D., Harvard Medical School. Topics: impacts of past 
traumatic experiences; how they affect relational capacities and current 
behaviors; common parenting dilemmas; major emotional themes with 
mothers seeking to provide their children with more supportive mothering 
than they received themselves. Brochure. 
. Conference December 4, 2000 Within the Walls of Change: Trauma 
Treatment in Correctional Settings, presented by Andrea Karfgin, Ph.D., 
Director of Trauma Services for MHA and Elizabeth Vermilyea, M.A., of 
Sidran Institute. Educate correctional personnel about the relationship 
between trauma, substance abuse, mental illness, and criminal behavior. 
Topics: interventions for managing traumatized inmates, reducing re-
traumatization, basic trauma understanding and responses, effect on workers. 
Brochure. 
. Conference December 14, 2000 Sisters Surviving Trauma, conducted by 
Jackie McKinney, founder National People of Color Consumer Survivor 
Network, and Denyse Hicks, Ph.D., Correctional Program and Training 
Specialist. Topics: treatment needs of, and delivering culturally sensitive 
services to, women of color who are survivors of trauma. Brochure. 
. October 19, 2001 Trauma, Parenting, and Attachment, presented by Sharon 
Melnick, Ph.D., Harvard Medical School, Andrea Karfgin, Ph.D., Director of 
Trauma Services for MHA, Victor Welzant, Psy.D., Director of Anne Arundel 
County Critical Incident Stress Management Team. Topics: effects of trauma 
on individual’s ability to parent. Brochure 

. Working with Borderline Personality Disorder/Crisis Management for 
Survivors, February 2002 and March 2002 trainings conducted by Elizabeth 
Vermilyea, M.A., Sidran Institute. 
. Trauma Symptom Management Training March 2002, by Elizabeth 
Vermilyea, M.A., Sidran Institute. 
. Maryland Mental Hygiene Administration Annual Conference: Trauma, 
Disaster, and Resiliency. National presenters covered topics related to trauma 
issues. Brochure. 
Massachusetts: 
. Child-oriented trauma training provided by Glenn Saxe, M.D. to the Child and 
Adolescent Acute and Continuing Care inpatient and intensive residential 
program providers. Funded through SAMHSA grant provided by National 
Center for Child Traumatic Stress Studies. 
. ASAP (Assaulted Staff Assistance Program) offers immediate telephone and 
on-site crisis intervention and support to staff victims of assault. 
. The Child and Adolescent Restraint Reduction Initiative (September 2000 – 
present) includes all acute (licensed) and continuing care (state-operated and 
contracted) and intensive residential treatment programs serving children and 
adolescents in Massachusetts. Providers receiving statewide trauma training 
on development of collaborative strength-based models of care. 
Minnesota: 
. Addressing vicarious traumatization of staff that work with trauma survivors 
to prevent burnout. Partially based on Perlman and Saakvitne’s Trauma and 
the Therapist. 
New York: 
. OMH Core Curriculum mandatory for all state employees with client contact, 
from housecleaners to doctors. Clinical module addresses trauma. 
. Comprehensive trauma training initiative for seven years including statewide 
training programs, conferences, consultations, discipline-based trainings, 
agency and facility-based trainings. Training descriptions, training models, 
conference brochures, training materials, and training strategic plans 
available. 
Oregon: 
. Trauma focused trainings, forums and conferences (two hours to two days) 
given, on average, three times a month in 2001 and 2002. Trainings are 
statewide, multi-agency, culturally diverse, and for the full age range. 

Brochures, handouts and overheads available following all trainings and 
conferences. 
. Trauma training programs have introduced providers of public mental health 
services to the following models for understanding and responding to trauma: 
o Risking Connection: A Training Curriculum for Working with Survivors 
of Childhood Abuse 
o TREM: Trauma Recovery and Empowerment Model for Working with 
Women in Groups 
o MTREM: Trauma Recovery and Empowerment Model for Working with 
Men in Groups 
o Seeking Safety: Model for Working with Trauma and Addiction 
o Dialectical Behavior Therapy 
. Conferences: 
o Beyond Sensitivity and Awareness: Improving Mental Health Services to 
Diverse Communities. Statewide Conference 
o Recovery Model Services for Trauma Victims: Learning from the Oregon 
Experience. North Sound Regional Support Network 
o Psychological Trauma Policy: Statewide Regional Forums 
o Trauma Awareness and Responsive Mental Health Services: OR HMOs 
o Trauma and Transformation. Trauma Relief Services of the Northwest 
Rhode Island: 
. Kent County MHC staff receive regular training from the Sexual Assault and 
Trauma Resource Center through a reciprocal agreement with the Center. 
Staff are trained in DBT and EMDR to work with trauma survivors, co-
sponsor an annual trauma conference, and to perform alternative dispute 
resolution and CPI (Crisis Prevention and Intervention). Agency designated 
by Center for Nonviolence and Peace Studies as the only nonviolent 
community mental health center in Rhode Island. Documents describing 
trainings; conference brochures. 
Vermont: 
. Training and consultation for Agency of Human Service (AHS) department 
managers re: Trauma Informed Service Systems. One hundred and fifty AHS 
department senior managers will receive a half-day of orientation from 
Maxine Harris and Roger Fallot of Community Connections, plus half-day of 
consultation for each department concerning planning for improving trauma 
sensitivity within the department. Model described in published monograph 
Using Trauma Theory to Design Service Systems, by Harris and Fallot. 
Wisconsin: 

. Three models for in-service training of department employees and staff of 72 
county mental health service systems are included in Wisconsin Trauma 
Workgroup recommendations to the Bureau of Community Mental Health and 
the Bureau of Substance Abuse: 1) Risking Connections developed by Sidran 
Foundation and Traumatic Stress Institute in collaboration with states of 
Maine and New York and adapted for cross-systems training; 2) a trauma 
curriculum and materials developed as a result of the Women and Violence 
project (description available); and 3) a Consumer Curriculum developed by 
consumers and providers. Curriculum draft available. 
Wyoming: 
. Staff certification and re-certification procedures incorporate understanding 
and sensitivity to trauma. 
7. Linkages with higher education on trauma issues 
Maine: 
. Mental Health Rehabilitation Technician (MHRT) Certification Program 
requires 10 Associates Degree level courses, including one on trauma (see 
MHRT Trauma Competencies). Certification necessary for variety of direct 
care positions including community support workers and crisis workers. 
Rhode Island: 
. Rhode Island Council of Community Mental Health Organizations Case 
Management Certification Program, sponsored and funded by the Department 
of Mental Health and Mental Retardation, includes a trauma assessment 
treatment module. 
8. Quality improvement, regulations and evaluation processes addressing trauma 
Maine: 
. Rules currently under revision will strengthen existing requirement to reduce 
use of restraint or time-out in mental retardation settings and to include a 
specific evaluation for the presence of trauma-related issues in the 
development of treatment plans that may include intrusive procedures. 
. Licensing rules are being developed to bring all services regulated by BDS 
into a common level of compliance. Included in these rules are assessment 
standards that require steps to identify both the presence of trauma and any 
self-soothing or self-calming techniques developed by the person receiving 
services. The rules further require that treatment plans recognize and support 
these techniques. 
Massachusetts: 

. DMH Regulations effective January 1, 1998, require that all inpatients be 
asked about trauma history, that this information be considered in the use of 
restraint, and that staff develop approaches and strategies to reduce use of 
restraint and its traumatic impact on clients with a trauma history. Regulations 
apply equally to all public and private inpatient facilities that are operated, 
licensed or “contracted for” by DMH. Included in Massachusetts Dept of 
Mental Health Licensing and Operational Standards for Mental Health 
Facilities. Accompanied by clinical guidelines. 
. The Child and Adolescent Restraint Reduction Initiative (Sept. 2000 – 
present) includes all acute (licensed), continuing care (state-operated and 
contracted), and intensive residential treatment programs serving children and 
adolescents in Massachusetts. Regulations to eliminate the use of restraint for 
children under the age of 10 and to increase trauma-sensitive training 
requirements are under development as part of the initiative. 
New Hampshire: 
. State Contracts with CMHCs Exhibit A state that the development of the 
Individual Service Plan (ISP) shall also address trauma related issues, if the 
provision of those services is deemed medically necessary. 
9. Research, surveys, needs assessments regarding trauma used for planning 
California (Los Angeles): 
. A five-year NIDA-funded UCLA Integrated Substance Abuse Program dual 
diagnosis treatment outcome study that evaluates the delivery of public sector 
mental health and substance abuse treatment services within Los Angeles 
County delivered to individuals with both severe mental illness and substance 
use disorders. Extensive assessments of demographic and background data, 
level of functioning, psychiatric and drug treatment histories, drug and mental 
health treatment services received, substance use and psychiatric family 
histories, criminal activities, risky sexual behaviors, trauma symptoms, trauma 
exposure and PTSD and other Axis I diagnoses assessed with the SCID for the 
DSM-IV. Participants were 400 men and women (age 18 or older) 
consecutively recruited from 11 residential drug treatment programs and also 
either receiving or seeking mental health services from outpatient mental 
health programs in Los Angeles County. Study found 60% of sample 
experienced five or more different types of exposures to traumatic events at 
some time in their lives. Article “Perceived Need for Treatment Services 
Among the Dually Diagnosed In Drug Treatment With and Without 
Posttraumatic Stress Disorder” by Leslie Cooper, Christine E. Grella, and Lisa 
Greenwell is under submission for publication. 
Connecticut: 

. Through the DMHAS Research Division and in collaboration with the 
University of Connecticut Health Center Department of Psychiatry, the 
following ongoing projects guide Department thinking about how to approach 
trauma treatment: 
o Clinical Feasibility Study: Consultation with teams of front-line clinicians 
interested in trauma-related services from two community mental health 
agencies and three community substance abuse treatment agencies led to 
the successful adaptation, pilot testing for clinical feasibility, and 
refinement of a manualized treatment model (TARGET) over a 12-month 
period (Ford, 1999). Target Manual. 
o Assessment Study: Funded by DMHAS and the University of Connecticut 
Health Center, this study involves an intensive interview assessment of 
trauma history, PTSD, disorders of extreme stress, other psychiatric, 
addictive, and medical illnesses, resilience and positive adaptation, and 
health care utilization in women and men in community mental health 
treatment for severe and persistent mental illness (including hearing 
impaired, Spanish-speaking, and African American clients). Results used 
to assist in determining criteria for the selection of trauma treatment 
models. Article available. 
o Randomized Controlled Trial: A three-year SAMHSA-funded randomized 
controlled trial of the TARGET treatment model versus trauma sensitive 
usual care is ongoing in three outpatient substance abuse treatment 
facilities. Article available. 
Illinois (Chicago): 
. The Domestic Violence Mental Health Policy Initiative conducted a needs 
assessment with 16 domestic violence agencies and 55 community mental 
health and social service agencies (47% return rate) re: trauma and domestic 
violence. Eighteen agencies (9 OMH-funded) completed a baseline trauma 
self-assessment as part of an ongoing evaluation of an Intensive Trauma 
Training and Implementation Program to address adult and child trauma in the 
context of domestic violence. 
Maine: 
. Trauma Cost Study Using Medicaid Claims Data from 1996 to 2001 on 1,397 
Class Members (past and present consumers at Augusta Mental Health 
Institute). Projected Completion of findings: fall, 2002. Study in collaboration 
with Nathan Kline Institute. Report on methodology and preliminary findings 
available. 
. Trauma Advisory Groups Needs Assessment of Survivors and Professionals: 
Written description of process and focus group question. 

. In Their Own Words: Trauma Survivors and Professionals They Trust Tell 
What Hurts, What Helps, and What Is Needed for Trauma Services. (1997). 
Report on Trauma Advisory Groups findings. 
. Survey of Maine Mental Health Service Providers regarding Trauma Training 
and Service Needs: Questionnaire. 
. Maine Mental Health Services Provider Survey Report: Trauma Training and 
Service Needs. (1997). 
New Hampshire: 
. New Hampshire Dartmouth Psychiatric Research Center (PRC) is piloting 
programs and conducting trials at the state psychiatric hospital to improve 
recognition and treatment of trauma and post-traumatic disorders. 
. At New Hampshire Hospital, testing the use of computerized assessment to 
screen for trauma exposure and PTSD in acute admissions, and providing 
psycho-education and triage for those with post-traumatic symptoms. 
. At multiple regional mental health centers, conducting a randomized clinical 
trial of an individual. Twelve to sixteen-session cognitive-behavioral 
treatment for PTSD for people with another severe mental illness. 
. At one regional mental health center, conducting a pilot study of a 21-session, 
group-based, cognitive-behavioral intervention for symptoms of PTSD in 
clients with severe mental illness. 
Pennsylvania (Philadelphia): 
. The PVS (Poverty, Violence, and Substance Abuse) Disaster Pilot, conducted 
by the Philadelphia Women’s Law Project and funded by a grant from the city 
of Philadelphia to evaluate treatment for pregnant, parenting, substance-
abusing women. Final Report includes recommendations to the City and a 
literature review by Sandra Bloom, M.D. Trauma was identified as central to 
all other issues. Final Report available from Women’s Law Project. 
South Carolina: 
. Survey of adequacy of assessment and clinical services in SCDMH centers 
and hospitals: Summary of findings. 
. Survey of clinician training needs and summary of findings. 
. Pilot study of Trauma in the Psychiatric Setting and summary of findings. 
. Study of trauma history and PTSD diagnosis from intake, summary of 
findings. 

10. Financing mechanisms to pay for trauma services 
Connecticut: 
. Providers bill third party payers for group trauma treatment as they would for 
other services. 
Maryland: 
. Fee for Service system includes treatment of trauma as a medical necessity. 
Rhode Island: 
. Insurance companies pay for clinical services such as EMDR, DBT, treatment 
of Posttraumatic Stress Disorder. 
Wyoming: 
. Financing process is liberal and flexible; covers individual and group trauma 
treatments. 
11. Consumer trauma survivor involvement in all aspects of planning, evaluation 
and delivery of trauma services 
Connecticut: 
. Along with clinical training, each of the 25 state-operated and private non-
profit mental health and addiction treatment agencies participate in a training 
presented by consumers and based on a film developed by the Department 
entitled No More Secrets. Videotape and guidebook are available. 
Maine: 
. Consumer/trauma survivor staff of Department’s Office of Consumer Affairs 
are members of the Department Trauma Services Implementation Team, 
responsible for trauma planning and implementing as well as overseeing the 
delivery and evaluation of trauma services. Described in A Plan for Improving 
Behavioral Health Services for Persons with Histories of Trauma and in two 
Updates. 
Maryland: 
. Consumers are consulted during all aspects of planning, evaluation, and 
delivering trauma services for every project developed within the Mental 
Hygiene Administration. The Division of Special Populations has developed a 
position, Director of Advocacy Services, that oversees development of peer 
support groups as well as the TAMAR Advocates Board, a group of 
consumers who meet monthly to discuss the delivery of trauma informed 
services. Description documents available. 
Rhode Island: 

. Coalition for Abuse Recognition and Recovery (CARR)—a group of 
consumers and professionals—designed a system of care for Kent County 
MHC, established criteria for consumer friendly programs, and performed 
community education and training on trauma issues. Trauma survivors serve 
on Kent County MHC Board of Directors. Written documents available. 
South Carolina: 
. The DMH Trauma Initiative committee is co-chaired by the Director of the 
Office of Consumer & Family Affairs, with 5 Consumer Affairs Coordinators 
on the committee. Consumer speakers conduct sensitivity training at state 
facilities and mental health centers. Description of work available. 
Wisconsin: 
. Promoting Partnerships with Consumers: An Experiential Report and “How 
To” Guide, (Greenley, Barton, Hennings, Marquez, and Michaelis). Paper 
informing state system developed through The Women and Mental Health 
Study Site of Dane County. 
12. Culturally, racially, and ethnically relevant trauma policies and services 
Connecticut: 
. Trauma policy addresses cultural issues. 
. Three-day training offered one time per year to address cultural issues in 
treatment of trauma. Brochure. 
. Training film being developed on trauma/culture. Video will be available by 
2003. 
. All trauma planning, policy, and training is reviewed by the Office of 
Multicultural Affairs. Policy description. 
Maryland: 
. Any policy or service that is developed is reviewed by Mental Hygiene 
Administration’s Coordinator of Multi-Cultural Affairs to ensure the product’s 
cultural competency. Policy description. 
. A training held December 14, 2000, Sisters Surviving Trauma: Women of 
Color and Trauma, addressed how the treatment needs of women of color may 
be different than traditional needs and how to deliver culturally sensitive 
services to women of color who are survivors of trauma. Training brochures 
and materials. 

13. Systems integration/coordination between and among systems of care serving 
trauma survivors and including life-span perspective 
Illinois: 
. Chicago Domestic Violence Mental Health Policy Initiative (DVMHPI) 
facilitates ongoing cross-training between domestic violence and mental 
health agencies, and has conducted a cross-training conference on Domestic 
Violence, Lifetime Trauma and Mental Health: Addressing the Mental Health 
Needs of Domestic Violence Survivors and their Children, November 2001. 
DVMHPI is currently cross-training nine Domestic Violence and nine Mental 
Health agencies in Risking Connection, Trauma Recovery Empowerment 
Model (TREM), Trauma Recovery Empowerment Profile (TREP) client 
rating sheet, Trauma Informed Systems (Community Connections), and 
Shelter From the Storm (a curriculum for treating children exposed to 
violence, developed by Betsy McAlister Groves at Boston University). 
Additional cross-trainings planned for 2002-2003 include Creating Sanctuary; 
Domestic Violence, Mental Health Trauma and the Law; Addressing Issues of 
Culture, Community and Spirituality. 
Massachusetts: 
. WELL project (Women and Co-occurring Disorders and Violence grant 
awarded to IHR) state leadership council (including DMH) is developing 
recommendations for integrating systems of care across state agencies for 
trauma survivors with co-occurring mental health and substance abuse 
disorders 
Minnesota: 
. Ananda Project/Dialectical Behavior Therapy: for multi-diagnosed, difficult-
to-treat clients, usually with histories of severe trauma; used to treat clients 
who are demonstrating out-of-control behaviors that interfere with standard 
treatments for individuals with trauma histories. Intensively trained team that 
teaches and consults with both state-operated and community-based agencies 
to treat clients with Borderline Personality Disorder and other trauma-related 
disorders within their home counties/cities. Service delivery plan and updated 
work plan now available. 
Vermont: 
. Vermont Agency of Human Services: Trauma Policy Cluster, a multi-
department and multi-discipline approach to implementing Year 2000 
Vermont Legislative Commission on Psychological Trauma 
recommendations. Based on criteria outlined by Maxine Harris and Roger 
Fallot in monograph Using Trauma Theory to Design Service Systems (New 
Directions for Mental Health Services #89, Spring 2001). A Policy Cluster 
approach to providing services is being implemented by AHS among 
department leaders in order to integrate multi-departmental responses and 
break down barriers so they can map out unified, coherent strategies for 

individuals and families in trouble 
(www.ahs.state.vt.us/PolicyClusters/Trauma020507update.cfm). 
Wisconsin: 
. Bureau of Community Mental Health Cross Trauma Training with mental 
health, substance abuse, domestic violence and sexual assault organizations. 
Crossroads Cross Training Manual, 1999 Crossroads Conference Proceedings, 
and video Meeting at the Crossroads. 
. Cross-systems training using the Risking Connections model with Substance 
Abuse, Mental Health, Developmental Disabilities Network, Sexual Assault 
Coalition, Lutheran Social Services, and the Department of Corrections. 
14. Disaster planning and response (including response to terrorism) is trauma 
informed 
Connecticut: 
. Center for Trauma Response, Recovery, and Preparedness (CTRP) is joint 
project of DMHAS, UConn Health Center Department of Psychiatry and Yale 
Department of Psychiatry. Statewide training and development of behavioral 
health response infrastructure. www.CTRP.org 
Rhode Island: 
. Kent County Mental Health Center services to school children around issues 
of trauma and terrorism through United We Stand Grant. Numerous 
community presentations after September 11th about trauma and its 
relationship to terrorism. Descriptive documents available. 

Other Available Resources 
State Publications, Newsletters, Web Sites Addressing Trauma 
Connecticut: 
. Trauma Matters: Newsletter to keep the behavioral health community, trauma 
survivors, and other interested persons informed about current efforts to 
address trauma as a public health issue. Produced by the Connecticut 
Women’s Consortium and the Connecticut Department of Mental Health and 
Addiction Services in support of the Connecticut Trauma Initiative. 
. Trauma Matters Web site includes information on Trauma Initiative and 
bulletin board Q&A for clinical staff who can pose questions to Lisa Najavits, 
Julian Ford, and Maxine Harris. www.traumamatters.org 
. Training Videotape and guidebook, No More Secrets. 
. From the Heart: Women Speak Out About Trauma. (2001). DVD. 
Illinois: 
. Domestic Violence Mental Health Policy Initiative quarterly newsletter. 
. Forthcoming working papers (print and Web-based): 
o Recommendations for Addressing Domestic Violence in Mental Health 
Settings 
o Mental Health and Domestic Violence: Collaborative Initiatives, Service 
Models and Curricula 
o Report on Mental Health Issues and Service Needs in Chicago Area 
Domestic Violence Advocacy Programs 
o Domestic Violence, Trauma and Mental Health: Developing Collaborative 
Responses, Domestic Violence, Trauma and Mental Health: Critical issues 
for Public Policy 
Maine: 
. Break the Silence, Support the Healing: What Happens To Abused Children 
When They Grow Up? (1999). Public Education pamphlet. 
. What Happens to Abused Children When They Grow Up – If No One Notices, 
Listens or Helps? Some Statistics from the Research. (2001). 
. In Their Own Words: Trauma Survivors and Professionals They Trust Tell 
What Hurts, What Helps, and What Is Needed For Trauma Services. (1997). 
Book. 

. Community Retraumatization. (1997). 
. Trauma and Recovery Resource: Books Recommended by Survivors for 
Survivors: An Annotated Bibliography. (1997). 
. Trauma Referral, Training, Consultation: Resource Book. (May, 1999). Book. 
New York: 
. Office of Mental Health Trauma Newsletter. 
Oregon: 
. Listening to High Utilizers of Mental Health Services: Recognizing, 
Responding to and Recovering from Trauma. By Lyn Blackshaw, Ph.D., 
Andrea Levy, M.A., L.P.C., Janice Perciano, B.S., State of Oregon Mental 
Health and Developmental Disability Services Division (2/1999). This 114-
page report recommends a map of safe options model of treatment and support 
for survivors of severe childhood and adult trauma. 
South Carolina: 
. The South Carolina Department of Mental Health Trauma Initiative 
Newsletter: A publication of the Trauma Initiative Task Force. 
Vermont: 
. Integrated Responses to Complex Problems: Trauma Policy Cluster. A Web 
site of Vermont Agency of Human Services: 
www.ahs.state.vt.us/PolicyClusters/ 
Wisconsin: 
. Networking Exchange Web site: A consumer-run Web site facilitating 
communication between providers and consumers, and between consumers 
and consumers. Addresses trauma, substance abuse, and mental health issues. 
www.networkingxchange.advoc8.com 
State System Progress Reports and Planning Documents Addressing Trauma 
Connecticut: 
. Summary of Trauma Initiative, March 28, 2002 
. Preferred Practices Guidelines for Treatment of Trauma 
Maine: 
. A Plan for Improving Behavioral Health Services for Persons with Histories 
of Trauma, August 2001: Includes historical background, accomplishments, 
next steps and future activities, with objectives, action steps, timing and 

budget. Two Updates to the Field have been distributed describing progress 
made. 
Maryland: 
. Mental Hygiene Administration’s Annual State Mental Health Plan FY 2001, 
FY 2002 and FY 2003 objectives all address using State funds to implement 
and expand trauma treatment programs in correctional facilities and their 
surrounding communities. 
New Hampshire: 
. New Hampshire State Mental Health Plan: Goal 1–3 stipulates recognition 
through practice that the experience of trauma is common in the lives of 
people served within the public mental health system, and outlines objectives 
which address trauma assessment, best practices, staff and peer education in 
trauma, and minimization of traumatizing restrictive/coercive measures. 
Rhode Island: 
. Kent County Mental Health Center Strategic Plan and operational goals 
specifically address trauma issues. 
South Carolina 
. Department of Mental Health Trauma Initiative Progress Report: 6/20/02: 
Includes mission, committee description, trauma definitions, progress to date, 
timeline, research summaries, and attachments of newsletters, conference 
brochure, assessment instruments and DMH Community Plan excerpts. 
. Making Recovery Real: A Planning Document for the South Carolina 
Department of Mental Health: Includes goals and implementation plan for 
improved screening and diagnostic practices to appropriately identify and treat 
trauma-related symptomatology in children, adolescents and their families; 
includes goals and implementation plans to improve understanding of the 
relationship between trauma and mental health, and to improve services to 
address trauma issues for adults with trauma histories. 
Vermont: 
. Report of The Commission On Psychological Trauma to the Vermont House 
and Senate Committees on Health and Welfare: Impact on Vermont citizens 
and Recommendations for Public Policy (November 2000). 
Wisconsin: 
. Wisconsin Workgroup on Trauma’s Draft Recommendations to Bureau of 
Community Mental Health. 
Wyoming: 
. Sensitivity to trauma is imbedded in system of care plans including suicide 
prevention and programs that address community trauma 


Publication Contacts 
If you are interested in obtaining more information about the underlined documents listed 
in Appendix A of this document, contact the appropriate official from the following state 
offices. 
California: 
Leslie Cooper, Ph.D. 
Project Director 
ULA Integrated Substance Abuse Program 
1640 South Sepulveda Blvd 
Suite 200 
Los Angeles, CA 90025 
310-445-0874 Ext. 276 
Fax: 310-473-7885 
E-mail: LBCooper@ucla.edu 
Connecticut: 
Judy Ford 
Trauma Initiative Coordinator 
Department of Mental Health and Addiction Services 
410 Capital Ave. 
P.O. Box 34143 MS 14 COM 
Hartford, CT 06134 
860-418-6732 
E-mail: Judith.ford@po.state.ct.us 
Illinois: 
Carol Warshaw, M.D. 
Director, Domestic Violence and Mental Health Policy Initiative 
Cook County Hospital 
1900 W. Polk St., Rm 930 
Chicago, IL 60612 
213-419-9220 
Fax: 773-327-0962 
E-mail: Clwarshaw@aol.com 
Maine: 
Brenda M. Harvey, M.S.Ed., C.R.C. 
Acting Deputy Commissioner 
Maine Department of Behavioral 
and Developmental Services (BDS) 
Station 40 
Augusta, Maine 04333 
207-287-4205 
Fax: 207-287-4268 

E-mail: Brenda.Harvey@maine.gov 
Maryland: 
Joan Gillece, Ph.D. 
Assistant Director, Special Needs Populations 
Mental Hygiene Administration 
Clifton T. Perkins Hospital 
P.O. Box 1000 
Jessup, MD 20794 
410-724-3238 
E-mail: gillecej@dhmh.state.md.us 
Massachusetts: 
Nan Stromberg 
Psychiatric Clinical Nurse Specialist 
Director of Nursing 
Licensing Division, DMH Central Office 
25 Staniford St., Room 3082 
Boston, MA 02114 
617-626-8119 
E-mail: Nan.Stromberg@dmh.state.ma.us 
E-mail: stromwick@aol.com 
Minnesota: 
Beverly Long, M.A., L.P. 
Training Coordinator, Ananda Project 
Suzanne Witterholt, M.D., Director, Ananda Project 
Anoka-Metro Regional Treatment Center 
3301 Seventh Avenue North 
Anoka, Minnesota 55303 
763-712-4387 (Bev) 
763-712-4391 (Suzanne) 
E-mail: Beverlly.Long@state.mn.us 
New Hampshire: 
Marilyn Cloud, Administrator 
Office of Policy and Planning 
Division of Behavioral Health 
105 Pleasant Street 
Concord, NH 03301 
603-271-5160 
E-mail: mfraser@dhhs.state.nh.us 
New York: 
Janet Chassman, Director 
Trauma Unit 

New York Office of Mental Health 
44 Holland Avenue 
Albany, NY 12229 
518-474-8472 
E-mail: jchassman@omh.state.ny.us 
E-mail: cosojxc@omh.state.ny.us 
Oregon: 
Lyn Blackshaw, Ph.D. 
Coordinator of Trauma Policy & Implementation 
State of Oregon 
Mental Health and Developmental Disability Services Division 
2575 Bittern Street, NE 
Salem, OR 97310 
503-945-9700 
E-mail: Lyn.blackshaw@state.or.us 
Rhode Island: 
David Lauterbach, President/CEO 
The Kent County Mental Health Center 
300 Centerville Rd., Suite 301s 
Warwick, RI 02886 
401-738-1338 Ext. 220 
Fax: 401-738-6442 
E-mail: Dlauterbach@KCMHC.org 
South Carolina: 
Karen Cusack, Ph.D. 
Project Director, SCDMH Trauma Initiative 
Charleston/Dorchester Mental Health Center 
701 East Bay St. MSC1110 
Charleston, SC 29403 
E-mail: kjc42@chamhc.dmh.state.sc.us 
Vermont: 
John Pierce 
Assistant Director Mental Health Programs 
VT DDMHS 
103 S. Main St. 
Weeks Building 
Waterbury, VT 05671-1601 
802-241-2604 
E-mail: jpierce@ddmhs.state.vt.us 
Wisconsin: 
Marge Tully, Consultant 

Bureau of Community Mental Health 
Room 443 
Wisconsin Department of Health and Family Services 
1 West Wilson 
P.O. Box 7851 
Madison, WI 53707-7851 
608-267-5139 
Fax: 608-267-7793 
E-mail: Tullyme@dhfs.state.wi.us 
Wyoming: 
Pablo Hernandez M.D., Administrator 
Division of Behavioral Health, 4th Floor 
447 Hathaway Bldg 
Cheyenne, WY 82002 
307-777-7997 
E-mail: Jskog@state.wy.us 

Appendix B: 
NTAC National Experts Meeting on Trauma and 
Violence 
Participants List 


National Technical Assistance Center 
for State Mental Health Planning 
National Experts Meeting on Trauma and Violence 
Participants List 
August 5-6, 2002 
Alexandria, VA 
Rene Andersen 
Associate Executive Director 
The Western Massachusetts Training 
Consortium 
187 High Street 
Holyoke, MA 01040 
413-536-2401 
Fax: 413-536-4166 
E-mail: 
randersen@theconsortiumwmtc.org 
Andrea Blanch, Ph.D. 
Director 
Collaborative for Conflict Management 
in Mental Health 
205 Garden Lane 
Sarasota, FL 34242 
941-312-0105 
E-mail: akblanch@aol.com 
Celia Brown 
Director 
Peer Specialist Services 
New York City Field Office of Mental 
Health 
330 Fifth Avenue, 9th Floor 
New York, NY 10001 
Phone: 212-330-6352, ext. 352 
Fax: 212-330-6359 
E-mail: oncsceb@gw.omh.state.ny.us 
Vivian Brown, Ph.D. 
President and CEO 
PROTOTYPES 
5601 West Slauson Avenue, Suite 200 
Culver City, CA 90230 
310-641-7795 
Fax: 310-649-3096 
E-mail: protoceo@aol.com 
Elaine Carmen, M.D. 
Medical Director 
Brockton Multi-Service Center 
165 Quincy Street 
Brockton, MA 02302 
508-897-2065 
Fax: 508-897-2075 
E-mail: elaine.carmen@dmh.state.ma.us 
Janet Chassman 
Trauma Coordinator 
New York Office of Mental Health 
44 Holland Avenue 
Albany, NY 12229 
518-486-4302 
Fax: 518-473-3456 
E-mail: jchass@omh.state.ny.us 
Linn Cohen-Cole 
1464 Rainier Falls 
Atlanta, GA 30329 
404-321-0433 
E-mail: ymmonroe@yahoo.com 

Text Box: The Damaging Consequences 
of Violence and Trauma
Facts, Discussion Points, and Recommendations for 
the Behavioral Health System
2004 
Bruce D. Emery, M.S.W. (facilitator) 
Strategic Partnership Solutions, Inc. 
709 Devonshire Road 
Takoma Park, MD 20912 
301-270-0530 
Fax: 301-270-0531 
E-mail: emerybd@msn.com 
Roger D. Fallot, Ph.D. 
Co-Director 
Community Connections 
801 Pennsylvania Avenue, S.E., Suite 
201 
Washington, DC 20003 
202-546-1512 
Fax: 202-544-5365 
E-mail: 
rfallot@communityconnectionsdc.org 
Gloria Grijalva-Gonzales 
Certified Senior Substance Abuse Case 
Manager 
San Joaquin County Health Care 
Services, 
Mental Health—ACM 
1212 North California Street 
Stockton, CA 95202 
209-468-8830 
Fax: 209-468-8025 
E-mail: ggonzales@sjcbhs.org 
Chief Executive Officer 
Columbia Behavioral Health System 
220 Faison Drive 
Columbia, SC 29203 
803-935-7146 
Fax: 803-935-7110 
E-mail: wrh55@bryph.dmh.state.sc.us 
Ann Jennings, Ph.D. 
Director, Office of Trauma Services 
Department of Behavioral and 
Developmental Services 
#40 State House Station 
Augusta, ME 04333 
207-287-4207 
Fax: 207-287-7571 
E-mail: (1) ann.jennings@state.me.us 
(2) afj@midcoast.com 
d. a. johnson 
Director 
Recipient Affairs 
Office of Mental Health 
New York City Region 
330 Fifth Avenue 
New York, NY 10001 
212-330-6368, ext. 368 
Fax: 212-330-6414 
E-mail: coradaj@gw.omh.state.ny.us 
Steven J. Karp, D.O. 
Chief Psychiatric Officer 
Department of Public Welfare 
Office of Mental Health and Substance 
Abuse Services 
501 Health and Welfare Building 
P. O. Box 2675 
Harrisburg, PA 17105-2675 
717-772-2351 
Fax: 717-787-5394 
E-mail: skarp@state.pa.us 
Dorothy M. Madden 
Vice President 
Catalyst Counseling, Inc. 
230 Logan Avenue 
North Hills, PA 19038 
215-698-9950, ext. 103 
Fax: 509-271-9413

Ruta Mazelis 
Publisher 
The Cutting Edge 
6125 Vale View Drive, S.W. 
Sherrodsville, OH 44675 
330-735-4111 
E-mail: rutamaz@eohio.net 
Jacki McKinney 
5124 Newhall Street 
Philadelphia, PA 19144 
215-844-2540 
Mary Ann Nihart, M.A., A.R.N.P., 
C.S. 
146 Hilton Lane 
Pacifica, CA 94044 
650-359-7624 
Fax: same 
E-mail: mnihart@pacbell.net 
Kathryn Power, M.Ed. 
Director 
Department of Mental Health, Mental 
Retardation and Hospitals 
600 New London Avenue 
Cranston, RI 02920 
401-462-3201 
Fax: 401-462-3204 
E-mail: kpower@mhrh.state.ri.us 
Alan Radke, M.D. 
Medical Director 
Department of Human Services 
444 Lafayette Road North 
St. Paul, MN 55155-3826 
651-582-1881 
Fax: 651-582-1804 
E-mail: alan.q.radke@state.mn.us 
Donzell Robinson 
Disability Accommodations Consultant 
1852 Addison Road South 
Forestville, MD 20747-1571 
202-307-0841 
E-mail: donzell.j.robinson@usdoj.gov 
Kathy E. Sawyer 
Commissioner 
Department of Mental Health 
and Mental Retardation 
P. O. Box 301410 
Montgomery, AL 36130-1410 
334-242-3640 
Fax: 334-242-0684 
E-mail: ksawyer@mh.state.al.us 
Danette J. Ross, M.S. 
Mediator 
Solomon’s Way 
6103 Jost Street 
Capitol Heights, MD 20743-1450 
301-925-9880 
E-mail: solomonsway@yahoo.com 
Larry Schomer 
Consumer Advocate 
Winnebago Mental Health Institute 
P. O. Box 9 
Winnebago, WI 54985 
920-725-5917 
*mailing address: 
134 Langley Blvd. 
Neenah, WI 54956 
Dorn Schuffman 
Director 
Department of Mental Health 
1706 East Elm Street 
P. O. Box 687 
Jefferson City, MO 65101 
573-751-3070 
Fax: 573-526-7926 
E-mail: mzschud@mail.dmh.state.mo.us

Susan Stefan, J.D. 
Senior Staff Attorney 
Center for Public Representation 
246 Walnut Street 
Newton, MA 02460 
617-965-0776, ext. 15 
Fax: 617-928-9071 
E-mail: sstefan@cpr-ma.org 
Substance Abuse and Mental Health 
Services Administration / Center for 
Mental Health Services 
Susan E. Salasin 
Director 
Women=s Mental Health Program 
Division of Knowledge Development 
and Systems Change 
Center for Mental Health Services 
5600 Fishers Lane, Room 11C-22 
Rockville, MD 20857 
301-443-6127 
Fax: 301-443-0541 
E-mail: ssalasin@samhsa.gov 
National Association of State Mental 
Health Program Directors / 
NASMHPD Research Institute, Inc. / 
National Technical Assistance Center 
for State Mental Health Planning 
Robert W. Glover, Ph.D. 
Executive Director 
NASMHPD 
66 Canal Center Plaza, Suite 302 
Alexandria, VA 22314 
703-739-9333, ext. 129 
Fax: 703-548-9517 
E-mail: bob.glover@nasmhpd.org 
Kevin Ann Huckshorn, R.N., M.S.N., 
I.C.A.D.C. 
Director 
Office of Technical Assistance 
NASMHPD/NTAC 
66 Canal Center Plaza, Suite 302 
Alexandria, VA 22314 
703-739-9333, ext. 140 
Fax: 703-548-9517 
E-mail: kevin.huckshorn@nasmhpd.org 
Lucille Schacht, Ph.D. 
Director of Statistical Analysis 
NASMHPD Research Institute, Inc. 
(NRI) 
66 Canal Center Plaza, Suite 302 
Alexandria, VA 22314 
703-739-9333, ext. 125 
Fax: 703-548-9517 
E-mail: lucille.schacht@nasmhpd.org