Roadmap to Seclusion and Restraint Free Mental Health Services

MODULE 2
Understanding the Impact of Trauma

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Roadmap to Seclusion and Restraint Free Mental Health Services

MODULE 2
Understanding the Impact of Trauma

“What helps me (deal with trauma) is professionals who have

the ability to take care of themselves, be centered, and not take on
what comes out of me—not hurt by what I say—sit, be calm
and centered and not personally take on my issues.”
—Survivor from Maine

“Traumatic experiences shake the foundations of our beliefs

about safety and shatter our assumptions of trust.”
—David Baldwin

Learning Objectives
Upon completion of this module the participant will be able to:
• Define trauma and describe how it can impact consumers in mental health settings.
• List common reactions to trauma and identify how trauma affects the brain.
• Understand how hospitalization/seclusion/restraint can be retraumatizing for consumers.
• Incorporate trauma assessment and de-escalation forms into current practices.
• Recognize and utilize positive coping mechanisms to deal with secondary traumatization.

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MODULE 2: UNDERSTANDING THE IMPACT OF TRAUMA

Background for the Facilitators. . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Presentation (3 hours) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Exercise: Trauma Background (25 minutes) . . . . . . . . . . . . . . . 11
Definitions Related to Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Common Reactions to Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Exercise: Common Reactions to Trauma (20 minutes) . . . . . . . . 14
Effects of Trauma on the Brain . . . . . . . . . . . . . . . . . . . . . . . . . 15
Differential Response to Threat . . . . . . . . . . . . . . . . . . . . . . . . . 16
Assessment of Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Exercise: Assessment of Trauma (20 minutes) . . . . . . . . . . . . . 20
Retraumatization via Hospitalization . . . . . . . . . . . . . . . . . . . . . 21
De-Escalation Preferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Exercise: De-Escalation Preferences (20 minutes) . . . . . . . . . . . 23
What Survivors Want in Times of Crisis . . . . . . . . . . . . . . . . . . . 24
Staff Trauma (Secondary Traumatization) . . . . . . . . . . . . . . . . . . 25
Healing from Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Grounding Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Exercise: Grounding Techniques (10 minutes) . . . . . . . . . . . . . . 27
Journal/Take Action Challenge (15 minutes)

Handouts for Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Journal Topics and Take Action Challenges for . . . . . . . . . . . . . . . 28
Modules 1 and 2
National Association of State Mental Health Program . . . . . . . . . . 29
Directors (NASMHPD) Position Statement on Services
and Supports to Trauma Survivors
Excerpts from Kate Reed’s Speech . . . . . . . . . . . . . . . . . . . . . . . 31
NAC/SMHA Position Paper on Trauma and Abuse Histories . . . . . . 35
What Can Happen to Abused Children . . . . . . . . . . . . . . . . . . . . 41
Some Common Reactions to Trauma . . . . . . . . . . . . . . . . . . . . . 50
Trauma Assessment for Department of Mental Health . . . . . . . . . 51
Facilities/Vendors
Guidelines for De-Escalation Preference Form . . . . . . . . . . . . . . . 54
De-Escalation Form for Department of Mental Health . . . . . . . . . . 55
Facilities/Vendors

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Excerpts from Dealing With the Effects of Trauma: . . . . . . . . . . . 59

A Self-Help Guide
Grounding Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Web Sites Related to Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Resources on Secondary Trauma . . . . . . . . . . . . . . . . . . . . . . . . 65
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

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BACKGROUND FOR THE FACILITATORS:

BACKGROUND
UNDERSTANDING THE IMPACT OF TRAUMA

Overview
A useful resource you may wish to read is 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, 1997). All of the consumer quotes used
in this module are from this source. For copies, please call the Maine Department of Mental
Health, Mental Retardation and Substance Abuse Services, Office of Trauma Services at
(207) 287-4250.

Adult survivors of trauma are disproportionately represented in the mental health system.
Research suggests that at least half of all women and a substantial number of men who are
diagnosed with a mental illness have a history of physical or sexual abuse or both (Brennan,
1997). Data on children and adolescents suggest even higher percentages (Massachusetts
Department of Mental Health, 1995). Traditional treatment modalities, including the use of
seclusion and restraint, are not always appropriate for trauma survivors, and may in fact be
retraumatizing. “Any intervention that recreates aspects of previous traumatic experiences or
that uses power to punish is harmful to the individual involved” (NASMHPD, 1998). It is im-
portant for staff to recognize the impact trauma can have on people diagnosed with a mental
illness. Understanding how seclusion and restraint can in fact retraumatize and further abuse
individuals who are already coping with a number of issues is vital to the elimination of the
practice of seclusion and restraint.

Definitions Related to Trauma

(Source: www.childtraumaacademy.com)
Trauma can be defined as extreme stress that overwhelms a person’s ability to cope. Some
of the behaviors that developed in response to the initial trauma were survival strategies that
no longer work. Many factors affect how any one person responds to trauma, including life
experiences before and after the trauma, the age at which the trauma first occurred, the length
and frequency of the trauma, the coping skills developed to deal with the trauma, who caused
the trauma, and what help was provided after the trauma. Symptoms of trauma can include
self-injury, assaultiveness, suicidality, substance abuse, impaired interpersonal relationships,
repeated victimization, flashbacks, dissociation, and disturbances of mood and self-esteem.

Flashbacks are reoccurring memories, feelings, or perceptual experiences of a past event.

Most times, flashbacks are traumatic and the person may lose awareness of present reality.
The person re-experiences the past as if it were happening right now.

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Dissociations are a wide range of responses that are usually some form of numbing or “tuning

BACKGROUND
out.” The person is disconnected from full awareness of self, time, and or/external circumstances.

Triggers are clues that remind a person of the trauma (often unconsciously) and start the
response of re-experiencing or avoiding the trauma. Identifying triggers and realizing they
are a normal response to trauma is part of the healing process. People who have experienced
trauma often refer to themselves as “survivors.”

Common Reactions to Trauma

Common reactions to trauma can include physical reactions such as nervous energy, muscle
tension, grinding one’s teeth, and upset stomach. Mental reactions to trauma may vary from
a heightened sense of awareness of surroundings to a lessened sense of awareness or even
disconnection from oneself. Difficulty making decisions and difficulty concentrating are also
common. Fear, inability to feel safe, loss of trust and self-esteem, and feeling chronically
empty are common emotional reactions. Finally, behavioral reactions include changes in eat-
ing habits, an increase or decrease in sexual activity, becoming withdrawn or isolated from
others, and becoming confrontational.

Effects of Trauma on the Brain

(Source: www.childtraumaacademy.com)
We are just beginning to understand and recognize the physiological, neurological, and
cognitive responses to trauma. Trauma in childhood can permanently alter neuron response
and cognitive pathways in the brain. Trauma also affects the autonomic nervous system,
which reaches into every major organ of the body. Trauma may be associated with abnormal
activation of the amygdala, abnormal levels of cortisol, epinephrine, and norepinephrine,
and structural changes to the hippocampus. All of these brain structures and neurochemicals
play key roles in regulating our emotional, behavioral, physical, and mental health. Finally,
the incidence of other serious illnesses, including chronic pain with no medical basis and
cardiovascular and digestive problems, is higher among people who have experienced severe
trauma. They are also more likely to have high blood pressure, atherosclerotic heart disease,
abnormal thyroid and other hormone functions, and to be more susceptible to infections and
other immune system disorders.

Differential Response to Threat

(Source: www.childtraumaacademy.com)
Research indicates that people generally respond in one of two ways to a perceived threat:
dissociation or hyperarousal (Perry, www.ChildTrauma Academy.com). People who dissoci-
ate become detached, numb, compliant, have a decreased heart rate, and experience a suspen-
sion of time, de-realization, “mini-psychoses,” and fainting. People who respond
with hyperarousal may become hypervigilant, have anxiety, be reactive and have an alarm
response, have an increased heart rate, and experience either fight (terror) or flight (panic).

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Understanding and using a trauma paradigm can be significant in creating and sustaining cultural

BACKGROUND
change on a unit. A trauma paradigm includes examining how a person with a mental illness
might be retraumatized, particularly by the use of seclusion and restraint. People who have been
sexually assaulted have said repeatedly that the retraumatization of being stripped and strapped
down by staff was unbearable and caused further harm. “After they unlocked the door and they
dragged me in there, they said, well you can’t keep your clothes for danger issues. And they made
me strip down. They kept a video on me the whole time. For a girl who is awkward and is in there
for issues of abuse at home, all that did was extend my hate.”

A trauma paradigm helps both staff and persons with a mental illness understand and change
behaviors that no longer work. For all people who have a background of experiencing trau-
ma, a clinical assessment of specific circumstances that elicit potentially harmful behaviors
and what responses may help de-escalate problem behaviors is necessary and required by
Joint Commission on Accreditation of Healthcare Organizations standards (JCAHO, 1995).

Assessment of Trauma
Accurately diagnosing trauma early on in hospitalization can significantly decrease the use
of seclusion and restraint. Misdiagnosis is common and can lead to inappropriate medication,
and wrong or ineffective treatment. Consumers are often reluctant to disclose a history of
trauma because they are fearful of being judged, invalidated, or not believed. It is important
for staff to recognize that how they ask about a history of trauma can significantly influence
how a consumer responds. It is recommended that trauma history questions be asked rou-
tinely as part of a standard interviewing process, and the information, once obtained, be used
to help guide treatment choices and recovery. In addition, staff needs to be trained in under-
standing behavior from a trauma paradigm.

Gayle Bluebird, a nurse and a consumer, developed tools for assessing trauma and de-escala-
tion preferences for consumers with trauma histories. Similar forms have been developed by
the Massachusetts Department of Mental Health Services and are available as handouts. We
strongly encourage participants to take these forms back to their facilities and adapt them
for their own use. An essential step to include is how this information will be used on a daily
basis once it has been gathered.

Retraumatization via Hospitalization

Consumers often view hospitalization itself as retraumatizing, not to mention the use of se-
clusion and restraints. “You are terrified and you try to get away from them and you strike out
to protect yourself. Then they call you ‘assaultive’ and that follows you to the next hospital
and they say to you, ‘I hear you hit someone.’” Unfortunately, people who are labeled as the
most difficult clients often end up getting restrained or secluded. It is important to recognize
the secondary traumatization of seclusion and restraint for both consumers and staff.

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De-Escalation Preferences

BACKGROUND
Gathering information, in advance, from consumers about what helps and what hurts during
times of crisis is key. Consumers can often tell staff specifically what works for them and
what triggers them in advance of a crisis. This information needs to be readily accessible for
staff and discussed well in advance of any crisis. An example of a de-escalation preference
form that can be used as a template is included in the handouts.

What Survivors Want in Times of Crisis

In general, if staff thinks about what they would want in times of crisis, the same would hold
true for consumers. It is often the simple things. For example, “I want someone who can BE
with me when I am in distress; be present with me when I am in pain.” “I want someone who
will acknowledge my pain without trying to ‘fix’ it. This takes someone who knows his/her
own pain and is not afraid of it or of yours.”

Staff Trauma (Secondary Traumatization)

Staff members can experience both primary and secondary traumatization in their work
environment. We know that 60 percent of all direct care staff are injured at some point in their
work, which is a type of primary traumatization (JCAHO, 1999, George Blake testimony).
Secondary traumatization is known by many names: compassion fatigue, secondary or vicari-
ous traumatization, and burn out. The symptoms of secondary traumatization are usually less
severe, but can affect the livelihoods and careers of mental health workers. It is important for
staff to examine their own trauma, recognize their own symptoms and triggers, and develop
their own plan of self-care in this demanding line of work. Finally, we cannot forget sec-
ondary traumatization that may occur for consumers and staff as they witness the violence
(seclusion and restraint) that may happen on a unit. This is an area that needs much more
exploration in the literature.

Healing From Trauma

Sue Coates from Turning Points, an agency in Grand Rapids, MI, in a presentation listed the
following five elements necessary for healing from trauma: safety, empowerment, creation or
restoration of positive self-regard, reconnecting to the world, and intimacy.

Grounding Techniques
Grounding refers to methods for stopping the re-experiencing of a trauma, or related symp-
toms, and getting back to the here and now. When a consumer reports/appears unusually
anxious or vulnerable, is nonresponsive, or is reacting in other ways suggestive of re-experi-
encing trauma, try to help him or her focus on something in the present using one or more of
the five senses: sight, smell, hearing, taste, or touch. For example, looking at a calendar with
a current date on it may be helpful.

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PRESENTATION

PRESENTATION
Welcome participants and review names. Make sure everyone has a
nametag or name tent. It may be helpful to provide a quick review of
Module 1: The Personal Experience of Seclusion and Restraint. Then go
over the learning objectives.

Learning Objectives
Upon completion of this module the participant will
be able to:

• Define trauma and describe how it can impact consumers in

mental health settings

• List common reactions to trauma, and identify how trauma

affects the brain

• Understand how hospitalization/seclusion/restraint can be

retraumatizing for consumers

• Incorporate trauma assessment and de-escalation forms into

current practices

• Recognize and utilize positive coping mechanism to deal with

secondary traumatization

Overview
• This module is an overview of trauma and how trauma can impact working with consum-
ers and direct care staff. Included is how hospitalizations, seclusion, and restraint can be
retraumatizing to consumers and/or direct care staff that have a history of abuse or trauma.
• Adult survivors of trauma are disproportionately represented in the mental health system.
Depending on how the research was conducted, it appears consistently that approximately
70 to 80 percent of consumers diagnosed with a mental illness also have a history of
trauma. Trauma is often underdiagnosed. Little research is available on the rates of direct
care staff with histories of trauma.
• Early childhood trauma actually physiologically impacts brain development. Many of the
behaviors associated with trauma may be a result of this altered brain functioning.
• “Any intervention that recreates aspects of previous traumatic experiences or that uses
power to punish is harmful to the individual involved” (NASMHPD, 1998).
• When working from a trauma paradigm, difficult behaviors are not pathologized, but
rather are seen as brilliant coping mechanisms developed as a response to previous trauma.
• Ideally, trauma would be assessed and included in the treatment plan for all consumers/
survivors, and direct care staff would be aware of and trained in issues of trauma.

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• The quotes and information from consumers in this module come from In Their Own

PRESENTATION
Words: Trauma Survivors and Professionals They Trust Tell What Hurts, What Helps,
and What Is Needed for Trauma Services. The Maine Trauma Advisory Groups
compiled this report in 1997.

“Being a survivor is feeling isolated, not

daring to share that part of my life
(trauma) with people for fear of being
rejected, feeling defective, feeling
powerless, lack of understanding from
professionals that whatever behaviors we
took on was our way of calling for help
even if it doesn’t fit society’s view of what
is ‘normal’ behavior.” Survivor from Maine

• For consumers, there is a real fear of sharing trauma histories with direct care staff,
because oftentimes it negatively impacts how they are treated.

“What helps me (deal with trauma) is

professionals who have the ability to
take care of themselves, be
centered, and not take on what comes
out of me – not hurt by what I say –
sit, be calm and centered and not
personally take on my issues.”
Survivor from Maine

• Consumers are really asking for direct care staff to be present with them—not to fix the
trauma or its outcome, but to really listen and be present.
• Trauma often feels like a loss of control. For consumers, being in the hospital also feels
like loss of control. Being secluded or restrained really feels like loss of control.

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PRESENTATION
Exercise/Discussion—Module 2
Trauma Background

OBJECTIVE: Familiarize participants with trauma paradigms.

PROCESS: Divide the class into four groups. Assign each group a different
one of the four articles listed below and distribute copies to each
participant. Have each group report to the large group on the
article they read. They should tell the group who wrote the article
and which stakeholder groups the author(s) represents. Then they
should share three key points they think are the most important
things to know about the information in the article they read.
Facilitate a discussion.

DISCUSSION
QUESTIONS: What was most compelling to you about these articles?
What do you disagree with?
What has your experience been dealing with trauma survivors?

MATERIALS
REQUIRED: Copies of each article for each participant to take home:
• National Association of State Mental Health Program Directors—
Position Statement on Services and Supports to Trauma Survivors
• Excerpts from Kate Reed’s speech
• National Association of Consumer/Survivor Mental Health
Administrators—Position Paper on Trauma and Abuse Histories:
The Prevalence of Abuse Histories in the Mental Health System
• What Can Happen to Abused Children When They Grow Up—
If No One Notices, Listens, or Helps? (Maine Office of Trauma
Services, 2001)

APPROXIMATE
TIME REQUIRED: 25 minutes

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Definitions Related to Trauma

PRESENTATION
It is important to be on the same page using the same language about trauma. This training
will use the following definitions related to trauma:

Definition of Trauma:

Extreme stress that

overwhelms someone’s
ability to cope.

Flashback
A recurring memory, feeling or
perceptual experience of a past
event, usually traumatic, including
losing awareness of present reality.
The person feels like they are re-
experiencing the past as if it were
happening right now.

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PRESENTATION
Dissociations

A wide range of responses that are

usually some form of numbing or
“tuning out.” The person is
disconnected from full awareness
of self, time, and/or external
circumstances.

Triggers
Cues that remind a person of the
trauma (often unconsciously) and
start the response of re-
experiencing or avoiding the
trauma. Identifying triggers and
realizing they are a normal
response to trauma is part of the
healing process.

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PRESENTATION
Exercise/Discussion—Module 2
Common Reactions to Trauma

OBJECTIVE: Familiarize participants with common reactions to trauma.

PROCESS: Ask participants to think of people they have worked with who are
trauma survivors and then ask them to brainstorm common reac-
tions to trauma. Keep track of the list on the overhead/chalkboard/
paper. Once they have listed as many as they can think of, hand
out the Some Common Reactions to Trauma article.

DISCUSSION
QUESTIONS: Which common reactions to trauma did we miss?
Which common reactions to trauma do you most frequently deal
with on the unit?
Which common reactions to trauma are the most difficult to deal
with and why?

MATERIALS
REQUIRED: Some Common Reactions to Trauma by Mary S. Gilbert, Ph.D.

APPROXIMATE
TIME REQUIRED: 20 minutes

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Effects of Trauma on the Brain

PRESENTATION
Science is just beginning to understand the physiological, neurological, and cognitive
responses to trauma. The following information is from www.childtraumaacademy.com.

Effects of Trauma on the Brain

• Trauma can activate various systems in the brain that actually
change neuron response and cognitive pathways.

• Children can develop systems in their brains that cause them to be

constantly hyperaroused and hypervigilant or dissociate.

• Trauma affects the autonomic nervous system.

• Trauma may be associated with abnormal activation of the

amygdala, abnormal levels of cortisol, epinephrine, and
norepinephrine, and structural changes to the hippocampus.

• The incidence of other serious illness, including chronic pain with no

medical basis, cardiovascular and digestive problems, is higher
among people who have experienced severe trauma.

Effects of Trauma on the Brain

www.ChildTrauma.org

• “These images illustrate the negative impact of neglect on the developing brain. In the CT
scan on the left is an image from a healthy 3-year-old with an average head size. The image
on the right is from a 3-year-old child suffering from severe sensory-deprivation neglect.

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This child’s brain is significantly smaller than average and has abnormal development of

PRESENTATION
cortex.” These images are from studies conducted by a team of researchers from the Child
Trauma Academy (www.ChildTrauma.org) led by Bruce D. Perry, M.D., Ph.D.

Differential Response to Threat

(Source: www.childtraumaacademy.com)
• Many factors affect one’s response to trauma, including life experiences before and after
the trauma, age at which the trauma occurred, length and frequency of the trauma, coping
skills, who caused the trauma, and help that was available after the trauma.
• Responses to threat vary greatly from individual to individual.
• The flight (panic) or fight (terror) response is a well-documented reaction to danger. Our
bodies have the same physiological reactions to dangers, whether it is a charging tiger or
an episode of restraint.
• Other responses to trauma include dissociation and hyperarousal or a combination of
the two.
• Children may not be able to fight or flee during times of threat—and may therefore use
dissociation as a coping mechanism.
• We all use dissociative mental mechanisms even when we are not threatened—
for example, daydreaming.

Differential Response to
Threat
Dissociation Hyperarousal

Detached Hypervigilance
Numb Anxious
Compliant Reactive
Decreased Heart Rate Alarm Response
Suspension of Time Increased Heart Rate
De-realization Freeze: Fear
Mini-psychoses Flight: Panic
Fainting Fight: Terror

Source: Perry, M.D., Ph.D. www.childtraumaacedemy.com

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Assessment of Trauma

PRESENTATION
• Misdiagnosis of trauma may lead to ineffective treatment.

Assessment of Trauma
• Mental health professionals cannot develop
appropriate treatment plans or
interventions for clients in the absence of
knowledge about their histories of physical
or sexual abuse (JCAHO, Accreditation
Manual for Mental Health, 1995).

• All clients need to be asked about their

history of sexual, physical, and verbal
abuse in all clinical settings.

• When doing an assessment, it is important to gather accurate information. At the same

time, it is important not to reopen a traumatic event without having the resources avail-
able to adequately deal with it. This can be a source of tension on short stay units. How-
ever, it is important to ask the questions about trauma directly.

“Never being asked about trauma is like

the abuse as a child.”

Survivor from Maine

• The following material and quotes were taken from In Their Own Words, a work of over
200 women and men in the State of Maine who hope that the truth and wisdom of their
work will be heard by those who are in power.

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• Both survivors of abuse and professionals they trust gave voice to their experiences with

PRESENTATION
the individuals, organizations, and systems that have been shaped and influenced in such
a way that they frequently harm, instead of help, consumers.

Survivors and Trusted Professionals Speak About

Recognizing (or Avoiding) the Prevalence, Indicators,
and Impact of Trauma: What Hurts

• The way questions were asked was impersonal, cold, and intimidating.
(Survivor)

• It is fearful to disclose the abuse.

„ “You risk being judged, being penalized, being discredited, invalidated, and
having your feelings minimized.” (Survivor)
„ “When you get a mental illness label, you lose all credibility.” (Survivor)

• The consequences of misdiagnosis include wrongful medication, over-

medication, tardive dyskinesia and other reactions to medications,
inappropriate and ineffective treatment. (Professional)

• Stigma in the mental health field is a problem. It takes a longer time for
men to disclose abuse than women.

• “Men do not disclose their histories of sexual and physical abuse because
of the stigma attached to being a male survivor.” (Professional)

Survivors and Trusted Professionals Speak About

Recognizing (or Avoiding) the Prevalence,
Indicators, and Impact of Trauma: What Helps

• Staff who are calm, who will sit and listen in a relaxed
manner, are essential. (Survivor)

• The person doing the intake should understand the fear (of
disclosing abuse).
„ “Threats from the past are still present. If you tell, you will
die, your sister will die.” (Survivor)

• Training is needed in looking for, identifying, assessing, and

treating mental health clients in the framework of trauma.
(Professional)

• Training is needed in putting aside one’s own beliefs and

expectations, and meeting clients where they are at, rather
than where I think they may be. (Professional)

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• Massachusetts has worked extensively in this area and has developed a Trauma

PRESENTATION
Assessment Form that can be used as a guideline for obtaining trauma histories.
• Once the information has been collected, it is critical to do the next step of designing
treatment plans using the trauma information.
• It is also critical to obtain information from the consumer on what strategies have been
effective to reduce or avoid the use of seclusion and restraint. This includes identifying
interventions that might further traumatize them.
• Massachusetts has developed a Restraint Reduction Form that is also included in the
intake session with a consumer.
• It is important to know the gender of the perpetrator and give consumers a choice about
who will be with them during and after a restraint episode.
• In summary, it is critical to obtain information relevant to (1) history or abuse,
(2) de-escalation strategies that have worked, and (3) what forms of seclusion/restraint
are most helpful and least traumatic.

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PRESENTATION
Exercise/Discussion—Module 2
Assessment of Trauma

OBJECTIVE: Familiarize participants with one method of assessing trauma.

PROCESS: Direct participants to pair up. One person will role-play a consumer.
It may be helpful for staff to think of a specific consumer to use as
a model for this role-play. Have the person role-playing the con-
sumer think of what kind of trauma (known or unknown) might be
present for the consumer. The consumer is not allowed to look at
the form as the staff person is filling it out.

Use the Trauma Assessment for Department of Mental Health

Facilities/Vendors and have the person role-playing a staff person
fill out the form. Facilitate a discussion.

DISCUSSION
QUESTIONS: What worked well about this kind of assessment form?
What concerns do you have about using this type of form?
How is this similar or different from intakes you currently do on
your unit?

MATERIALS
REQUIRED: Trauma Assessment for Department of Mental Health Facilities/
Vendors handout

APPROXIMATE
TIME REQUIRED: 20 minutes

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Retraumatization via Hospitalization

PRESENTATION
Survivors Speak About Retraumatization via
Hospitalization - Creating Safe Places for
Healing: What Hurts – pg 1

• There is a lack of knowledge/training for survivors and

staff regarding therapeutic approaches and the link
between trauma histories and the presenting symptoms
causing the need for hospitalization. (Survivor)

• There is a general disrespect for patients as human

beings that should be valued as full partners in the
treatment and recovery process.

• “They take your clothes away and watch you take

showers.” (Survivor)

• Insurance payments control the length of

hospitalization.

Survivors Speak About Retraumatization via

Hospitalization - Creating Safe Places for
Healing: What Hurts – pg 2

• “You’re sick enough to stay when you have insurance. You’re

suddenly improved enough to leave as soon as your insurance
runs out.”

• Seclusion and restraint techniques are retraumatizing and

inhumane approaches to managing symptoms.

• “I would rather die than go back to the hospital.”

• “It involves 5-6 guys chasing you down, holding you down – just
like rape. So you are terrified and you try to get away from
them and you strike out to protect yourself. Then they call you
’assaultive’ and that follows you to the next hospital and they
say to you, ‘I hear you hit someone.’” (Survivor)

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PRESENTATION
Survivors and Trusted Professionals Speak About
Retraumatization via Hospitalization - Creating Safe
Places for Healing: What Helps

• Training needs to be offered that addresses all the aspects

of trauma recovery (staff and client issues).

• “Training needs to be done in (1) how the staff can avoid

being reactive; (2) recognizing when the staff or the client
is in a state when they cannot receive information, for
example because of high anxiety; and (3) when the staff
should be interactive.” (Professional)

• Survivors need training also.

• “When asking survivors about seclusion and restraint, ask

them about what responsibility they have in the situation.
Do not automatically put the person in a victim role.”
(Survivor)

De-Escalation Preferences
• Gathering information about what helps and what hurts consumers during times of crisis
is useful.
• Consumers can often tell staff specifically what works for them and what triggers them in
advance of a crisis.
• If this information is gathered in advance, and all staff are aware of the information, it
can be very helpful in defusing a crisis situation.

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PRESENTATION
Exercise/Discussion—Module 2
De-Escalation Preferences

OBJECTIVE: Familiarize participants with one method of determining

de-escalation preferences.

PROCESS: Direct participants to pair up in the same pairs as in the previous

exercise. This time, switch roles; one person will play a consumer
and the other will play a staff member.
Hand out the Guidelines for De-Escalation Form.
Have the person role-playing a staff person fill out the
De-Escalation Preference Form.

Facilitate a discussion.

DISCUSSION
QUESTIONS: What worked well about this kind of preference form?
What concerns do you have about using this type of form?
What do you see as the pros and cons of asking consumers these
types of questions?

MATERIALS
REQUIRED: Guidelines for De-Escalation Form handout
De-Escalation Preference Form handout

APPROXIMATE
TIME REQUIRED: 20 minutes

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What Survivors Want in Times of Crisis

PRESENTATION
• Think about a time you were in crisis. What did you want? Have the group brainstorm
ideas out loud.

Survivors: When I am in
crisis, I need persons:
• “Who can BE with me when I am in distress; be
present with me when I am in pain.”

• “Who will acknowledge my pain without trying to

‘fix’ it. This takes someone who knows his/her own
pain and is not afraid of it or of yours.”

• “Who is not afraid of my sexual abuse. I don’t

need someone else’s fear.”

• “Who has worked with their own sexual abuse –

another survivor can do this.”

Survivors: When I am in
crisis, I need persons: (pg 2)
• “Who will ask what would help and trust I know whether or
not I need hospitalization.”

• “Who understands the coping role of suicidal thoughts, as a

relief, and end to the pain, as giving a sense of some
control.”

• “Who knows the difference between “I want to die”

(despair, hopelessness) and “I want to kill myself” (anger,
defiance).”

• “Who will understand, control, and prevent me from hurting

myself when I am in danger, but still give me options and
choices, and respect me in a way that doesn’t treat me like
an animal.”

• What consumers and direct care staff want in times of crisis is universal. We all want the
same things.

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Staff Trauma (Secondary Traumatization)

PRESENTATION
• Working in mental health is a demanding career that impacts all of us. Whatever happens
on the units, impacts direct care staff and consumers.
• Secondary traumatization is known by many names: compassion fatigue, secondary or
vicarious traumatization, absenteeism, and “burn out.”
• Secondary traumatization affects primarily the workers who help trauma and disaster
victims—including mental health staff.
• The symptoms of secondary traumatization are usually less severe than Post-Traumatic
Stress Disorder like symptoms (e.g., hypervigilance, flashbacks to previous trauma, dif-
ficulty concentrating), but they can affect the livelihoods and careers of mental health
workers.
• Secondary traumatization can also occur when one is a witness to violence. For example,
other consumers watching a forceful escort to the seclusion room might experience sec-
ondary traumatization. Staff members watching another staff member get hurt in a take
down could also experience secondary trauma.

Healing From Trauma

• Sue Coates, from Turning Points, an agency in Grand Rapids, MI, in a presentation listed
five necessary elements for healing from trauma. (See slide.)

Five Necessary Elements for Healing From

Trauma - “Turning Points” by Sue Coates

„ Safety

„ Empowerment

„ Creation or Restoration of Positive Self

Regard

„ Reconnecting to the World

„ Intimacy

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• Safety includes physical needs such as food, clothing, and shelter. It also includes feeling

PRESENTATION
psychologically and emotionally safe with those around you—knowing you will not be
abused or harmed. If consumers are witnesses to other consumers’ seclusion and restraint,
this may impair their feelings of safety.
• Empowerment restores the hope that one has the potential and ability to recover.
Consumer-driven supports, such as the Wellness Recovery Action Plan, the advance
psychiatric directive, and peer mentoring are examples of empowerment.
• Creation or restoration of positive self-esteem naturally flows from empowerment.
As consumers learn to rely on their own abilities and skills, their outlook on their lives
and future improves and enhances their positive self-esteem.
• Reconnecting to the world gives consumers a sense of normalcy.
• All human beings need intimacy or closeness with another human being. Establishing
positive relationships adds to a consumer’s ability to heal from trauma.
• The Center for Mental Health Services, within the Substance Abuse and Mental Health
Services Administration, published a booklet, Dealing With the Effects of Trauma:
A Self-Help Guide. To see the complete publication, go to the Web at
www.mentalhealth.org/publications/allpubs/SMA-3717/default.asp.
• Assisting consumers to develop their own coping mechanisms around trauma can
be very empowering.

Grounding Techniques

Distribute the handout Grounding Techniques by Mary Gilbert and take

10 minutes to do the exercise on grounding techniques.

Journal/Take Action Challenge

Give participants time to write on one to two Journal topics and at least
one of the Personal Take Action Challenges and one of the Workplace
Take Action Challenges. They will use these Take Action Challenges
extensively on the last day of the training.

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PRESENTATION
Exercise/Discussion—Module 2
Grounding Techniques

OBJECTIVE: Familiarize participants with grounding techniques.

PROCESS: Have two volunteers do a role-play. One person will play the role
of the consumer who is having flashbacks and/or dissociating.
If possible, pick a person to play the role of the direct care staff
member who has experience in grounding techniques. Facilitate
a discussion.

DISCUSSION
QUESTIONS: What types of things were most helpful in this role-play for ground-
ing techniques?
What concerns do you have about using these types of techniques?
Which of these techniques do you typically use on a regular basis
on your unit?

MATERIALS
REQUIRED: Grounding Techniques by Mary S. Gilbert, Ph.D.

APPROXIMATE
TIME REQUIRED: 10 minutes

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JOURNAL TOPICS AND TAKE ACTION CHALLENGES

FOR MODULES 1 & 2

HANDOUT
Journal Topics
Pick one or two questions and respond. Your responses are confidential.
1. Consider the impact that using seclusion and restraints has had on you as a staff
member. Write about your first experience with seclusion and restraint. Describe the
incident in as much detail as possible and how it made you feel.
2. How have you personally changed as a result of secluding and restraining others?
3. What do you see as the pros and cons of using seclusion and restraints?
4. Write about your own trauma or secondary trauma.
5. How could you incorporate stress management skills into your life and/or your
workplace?
6. How would your daily work change if the mental health system wholeheartedly
adopted the underpinnings of a trauma model?

Personal Take Action Challenges

Pick one topic and develop a plan. You will use this plan on the last day of training.
1. Make a list of three things that you personally can commit to every day at work
to prevent the use of seclusion and restraint. Make a detailed plan of how you will
implement these changes.
2. Find one area in your life where you could work recovering from trauma. Make a list
of two things you can personally commit to in your daily life to move you forward in
your own journey of recovery from trauma.

Workplace Take Action Challenges

Pick one topic and develop a plan. You will use this plan on the last day of training.
1. Make a list of three things that you can personally commit to doing when you get
back to work to help change the system to eliminate seclusion and restraint.
2. Who has the power to eliminate seclusion and restraint in your facility? How could
you design an alliance with them?
3. How could you utilize the trauma assessment form and/or de-escalation preference
form in your workplace?

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National Association of State Mental Health Program Directors

HANDOUT
Position Statement on Services
and Supports to Trauma Survivors

The National Association of State Mental Health Program Directors (NASMHPD) recognizes
that the psychological effects of violence and trauma in our society are pervasive, highly dis-
abling, yet largely ignored. NASMHPD believes that responding to the behavioral health care
needs of women, men, and children who have experienced trauma from violence is crucial
to their treatment and recovery and should be a priority of State mental health programs. The
goal of recovery from trauma is a fundamental value held by NASMHPD and its individual
members, State mental health authorities. Toward this goal, it is important to develop an un-
derstanding of the resiliency factors, and the kinds of treatment, services, and supports
that contribute to recovery.

The experience of violence and trauma can result in serious negative consequences for an
individual’s mental health, self-esteem, use of substances, and involvement with the criminal
justice system. Indeed, trauma survivors can be among the people least well served by the
mental health system as they are sometimes referred to as “difficult to treat” —they often
have co-occurring mental health and substance use disorders, can be suicidal or self-injuring
and are frequent users of emergency and inpatient services.

Trauma is an issue that crosses service systems and requires specialized knowledge, staff
training, and collaboration among policymakers, providers, and survivors. Study findings in-
dicate that adults in psychiatric hospitals have experienced high rates of physical and/or sexu-
al abuse, ranging from 43 to 81 percent. Other research recently has found that 92 percent
of homeless women and 81 percent of non-homeless women in poverty had been physically
and/or sexually abused. Trauma is also frequently experienced as highly stigmatizing and of-
ten can create a reluctance to seek help. There is reason to believe that men may significantly
under-report childhood abuse.

Services for trauma survivors must be based on concepts, policies, and procedures that pro-
vide safety, voice, and choice as defined by consumers/survivors. Trauma services must focus
first and foremost on an individual’s physical and psychological safety. Services to trauma
survivors must also be flexible, individualized, culturally competent, and promote respect
and dignity. Innovations in trauma services are becoming a focus of increased discussion and
change within the public mental health system. A number of State mental health authorities
have begun to address the needs of trauma survivors in the mental health system by revising
seclusion and restraint guidelines to prevent the repetition of the experience of trauma, adopt-
ing clinical guidelines for people with serious mental illnesses who have histories of trauma,
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NASMHPD Statement (continued)

developing statewide strategic action plans, producing training materials, and empowering

HANDOUT
statewide committees to develop and improve trauma services.

NASMHPD is dedicated to furthering the understanding of the effects of physical and/or

sexual abuse and increasing its treatment within the public mental health system. State men-
tal health authorities are committed to recognizing and responding to the needs of trauma
survivors with mental illnesses and their families. It should be a matter of best practice to
ask persons who enter mental health systems, at an appropriate time, if they are experienc-
ing or have experienced trauma in their lives. NASMHPD recognizes that some policies and
practices in public and private mental health systems and hospitals, including seclusion and
restraint, may unintentionally result in the revictimization of trauma survivors, and therefore
need to be changed.

NASMHPD is committed to working with States, consumers/survivors, and experienced

professionals in the trauma field to explore ways to improve services and supports for trauma
survivors. These efforts may include, but are not limited to, developing improved methods
for reducing stigmas related to trauma; developing and disseminating information and tech-
nical assistance on best practices; providing forums for a national dialogue on the needs of
trauma survivors; and cooperating with other State and national organizations to develop
prevention and education initiatives to address the issue of trauma.

Passed unanimously by the NASMHPD membership on December 7, 1998.

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Excerpts from Kate Reed’s Speech

HANDOUT
Feeling safe is really hard….and this is the one place where I feel really unsafe because I
work in the system. I can sit up here and share my experience, but in the back of my mind I
wonder if I approach one of you in the Department for a job, you might take that and hold it
against me…..

I’m very moved by being here. I feel teary. There’s a lot of emotion because this is something
that I lived with in silence for 35 years of my life. To be sitting here and seeing other women
and men share their experiences, and know that it takes an enormous amount of courage to
live in terror on a daily basis and just put your feet on the floor every morning. But there are
many people who are not here who did not live through it and I want to say that I hold them
in memory now, too….

I was incested at the age of 2 ½ and it lasted until the time I was 8. It was by my paternal
grandfather who lived right next door. It lasted for approximately 8 years and the incest
progressively got worse and later on it involved bodily penetration. Those are the criteria
that sort of set people up for having long-term psychological problems. Judith Hermann, an
incredible feminist psychiatrist who writes about trauma issues, says that a single source of
trauma like rape of an adult with an existing healthy personality can abrade that personality,
can start eroding the health. But for women who have multiple traumas throughout child-
hood, the trauma itself both forms and deforms the personality. What we are hearing from
women talking about their experiences is the amount of reconstruction work you have to do.
This is not the walking wounded. I was lucky to come out with my life. I had multiple sui-
cide attempts. I overdosed and wound up in intensive care. To me, suicide held out a hope
that the terror, the pain, all of it would stop. I had some control. If that’s the only control I
had I knew at some point I would say I’m not going to commit suicide today, maybe I will
tomorrow. That’s the reality. I had emotional problems right from the start. I struggled with
depression. I struggled with low self-esteem that was off the charts. I mean low self-esteem
is putting it mildly when you think of yourself as evil, as bad, as holding some energy that is
incredibly dark.

I think I lived with just an enormous amount of terror. I was victimized again and again by
my grandfather and I lived in terror. I didn’t know when he was going to start again. I didn’t
know where. I was always on the lookout for what was coming; what was going to broadside
me, and my body remembers that terror. I could forget. I could say that my childhood was
fine, but my body remembered in a way that I could not forget, and my body reminds me
frequently that it’s still in charge. The post-traumatic stress is for me the hyperarousal level
where your arousal level, your base line of anxiety level might hover around a 4 or 5. So that
anything that happens can spike me into panic in an instant.
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Kate Reed’s Speech (continued)

I lost most of my life to trauma. I made choices out of the lie that I was forced to live, and my

HANDOUT
marriage was a victim of my healing process. I was hospitalized at the age of 21 and it took
me 3 or 4 years to come out of that bout. What happened is that I got triggered into a string of
post-traumatic stress where it was like getting tumbled over and over again in a wave; every
time I tried to come out something else would hit me and I’d go back into the terror and I’d
come back out and I’d go back into the terror and I lived that way pretty much daily, suicidal,
in an enormous amount of pain and shame for probably 3 years at the first round. Then I
managed to crawl out kind of like by the skin of your teeth and your nails to a place where I
got married, had children. That was sort of a quiet period for a while and then my marriage
was unraveling and I got incest memories at the same time.

When I say I have made multiple suicide attempts and been hospitalized many times, I worry
about what some of you do with that in your head. Because I think that what happens in the
system that has historically happened – is that they look at me or any of us who spoke and
said what’s wrong with you; what is wrong with you! I want to say it takes an enormous
amount of courage to do what we have all done and I’m really grateful to be in the presence
of women who have been creative and survived by hook or by crook in whatever way we
could. When I look at myself, I think today I can be an incredibly compassionate judge of
myself and others. I can be very nurturing; I have nurturing skills. I have an incredible ability
to figure out how to heal myself in the face of a system that only retraumatized me, and I’ve
hooked up with other people who were healing. I have wonderful people in my life today.
I’m in a graduate program; I hope to have a private practice where I will treat incest survi-
vors. My life to me is very hopeful today.

I want to talk a little bit about how I got here. I think one of the things that helped me to heal
was to not label myself, because I needed to be a human being with human feelings, even if
they were in the kind of extreme range of intense emotions. When my divorce was happen-
ing and I was getting a lot of incest memories, I had always had a few picture memories but I
never had the affect. Then, it was like strap your seat belt; put your crash helmet on and hold
on because now here come the pictures WITH the affect. There was an enormous amount
of rage; there was an enormous amount of grief; there was an enormous amount of terror,
and that went on for 3 or 4 years while I was getting the memories. What helped for me is
my husband and I had built a house on the backside of Peaks Island. It was oceanside and it
was a beautiful, beautiful setting and I had the backside of the island pretty much to myself.
I would be flooded with grief and I would be on the floor in a fetal position just sobbing for
hours and then in the middle I’d sort of stop and kind of try to regroup. Then I had my way
of a rage that would go on and this process went on for a long, a long time. I had two Escort
wagons where the dashboard was broken on both of them because I would be in the car and
the rage would just be…like it was too much to contain the intensity of the emotion of the
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Kate Reed’s Speech (continued)

experience that I was going through; just to try to have it tip all the scales of what I could

HANDOUT
possibly cope with.

What I did was I got a therapist who was herself a survivor and she believed very simply that
the baseline was that we can heal ourselves; that we have an internal healer and given the
proper environment, we can initiate a healing process that will take us to where we need to
go. It didn’t take any fancy technology; for me it didn’t take any medication; it didn’t take
any psychiatric diagnoses.

I want to put in perspective how the psychiatric community can come to use and try to help
us; try to be of service to us. I got rid of as many of the system pieces in my life as I could
because I realized that for the last 3 years I’ve been healing from the “help” that I got. I was
thrown into restraints when I was suicidal; I was thrown into a straight jacket. I was coming
out of an overdose and somebody said to me “What do you want do” and I said, “I want to go
out to dinner” and they said “No.” I was in a State hospital for a while and I’ve been in the
fashionable Institute of Living in Hartford, Connecticut.

What really worked for me was to frame my experience not in a diagnosis but in a spiritual
experience. It became a spiritual journey for me. I just let the feelings go. I tried to learn
to trust my process and trust my inner healer and that worked for me. I danced a lot; just a
dance that would sort of ground the enormous energies that were moving through me. I did
a lot of externalization of the internal energy. I did Elizabeth Kübler Ross work where you
basically get in a room with 80 people and they throw mattresses on the floor and it’s like
being in Dante’s Inferno, but it’s all of that dark stuff that we hold on to. It’s all of the rage;
it’s all of the grief; it’s all of the stuff that’s actually very fertile because I think if you mind
those emotions that what you come out with is an incredible gift, and I do believe that there
are gifts in the experience of healing from incest, for me, I will say. I think you have to be in
a certain place in a certain time in your recovery to acknowledge that, and some people may
never want to and that’s their choice, but for me there have been an enormous amount of gifts
in the process. too.

I went to a 12-step program. I had a lot of shame and what worked for me was for somebody
else to listen to me talk and to just accept who I was at that moment. To look back at me as
another human being and to say, by the way they were holding me with their expression, that
I was okay.

So I guess what I want to say is there’s no technique stuff that’s really the total answer. To me
the people who were most powerful in my life were other people who could be with me in
the intensity of my pain and just acknowledge that they were there. They didn’t necessarily
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Kate Reed’s Speech (continued)

know how to help me sometimes but that they were there with me and I didn’t have to be in

HANDOUT
terrified place alone.

I also had trouble getting a therapist. I also had trouble paying for my therapist because she
was not reimbursable and she was my therapist of choice. I worked with her for 5 years and I
had to pay out of pocket.

I just want to say I’m glad that everyone is here; I’m glad that the topic is on the table. I think
it kills people all of the time and it’s time to start ending the silence around it. Thank you.

This selection is excerpts from a speech by Kate Reed, Maine, trauma survivor and mental
health professional, from 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, 1997.

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National Association of Consumer/Survivor Mental Health Administrators

HANDOUT
Position Paper on Trauma and Abuse Histories
The Prevalence of Abuse Histories
in the Mental Health System

In the last decade, the mental health system has begun to demonstrate some awareness of the
prevalence of abuse histories among its clientele. Studies consistently confirm a 50-80 per-
cent prevalence rate of sexual and physical abuse among persons who later acquire diagnoses
of mental illness (Breyer, 1987; Beck & Van der Kolk, 1987; Rose et al, 1992; Craine et al,
1988; Stefan, 1996). While many professionals in the field still deny the validity of work
documenting these histories, the mental health system is beginning to catch up with groups
that have addressed violence toward women, child abuse, and runaway adolescents in realiz-
ing the connections between abuse and later difficulties (Alexander & Muenzenmaier, 1998;
Smith, 1995; Harris, 1994; New York State Office of Mental Health, 1993; Mental Health
Association in New York State & New York State Office of Mental Health, 1994).

Among consumers/survivors/ex-patients (C/S/Xs) themselves, the commonality of abuse

histories has begun to be acknowledged. With that acknowledgment, the irrelevance of much
of their “treatment” in the mental health system has begun to make sense in a new way. Many
whose treatment focus has changed from medical model interventions to trauma-oriented ther-
apies, whether professional or peer-run, have recovered in ways once considered impossible.

It would seem, therefore, that the mental health system’s recognition of abuse histories would
be welcome news among C/S/Xs. However, for many who know the system well, the news is
greeted with deep ambivalence. For some, it is somewhat ironic, given the history of silence
among most mental health professionals about abusive treatment that is often routine in
mental health settings. Others are deeply relieved by professionals’ long-overdue recogni-
tion of trauma as a primary issue to be addressed therapeutically, but fear that a system so
entrenched in punitive ways will not be able to incorporate the kind of work necessary to heal
from trauma (Kalinowski & Penney, 1998).

Some C/S/Xs have learned that the abuse in their histories has been the primary formative
factor in what was called their “mental illness.” Others see abuse or trauma as part of what
affected them, but also believe that their symptoms had a variety of origins, including socio-
economic, spiritual, and/or biological causes. Whatever view individuals hold concerning
the role of trauma and abuse in the etiology of their problems, their experiences in the men-
tal health system may color their reaction to the system’s new-found interest in trauma and
abuse. Many people have spent years in the system without being asked about their trauma

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NAC/SMHA Position Paper (continued)

history or other aspects of their personal stories; their behavior, rather than their experience,

HANDOUT
has been the focus of treatment. Many have also felt constantly threatened with the loss of
autonomy and civil rights (Blanch & Parrish, 1993). For these individuals, it may be difficult
to appreciate the professional world’s “discovery” of a new theory of mental illness, regard-
less of its relevance to the majority of people caught up in the mental health system.

Until recently, the term “survivor,” as used within the C/S/X movement, meant one who
survived the irrelevance and frequently the harm of psychiatric interventions. Commonly,
individuals have needed to recover from the effects of being labeled and institutionalized in
order to begin addressing the issues that led to their encounter with psychiatry. Now that the
term means “survivor of abuse” to many practitioners, C/S/Xs seek evidence that the abuse
perpetrated by the mental health system itself is also recognized. They are deeply skeptical
of trusting clinicians who have never questioned the criteria for involuntary commitment
and deprivation of civil rights for so many diagnosed persons. People who have experienced
trauma and abuse perpetrated by the very system which purports to help them may have a
hard time believing that this same system is now willing and able to assist them in overcom-
ing the effects of trauma.

Thus, C/S/Xs who advocate against forced and punitive treatment as traumatizing violations
of their humanity, now point out that the majority of diagnosed individuals are actually be-
ing retraumatized in psychiatric settings (New York State Office of Mental Health, 1993). In
the words of one C/S/X, if one was not a trauma survivor before entering the mental health
system, one is sure to become one once labeled and locked up. In other words, no matter
what theory an intervention is based on, unless the coercive culture of psychiatry is radically
altered, many persons will continue to be traumatized, whether or not such experience is
repetitious of their pasts.

In regard to the theory itself, some C/S/Xs are relieved by the long-overdue recognition of
trauma and abuse as primary factors in the development of symptoms that were once adap-
tive coping strategies. Believing that this recognition must preclude further violations, they
want to do therapeutic work on the issues that trauma and abuse created. Their choice might
be to work on this and only this in individual or group work with professionals and/or peers.
Others see the traumatic aspect of their histories as part of what affected them, but also be-
lieve they have biological or socioeconomic reasons for “symptoms” as well. Thus, they see
multifaceted approaches as the only viable way to work.

Regardless of what C/S/Xs believe about the etiology of their difficulties, they want what
they have always stated to be important: to be heard and treated as individuals and to have

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NAC/SMHA Position Paper (continued)

their subjective experience and self-perception respected. Also consistent with C/S/Xs’ stated

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wishes over the years is the desire to be perceived and treated with hope (Zinman, Harp. &
Bead, 1987; Campbell, 1989; Chamberlin, 1990; Knight, 1991; Fisher, 1994; Penney, 1995).
It is difficult to count on a system that has routinely dashed hope to now operate from a belief
that recovery is possible. But this is essential to any therapeutic plan and one seldom empha-
sized in professional training.

C/S/Xs frequently report that they were never asked about trauma or abuse, and if they
were, divulging such history did not yield a specifically responsive result. Most believe the
relevance of abuse and trauma should be communicated sensitively, early, and consistently
throughout encounters with the system. However, it must be understood that such an
approach is still only theory until chosen as useful by the individual consumer/survivor.

Given the documentation that the majority of people with psychiatric diagnoses are abuse
survivors, many C/S/Xs think the most effective way to address trauma and abuse histories is
to assume that all C/S/Xs are potentially abuse survivors. It should be considered integrally
important to one’s development up to assessment/admission, and the process of encountering
the mental health system can be assumed as potentially retraumatizing or at least “triggering”
of previous experience. If trauma were presumed, anyone entering the system would be sub-
ject to a more humane, considerate, and relevant approach. Importantly, this would eliminate
the need for separate units for “trauma survivors” as if they were different people from those
called “mentally ill.” Interventions such as restraint and seclusion would be deemed too trau-
matizing for anyone in crisis, not only for one whose trauma history is known.

This becomes more of an issue as mental health professionals begin to address how to treat
abuse survivors, particularly on an inpatient basis. Indeed, the “trauma models” they use
often appear much more humane and respectful of the person than do traditional approaches
to people with psychiatric diagnoses, and some who specialize in this area believe the new
paradigm should dominate the field, regardless of what has brought a person to a mental
health crisis. However, as psychiatry gains a foothold in the area, a new division of “patients”
can be seen: trauma survivors, with diagnoses like Dissociative Identity Disorder (DID) and
Post-Traumatic Stress Disorder (PTSD) vs. (and sometimes co-occurring with) more standard
diagnoses of mental illness. In this context, the system continues to employ inhumane meth-
ods, such as forced medications or restraints, with some diagnosed persons, while an effort is
made to avoid “retraumatizing” others.

This division is disturbing to C/S/Xs who see a new hierarchy of oppression forming before
their eyes after years of fighting for the full human rights of all who cross the path of the

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mental health system. They do not wish to see two groups of diagnosed individuals set up in

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opposition to each other, one treated with concern and compassion because of their trauma
histories, the other treated in coercive, inhumane ways because they are thought to have a
biological illness.

The issue of power differentials is crucial here. Abuse is about one person subjugating anoth-
er—the violent assertion of one’s will over another. Traumatic experiences, while not always
interpersonal, similarly leave people feeling as helpless victims whose control was usurped
by a more powerful condition or event. The risk for anyone entering the mental health system
is fundamentally a loss of power. Even voluntary admissions to in- or out-patient services are
governed by the coercive power held by psychiatry. The loss of power over one’s life, which
usually accompanies a diagnosis, is traumatizing for all people, whatever their past history of
trauma or abuse.

Most C/S/Xs want to believe that practitioners care about outcomes beyond cost efficiency
and behavior control. Thus, it is crucial in their opinion that practitioners be aware of the
often dramatic improvements in the lives of C/S/Xs that result from being listened to and
treated as individuals. This also means not forcing a trauma-related diagnosis or trauma-
model services on individuals who are not comfortable with that approach. Again, individu-
als need to be listened to; while it might be useful to have theories suggested, no success is
possible when one is imposed.

Mental health professionals would do well to consider how survivors managed all the years
their abuse histories remained hidden. The strengths of individuals, peer support, and self-
help gain new respect when it is recognized that for many, these have been the only avenues
that have been available to them for support. The incorporation of trauma theories into the
design and delivery of mental health services can provide a new opportunity to consider the
integration of peer-run and other community resources as equally important to professional
interventions.

Possibly the most important area being explored in services specific to trauma is one that
C/S/Xs have also been exploring and advocating for years—that of advance directives (Back-
lar & McFarland, 1996; Sherman, 1994). Out of efforts to avoid retraumatizing survivors of
abuse, some mental health assessments now include questions about what triggers difficulty
for individuals and what they find most helpful in especially troubled moments. Perhaps this
is because trauma survivors are seen as more capable of knowing themselves and what helps
them, but it is a way of planning in partnership with professionals that C/S/Xs have long been
aware of and supported. Many would go so far as to say that recovery is only possible where
this kind of partnership is built and honored.
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Given the dominance of the medical or biological model of mental illness in the field at

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this time, C/S/Xs are eager to use what is effective from the framework of trauma survival.
A great deal of difference could be made in the lives of individuals if this growing body of
information were used to support holistic and hopeful views of what is happening to them
and what is possible for their futures. As one C/S/X put it, perhaps the “Decade of the Brain”
could give way to the “Decade of Recovery”—recovery only being possible when all aspects
of a person’s development in context are given equal value, and a spectrum of healing possi-
bilities are offered as real choices.

References

Alexander, M.J., & Muenzenmaier, K. (1998). Trauma, addiction and recovery: Addressing public
health epidemics among women with severe mental illness. In Levin, B., Blanch, A., & Jennings,
A. (Eds.), Women’s mental health services: A public health perspective. Thousand Oaks, CA:
Sage.

Backlar, P., & McFarland, B. (1996). A survey on use of advance directives for mental health
treatment in Oregon. Psychiatric Services, 47, 12.

Beck, J., & Van der Kolk, B. (1987). Reports of childhood incest and current behavior of chronically
hospitalized women. American Journal of Psychiatry, 144, 1474.

Blanch, A., & Parrish, J. (1993). Alternatives to involuntary treatment: Results of three roundtable
discussions. Rockville, MD: Center for Mental Health Services, Community Support Program.

Breyer, J., et al. (1987). Childhood sexual abuse as factors in adult psychiatric illness, American
Journal of Psychiatry, 144, 1426-1427.

Campbell, J. (1989). In pursuit of wellness: The Well-Being Project. Sacramento, CA: California
Network of Mental Health Clients.

Chamberlin, J. (1990). The ex-patients’ movement: where we’ve been and where we’re going.
Journal of Mind and Behavior, 11(3-4), 323-336.

Craine, L., Henson, C., Colliver, J., & MacLean, D. (1988). Prevalence of a history of sexual
abuse among female psychiatric patients in a State hospital system. Hospital and Community
Psychiatry, 39 (3), 300- 304.

Fisher, D. (1994). A new vision of healing as constructed by people with psychiatric disabilities
working as mental health providers. Psychosocial Rehabilitation Journal, 19(3), 67-81.

Harris, M. (1994) Modifications in service delivery and clinical treatment for women diagnosed with
severe mental illness who are also survivors of sexual abuse trauma. Journal of Mental Health
Administration, 21, 4.

Kalinowski, C., & Penney, D. (1998). Empowerment and women’s mental health services. In Levin,
B., Blanch, A., & Jennings, A. (Eds.), Women’s mental health services: A public health perspec-
tive. Thousand Oaks, CA: Sage.

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Knight, E. (1991). Self-directed rehabilitation. Empowerment, 2(7), 1-4.

Mental Health Association in New York State & New York State Office of Mental Health. (1994).
Proceedings from the forum on sexual abuse survivors in the mental health system. Albany, NY:
Office of Mental Health.

New York State Office of Mental Health (1993). Report of the task force on restraint and seclusion.
Albany, NY: Author.

Penney, D.J. (1995). Essential elements of case management in managed care settings: A service
recipient perspective. In L.J. Giesler (Ed.), Case management for behavioral managed care
(pp. 97-113). Cincinnati, OH: National Association of Case Management.

Rose, S., Peabody, C., & Stratigeas, B. (1991). Undetected abuse among intensive case manage-
ment clients. Hospital and Community Psychiatry, 42, 5.

Sherman, P. (1994). Advance directives for involuntary psychiatric care. Evergreen, CO: Resources
for Human Services Managers.

Smith, S. (1995). Restraints: Retraumatization for rape victims? Journal of Psychosocial Nursing,
33, 7.

Stefan, S. (1996). Reforming the provision of mental health treatment. In Moss, K. (Ed.),
Man-made medicine: Women’s health, public policy, and reform (pp. 195-218). Durham, NC:
Duke University Press.

Zinman, S., Harp, H., & Bead, S. (Eds.). (1987). Reaching across: Mental health clients helping
each other. Sacramento, CA: California Network of Mental Health Clients.

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What Can Happen to Abused Children When They

Grow Up—If No One Notices, Listens, or Helps?

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Some Statistics from the Research

For purposes of this document, “abuse” and “trauma” are defined as interpersonal violence
in the form of sexual abuse, physical abuse, severe neglect, loss, and /or the witnessing of
violence.

If no one notices, listens, or helps, childhood abuse can lead in adult years to—

SERIOUS MENTAL HEALTH PROBLEMS

The mental health system is filled with survivors of prolonged, repeated childhood trauma.
• Fifty to 70 percent of all women and a substantial number of men treated in psychiatric
settings have histories of sexual or physical abuse, or both. (Carmen et al., 1984; Bryer et
al., 1987; Craine et al., 1988)
• As high as 81 percent of men and women in psychiatric hospitals with a variety of major
mental illness diagnoses have experienced physical and/or sexual abuse. Sixty-seven per-
cent of these men and women were abused as children. (Jacobson & Richardson, 1987)
• Seventy-four percent of Maine’s Augusta Mental Health Institute patients, interviewed as
class members, report histories of sexual and physical abuse.
(Maine BDS, 1998)
• The majority of adults diagnosed with Borderline Personality Disorder (81 percent) or
Dissociative Identity Disorder (90 percent) were sexually and/or physically abused as
children. (Herman et al., 1989; Ross et al., 1990)
• Women molested as children are four times more at risk for Major Depression as
those with no such history. They are significantly more likely to develop bulimia and
chronic PTSD. (Stein et al., 1988; Root & Fallon, 1988; Sloane, 1986; Craine, 1990)
• Childhood abuse can result in adult experience of shame, flashbacks, nightmares, severe
anxiety, depression, alcohol and drug use, feelings of humiliation and unworthiness, ugli-
ness, and profound terror. (Harris & Landis, 1997; Rieker & Carmen, 1986; Herman,
1992; Janoff-Bulman & Frieze, 1983; van der Kolk, 1987; Brown & Finkelhor, 1986;
Rimsza, 1988)
• Adults 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 two and a half times as likely to have phobias
o over ten times as likely to have a panic disorder

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o almost four times as likely to have an antisocial personality disorder (Stein et al., 1988)

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• 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. (Goodman, Johnson, Dutton, & Harris, 1997)

SUICIDE AND SELF-INJURY

• There is a highly significant relationship between childhood sexual abuse and various
forms of self-harm later in life, i.e., suicide attempts, cutting, and self-starving, particu-
larly. (van der Kolk et al., 1991)
• For adults and adolescents with childhood abuse histories, the risk of suicide is increased
4- to 12-fold. (Felitti et al., 1998)
• Most self-injurers have childhood histories of physical or sexual abuse. Forty percent of
persons who self-injure are men. (Graff & Mallin, 1967; Pattison & Kahan, 1983; Briere
& Runtz, 1988)

ALCOHOL AND DRUG ABUSE

• Nearly 90 percent of alcoholic women were sexually abused as children or suffered
severe violence at the hands of a parent. (Miller & Downs, 1993)
• Up to two-thirds of both men and women in substance abuse treatment report childhood
abuse or neglect. (SAMHSA CSAT, 2000)
• Teenagers with alcohol problems are 21 times more likely to have been sexually abused
than those without such problems. (Clark et al., 1997)
• Seventy-one to 90 percent of adolescent and teenage girls and 23 to 42 percent of adoles-
cent and teenage boys in a Maine inpatient substance abuse treatment program reported
histories of childhood sexual abuse. (Rohsenow et al., 1988)
• 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. (Felitti et al., 1998)
• Adults abused during childhood are more than twice as likely as those not abused during
childhood to have serious substance abuse problems. (Stein et al., 1988)
• Fifty-five percent of Augusta Mental Health Institute class members with a dual diagnosis
of mental illness and substance abuse report histories of physical and/or sexual abuse.
(Maine BDS, 1998)

SERIOUS MEDICAL PROBLEMS AND HEALTH RISKS

• Medical impacts of childhood abuse include head trauma, brain injury, sexually trans-
mitted 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
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spasms, elevated blood pressure. (Prescott, 1998; Cunningham et al., 1988, Morrison,
1989; Springs & Friedrich, 1992; Walker et al., 1988)
• Adults who had experienced multiple types of abuse and violence in childhood compared
to those who had not, had a 2- to 4-fold increase in smoking, poor self-rated health, 50+
sexual intercourse partners, sexually transmitted disease, a higher rate of physical inactiv-
ity, and severe obesity. (Felitti et al., 1998)
• A major HMO study reports adverse childhood exposures showed a relationship with the
presence of adult diseases, including ischemic heart disease, cancer, chronic lung disease,
skeletal fractures, and liver disease. (Felitti et al., 1998)
• Research reveals severe and prolonged childhood sexual abuse to underlie damage to
the brain structure, resulting in impaired memory, dissociation, and symptoms of PTSD.
(Briere, 1997; van der Kolk, 1996; Perry, 1994)

DELINQUENCY, VIOLENCE, AND CRIMINAL BEHAVIOR

Reenactment of childhood victimization is the major cause of violence in our society.
• Numerous-studies have documented that most violent criminals were physically or sexu-
ally abused as children. (Groth, 1979; Seghorn et al., 1987)
• Over 95 percent of perpetrators who sexually abuse female children and over 80 percent
of those who abuse male children, are men. Most of these men were abused themselves in
childhood. (Fergusson & Mullen, 1999)
• Children from violent homes are 24 times more likely to commit sexual assault than their
counterparts from nonviolent homes. (Dinzinger, 1996)
• Of 14 juveniles condemned to death for murder in the United States in 1987, 12 had been
brutally physically abused and 5 had been sodomized by relatives as children. (Lewis et
al., 1998)
• A study of convicted killers reports 83.8 percent suffered severe physical and emotional
abuse and 32.2 percent were sexually violated as children. (Blake et al., 1995)
• Eighty-five percent of boys and girls committed to the Maine Youth Center report a his-
tory of childhood trauma. (MAYSI: Massachusetts Assessment Youth Screening Inventory
Assessment, Sept. 1999)
• Over 75 percent of juvenile girls identified as delinquent by courts have been sexually
abused. When they run away from the abuse at home, they are often labeled as delin-
quent. (Calhoun et al., 1993)
• Eighty percent of women in prison and jails have been victims of sexual and physical
abuse. These women are far more likely to be abused while in prison. (Smith, 1998)
• Without help, one-third of those abused in childhood may abuse or neglect their own
children, perpetuating an intergenerational cycle of abuse. (Kaufman & Zigler, 1987)

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DEVELOPMENTAL OR PHYSICAL DISABILITIES
• Violence is a significant causal factor in 10 to 25 percent of all developmental disabilities.
(Sobsey, 1994; Valenti-Hein & Schwartz, 1995)
• Three to 6 percent of all children will have some degree of permanent disability as a
result of abuse. (Sobsey, 1994; Valenti-Hein & Schwartz, 1995)
• Between 20 and 50 percent of abused children suffer mild to severe brain damage. (Rose
& Hardman, 1981)

SEVERE SOCIAL PROBLEMS

Homelessness
• Seventy percent of women living on the streets or in shelters report abuse in childhood.
Over 70 percent of girls on the streets have run away to flee violence in their homes.
(Goodman, 1991; Chesney-Lind & Shelden, 1998)
Prostitution
• Victims of child sexual abuse are at high risk of becoming prostitutes in adolescence or as
adults. More than 50 percent of prostitutes were sexually abused as children. (Silbert &
Pines, 1981; Bagley & Young, 1987)
Poverty and Welfare
• More than 40 percent of women on welfare with multiple persistent problems in leaving
the welfare roles were sexually abused as children. (DeParle, 1999)
• Sixty percent of housed, low-income mothers on AFDC, experienced severe childhood
physical abuse and 42 percent were sexually molested as children. (Bassuk et al., 1998)
Truancy, Running Away, Risky Sexual Behavior
• Childhood abuse has been correlated with increased adolescent and young adult truancy,
running away, and risky sexual behavior. (Briere, 1997)

REVICTIMIZATION
Predators look for weak or vulnerable people. Having been abused as a child—especially
having been sexually abused, makes one vulnerable to being revictimized.
• Women who are sexually abused during childhood were 2.4 times more likely to be
revictimized as adults as women who were not sexually abused. (Wyatt et al., 1992)
• Sixty-eight percent of women with childhood history of incest reported incidents of rape
or attempted rape after age 14 compared to 38 percent of a random sample. (Russell,
1986)
• Girls who experience violence in childhood are three to four times as likely to be victims
of rape. (Browne, 1992)
• Childhood sexual assaults are associated with increased risk of adult assaults of both a
physical and sexual nature, whereas childhood physical assaults, by contrast, were not
related to adult victimization experiences. (Newman et al., 1998)
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• Twice as many women with a history of incest as women without such a history are

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victims of domestic violence, and twice as many also report unwanted sexual advances
by an unrelated authority figure. (Russell, 1986)
• Victims of father-daughter incest are four times more likely than non-incest victims to
be asked to pose for pornography. (Russell, 1986)

References

SERIOUS MENTAL HEALTH PROBLEMS

Bryer, J.B., Nelson, B., Miller, J.B., & Krol, P. (1987). Childhood sexual and physical abuse as
factors in adult psychiatric illness. American Journal of Psychiatry, 144, 1426-1430.

Carmen, E., Rieker, P., & Mills, T. (1984). Victims of violence and psychiatric illness. American
Journal of Psychiatry, 141(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.

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.

Augusta Mental Health Institute. (1988). Consent decree class member assessment. Augusta:
Maine Department of Mental Health, Mental Retardation and Substance Abuse Services.

Herman, J, Perry, C., & van der Kolk, B. (1989). Childhood trauma in Borderline Personality
Disorder. American Journal of Psychiatry, 164, 490-495.

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. Journal of Psychiatry, 147,
596-601.

Stein, J.A., Golding, J.M., Siegel, J.M., Burnam, M.A., & Sorenson, S.B. (1988). Long-term psycho-
logical 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 Ed., Vol. 100,
pp.135-154). Newbury Park, CA; Sage.

Root, M,, & Fallon. (1989). The Incidence of victimization experiences in a bulimic sample. Journal
of Interpersonal Violence, 4, 90-100.

Sloane, G., & Leichner, P. (1986). Is there a relationship between sexual abuse or incest and
eating disorders? Canadian Journal of Psychiatry, 31, 656-660.

Craine, P. Cited by Gondolf, E.W. (1990). Psychiatric responses to family violence: Identifying and
confronting neglected danger. Lexington, MA: Lexington Books.

Harris, M., & Landis. (Eds.). (1997). Sexual abuse in the lives of women diagnosed with serious
mental illness. Netherlands: Harwood Academic Publishers.

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What Can Happen (continued)

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Rieker, P.P., & Carmen, E.H. (1986). The victim-to-patient process: The disconfirmation and
transformation of abuse. American Journal of Orthopsychiatry, 56(3).

Herman, J. (1992). Trauma and recovery: The aftermath of violence—From domestic abuse to
political terror. New York: Basic Books.

Janoff-Bulman, R., & Frieze, I.H. (1983). A theoretical perspective for understanding reactions
to victimization. Journal of Social Issues, 39(2), 1-17.

van der Kolk, B.A. (Ed.). (1987). Psychological trauma. Washington, DC: American Psychiatric Press.

Brown, A., & Finkelhor, D. (1986). Impact of child sexual abuse: A review of the literature.
Psychological Bulletin, 99, 66-77.

Rimsza, M.E., Berg, R.A., & Locke, C. (1988). Sexual abuse: Somatic and emotional reactions.
Child Abuse and Neglect, 12(2), 201-8.

Goodman, L., Johnson, M., Dutton, M.A., & Harris, M. (1997). Prevalence and impact of sexual
and physical abuse. In M. Harris & Landis. (Eds.), Sexual abuse in the lives of women diagnosed
with serious mental illness. Netherlands: Harwood Academic Publishers.

SUICIDE AND SELF-INJURY

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.

Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P., &
Marks, J.S. (1998). Relationship of childhood abuse and household dysfunction to many of the
leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American
Journal of Preventive Medicine, 14, 245-258.

Graff, H., & Mallin, R. (1967). The syndrome of the wrist cutter. American Journal of Psychiatry,
12A(1), 36-42.

Pattison, E.M., & Kahan, J. (1983). The deliberate self-harm syndrome. American Journal of
Psychiatry, 140(7), 867-872.

Briere, J., & Runtz, M. (1988). Post sexual abuse trauma. In G.E. Wyatt & G.J. Powell (Eds.),
Lasting effects of child sexual abuse. Newbury Park, CA: Sage.

ALCOHOL AND DRUG ABUSE

Miller, B., & Downs, W. (1993). Journal of Studies in Alcohol, Suppl. No. 11:109-117.

Center for Substance Abuse Treatment. (2000). Substance abuse treatment for persons with
child abuse and neglect issues. Treatment Improvement Protocol (TIP) Series, No. 36. (DHHS
Publication No. (SMA) 00-3357). Washington, DC: U.S. Government Printing Office

Clark, H.W., McClanahan, T.M., & Sees, K.L. (1997). Cultural aspects of adolescent addiction and
treatment. Valparaaiso University Law Review, 31(2).

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Rohsenow, D.J., Corbett, R., & Devine, D. (1988). Chemical Dependency Treatment Program,
Mid-Maine Medical Center, Waterville, ME: Molested as children: A hidden contribution to sub-
stance abuse? Journal of Substance Abuse Treatment, 5, 13-18.

Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P., &
Marks, J.S. (1998). Relationship of childhood abuse and household dysfunction to many of the
leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American
Journal of Preventive Medicine, 14, 245-258.

Stein, J.A., Golding, J.M., Siegel, J.M., Burnam, M.A., & Sorenson, S.B. (1988). Long-term psycho-
logical 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 Ed., Vol. 100,
pp.135-154). Newbury Park, CA; Sage.

Augusta Mental Health Institute. (1988). Consent decree class member assessment. Augusta:
Maine Department of Mental Health, Mental Retardation and Substance Abuse Services.

SERIOUS MEDICAL PROBLEMS

Prescott, L. (1988). Women emerging in the wake of violence. Los Angeles: Prototype Systems
Change Center.

Cunningham, J., Pearce, T., & Pearce, P. (1988). Childhood sexual abuse and medical complaints in
adult women. Journal of Interpersonal Violence, 3, 131-144.

Morrison, J. (1989). Childhood sexual histories of women with somatization disorder. American
Journal of Psychiatry, 146, 239-241.

Springs, F., & Friedrich, W. (1993). Health risk behaviors and medical sequelae of childhood sexual
abuse. Mayo Clinic Proceedings.

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 Journal of
Psychiatry, 145, 75-80.

Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P., &
Marks, J.S. (1998). Relationship of childhood abuse and household dysfunction to many of the
leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American
Journal of Preventive Medicine, 14, 245-258.

Briere, J. (1997). Child abuse trauma: Theory and tTreatment of the lasting effects. Newbury Park,
CA: Sage.

van der Kolk, B. (1996). The body keeps the score: Approaches to the psychobiology of posttrau-
matic stress disorder. In Van der Kolk et al. (Eds.), Traumatic stress: The effects of overwhelm-
ing experience on mind, body, and dociety. Guilford Press.

Perry. (1994). Biological and neurobehavioral studies of Borderline Personality Disorder. In K. Silk
(Ed.) Progress in psychiatry, No. 45. American Psychiatric Press.

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DELINQUENCY, VIOLENCE, AND CRIMINAL BEHAVIOR

Groth, A.N. (1979). Men who rape: The psychology of the offender. New York: Plenum.

Seghorn, T.K., Prentky, R.A., & Boucher, R.J. (1987). Childhood sexual abuse in the lives of sexu-
ally aggressive offenders. Journal of American Academy of Child and Adolescent Psychiatry,
26(2):262-267.

Fergusson, D., & Mullen, P. (1999). Childhood sexual abuse: An evidence-based perspective.
Newbury Park, CA: Sage.

Dinzinger, S. (1996). The real war on crime: The report of the National Criminal Justice
Commission. New York: Harper.

Lewis, D., Pincus, J., Bard, B., et al. (1988). Neuropsychiatric psychoeducational and family
characteristics of 14 juveniles condemned to death in the United States. American Journal
of Psychiatry, 145, 584-589.

Blake, B., Pincus, J.H., & Buckner, C. (1995). Neurologic abnormalities in murderers. Neurology,
45, 1641-1647.

MAYSI Massachusetts Assessment Youth Screening Inventory Assessment. September 1999

Calhoun, G., Jurgens,J., & Chen, F. (1993). The neophyte female delinquent: A review of the
literature. Adolescence, 28, 461-471.

Smith, B. (1998). An end to silence: Women prisoners’ handbook on identifying and addressing
sexual misconduct. National Women’s Law Center.

Kaufman. J., & Zigler, E. (1987). Do abused children become abusive parents? American Journal
of Orthopsychiatry, 57(2).

DEVELOPMENTAL OR PHYSICAL DISABILITIES

Sobsey, D. (1994). Violence and abuse in the lives of people with disabilities: The end of silent
acceptance? Baltimore: Paul Brookes.

Valenti-Hein, D., & Schwartz, L. (1995). The sexual abuse interview for those with developmental
disabilities. Santa Barbara, CA: James Stanfield.

Rose, E., & Hardman, M.L. (1981). The abused mentally retarded child. Education and Training
of the Mentally Retarded, 16(2), 114-118.

SEVERE SOCIAL PROBLEMS

Homelessness

Goodman, L.A. (1991). The prevalence of abuse among homeless and housed poor mothers:
A comparison study. American Journal of Orthopsychiatry, 61(4), 489-500.

Chesney-Lind & Shelden. (1998, December). What to do about girls? Promising perspectives and
effective programs. ICCA Journal.

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What Can Happen (continued)

HANDOUT
Prostitution

Silbert, M.H. & Pines, A.M. (1981). Sexual child abuse as an antecedent to prostitution.
Child Abuse and Neglect, 5(4), 407-411.

Bagley, C., & Young, L. (1987). Juvenile prostitution and child sexual abuse: A controlled study.
Canadian Journal of Community Mental Health, 6, 5-26.

Poverty and Welfare

DeParle, J. (1999, November 28). Life after welfare. The New York Times.

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, 155(11), 11.

Truancy, Running Away, Risky Sexual Behavior

Briere, J. (1997). Child abuse trauma: Theory and treatment of the lasting effects. Newbury Park,
CA: Sage.

REVICTIMIZATION

Wyatt, G.E., Guthrie, D., & Notgrass, C.M. (1992). Differential effects of women’s child sexual
abuse and subsequent sexual revictimization. Journal of Consulting and Clinical Psychology, 60,
167-173.

Russell, D.E.H. (1986). The secret trauma: Incest in the lives of girls and women. New York: Basic
Books.

Browne, A. (1992). Violence against women: Relevance for medical practitioners. Council on
Scientific Affairs, American Medical Association report. Journal of American Medical Association,
257, 23.

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 (Eds.), Women’s mental
health services: A public health perspective (pp. 279-308). Newbury Park, CA:Sage.

These references were prepared by the Office of Trauma Services, Department of Behavioral and
Developmental Services, 40 State House Station, Augusta, ME 04333.
Phone: 207-287-4250 TTY: 207-287-2000 Fax: 207-287-7571
E-mail: [email protected]
January, 2001

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Some Common Reactions to Trauma

by Mary S. Gilbert, Ph.D.

HANDOUT
Physical Reactions Mental Reactions Emotional Behavioral
Reactions Reactions
Nervous energy, Changes in the way Fear, inability to Becoming withdrawn
jitters, muscle tension you think about feel safe or isolated from
yourself others
Upset stomach Sadness, grief,
Changes in the way depression Easily startled
Rapid heart rate you think about the
world Guilt Avoiding places or
Dizziness situations
Changes in the way Anger, irritability
Lack of energy, you think about other Becoming confronta-
fatigue people Numbness, lack of tional and aggressive
feelings
Teeth grinding Heightened Change in eating
awareness of Inability to enjoy habits
your surroundings anything
(hypervigilance) Loss or gain in weight
Loss of trust
Lessened awareness, Restlessness
Loss of self-esteem
disconnection from
Increase or decrease
yourself (dissociation) Feeling helpless in sexual activity
Difficulty concentrating Emotional distance
from others
Poor attention or
memory problems Intense or extreme
feelings
Difficulty making
decisions Feeling chronically
empty
Intrusive images
Blunted, then
extreme, feelings

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Commonwealth of Massachusetts
Department of Mental Health

HANDOUT
Trauma Assessment for DMH Facilities/Vendors

This form is a guide to gathering information with clients about a possible trauma history.
It is recommended for use as part of the intake assessment for all DMH clients in all settings
(inpatient, outpatient, emergency/crisis, day treatment, etc.). It should be used in conjunction
with the De-Escalation Form. After clinical review, information obtained should be incorpo-
rated into the client’s treatment plan.

1. Do you have a history of physical abuse (e.g., hit, punched, slapped, kicked,
strangled, burned, threatened with object or weapon, etc.)?

Yes___ No___ Don’t Know ___

If yes, in childhood? ___ adolescence? ___ adulthood? ___

at present? ___

By whom?

stranger ___ acquaintance ___ partner/spouse ___

parents ___ other family member ___ ritual abuse ___

2. Do you have a history of sexual abuse (e.g., unwanted kissing, hugging, touching,
nudity, attempted or completed intercourse)?

Yes___ No___ Don’t Know ___

If yes, in childhood? ___ adolescence? ___ adulthood? ___

at present? ___

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Trauma Assessment (continued)

HANDOUT
By whom?

stranger ___ acquaintance ___ partner/spouse ___

parents ___ other family member ___

3. Have you ever been raped?

Yes___ No___ Don’t Know ___

If yes, in childhood? ___ adolescence? ___ adulthood? ___

recently? ___

By whom?

stranger ___ acquaintance ___ partner/spouse ___

parents ___ other family member ___ ritual abuse ___

4. Have you experienced an acute trauma such as a natural disaster, severe accident,
or threat to life, or have you witnessed a death or violence to someone else, or been a
victim of a crime?

Yes__ No __ Don’t Know ___

If yes, at what age and circumstances?

________________________________________________________________________

________________________________________________________________________

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Trauma Assessment (continued)

HANDOUT
5. If yes to any of the above, are you experiencing flashbacks, nightmares, insomnia,
numbness, confusion, memory loss, self injury, extreme fearfulness or terror, etc.,
related to the trauma?

Yes ___ No___

If yes, describe.

________________________________________________________________________

________________________________________________________________________

Please incorporate the information obtained in the trauma assessment into the treatment
plan for this client.

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Guidelines for De-Escalation Preference Form

by Gayle Bluebird

HANDOUT
1. The De-Escalation Preference Form should be completed within 24 to 72 hours of
admission.
2. It is preferable that this form not be included in the admission packet or completed along
with admission forms because most clients are not emotionally prepared to focus on these
questions during that time.
3. The form may be administered during an individual interview or a group session. Even though
the material is sensitive, it is often helpful to administer it in a group session. Persons sitting
together at a table may feel more comfortable talking about the information while they answer
the questions and may also encourage others to complete the form more thoughtfully. A group
setting offers a more informational-type gathering as opposed to a clinical setting. If given dur-
ing a group session, there should be several staff members present to help individuals who need
support or assistance with reading, understanding, or answering the questions.
4. Careful consideration should be given as to who will administer the form. Ideally, it
should always be the same person, someone who is both familiar and comfortable with the
material. A consumer advocate employed by the hospital would be ideal, because peers are
often less threatening than professional staff. It must be understood by the person adminis-
tering the form that the form is not presented as treatment or therapy, but as helpful infor-
mation that can be included in the treatment plan.
5. To effectively provide information, persons administering the form should be knowledgeable
about the material. For example, it is helpful for a person to learn about additional efforts
that are being made at the hospital to reduce seclusion and restraint and how this information
will be used as part of that process. These persons should be able to answer questions about
the request for sensitive information. For example, it is important that the information about
touching at the hospital be presented as promoting appropriate, not inappropriate, touching.
6. When patients are not communicative enough to answer a question, they may be provided
an opportunity to answer the question at another time, if they so desire.
7. Patients must always be given the option to decline answering a question.
8. The form, when completed, should be placed in the patient’s file where it is known and
used effectively by staff.
9. Persons served should be told how the form is to be used. They should be given a copy of
the form to keep.
It may be helpful for the hospital to collect data on answers to these questions to

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identify patterns and trends that are important to patients.

HANDOUT
Commonwealth of Massachusetts
Department of Mental Health

De-Escalation Form for DMH Facilities/Vendors

This form is a guide to gathering information with clients for the development of strategies
to de-escalate agitation and distress so that restraint and seclusion can be averted. It should
be used in conjunction with the Trauma Assessment Form. It is recommended for use in all
inpatient facilities, psychiatric emergency rooms, crisis stabilization and other diversion
units, when clinically indicated. Indications include a past history or likelihood of loss of
control of aggressive impulses. After clinical review, the information obtained should be
incorporated into the treatment plan for this client.

1. It is helpful for us to be aware of the things that can help you feel better when you’re
having a hard time. Have any of the following ever worked for you? We may not be
able to offer all these alternatives, but I’d like us to work together to figure out how
we can best help you while you’re here. o exercise
o voluntary time out in your room o writing in a diary/journal
o listening to music o using ice on your body
o voluntary time out in quiet room o deep breathing exercises
o reading a newspaper/book o putting hands under cold water
o sitting by the nurses station o going for a walk with staff
o watching TV o lying down with cold facecloth
o talking with another consumer o taking a hot shower
o pacing the halls o wrapping up in a blanket
o talking with staff o other (please list)
o calling a friend _________________________________
o having your hand held _________________________________
o calling your therapist _________________________________
o having a hug
o pounding some clay
o punching a pillow

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De-Escalation Form (continued)

HANDOUT
2. Is there a person who has been helpful to you when you’re upset? (Y/N)

Would you like them to come and visit you? (Y/N)

Can we assist in this process? (Y/N)

If you are in a position where you are not able to give us information to further your
treatment, do we have your permission to call and speak to

______________________________ (name) _________________ (phone)? (Y/N)

If you agree that we can call to get information, sign below:

Client signature _______________________ Date ______________

Witness _____________________________ Date ______________

3. What are some of the things that make it more difficult for you when you’re already
upset?

Are there particular “triggers” that you know will cause you to escalate?
o being touched
o being isolated
o bedroom door open
o people in uniform
o particular time of day (when?)
o time of the year (when?)
o loud noise
o yelling
o not having control/input (explain)
o other (please list)

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De-Escalation Form (continued)

HANDOUT
4. Have you ever been restrained in a hospital or other setting—for example, in a crisis
stabilization unit or at home?

Physically/Mechanically Chemically
When?

Where?

What happened?

5. If you are escalating or in danger of hurting yourself or someone else, we may need to
use a physical, mechanical, or chemical restraint. We may not be able to offer you all
of these alternatives, but if it becomes necessary, we’d like to know your preferences.
o Quiet room
o Seclusion
o Physical hold
o Safety coat
o Papoose board
o 3-point restraint Face up? ____ Face down? ____
o 4-point restraint Face up? ____ Face down? ____
o Chemical restraint

6. Do you have a preference regarding the gender of staff assigned to you during and
immediately after a restraint?
o Women staff
o Men staff
o No preference

7. Is there anything that would be helpful to you during a restraint? Please describe.

_______________________________________________________________________

_______________________________________________________________________

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De-Escalation Form (continued)

HANDOUT
8. We may be required to administer medication if physical restraints aren’t calming
you down. In this case, we would like to know what medications have been especially
helpful to you. Please describe.

________________________________________________________________________

________________________________________________________________________

9. We do room checks here to make sure you are okay at night. We are trying to make
these room checks as nonintrusive as possible. Is there anything that would make
room checks more comfortable for you?

_______________________________________________________________________

_______________________________________________________________________

Please incorporate the information obtained in the de-escalation form into the
treatment plan for this client.

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Excerpt from Dealing With the Effects of Trauma:

A Self-Help Guide

HANDOUT
Things You Can Do Every Day to Help Yourself Feel Better
There are many things that happen every day that can cause you to feel ill, uncomfortable,
upset, anxious, or irritated. You will want to do things to help yourself feel better as quickly
as possible, without doing anything that has negative consequences, for example, drinking,
committing crimes, hurting yourself, risking your life, or eating lots of junk food.
• Read through the following list. Check off the ideas that appeal to you and give each of
them a try when you need to help yourself feel better. Make a list of the ones you find to
be most useful, along with those you have successfully used in the past, and hang the list
in a prominent place—like on your refrigerator door—as a reminder at times when you
need to comfort yourself. Use these techniques whenever you are having a hard time or as
a special treat to yourself.
• Do something fun or creative, something you really enjoy, like crafts, needlework, paint-
ing, drawing, woodworking, making a sculpture, reading fiction, comics, mystery novels,
or inspirational writings, doing crossword or jigsaw puzzles, playing a game, taking some
photographs, going fishing, going to a movie or other community event, or gardening.
• Get some exercise. Exercise is a great way to help yourself feel better while improving
your overall stamina and health. The right exercise can even be fun.
• Write something. Writing can help you feel better. You can keep lists, record dreams,
respond to questions, and explore your feelings. All ways are correct. Don’t worry about
how well you write. It’s not important. It is only for you. Writing about the trauma or
traumatic events also helps a lot. It allows you to safely process the emotions you are
experiencing. It tells your mind that you are taking care of the situation and helps to re-
lieve the difficult symptoms you may be experiencing. Keep your writings in a safe place
where others cannot read them. Share them only with people you feel comfortable with.
You may even want to write a letter to the person or people who have treated you badly,
telling them how it affected you, and not send the letter.
• Use your spiritual resources. Spiritual resources and making use of these resources
vary from person to person. For some people it means praying, going to church, or reach-
ing out to a member of the clergy. For others it is meditating or reading affirmations and
other kinds of inspirational materials. It may include rituals and ceremonies—whatever
feels right to you. Spiritual work does not necessarily occur within the bounds of an orga-
nized religion. Remember, you can be spiritual without being religious.
• Do something routine. When you don’t feel well, it helps to do something “normal”—
the kind of thing you do every day or often, things that are part of your routine, like

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Things You Can Do (continued)

HANDOUT
taking a shower, washing your hair, making yourself a sandwich, calling a friend or
family member, making your bed, walking the dog, or getting gas in the car.
• Wear something that makes you feel good. Everybody has certain clothes or jewelry
that they enjoy wearing. These are the things to wear when you need to comfort yourself.
• Get some little things done. It always helps you feel better if you accomplish some-
thing, even if it is a very small thing. Think of some easy things to do that don’t take
much time. Then do them. Here are some ideas: clean out one drawer, put five pictures
in a photo album, dust a book case, read a page in a favorite book, do a load of laundry,
cook yourself something healthful, send someone a card.
• Learn something new. Think about a topic that you are interested in but have never
explored. Find some information on it in the library. Check it out on the Internet. Go to
a class. Look at something in a new way. Read a favorite saying, poem, or piece of scrip-
ture, and see if you can find new meaning in it.
• Do a reality check. Checking in on what is really going on rather than responding to
your initial “gut reaction” can be very helpful. For instance, if you come in the house
and loud music is playing, it may trigger the thinking that someone is playing the music
just to annoy you. The initial reaction is to get really angry with them. That would make
both of you feel awful. A reality check gives the person playing the loud music a chance
to look at what is really going on. Perhaps the person playing the music thought you
wouldn’t be in until later and took advantage of the opportunity to play loud music. If you
would call upstairs and ask him to turn down the music so you could rest, he probably
would say, “Sure!” It helps if you can stop yourself from jumping to conclusions before
you check the facts.
• Be present in the moment. This is often referred to as mindfulness. Many of us spend
so much time focusing on the future or thinking about the past that we miss out on fully
experiencing what is going on in the present. Making a conscious effort to focus your
attention on what you are doing right now and what is happening around you can help
you feel better. Look around at nature. Feel the weather. Look at the sky when it is filled
with stars.
• Stare at something pretty or something that has special meaning for you. Stop what
you are doing and take a long, close look at a flower, a leaf, a plant, the sky, a work of art,
a souvenir from an adventure, a picture of a loved one, or a picture of yourself. Notice
how much better you feel after doing this.
• Play with children in your family or with a pet. Romping in the grass with a dog,
petting a kitten, reading a story to a child, rocking a baby, and similar activities have a
calming effect which translates into feeling better.

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Things You Can Do (continued)

HANDOUT
• Do a relaxation exercise. There are many good books available that describe relaxation
exercises. Try them to discover which ones you prefer. Practice them daily. Use them
whenever you need to help yourself feel better. Relaxation tapes that feature relaxing mu-
sic or nature sounds are available. Just listening for 10 minutes can help you feel better.
• Take a warm bath. This may sound simplistic, but it helps. If you are lucky enough to
have access to a Jacuzzi or hot tub, it’s even better. Warm water is relaxing and healing.
• Expose yourself to something that smells good to you. Many people have discovered
fragrances that help them feel good. Sometimes a bouquet of fragrant flowers or the smell
of fresh baked bread will help you feel better.
• Listen to music. Pay attention to your sense of hearing by pampering yourself with de-
lightful music you really enjoy. Libraries often have records and tapes available for loan.
If you enjoy music, make it an essential part of every day.
• Make music. Making music is also a good way to help yourself feel better. Drums and
other kinds of musical instruments are popular ways of relieving tension and increasing
well-being. Perhaps you have an instrument that you enjoy playing, like a harmonica,
kazoo, penny whistle, or guitar.
• Sing. Singing helps. It fills your lungs with fresh air and makes you feel better. Sing to
yourself. Sing at the top of your lungs. Sing when you are driving your car. Sing when
you are in the shower. Sing for the fun of it. Sing along with favorite records, tapes, com-
pact discs, or the radio. Sing the favorite songs you remember from your childhood.

Perhaps you can think of some other things you could do that would help you feel better.

Source: U.S. Department of Health and Human Services. (2002). Dealing With the Effects of
Trauma: A Self-Help Guide. DHHS Pub. No. SMA-3717. Rockville, MD: Center for Mental Health
Services, Substance Abuse and Mental Health Services Administration. www.mentalhealth.org/
publications/allpubs/SMA-3717/things.asp

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Grounding Techniques
by Mary S. Gilbert, Ph.D.

HANDOUT
Grounding refers to methods for stopping the re-experiencing of a trauma, or related symp-
tom, and getting back to the here and now. Often those with a trauma history experience such
symptoms as flashbacks (a sudden, vivid memory of the event) or dissociation (various ways
of disconnecting with traumatic experiences mentally, emotionally, or both by disconnect-
ing in current reality). These symptoms happen against the consumer’s will and feel out of
control. A staff member can often help ground consumers by asking questions or directing
them based on the suggestions below. Learning and applying grounding techniques are very
important parts of consumers gaining some control over these symptoms.

When a consumer reports/appears unusually anxious or vulnerable, is nonresponsive,

or is reacting in other ways suggestive of re-experiencing a trauma:

As an overall guide, mainly try to help the consumer focus on something in one or more of
the five senses in the present: sight, smell, hearing, taste, or touch.
• Crucial to maintain visual contact with environmental cues.
o Make sure the consumer is in a well-lit area—stay out of dark or dim areas, or turn on
the lights. Recommend a night-light. (Beware of nighttime—darkness, fatigue, and a
history of evening sexual abuse are often problems.)
o Don’t allow hiding in dark or confined places, even if s/he feels frightened or disorga-
nized. Make sure eyes remain open.
o Assist the consumer in looking at and focusing on things around her/him. For ex-
ample, describe the color of the walls or carpet. Or, if s/he has a favorite object, like a
stuffed animal, give that to her/him and assist the person in noticing how it looks, feels,
and smells. (Focusing on familiar, comforting objects helps the consumer remain in or
return to the present.)
o Present previously developed flashcards that assist the consumer in recognizing s/he is
only experiencing a flashback, not reality. (Statements on the cards need to come from
the consumer.) These can also be placed on a mirror, for example, so you can direct the
consumer’s attention to them when necessary.
• Maintain personal contact with the consumer.
o Say that person’s name and identify yourself. Tell him/her where s/he is and the full
date. Keep repeating this in reassuring, but normal voice tones (not soft or rhythmic).
Tell the consumer you know s/he is frightened, but s/he is safe. Ask the consumer to
look at your face and try to make direct, focused eye contact with the consumer. If
frightened by eye contact, redirect to a different part of your body, like hair or shirt.
Ask the consumer to move her/his eyes so as not to go into a daze. Be firm and direct.

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Grounding Techniques (continued)

HANDOUT
o Remind the consumer of significant others, such as a child or partner, if appropriate.
(These interpersonal connections can be very grounding.)
• Direct the consumer to focus on a physical sensation.
o Ask the consumer to start naming what s/he sees in the room, or what color her/his
shirt is, etc.
o Suggest s/he feels own weight, or the chair s/he is sitting on, or notices how his/her
feet feel on the floor. Help the consumer take a walk (try stamping feet) around the
room and notice all that s/he sees and feels. (These help remind the consumer that s/he
is in reality here and now, not a part of a memory or reliving the event.)
o Recommend the consumer get in the “in control” body posture.
• Focus on the present.
o If not alarmed by it, help consumer look in the mirror and see that s/he is an adult, not
a child in a traumatic situation.
o Call the consumer’s attention to a calendar and/or a clock and help him/her figure out
what day and time it is. (Again, this can help the consumer realize s/he is not back in
the midst of the trauma and return to the present.)
o Ask the consumer questions about the present, like what TV shows s/he likes, or
plans for the weekend, or the first thing s/he wants to do when s/he gets home.
o Ask the consumer about her/his interests or activities, such as recreational activities or
a pet. Don’t choose anything emotionally charged or related to his/her trauma.
o Direct and assist in writing or drawing about something positive. (These activities can
often be soothing.)
• After a period of loss of control:
o Help reassure consumer and normalize event/current situation.
o If consumer is able, assist with relaxation techniques to help consumer further calm down.
o Try to identify what causes the consumer’s symptoms. Attempt to determine any possi-
ble external triggers. Help the consumer identify preceding internal emotional events
or states. When possible and reasonable, help the consumer work out how to avoid
their triggers until better able to ground her/himself and cope more effectively.
o Determine body postures that accompany feelings of being flooded and/or over-
whelmed, as well as in control/adult body postures. Help the consumer describe and
practice the “in control” posture.
o Plan new ways to attempt to cope with stress in the future (e.g., redirecting, transitional
object, relaxation, etc.).
o Develop a crisis response plan for the next occurrence. Plan a simple strategy and note
what techniques worked best with consumer.

Source: Mary S. Gilbert, 2001. Partially adapted from Rebuilding Shattered Lives by Chu; and
Courtois & Briere.

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WEB SITES RELATED TO TRAUMA

HANDOUT
www.rossinst.com
The Colin A. Ross Institute was formed to further the understanding of psychological trauma
and its consequences by providing educational services, research, and clinical treatment of
trauma-based disorders.

www.childtrauma.org
The Child Trauma Academy is a nonprofit organization based in Houston, TX. The mission
of the Academy is to help improve the lives of traumatized and maltreated children and their
families. The Academy encourages innovations in clinical practice, program development,
and public policy. Many individuals and organizations share the Academy’s vision and hopes
for children; it is a central operating principle of the Academy to seek out, support, and work
side by side with these individuals and organizations—both public and private.

www.sidran.org
The Sidran Institute is a leading provider of traumatic stress education, publications, and re-
sources. It is a national nonprofit organization dedicated to supporting people with traumatic
stress conditions, providing education and training on treating and managing traumatic stress,
providing trauma-related advocacy, and informing the public on issues related to traumatic
stress. Sidran is also a leading publisher of books about traumatic stress.

David Baldwin’s Trauma Information Pages—www.trauma-pages.com

These pages focus primarily on emotional trauma and traumatic stress, including PTSD
(Post-Traumatic Stress Disorder), whether following individual traumatic experience(s) or a
large-scale disaster. New information is added to this site about once a month. The purpose of
this site is to provide information for clinicians and researchers in the traumatic stress field.
Baldwin’s interests include both clinical and research aspects of trauma responses and their
resolution. For example,

1. What goes on biologically in the brain during traumatic experience and its resolution?
2. Which psychotherapeutic procedures are most effective for which patients with traumatic
symptoms, and why?
3. How can we best measure clinical efficacy and treatment outcome for trauma survivor
populations?

Supportive resources supplement the more academic or research information of interest to

clinicians, researchers, and students.

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RESOURCES ON SECONDARY TRAUMA

HANDOUT
The Traumatic Stress Institute/Center for Adult and Adolescent Psychotherapy
Located in South Windsor, CT, the Traumatic Stress Institute has a dual mission: (1) to
promote understanding and improve treatment of traumatic stress and (2) to promote
psychology as a discipline and profession. This Institute has developed some very useful
resources for professionals struggling with secondary traumatic stress.

The Traumatic Stress Institute

Center for Adult and Adolescent Psychotherapy
22 Morgan Farms Drive
South Windsor, CT 06074
(860) 644-2541
www.tsicaap.com

The Traumatology Institute

The Traumatology Institute is the home of psychologist Dr. Charles Figley, a pioneer in the
field of compassion fatigue or secondary trauma. Dr. Figley is the founding editor of the
Journal of Traumatic Stress and has written many articles and books on compassion fatigue
or secondary traumatic stress.

The Traumatology Institute

School of Social Work
Florida State University
2407C University Center
Tallahassee, FL 32306-2570
(850) 644-4751
mailer.fsu.edu/~cfigley/TraumatologyInstitute.html

International Society for Traumatic Stress Studies (ISTSS)

ISTSS, founded in 1985, provides a forum for the sharing of research, clinical strategies,
public policy concerns, and theoretical formulations on trauma in the United States and
around the world. ISTSS is dedicated to the discovery and dissemination of knowledge and
to the stimulation of policy, program, and service initiatives that seek to reduce traumatic
stressors and their immediate and long-term consequences.

ISTSS
60 Revere Drive, Suite 500
Northbrook, IL 60062
(847) 480-9028
Fax: (847) 480-9282
www.istss.org
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Resources on Secondary Trauma (continued)

American Professional Society on the Abuse of Children (APSAC)

HANDOUT
APSAC’s mission is to ensure that everyone affected by child maltreatment receives the best
possible professional response. This organization has many useful scholarly and clinical
materials focused primarily at the professional audience. Nonetheless, caregivers working
with abused or maltreated children may find this a useful resource.

APSAC
P.O. Box 30669
Charleston, SC 29417
(843) 764-2905
Toll-free: (877) 402-7722
Fax: (803) 753-9823
www.apsac.org

The National Center for PTSD

The National Center for PTSD is a program of the U.S. Department of Veterans Affairs
and carries out a broad range of activities in research, training, and public information.
The primary focus of the Center has been combat veterans and their families. Over the last
few years, however, this focus has been expanded. The Center has many useful programs,
activities, and resources for anyone interested in the effects of traumatic stressors.

The PILOTS database is an electronic index to the worldwide literature on PTSD and other
mental health sequelae of exposure to traumatic events. It is available to Internet users
through the courtesy of Dartmouth College, whose computer facilities serve as host to the
database. No account or password is required, and there is no charge for using the PILOTS
database.

The National Center for PTSD

www.ncptsd.org

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MODULE 2 - REFERENCES

HANDOUT
Bills, L. (1996). Abuse: Connecting the past with present symptoms. Office of Mental Health
Quarterly, 2, 13-15.

Blanch, A., & Parrish, J. (1993). Alternatives to involuntary treatment: Results of three roundtable
discussions. Bethesda, MD: National Institute of Mental Health.

Bolen, J.D. (1993). The impact of sexual abuse on women’s health. Psychiatric Annals, 23(8),
446-453.

Brennen, K. (1997). Adult survivors of childhood sexual abuse in the mental health system:
Involuntary intervention, retraumatization and staff training. Tampa, FL: Department of
Community Health.

Cahill, C., Stuart, G., Laraia, M., & Arana, G. (1991). Inpatient management of violent behavior:
Nursing prevention and intervention. Issues in Mental Health Nursing, 12, 239-252.

Chu, J.A. (1998). Rebuilding shattered lives: Treating complex post-traumatic and dissociative
disorders. New York: Wiley.

Copeland, M.E. (2002). Dealing with the effects of trauma. DHHS Publication No. SMA-3717.
Rockville, MD: U.S. Department of Health and Human Services.

Doob, D. (1992). Female sexual abuse survivors as patients: Avoiding retraumatization. Archives
of Psychiatric Nursing, 6, 245-251.

Flynn, H. (1996, July). Mental health policy issues related to the use of seclusion and restraint
with adult survivors of childhood sexual abuse. Paper presented at the Florida Mental Health
Institute, Tampa, FL.

Gilbert, M.S. (2002). Materials from presentation at Pine Rest Hospital, Grand Rapids, MI.

Goren, S., Abraham, I., & Doyle, N. (1996) Reducing violence in a child psychiatric hospital
through planned organizational change. Journal of Child and Adolescent Psychiatric Nursing,
9(2), 27-36.

Hammond, W. (1996. January 7). Facing sexual abuse: State mental health system changing
treatment methods. Gazette Reporter.

Harris, D., & Morrison, E. (1995). Managing violence without coercion. Archives of Psychiatric
Nursing, 9(2), 203-210.

Jennings, A. (1994). Imposing stigma from within: Retraumatizing the victim. Resources,
6(3) 11-15.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (1995). Accreditation

manual for mental health, chemical dependency, and mental retardation/developmental disabil-
ity services. Vol.1, Standards; Vol. 2, Scoring guidelines. Oakbrook Terrace, IL: Author.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (1999). Testimony at

Senate hearings.

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Module 2 - References (continued)

HANDOUT
Kabat-Zinn, J. (1991). Full catastrophe living: Using the wisdom of your body and mind to face
stress, pain, and illness. New York: Delta.

Maine Office of Trauma Services. (2001). What can happen to abused children when they grow up
if no one notices, listens, or helps? Augusta, ME: Maine Department of Mental Health, Mental
Retardation, and Substance Abuse Services.

Maine Trauma Advisory Groups. (1997). In their own words: Trauma survivors and professionals
they trust tell what hurts, what helps, and what is needed for trauma services. Augusta, ME:
Maine Department of Mental Health, Mental Retardation, and Substance Abuse Services.

Massachusetts Department of Mental Health. (1995). Trauma assessment for Department

of Mental Health facilities/vendors. Boston: Author.

Massachusetts Department of Mental Health (1996) Clinical guidelines: Department of Mental

Health clients with a history of trauma. Boston: Author.

National Association of Consumer/Survivor Mental Health Administrators. (1998). Trauma and

abuse histories: Connections to diagnosis of mental illness, implications for policy and service
delivery. Unpublished position paper.

National Association of Consumer/Survivor Mental Health Administrators. (2000). In Our Own

Voices Survey. Unpublished.

National Association of State Mental Health Program Directors (NASMHPD). (1998). Position
statement on services and supports to trauma survivors. Alexandria, VA: Author.

Ridgely, S., & Van den Berg, P. (1997. April). Women and coercion: Commitment, involuntary
treatment, and restraint. Tampa, FL: Louis de la Parte Florida Mental Health Institute,
Department of Mental Health Law and Policy.

U.S. Department of Health and Human Services (DHHS). (2002). Dealing with the effects of
trauma: A self-help guide. Rockville, MD: Author. Online at www.mentalhealth.samhsa.gov.

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