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This Web site is a component of the SAMHSA Health Information Network.

Trauma Matters – January 2009

The e-Newsletter from CMHS' National Center for Trauma-Informed Care

Dynamic New Partnerships Created to Build Trauma-Informed Care (TIC) into State Mental Health Systems

Consumers/Survivors Dialog with States to Strategize for Trauma-Informed Change

For two days in December something quite remarkable happened. On December 9th and 10th, just after the NASMHPD Commissioner's Winter Meeting, a conference was convened and facilitated by NCTIC. The meeting brought together State Mental Health Agency (SMHA) trauma program representatives, Statewide Consumer Networks, State Offices of Consumer Affairs, representatives from Consumer/Consumer Supporter TA Centers, as well as additional consumers and administrators involved in TIC development from eight states, with the high-priority focus on leadership development for the implementation of TIC in state systems. Throughout the meeting these multiple voices resonated with ideas that embodied hope, strength, courage, collaboration, and commitment to trauma-informed change.

Hearing from those with lived experiences, consumers/survivors talked about what they have felt to be barriers to creating a trauma-informed peer specialist workforce. Given that the authoritarian/hierarchical medical diagnostic model has driven many of the current treatment practices and policies, by definition these environments do not view or embrace the consumer/survivor as equal in voice and authority. To overcome such barriers, new practices were discussed including TIC training curricula development and TIC credentialing criteria, screening and assessment procedures and processes, and how peer specialists are brought into service. The group also identified systems and programs where Statewide Consumer Networks play an important role in facilitating trauma-informed change by collaborating with and assisting SMHA's while putting the consumer-centered voice first.

The states that participated included Connecticut, Illinois, Maine, Maryland, Massachusetts, Oklahoma, Pennsylvania, Virginia, and Wisconsin - all offering their perspectives and insights regarding the challenges of changing traditionally coercive policies and practices to TIC. The inclusion of consumers/survivors as peer leaders and supporters was discussed, regarding the development of their own state paths of transformation. The environments in which people receive services were looked at from a number of perspectives, beginning with "safety" (and how safety may have different meanings and measures for staff and for those receiving services), to use of the "plain speak" language of lived experience, and at the multi-faceted role of peer leaders and supporters in fostering these TIC changes.

A new topic was put on the agenda: the creation and development of "Trauma-Informed Ethics," similar to the Hippocratic Oath taken by physicians, as an essential underpinning for all state-run and other human service providers working with trauma survivors to use as a standard for program and service practice. The notion of Trauma-Informed Ethics was enthusiastically embraced by meeting participants, and planning for the development if this code of conduct is currently underway.

NCTIC sees this meeting as the "first" of more to come, and plans to use the rich meeting discussion to further develop technical assistance capacity for state mental health trauma-informed care implementation in many ways. NCTIC will be revisiting the current NASMHPD "State System Assessment Strategies for Trauma-informed Care" to incorporate new trends, specialized needs, and new measures of care that will be incorporated into a new NASMHPD Position Statement on TIC to serve as a foundation and guide for further trauma-informed education and training.

Participant dialog at this meeting provided new insights into what implementation has been deemed successful, and NCTIC will be sharing this information to create parallel processes of learning among states. NCTIC will also be examining the various barriers noted and will attempt to identify implementation plans that would address these barriers and help facilitate a seamless process of education, training, and service delivery.

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"Plain Talk" Language and the Peer Role in TIC Change

By Beth Filson

There is a wide continuum of experience common to all of us, the human condition, the universal experience of what it means to be alive. It's what allows us to feel empathy, compassion, and regard: We don't just know each others' plight, we feel it, we relate to it. We see ourselves in each other. Yet the diagnostic and clinical language used to describe mental illness often has no real reference to human or shared events. Diagnostic and clinical language shifts how we relate to each other, as well as how we relate to ourselves, and often dictates priorities about what - out of all our experiences - is relevant.

In a trauma inducing mental health system, the emphasis on diagnostic language to convey information about the people receiving services frequently obscures the ways we are all linked. It runs the risk of creating the illusion that there are two groups of people whose expectations about life, meaning, and purpose are not the same. The less one group is able to relate to the other group, the more likely disregard, disrespect, and disenfranchisement will erupt.

With the terrorist attacks in 2001, as well as the 2005 hurricanes, we have come to understand that none of us is immune to trauma, whether natural or manmade. If we've learned anything, it's that we're in this together. Trauma-informed care provides us with an opportunity to create healing relationships in the context of shared events by acknowledging not just the prevalence of trauma in the lives of consumers, but also in the lives of those offering support.

The power of lived experience that peer providers bring to mental health services has provided a foundation for acknowledging the relevance of human experience in the design, implementation, practice, and evaluation of TIC change.

In thinking about the role of the peer workforce in the TIC culture shift, there is a promising avenue for vital consideration: The intentional use by peer providers of non-clinical or "plain talk" language of lived experience in communicating with the mental health system, at staff meetings, in consultation, in our documentation, and in direct care changes the nature and quality of those exchanges. This intentional use of human experience language naturally broadens the reference points for understanding the person's distress, and building connections through words we can all relate to. Understanding how certain behaviors have met needs for self-preservation becomes the fulcrum for new direction. We begin to recognize and change those practices within the system that cause disconnection and aloneness, rage and despair -- because these are words all of us understand.

Distressing behavior moves from product of internal flaw to the best way I have right now to tell you what I need, what I know, and where I've been. Acting on that information is how we collaboratively build Trauma-informed systems of care.

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Left, Right, Left Right: Experiencing a Fuller Range of Healing Modes

FACT: trauma survivors need to communicate their experiences.
FICTION: they must do it using words.

Many trauma survivors may find expressing their trauma experiences in words difficult or even impossible. Enter Art Therapy and Media Arts Therapy-two innovative approaches to helping trauma survivors communicate about and subsequently cope with memories they find too difficult or too horrific to express in words. "Media Arts," Basia Mosinski explains on "Media Arts in Art Therapy"-a forum discussion the Art Therapist hosts on the Dare to Transform website-"reflect the inner psychic world of those who engage in their use."

After all, human experience is like a movie that combines a three-dimensional film with odors and even a splash of water to create a four-dimensional experience. People experience life in four dimensions, not in the single-dimension of vocabulary, so it makes sense that effective therapy for trauma survivors would employ the various senses. This approach is supported both by science and by case study.

Experts maintain that the right brain, which is responsible for emotions and visual processes, holds the memories of traumatic experiences. A therapy that employs the right hemisphere of the brain, like art therapy, offers a way to access the traumatic memories stored there. The left brain need not feel excluded, though. The left brain-responsible for logic and verbal skills-often becomes involved during the art process through the creation of coherent art narratives and subsequent discussion. Now, all of a sudden, the trauma survivor finds himself talking about something that before the art he simply could not. The art becomes the vehicle toward expression and healing.

To place this into context, consider a hypothetical case of a Vietnam veteran who survived the 1968 siege at Khe Sanh. For years, he cannot talk about what happened there. Then one day while at a restaurant, he picks up a red crayon and he begins to scrawl images on a napkin: images of a twisted landscape dotted with twisted bodies. This feels goodhe's talking about it but also experiencing it. A red crayon led to a paintbrush, and now he leads an Art Therapy class for veterans suffering from post-traumatic stress disorder (PTSD).

This is just barely a hypothetical. Several studies have found that art provides an effective therapy for those suffering from PTSD. According to a 2006 article published in the LA Times, a 1997 study of various treatment methods applied to veterans suffering from PTSD concluded that art therapy was the most effective for the most severe cases. Interested readers can find a link to the LA Times article and many other, invaluable resources about Art Therapy on a website called Healing Combat Trauma.

One of the links leads to the webpage of Dr. Kate Collie, a researcher and visual artist. A gallery of Collie's paintings titled "A Soldier's Heart" details one veteran's experiences with PTSD and art therapy. Clicking on each image in the gallery results in a larger image and some text describing the context of the painting. What is evident from this study is the value of art as an emotional cathartic and a tool for healing.

Of course, art takes many forms, and technology has provided many different ways for the trauma survivor to voice her anguish. One of these media is video. As Art Therapist Basia Mosinski explains on "Media Arts in Art Therapy," "Video is a unique art form in that it stimulates audio and visual regions of the brain at the same time, particularly during editing." Her forum discussion, which contains a few video clips posted by participants, is an excellent starting point for an exploration of Media Arts Therapy.

Using technology such as video, the trauma survivor can become writer, director, and editor of his own experience. And, like brushstrokes on a canvas, the process can lead to healing in a way that words alone most often cannot.

Left-right, left-right-through art and art media, trauma survivors are increasingly learning to experience both modes of healing...

...and a new life.

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New on "Ning"

NCTIC's social network Dare to Transform on Ning.com continues to witness fascinating conversations among those concerned with trauma and trauma-informed care.

"Therapists' own trauma and family-centered care"-born on December 4 and therefore the youngest forum on the network-invites input for the Spring issue of Crosscurrents, "a Canadian mental health and addiction magazine for frontline workers published by the Centre for Addiction and Mental Health in Toronto." The forum requests information for two articles that will appear in the Spring issue of the periodical, which will be devoted to trauma-informed care. One article will be about the trauma experienced by caregivers. Known by various names in the field of TIC, such as "vicarious trauma," "compassion fatigue," "secondary traumatic stress," or "indirect trauma," the issue has as of late been pushed onto the front burner of TIC's hot stove. The second article will focus on the relationship between trauma-informed care and family-centered care. Also, in the forum, Crosscurrents' editor Hema Zbogar invites readers to visit the periodical's website.

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Calendar of Events

01/15/2009 - NY Trauma, PTSD & Grief Seminar, sponsored by Professional Education Systems, Inc., White Plains, NY

01/16 - 01/17/2009 - Children in Trauma, sponsored by California State University Center for Regional and Continuing Education, Chico, CA

01/22/2009 - Trauma and Trauma-Informed Care Conference, sponsored by the Regional Community Support Center at Northern Virginia Mental Health Institute, Falls Church, VA. For more information contact: Amy Rushton at 703-645-3129

09/09 - 09/11/2009 - National Sexual Assault Conference, sponsored by the National Sexual Violence Resource Center, Alexandria, VA

09/21 - 09/26/2009 - Children in Trauma, sponsored by California State University Center for Regional and Continuing Education, Chico, CA

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NEW Contact Info!

p: 866-254-4819
NCTIC@NASMHPD.org