Remarks by
A. Kathryn Power, M.Ed.
Director
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services
Harnessing the Power of the Human Heart to Transform Lives
July 12, 2008
Washington, DC
Attached is the text prepared for delivery; however, some material may have been added or omitted at the time of delivery.
Thank you, Susan (Salasin) for your kind introduction and for your longstanding commitment to individuals impacted by trauma, especially women and children and individuals involved with the criminal justice system. You recognize both the depths of their pain and the heights to which they can soar, and I want to honor you, even as you honor me today.
In fact, I don't know that I can take full credit for this wonderful award you've bestowed on me. Winston Churchill once said, "I have never accepted what many people have kindly said—namely that I inspired a Nation. It was the Nation and the race dwelling all around the globe that had the lion's heart. I had the luck to be called upon to give the roar."
And roar I have, ever since my days as a rape crisis counselor and later as a victim services advocate. I learned again and again that a woman's searing exposure to the raw trauma of physical or sexual assault put her overall emotional health at very high risk for both the short and long term. I heard women tell us that they needed time and support to recover from the traumas of rape, incest, and domestic violence.
I have never forgotten those voices during the past 30 years. They have inspired me to work tirelessly to help open the Nation's eyes to the impacts of trauma—whether it is trauma induced by criminal violence, disasters, terrorism, or wars—and the need to promote emotional health and recovery for every man, woman, and child who has been affected by traumatic events.
Many of us have been calling for change, and SAMHSA's Center for Mental Health Services has responded. It's been 14 years since CMHS held a groundbreaking conference called "Dare to Vision." For the first time, national attention focused on the effect of physical and sexual abuse on the lives of women who were diagnosed with mental illnesses.
We heard from women in heart-rending detail the clear, undeniable, and dramatic relationship between trauma and symptoms of mental illness and co-occurring substance abuse. We also heard from the women that the power of traumatic life events to destabilize individuals had been systematically missed by the mental health field altogether.
The poignant evidence of the relationship between trauma and symptoms of mental illness, however, did not leave us without hope. Women who were at the conference opened our eyes to a person's enormous potential to recover from trauma and co-occurring disorders when individuals and practices involved in mental health treatment acknowledged the underlying effects of abuse and worked with women toward hope and recovery.
These brave and resilient women gave us the "vision" in the conference title; listening to them we could "dare to envision" a time in each woman's life when past violence would no longer cast its dark shadow over her future.
In the time we have together this morning, I'd like to ask us to continue be daring.
- We need to dare to understand the prevalence and impact of trauma on the lives of men, women, and children in this country.
- We need to dare to listen to and hear their stories.
- We need to dare to offer hope where others might see only despair.
- And, as the title of this conference suggests, we must dare to transform the delivery of health and mental health care in this country to a system that is client-driven, recovery-focused, and evidence-based.
The Prevalence and Impact of Trauma
To be effective at the work we do, we must first understand that trauma is not an isolated event.
It saddens me to note that interpersonal violence, including physical and sexual assault such as rape, incest, battering, and murder, is so common for women—regardless of cultural affiliation and socioeconomic class—that it has been described as a "normative" part of female experience in the United States today.
Studies reveal the startling facts that from 55 to 99 percent of women in substance use treatment and from 85 to 95 percent of women in the public mental health system report a history of trauma, with the abuse most commonly having occurred in childhood.
Nearly 100 percent of women in the criminal justice system report physical and sexual abuse, often by fathers, stepparents, or in foster care. And sadly, national surveys suggest that as many as one-third of women veterans have experienced rape during their military service, increasing their risk of PTSD and associated problems such as poorer health functioning, depression, and substance abuse. As a woman, a mental health professional, and a Captain in the United States Naval Reserve, I am deeply troubled about the increasing levels of trauma of all kinds experienced by the female members of our Armed Forces.
Our children are also at risk. Findings from the Adverse Childhood Experiences study—which is an ongoing collaboration between the Centers for Disease Control and Prevention and Kaiser Permanente—reveal that abuse, neglect, and other traumatic events are related to the adoption of risky behaviors, such as the abuse of alcohol and other drugs, smoking, multiple health problems, and early death.
When trauma is ignored in the lives of our children, they frequently develop mental health problems and chronic medical conditions that may worsen and continue into adulthood.
We also must honor the experiences of recent immigrants and refugees, who may face extra stresses and traumas associated with their immigration experiences. Migration itself is a stressful life event, requiring the need to adapt to a new culture. Women and girls who are refugees may face additional stress or trauma associated with factors such as turmoil in their home country, long stays in insecure refugee camps or processing centers, or experiences of trauma or violence.
At highest risk are the estimated 50,000 women and children who are victims of human trafficking each year into the United States. Research suggests that nearly 90 percent of internationally trafficked women rely on drugs or alcohol to cope with their situation and 85 percent experience depression.
Listening to Trauma Survivors
One of the best ways we can honor the experiences of individuals who have been impacted by trauma is to listen to what they have to tell us. Again, Winston Churchill guides us in the right direction with his observation that "Courage is what it takes to stand up and speak; courage is also what it takes to sit down and listen."
We must have the courage to hear the painful stories that abuse survivors have to tell us. They are suffering in their silence, and we are diminished as a society when we cannot, or will not, hear what they have to say.
Often, both women and men who have been physically or sexually abused are afraid to talk about their experiences for fear that they will be mislabeled, mistreated, or simply not believed. In many cases, their fears are not unfounded.
But when we don't ask, we risk causing harm. We may misinterpret an abuse survivor's coping mechanisms as symptoms of a mental illness.
Or worse, we may unintentionally recreate the abuse by the use of forced medication, seclusion, or restraints. We are perpetrating violence ourselves when, as in the words of a woman subjected to forced treatment, we "lock them up, shock them up, tie them up, or drug them up." Seclusion and restraint are not treatment options—they are treatment failures.
We must always remember to elicit stories of trauma slowly, respectfully, and with a focus on helping individuals heal. We can take a page from Dr. Mollica1, who says he has learned not to ask individuals to give elaborate, detailed accounts of their trauma. Instead, he asks his patients to teach him what they have learned from their experiences and what they are doing to cope.
Offering Hope
One of the primary ways in which we can help individuals learn to cope is by offering them the hope of recovery. Hope is a small word with a HUGE impact. "Hope is to the soul what oxygen is to the body," says Larry Fricks, former Director of Georgia's Office of Consumer Relations and Recovery.
In his book The Anatomy of Hope, Dr. Jerome Groopman of Harvard Medical School explores the essential relationship between hope and healing. He writes:
Without hope, recovery can seem like an elusive goal, a quest that demands too much of our body, our minds, and our spirit. But hope gives us the strength to fight for that better life. Hope helps us overcome hurdles that we otherwise could not scale and it moves us forward to a place where healing and recovery can begin.
The ingredients for offering hope are both simple and profound. Women who participated in the SAMHSA-sponsored, 5-year Women, Co-occurring Disorders, and Violence study—which was the first large-scale evaluation of trauma interventions—spoke to us about empathy and caring, validation, and emotional safety.
Serena talked about the importance of working in a relationship that is nonjudgmental, open, and not hurtful. She said, "I think what the whole therapeutic relationship is all about is this 'safe place' where you're really heard, where you're not judged, and where it's OK to put everything on the table and get another perspective from the other person who's sort of looking in..."
It is a privilege to be "looking in" and offering hope to individuals whose lives have been shattered by some of the most traumatic experiences a person can endure. When we do, we learn how resilient, strong, and brave they are. As Dawn said her about recovery, "...maybe now somebody will believe that I really want to try. Not try—I take that back. That I'm really going to do it, because the trying part is over."
Transforming Health and Mental Health Care
When we understand the trauma is the expectation, not the exception, for individuals with mental and substance use disorders...when we truly hear what trauma survivors have to tell us...and when we offer them hope by providing empathy, validation, and emotional safety, we are daring to transform the delivery of health and mental health care in this country.
First and foremost, in our efforts to transform the health care system to honor and offer support for trauma survivors, we must recognize that trauma is not a disease. Trauma is a public health issue that affects the quality of lives of individuals, of their families, and of our Nation as a whole.
The Institute of Medicine has defined public health as "what society does collectively to assure the conditions for people to be healthy." A public health approach to health care is based on the concept that we must promote health and prevent disease before it begins.
The public health model is well suited to help promote an individual's recovery from trauma. It recognizes that mental health does not reside solely in the individual but also within the web of interactions among the individual, the family, the school, the neighborhood, and the community in which he or she lives. In particular:
- Recognizing that untreated trauma can lead to mental health and substance use problems and other health and social problems, a public health approach is holistic, taking into consideration all aspects of the individual's wellbeing.
- Public health seeks long-term solutions that are best achieved by high-quality care before symptoms and co-occurring conditions become severe. Accordingly, prevention is as important as treatment. When we act to prevent abuse and trauma before they occur by creating safe, stable, and nurturing environments for children, youth, and families, we are practicing a public health approach.
- Public health employs evidence-based practices and always measures outcomes. Through the work of the SAMHSA National Center for Trauma-Informed Care and our National Child Traumatic Stress Initiative, we are developing leadership networks to disseminate information about emerging trauma best practices and providing technical assistance to help stimulate change in States and communities.
- Finally, a public health model focuses treatment and care on the needs of the individual, but also develops interventions for the entire population because it recognizes that each of us must be healthy for all of us to be healthy.
In essence, public health is mental health transformation in action!
Ultimately, a public health model focused on recovery from trauma must be characterized both by trauma-specific diagnostic and treatment services and by a "trauma-informed" environment capable of sustaining these services.
We learned from the Women, Co-occurring Disorders, and Violence Study I cited earlier what types of services are most effective. Findings of the study, which concluded in 2004, indicated that integrated treatment—for example, group and individual therapy that addressed trauma, mental health, and substance use conditions together—was the key element associated with better outcomes.
And we know what it means to be trauma-informed, thanks in part to clinical psychologist Roger Fallot, Director of Research and Evaluation at Community Connections in Washington, DC, who has written extensively about this topic. Trauma-informed systems, he tells us:
- Incorporate knowledge about trauma—including its prevalence and impact—in all aspects of service delivery;
- Are hospitable and engaging for survivors;
- Minimize revictimization; and
- Facilitate recovery.
Recovery is often thought of as the process of "recovering" that which was lost due to addiction, mental illness, or other medical condition. However, as we learned from the women who participated in our study, people recovering from trauma—particularly those who were abused as children—have no pre-abuse state to "recover." In this case, recovery may be better defined as a state of wellness.
Writing in a report called "It's My Time to Live" that highlights the stories of participants in the SAMHSA Women and Violence study, authors Bonita Veysey and Jennie Heckman note that the shared aspects of wellness do not differ by diagnosis or problem area. For each and every one of us, wellness involves having:
- A positive self-identity;
- Meaningful things to do;
- Opportunities to give back;
- Supportive social relationships;
- Pastimes;
- Methods of stress reduction and relaxation; and
- An encompassing world view, life philosophy, or spirituality that gives meaning to life experiences.
These aspects address the self, the self in relation, and the self in the universe, and support the human needs of the body, mind, and spirit.
Helping individuals achieve a state of wellness embodies what it means to adopt a public health approach to transforming the delivery of health care services in this country.
Wrap-up and Conclusion
I want to leave you today with a call to action that comes from the writings of Parker Palmer, author of Let Your Life Speak and The Courage to Teach. Speaking about inner power, Palmer says:
Think for a moment about the lives of oppressed people around the world. These people have had no access to the tools of control and domination—like money, status, or political clout—to work for change. The only power they have access to is inward.
But history shows time and again how people who might be regarded as "weak" have used the power of the human heart. History shows that they have taken hope and vision on the one hand and anger and fury on the other to create real and massive transformation. Whether we're talking about people of color or women or any other minority, no form of injustice would ever have been righted or transformed if it weren't for the fact that the human heart is a source of great power in the world.
This brings me full circle to where I began, talking about the lion's heart. Palmer tells us that the human heart—no matter how oppressed or violated—has the power to transform lives.
It is incumbent on each of us in this room to empower trauma survivors of all ages to harness their anger and embrace their vision for a better future.
We must help them use the power that is within their hearts—which mirrors the power within our own—to triumph over poverty, abuse, and mental illnesses.
And we must never lose sight of the fact that true power lies in the astonishing ability of the human heart to transcend the worst that man and nature have to mete out and, in so doing, to shine a light for all of us on our own humanity.
Thank you. If we have time, I'd be happy to take your questions.
1Richard Mollica, M.D., the preceding speaker, is Director of the Harvard Program in Refugee Trauma and author of Healing Invisible Wounds.
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