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
Paving the Road Home: The National Behavioral Health Conference and Policy Academy on Returning Veterans and Their Families
August 11, 2008
Washington, DC
Attached is the text prepared for delivery; however, some material may have been added or omitted at the time of delivery.
Good afternoon. I know you've had a busy and productive morning, and I hope you are enjoying camaraderie and good conversation along with your lunch.
I'd like to turn our attention for the next several minutes to a topic that is difficult to talk about but important to hear. Too often, we don't talk about trauma because we feel we don't have the information to understand it, the words to discuss it, or the treatments to help men, women and children recover from it.
Winston Churchill once said, "Courage is what it takes to stand up and speak. Courage is also what it takes to sit down and listen." Before we can fully understand trauma...before we have the words we need to discuss it...and before we can offer appropriate treatment, we must be willing to listen to the lives of those who for too long have suffered in silence.
I had the privilege to listen to trauma survivors when I began my work 30 years ago, first 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 they experienced. Most important, I learned that given that time and support, individuals have an enormous potential to recover from even the most unspeakable acts of violence against body, mind, and soul.
I have never forgotten those voices through the 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.
That is why I'm so pleased that over the past 15 years, SAMHSA has recognized the need to address trauma as a fundamental obligation for effective public health and substance abuse service delivery. We have both elevated the visibility of this critical public health issue and have provided helpful tools for States and communities to promote recovery and healing for trauma survivors.
Now we must move forward together. With our partners at DOD and DVA and with each and every one of you here today, we must recognize the prevalence of trauma, acknowledge its impact, and provide the evidence-based services that address trauma in a context that is trauma-informed and recovery-oriented. We know that trauma is universal, highly disabling and largely ignored.
The Prevalence of Trauma
It is distressing to share statistics about trauma—particularly among our military men and women—but we can only confront what we know. According to a recent study by the Rand Corporation, about one-third of the 1.64 million service members who have deployed in support of Operation Enduring Freedom or Operation Iraqi Freedom have major depression, posttraumatic stress disorder, or traumatic brain injury, and about 5 percent report symptoms of all three.
A one-time traumatic event can lead to PTSD, but so can ongoing stress—harsh climates, austere living conditions, constant danger, and repeated deployments put our servicemen and women at risk.
Past experiences also increase risk. Individuals who have previously been traumatized run a high risk of being re-traumatized (during wartime), and some will develop PTSD as a result.
We know that another potential source of PTSD is military sexual trauma, which includes sexual harassment, sexual assault, rape, and other acts of violence. National surveys suggest that from 13 to 30 percent of women veterans have experienced rape during their military service, though often these assaults go unreported. As a woman, a mental health professional, and a retired Captain of the United States Naval Reserve, I am deeply troubled about the increasing levels of trauma experienced by the female members of our Armed Forces.
Women may not seek help because they fear embarrassment, retribution, lack of career advancement, or dishonorable discharge, though these fears are not unique to women alone. As in civilian life, only about half of service members—both men and women—who need help for mental health problems seek it.
Finally, our military families bear a significant burden, as well. Three out of every five deployed service members have a spouse, child, or both. Estimates report that some 700,000 children have at least one parent deployed to support ongoing military operations in Iraq and Afghanistan.
The Impact of Trauma
The women and men who serve in our Armed Forces and the families they leave behind are incredibly resilient. Most service members have strong mental health that enables them to deal successfully with combat-related stressors and trauma.
Indeed, writing about the experiences of military families, psychologist Michelle Sherman notes that while the adverse affects of trauma receive the greatest attention, many survivors also experience positive changes, termed posttraumatic growth. They become more aware of inner strength and courage, build empathy for others, grow spiritually, and appreciate the opportunity for a "fresh start." Sherman notes that mental health professionals can gently challenge and empower their clients to explore the positive outcomes that may emerge when working through painful experiences.
But as mental health professionals, we must also be aware that left untreated, particularly in service members who are vulnerable to mental health problems, trauma can impair future health, work productivity, family and social relationships. Individuals whose mental health problems go unaddressed are at risk for comorbid substance use, homelessness, and suicide.
Last year alone, 121 active duty soldiers took their own lives, the highest number on record since the Army began tracking suicides in 1980. Attempted suicides are up, too, numbering 2,100 in 2007—six times the rate in 2002. This is one of the reasons that SAMHSA added a feature to the National Suicide Prevention Lifeline so callers can identify themselves as veterans and be connected to VA professionals. Thus far, more than 55,000 calls have been received, connecting over 22,000 veterans with direct support.
The common responses to trauma also may affect family relationships with partners and children. Trauma survivors often experience considerable social anxiety, which causes them to withdraw from everyday outings and family events. Frequently, they deal with significant anger, which can alienate them from their families, who experience their loved one as unpredictable, hostile, and frightening. Finally, many survivors become emotionally numb to avoid facing the pain associated with the trauma they experienced, which may cut them off from positive feelings and family support, as well.
Often, family members need to learn how to give their loved ones the time and space to heal. Sherman quotes a lieutenant colonel who says, "The journey home marks the beginning of an internal war for the [returning soldier]. Give them the space they require to slowly turn the switch. The switch from violence to gentle. The switch from tension to relaxation. The switch from suspicion to trust. The switch from anger to peace. The switch from hate to love..."
Evidence-based Services for Trauma
We can help our returning soldiers and their families make this transition because we know what to do to help them recover from the invisible wounds of war. Relative to just 10 years ago, we now have a wide range of models designed to help service providers meet the needs of individuals that have been traumatized by war, natural or manmade disasters, or interpersonal violence and abuse.
Many of these effective and promising models are compiled in the recently released report from the National Center for Trauma-Informed Care called Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services, which was prepared in conjunction with the National Association of State Mental Health Program Directors. To be effective, any model for treating individuals affected by trauma must begin with the understanding 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.
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 SAMSHA's Women, Co-occurring Disorders, and Violence Study, which was the first large-scale evaluation of trauma interventions, 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.
SAMHSA is not alone in our efforts to address trauma in the lives of our servicemen and women. DOD is launching an estimated $25 million project to discover the best treatments for combat-related PTSD. Called the STRONG STAR Multidisciplinary Research Consortium, this project will include eight randomized clinical trials of several treatment conditions, with active duty and veteran participants.
DVA, as well, recognizes both the problems of trauma among our Nation's veterans and its obligation to help. Military sexual trauma counselors at VA facilities meet with female veterans in private areas so they can safely hear a woman's feelings of fear, anxiety, shame, anger, and embarrassment and can connect her to the resources she needs to heal.
In addition, we can point to the wonderful work of the more than 200 community-based Vet Centers located in all 50 States, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. The Vet Centers are staffed by small multidisciplinary teams of dedicated providers, many of whom are combat veterans themselves.
Not long ago, I came across an interview with Doonesbury cartoonist Garry Trudeau about the research he did to create the experiences of his character B.D., a Vietnam vet, reservist in the first Gulf War, and now Iraq War amputee who has PTSD. Among the places he visited were Vet Centers, where he talked to counselors and veterans and sat in on counseling sessions.
I was especially struck by the fact that in one strip, Celeste, a VA receptionist, greets B.D. and all visitors with the words, "Welcome home." When B.D. asks why she says that, Celeste replies, "We don't think vets can hear it often enough."
We, too, must welcome our servicemen and women home with gratitude, respect, and the full support of the mental health community behind them. We must understand the prevalence of trauma, recognize its impact, and be prepared to offer evidence-based practices that help people recover not only their emotional and physical health, but also their hopes and dreams. Today is the day to begin.
Thank you. If we have time, I'd be happy to take your questions.
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