An Update on the South Carolina Trauma Initiative

In this journal in 2001, we described the South Carolina Department of Mental Health (SCDMH) statewide initiative to improve services to mental health consumers who are trauma survivors ( 1 ). Although some have questioned the need for such trauma initiatives ( 2 ), data are clear regarding the high prevalence of traumatic victimization among public mental health consumers ( 3 ), the poor rate of detection and diagnosis in routine public mental health settings ( 3 ), and the availability of empirically based treatments for posttraumatic stress disorder (PTSD) ( 4 ).

The SCDMH initiative developed in response to these findings, our own local research ( 5 , 6 ), and demand from mental health consumer organizations within our state. The initiative began as a grassroots effort with broad SCDMH administrative support. The goals were to sensitize stakeholders to the impact of trauma, influence relevant policies and administrative decisions, address concerns about the safety and dignity of psychiatric settings (for example, sanctuary trauma), educate and train clinicians on empirically validated assessment and intervention strategies for PTSD and related psychopathology, and increase knowledge by supporting a strong empirical research platform. This brief report describes some of the key issues that we encountered and progress related to these goals.

Developmental issues

In the first year, the Trauma Initiative Task Force devoted its efforts to carefully considering the scope, goals, and key approaches relevant to its mission. Special attention was paid to the well-documented challenges of disseminating new information in practice settings ( 7 , 8 ). Further, the need to involve major stakeholders at all levels of the organization ( 9 ) and to include a multiprong approach involving clear goals, policy change, training and supervision, and dissemination of new knowledge ( 10 ) was carefully considered. The task force agreed on the need to emphasize empirically based practices and strive for true collaboration between academic and public systems. We also believed that a bottom-up approach, with a small number of volunteer mental health centers, was necessary to foster lasting changes within the mental health centers. We articulated a clear definition of "trauma" in order to restrict our focus to experiences capable of producing PTSD and not trivialize these experiences by including merely stressful events.

One issue we debated was whether to begin by identifying consumers in need of treatment or by training a workforce capable of providing the treatment. Ultimately, the need to document the extent of the problem within our own system led to our decision to begin with screening efforts. A number of strategies were chosen to promote staff "buy-in," including a project director with clinical and research credibility, recognized as a part of the system and someone who understood it well; a task force cochaired by mental health center directors and the director of consumer affairs; and readily available "free" training and materials. Mental health consumers on the task force represented a passionate driving force for the initiative. When support was waning, consumers' first-hand experiences and perspectives were difficult to discount. In addition, consumers were often the only ones who could effectively dispute trauma myths, such as "asking about traumatic experiences will cause consumers to decompensate" or "exposure therapy is too risky for our consumers."

The unforeseen (and underappreciated) obstacles

Even with careful planning, numerous obstacles were encountered along the way. Perhaps we were least prepared for the seemingly "antitrauma" culture that we found throughout the system. We were initially puzzled by the strong resistance to such innocuous practices as making PTSD educational materials available or providing free clinical training on PTSD assessment and diagnosis. Over time we learned that this resistance involved several distinct issues.

First, there was a perception that the nature of our goals conflicted with the traditional role of the mental health center, where practices rely heavily on medication management and case management but not therapy. In many ways the organization did not seem to know how to make trauma treatment fit within the context of the campaign supported by the National Alliance on Mental Illness to have mental illness accepted as a brain disease. Many seasoned physicians and administrators were trained in a time when trauma treatment was almost exclusively associated with long-term psychoanalysis, and some of the resistance seemed to stem from misconceptions regarding trauma treatment and its target population. We learned to conceptualize our public education and training efforts to broadly address these issues. Once we were able to convincingly show that the trauma patient was the typical client of the mental health center and that cognitive-behavioral interventions had strong empirical support, we were able to make progress. Perhaps because we were a group of trauma-focused researchers, clinicians, and consumers, we simply did not appreciate the real fears of novice therapists regarding trauma. Demystifying the process through training with role plays, videotaped conversations with consumers, and supervision helped enormously.

We also had to identify and respond to the so-called "trumping rules" of psychiatric diagnosis that render meaningless the additional diagnoses of a person with schizophrenia, bipolar disorder, or other serious mental illness. Showing that real-life clients with serious mental illness could be successfully treated for PTSD was our most important teaching tool.

We also experienced one of the common characteristics of a large government agency: inertia. No one solution could address this, but rather we learned that involving motivated and energetic staff who possessed inherent leadership qualities created momentum. This led us to appoint a local trauma liaison in each of the 17 mental health centers and four hospitals who helped develop local teams with responsibility for local solutions.

Our efforts also taught us that training needs were much greater than anticipated and that we had to convince clinicians and the larger system of the general value of screening or diagnostic measures, treatment protocols, and clinical supervision if they were to appreciate them in the context of trauma. Often, this lesson came well into the process of implementing a new assessment or in-depth training in a specific treatment protocol. The pace of change was often frustrating, and we learned that each step of trauma screening, diagnosis, and treatment rarely led to the next logical step.

We also found the "curse" in relying too much on research findings. Although research and economic findings are powerful arguments for administrators, clinicians are more convinced by colleagues and clinical vignettes ( 11 ). Clinicians described that research did not apply to their daily lives (not entirely without basis) and said that researchers seem far removed from the day-to-day issues that they encounter. Therefore, we found it necessary to constantly be aware of the division between research and practice and learned to switch hats quickly depending on the audience and the situation. We had to be advocates, experienced clinicians, knowledgeable researchers, and "regular" DMH employees all at once.

Success and future directions

In light of the numerous obstacles outlined above, we believe that we have accomplished a great deal in the past seven years. We have sustained a statewide effort in a system that sees new policies, mandates, and priority areas come and go with each passing year. Detailed trauma screening is now conducted in 12 mental health centers and hospitals in the state system. We developed and began preliminary testing of cognitive-behavioral therapy for PTSD specifically adapted for the public mental health system ( 12 , 13 ), which has since provided the basis of an in-depth hands-on training program. Additionally, we conducted research on the phenomenon of sanctuary harm and trauma, the results of which have helped to change policies in our state hospitals and clinics in order to reduce seclusion and restraint and improve the safety and dignity of psychiatric settings ( 14 , 15 ).

We will continue to involve clinicians, administrators, consumers, and researchers as we pursue our goal of improving trauma-related services for all public-sector consumers. We hope that our experiences may serve to inform and encourage other states to take on these challenges and ultimately improve the lives of people with mental illness who are trauma survivors.

Acknowledgments and disclosures

This work was supported in part by grant MH-01660 from the National Institute of Mental Health to Dr. Frueh. The authors acknowledge the hard work and important contributions of the late Vicki Cousins, Director of Consumer Affairs and Trauma Initiative co-chair, South Carolina Department of Mental Health, who was instrumental in the development of the Trauma Initiative.

The authors report no competing interests.