Improving Public Mental Health Services for Trauma Victims in South Carolina

Recent studies have shown that among people with serious mental illness who are treated in the public sector, rates of traumatic victimization—defined according to DSM-IV criteria—range from 51 percent to 98 percent and rates of posttraumatic stress disorder (PTSD) from 14 percent to 43 percent (1,2). Although PTSD is a chronic disorder with serious adverse effects on social, familial, and occupational functioning, many people who suffer from the disorder receive inadequate mental health services, in part because a history of trauma and its sequelae often go unrecognized (3). Furthermore, among anxiety disorders, PTSD is associated with one of the highest rates of service use (4), and there is a striking lack of empirical data about effective interventions for public-sector consumers with chronic PTSD and severe mental illness.

In fact, although effective psychosocial treatments have been developed for other traumatized persons, such as male combat veterans and female rape victims, little effort has been made to adapt these treatments for use with trauma victims who are treated in large state-funded mental health systems. It is clear that trauma has a prominent impact on public health, and there is a pressing need to develop and evaluate appropriate interventions designed specifically for use in this population and practice setting.

Recently the National Association of State Mental Health Program Directors and many other groups that are concerned with public health policy issued a call to action to address the unmet service needs of trauma victims. Accordingly, South Carolina recently became one of at least 15 states whose departments of mental health initiated efforts to better address these needs.

The South Carolina Department of Mental Health developed a statewide trauma initiative task force in 1999. The mission of the task force is to improve the public health system's response to the clinical needs of public consumers who are victims of trauma. The goals of this initiative are to sensitize stakeholders to the impact of traumatic experiences, influence relevant policies and administrative decisions, educate and train clinicians on empirically validated assessment procedures and intervention strategies for PTSD and other trauma-related psychopathology, and increase knowledge by supporting a strong empirical research platform.

The initiative has the broad support of all stakeholders within the system, including the director of the mental health department, the directors of community mental health centers and inpatient facilities, and consumer advocates. The task force meets monthly and includes a diverse and multidisciplinary group of key stakeholders, including academic experts on trauma and consumer advocates from each of the 17 mental health centers in the state. To assist with the initiative, an annual budget of $60,000 has been dedicated by the director of the mental health department. This money will be used to provide training and education to staff and to fund a full-time trauma initiative coordinator with advanced clinical and research experience in the field of trauma.

The clinician survey

As one of several preliminary steps, we conducted a survey of clinicians—psychiatrists, nurses, social workers, and psychologists—from four of the 17 outpatient facilities in the state to determine their training needs and their perceptions of the prevalence of trauma-related problems among their clients. Most respondents held a master's degree and had between one and five years of clinical experience. The overall response rate to the survey was 61 percent (N=245). The results showed that most clinicians had little training that was specifically focused on trauma—for example, only 30 percent had more than six hours of training. However, 51 percent of the clinicians said they felt "comfortable" working with trauma victims, and another 42 percent said they felt "somewhat comfortable."

The clinicians were asked to rate the proportions of their clients who had trauma-related difficulties as low (less than 20 percent), medium, or high (40 percent or more). Overall, the proportion of clients with trauma-related difficulties was rated as very low. Only 28 percent of the clinicians rated trauma-related problems as high, whereas 23 percent rated such problems as medium and 49 percent rated them as low. These clinician-estimated rates are substantially lower than the rates of trauma and PTSD reported in the literature (1), including rates reported at one of our own facilities (5).

Fifty-five percent of the clinicians reported a personal history of trauma; 22 percent of these clinicians reported still being bothered by the event at least sometimes. Clinicians' personal history of trauma was not correlated with ratings of trauma-related problems among clients. However, a strong relationship was observed between hours of trauma training and perception of clients' trauma-related difficulties; respondents with more training reported perceiving more trauma-related difficulties among their clients (χ²= 25.44, df=6, p<.001). Neither level of education nor years of experience had any association with recognition of trauma and related symptoms.

These findings suggest that current practices do not facilitate the identification of trauma and trauma-related symptoms, such as symptoms of PTSD, among public mental health consumers. They also suggest that trauma-specific training would improve the identification and treatment of PTSD among consumers of public mental health care.

Trauma in the psychiatric setting

In response to concerns raised by consumers about traumatic and harmful experiences that occur in psychiatric settings across the state, we recently reviewed the available empirical literature (6). We suggested a conceptual framework, proposed a research agenda, and discussed implications for mental health administration and policy. To our surprise, the body of research that broadly addressed trauma in the psychiatric setting was limited, consisting primarily of case reports and anecdotal commentary.

In our conceptualization of the problem we proposed two terms— "sanctuary trauma" and "sanctuary harm"—to describe distinct deleterious experiences. We suggested that a distinction be made between events that are traumatic and those that are harmful, so as to not trivialize the most severe experiences—for example, sexual assault—or unfairly label the appropriate use of measures of last resort—for example, seclusion and restraint. Furthermore, use of the term "sanctuary" was initiated by consumers and refers to what the psychiatric setting should be in an ideal sense—a safe haven or a refuge from external stressors—not necessarily what it is in practice.

To inform important policy and personnel decisions that are made by administrators of mental health care services, empirical studies are needed to determine the prevalence, perceptions, consequences, and effective prevention strategies of sanctuary trauma or harm. Toward this end, we have begun collecting pilot data by using questionnaires and interviews. This work has been funded by a small grant from the Ensor Foundation, which will support the development of a larger research effort in the near future.

Current progress and future directions

In addition to the two preliminary efforts we have described, the task force has accomplished several other intermediate steps toward the overarching goal. The task force has been in close contact with representatives of trauma initiatives in other states and has visited the state-funded systems of Oregon and Maine. It has benefited from a series of educational presentations by trauma researchers and educators who are prominent at the local and national level—for example, the Crime Victim Center for Research and Treatment of the Medical University of South Carolina and the South Carolina Center for Innovation in Public Mental Health of the University of South Carolina School of Medicine.

In addition, the task force has conducted a survey of trauma services that are currently offered by all facilities in the state system. It has held a state conference to educate clinicians about trauma-related issues. The task force has hosted a national "think tank" meeting with representatives of seven other states—Connecticut, Maine, Massachusetts, Missouri, New Hampshire, Oregon, and Vermont—and other interested national-level stakeholders to compare experiences and progress. At that meeting, a new national organization called State Public Systems Collaborative on Trauma was created.

The task force also participated in a series of educational teleconferences that were broadcast throughout South Carolina in partnership with a local public television station in Columbia. Finally, the task force created four subcommittees to address specific trauma-related issues—sanctuary trauma or harm, treatment and training, policy and public education, and research and outcomes.

The South Carolina Trauma Initiative is still in the relatively early stages of development, and much work remains to be done. However, there is a strong sense of purpose and optimism that it will lead to improvements in clinical services for trauma victims across the state and a greater knowledge base that will be useful to other state systems. The focus of current efforts includes supporting the development of several investigator-initiated research grant applications to evaluate aspects of sanctuary trauma or harm and to adapt, develop, and evaluate appropriate psychosocial interventions designed specifically for use with public-sector consumers.

Over the next three years it is expected that this initiative will result in the development and implementation of standardized trauma assessment protocols, specialized treatment programs, and an ongoing research effort involving strong cooperation among policy makers, administrators, clinicians, researchers, consumers, and individuals who are leading the efforts of other state trauma initiatives.

Dr. Frueh and Dr. Hiers are affiliated with the department of psychiatry and behavioral sciences of the Medical University of South Carolina in Charleston. Dr. Hiers is also affiliated with the South Carolina Department of Mental Health in Columbia, with which Ms. Cusack, Ms. Monogan, Ms. Cousins, and Ms. Cavenaugh are affiliated. Send correspondence to Dr. Frueh at Mental Health Service (116), Veterans Affairs Medical Center, 109 Bee Street, Charleston, South Carolina 29401-5799 (e-mail, [email protected]).