The Need For Trauma Assessment and Related
Clinical Services in a State Public Mental Health System
Data shows that trauma is highly prevalent in public sector consumers, and it is associated with severe mental illness and high service use costs. Despite this evidence, trauma victims tend to receive inadequate mental health services. We surveyed all facilities within the South Carolina Department of Mental Health (6 inpatient, 17 outpatient) about their current services for trauma victims. Results indicate that many public mental health facilities are not routinely evaluating trauma history (e.g., only 41% of outpatient facilities do) or provide specialized trauma-related services. Examination of the trauma assessments revealed these to have significant flaws. Forty-seven percent of outpatient facilities reported offering "specialized trauma-related services," however, most did not offer what would be considered state of the art treatment for PTSD, but rather "stress management" or "women's issues" groups.
Frueh BC, Cousins VC, Hiers TG, Cavanaugh SD, Cusack KJ, Santos AB. The need for trauma assessment and related clinical services in a state public mental health system. Community Mental Health Journal, (in press).
The Clinician Survey
In South Carolina, the Department of Mental Health recently conducted a survey of clinicians (psychiatrists, nurses, counselors) from 4 of the 17 outpatient facilities in the state to determine their training needs and their perception of the prevalence of trauma-related problems among their clients. The majority of respondents held a master's degree, with 1-5 years of experience. The overall response rate of the survey was 61% (N=245). The results of the survey revealed that most clinicians had very little training specifically focused on trauma (e.g. only 30% had greater than 6 hours of training). However, fully 51% of clinicians said they felt "comfortable" working with trauma clients, while another 42% said they felt "somewhat comfortable".
Overall, clinicians rated the percentage of clients with trauma-related difficulties as very low. Responses were categorized into low (e.g. less than 20%), medium, and high (e.g. 40% or greater) rates of trauma-related difficulties. Only 28% of respondents rated trauma problems as high, while 23% rated it as medium, and 49% as low. These clinician ratings are substantially lower than rates of trauma and PTSD indicated in the literature, including research conducted at one of our own clinics. Fifty-five percent of clinicians reported a personal trauma history, 22% of which were still at least sometimes bothered by it. Personal history had no effect on ratings of trauma-related problems among clients. However, there was a strong relationship between hours of trauma training and perception of clients' trauma-related difficulties (X(6)2 =25.44, p<.001), meaning that respondents with more hours of training specific to trauma indicated a greater perception of trauma difficulties.
While not surprising given the previous studies mentioned above, these findings indicate that current practices are insensitive to the identification of trauma and trauma-related symptoms (e.g. PTSD) among public mental health consumers. In fact, the only variable that seemed to predict rating of trauma difficulties was the amount of trauma training the clinician had received. Neither level of education nor years of experience had any effect on trauma recognition. These findings highlight the substantial need to provide training in the identification and treatment of PTSD among consumers of public mental health, and hold promise for improving such practices through trauma-specific training.
Frueh BC, Cusack KJ, Hiers TG, Monogan S, Cousins VC, Cavenaugh SD. Improving public mental health services for trauma victims in South Carolina. Psychiatric Services 2001; 52:812-814.
Trauma Within the Psychiatric Setting:
A Preliminary Empirical Report
In addition to the high rates of trauma and PTSD noted among psychiatric patients, recent attention has been paid to the potential for the psychiatric setting itself to induce trauma and PTSD, directly or indirectly. However, research on the issue is lacking. The present study surveyed 55 mental health consumers regarding experiences of "sanctuary" harm and trauma. A number of harmful and traumatic experiences were reported, including rape (7%) and physical assault (18%). The lifetime rate of trauma was 96% and 27% met PTSD criteria. Results are discussed in terms of further research and policy regarding potentially harmful practices in psychiatric settings.
Cusack, K.J., Frueh, B.C., Hiers, T.G., Maierle, S., Bennet, S. Trauma within the psychiatric setting: A preliminary empirical report. Manuscript under review.