In the past thirty years a large body of evidence-based research has accumulated about the impact of a exposure to violence – both past violence and current violence – on the majority of behavioral health diagnoses, a large proportion of health problems, and virtually all existing social problems [1, 2]. Large epidemiological studies have indicated that the majority of the U.S. population will experience a traumatic event sometime in their lifetime [3-5]. Approximately 8% of individuals in the United States – 20 million people – will be diagnosed with Post-Traumatic Stress Disorder in their lifetime and as many as 20 million more people experience PTSD-related symptoms.

The most vulnerable adults in the population are women who have histories of exposure to violence throughout the lifespan, have behavioral health problems and social adjustment problems related to this exposure to trauma, are likely have substance abuse problems, as well as difficulties with parenting. Fifty to seventy percent of all women treated in psychiatric settings have histories of sexual or physical abuse or both. Up to 81% of men and women in psychiatric hospitals who are diagnosed with a variety of mental health illnesses have experienced physical and/or sexual abuse. Sixty-seven percent of these men and women were abused as children [6]. Adults who were abused in childhood are: more than twice as likely to have at least one lifetime psychiatric diagnosis; almost three times as likely to have an affective disorder; almost three times as likely to have an anxiety disorder; almost two and a half times as likely to have phobias; more than ten times as likely to have a panic disorder, almost four times as likely to have an antisocial personality disorder [7].  The majority of adults diagnosed with Borderline Personality Disorder (81%) or dissociative identity disorder (90%) were sexually and/or physically abused as children [8, 9]. Up to two-thirds of men and women in substance abuse treatment report childhood abuse or neglect [10]. Stress sculpts the brain to exhibit various antisocial, though adaptive, behaviors and can set off a ripple of hormonal changes and key brain alterations in children that may be irreversible [11]. One to two-third of individuals abused in childhood are at risk for maltreating their own children [12, 13].

Trauma survivors present sequentially and simultaneously to many different social service and healthcare settings and the response to their problems is fragmented, disjointed, sometimes overlapping, sometimes leaving gaps, and frequently offering contradictory advice and options [2, 14, 15]. If they do seek or are sent to behavioral health systems of care for treatment, they are unlikely to receive the kind of treatment they require.  Currently, behavioral health systems do not adequately address trauma-related behavioral/ health/relational issues due to training that has lagged behind actual progress in the field of treating trauma-related disorders. Worse yet, standard approaches to mental health treatment may actually re-traumatize people who have experienced violence and thus increase, rather than decrease chronicity and/or treatment failure [14, 15].

If they seek or are sent to substance abuse treatment programs they are unlikely to receive trauma-informed care for their addictive problems, nor are they likely to receive treatment that is oriented around the gender differences between men and women in treating addictive disorders. Instead, the failure to recognize and address trauma-related problems that co-occur with the addictions may in fact make the problems worse. In adults, the rates for co-morbid PTSD and substance use disorders are two to three times higher for females than males with 30-57% of all female substance abusers meeting the criteria for PTSD [16]. It is estimated that fewer than 20% of substance abuse programs offer specialized trauma-related services for dually diagnosed clients [17]. Programs for women are somewhat more likely to be addressing the issues of trauma in their clients’ background than programs for men.

If they seek or are sent to homeless shelters, their past and current exposure to violence is unlikely to be addressed at all and only the most problematic behavioral health problems are likely to be referred.  Ninety-two percent of homeless mothers have experienced physical and/or sexual assault [18]. More than 66% of homeless mothers have experienced severe physical violence by a caretaker and 43% were sexually molested during childhood. Sixty percent of homeless mothers were abused by the age of 12 [19]. Sixty-three percent of homeless mothers have been victims of intimate partner violence and 32% are current or recent victims of domestic violence [19]. Seventy percent of women living on the streets or in shelters report abuse in childhood [20]. Ninety-seven percent of mentally ill homeless women have experienced severe physical and/or sexual abuse and 87% experienced this abuse both as children and as adults [21]. Given the limited resources of the clients, consistent follow-up for these problems is unlikely to occur even if referral for services is made.

If they seek or are sent to domestic violence shelters, although the recent exposure to violence will serve as the reason for admission, the past history of exposure to violence is likely to be ignored, and little if any treatment will be offered for the past or present trauma-related disorders.  Women who were sexually abused during childhood are 2.4 times more likely to be revictimized as adults than women who were not sexually abused [22]. Many victims of family violence also suffer from mental illness. In a study of 941 young adults, half of those involved in partner violence had a psychiatric disorder and one-third of those with a psychiatric disorder were involved in partner violence. Individuals involved in severe partner violence had elevated rates of a wide spectrum of disorders [23].

If they are sent to prison, although their exposure to violence may continue, it is unlikely that they will receive behavioral health referral for anything other than the most glaring and problematic problems and the services that are delivered will not be trauma-informed. Eighty percent of women in prison and jails have been victims of sexual and physical abuse [24]. We do not yet have good statistics for men although people who work with male prisoners estimate extremely high rates of exposure to adversity in childhood and violence as adults [25].

If they are sent to healthcare facilities, it is somewhat more likely that their current exposure to violence will be recognized, and some links to domestic violence programs may exist, but the impact of past trauma is unlikely to be recognized or addressed, nor is there likely to be a connection made between their present physical disorders – other than the obvious traumatic injuries – and the past or present exposure to violence. Nonetheless the medical impacts of childhood and adult abuse include: head trauma, brain injury, sexually transmitted diseases, unwanted pregnancy, HIV infection, physical disabilities, chronic pelvic pain, headaches, gastrointestinal disturbances, sleep disorders, eating disorders, asthma, shortness of breath, chronic muscle tension, elevated blood pressure, ischemic heart disease, cancer, chronic lung disease, skeletal fractures and liver disease [26-31].

Additionally, chronic trauma survivors are likely to have multiple levels of engagement with law enforcement, the judiciary, child protection, housing, and welfare agencies related to their current and past exposure to violence. Victims of child sexual abuse are at increased risk of becoming prostitutes [32, 33]. More than 40% of women on welfare were sexually abused as children. These women are often unable to keep a job and become homeless along with their children [34]. Sixty percent of housed, low-income mothers on Aid for Dependent Children experienced severe childhood physical abuse and 42% were molested as children [35]. Victims of father-daughter incest are four times more likely than non-incest victims to be asked to pose for pornography [36].

The research is overwhelming in concluding that exposure to violence is the primary precursor to dysfunctional behavior of all kinds, including substance abuse.  Behavioral health problems and many core social issues cannot be addressed without understanding and addressing the consequences of violence-induced trauma. Currently, in most social service and mental health settings there is a lack of a clear, consistent, comprehensive and coherent model for delivering care that takes into account the impact of exposure to violence, abuse, and other forms of traumatic experience on individuals, families, staff, and organizations. This is what makes implementing trauma-informed services so important. But what is a “trauma-informed system”?

References

1.          Bloom, S.L. The PVS Disaster: Poverty, Violence and Substance Abuse in the Lives of Women and Children. A Literature Review. 2002; Available from:http://www.sanctuaryweb.com/main/women's_law_project.htm.

2.          Women's Law Project, Responding to the needs of pregnant and parenting women with substance use disorders in Philadelphia. 2002, Women's Law Project: Philadelphia. p. http://www.womenslawproject.org/reports/Pregnant_parenting_PVS.pdf.

3.          Kessler, R.C., Posttraumatic stress disorder: the burden to the individual and to society. J Clin Psychiatry, 2000. 61 Suppl 5: p. 4-12; discussion 13-4.

4.          Kessler, R.C., C.G. Davis, and K.S. Kendler, Childhood adversity and adult psychiatric disorder in the US National Comorbidity Survey. Psychol Med, 1997. 27(5): p. 1101-19.

5.          Kessler, R.C., et al., Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry, 1995. 52(12): p. 1048-60.

6.          Jacobson, A. and B. Richardson, Assault experiences of 100 psychiatric inpatients: Evidence of the need for routine inquiry. American Journal of Psychiatry, 1987. 144(7): p. 908-913.

7.          Stein, J.A., et al., Long-term psychological sequelae of child sexual abuse: The Los Angeles Epidemiological Catchment Area Study., in Lasting Effects of Child Sexual Abuse., G.E. Wyatt and G.J. Powell, Editors. 1988, Sage Publications: Newbury Park, CA.

8.          Herman, J.L., J.C. Perry, and B.A. van der Kolk, Childhood trauma in borderline personality disorder. Am J Psychiatry, 1989. 146(4): p. 490-5.

9.          Ross, C.A., et al., Structured interview data on 102 cases of multiple personality disorder from four centers. Am J Psychiatry, 1990. 147(5): p. 596-601.

10.        Center for Substance Abuse Treatment, Substance abuse treatment for persons with child abuse and neglect issues, in Treatment Improvement Protocol (TIP) Series. Number 36. DHHS Publication No. (SMA) 00-3357. 2000, U.S. Printing Office: Washington, D.C.

11.        Teicher, M.H., Scars that won't heal: The neurobiology of child abuse. Scientific American, 2002. 286(3): p. 68-75.

12.        Kaufman, J. and E. Zigler, Do abused children become abusive parents? American Journal of Orthopsychiatry, 1987. 572(2): p. 186-192.

13.        Oliver, J., Intergenerational transmission of child abuse: rates, research, and clinical implications. American Journal of Psychiatry, 1993. 150: p. 1315-1324.

14.        Moses, D.J., M. Huntingdon, and B. D'Ambrosio, Developing Integrated Services for Women With Co-Occurring Disorders and Trauma Histories: Lessons from the SAMHSA Women with Alcohol, Drug Abuse and Mental Health Disorders Who Have Histories of Violence Study. 2004, Policy Research Associates, Inc (Women, Co-Occurring Disorders and Violence Study Coordinating Center): Delmar, NY.

15.        Moses, D.J., et al., Creating Trauma Services For Women With Co-Occurring Disorders: Experiences from the SAMHSA women with Alcohol, Drug Abuse and Mental Health Disorders Who Have Histories of Violence Study. 2003, Delmar, NY: Policy Research Associates, Inc (Women, Co-Occurring Disorders and Violence Study Coordinating Center).

16.        Najavits, L.M., R.D. Weiss, and S.R. Shaw, The link between substance abuse and posttraumatic stress disorder in women. A research review. Am J Addict, 1997. 6(4): p. 273-83.

17.        Bollerud, K., A model for the treatment of trauma-related syndromes among chemically dependent inpatient women. J Subst Abuse Treat, 1990. 7(2): p. 83-7.

18.        Bassuk, E.L., et al., The characteristics and needs of sheltered homeless and low-income housed mothers. JAMA, 1996. 276(8): p. 640-6.

19.        Browne, A. and S.S. Bassuk, Intimate violence in the lives of homeless and poor housed women: prevalence and patterns in an ethnically diverse sample.Am J Orthopsychiatry, 1997. 67(2): p. 261-78.

20.        Goodman, L.A., The prevalence of abuse among homeless and housed poor mothers: A comparison study. American Journal of Orthopsychiatry, 1991.61(4): p. 489-500.

21.        Goodman, L.A., M.A. Dutton, and M. Harris, The relationship between violence dimensions and symptom severity among homeless, mentally ill women. J Trauma Stress, 1997. 10(1): p. 51-70.

22.        Wyatt, G.E., D. Guthrie, and C.M. Notgrass, Differential effects of women's child sexual abuse and subsequent sexual revictimization. J Consult Clin Psychol, 1992. 60(2): p. 167-73.

23.        Danielson, K.K., et al., Comorbidity between abuse of an adult and DSM-III-R mental disorders: evidence from an epidemiological study. Am J Psychiatry, 1998. 155(1): p. 131-3.

24.        Smith, B., Women Prisoners' Handbook on Identifying and Addressing Sexual Misconduct. 1998: National Women's Law Center.

25.        Gilligan, J., Violence: Our deadly epidemic and its causes. 1996, New York: G. P. Putnam's Sons.

26.        Prescott, L., Women Emerging in the wake of violence. . 1998, Culver City: Prototypes.

27.        Cunningham, J., T. Pearce, and P. Pearce, Childhood sexual abuse and medical complaints in adult women. Journal of Interpersonal Violence, 1988. 3: p. 131-144.

28.        Morrison, J., Childhood sexual histories of women with somatization disorder. American Journal of Psychiatry, 1989. 146: p. 239-241.

29.        Springs, F.E. and W.N. Friedrich, Health risk behaviors and medical sequelae of childhood sexual abuse. Mayo Clin Proc, 1992. 67(6): p. 527-32.

30.        Walker, E.A., et al., Medical and psychiatric symptoms in women with childhood sexual abuse. Psychosom Med, 1992. 54(6): p. 658-64.

31.        Felitti, V.J., et al., Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med, 1998. 14(4): p. 245-58.

32.        Browne, A. and D. Finkelhor, Impact of child sexual abuse: a review of the research. Psychol Bull, 1986. 99(1): p. 66-77.

33.        Silbert, M.H. and A.M. Pines, Sexual child abuse as an antecedent to prostitution. Child Abuse & Neglect, 1991. 5(4): p. 407-411.

34.        deParle, J., Life after welfare., in New York Times. 1999, November 28.

35.        Bassuk, E.L., et al., Prevalence of mental health and substance use disorders among homeless and low-income housed mothers. Am J Psychiatry, 1998.155(11): p. 1561-4.

36.        Russell, D.E.H., The Secret Trauma: Incest in the Lives of Girls and Women. 1986, New York: Basic Books.