A Decade of Progress: Dare To Act Affirms Vision

By Melissa Capers

More than 200 trauma survivors, service providers, researchers, and policymakers gathered in Baltimore in early December to celebrate a decade of progress and develop plans for further growth in the understanding and awareness of trauma in the lives of individuals seeking substance abuse and mental health services.

"Dare To Act: Trauma Survivors, Practitioners, Researchers, and Policymakers Creating a Blueprint for Change" was sponsored by SAMHSA and the National Trauma Consortium. The conference provided a forum where participants shared recent research findings regarding trauma and trauma services, strategies for addressing trauma within the fields of substance abuse and mental health services, and personal stories of survival and triumph.

The Dare To Act conference recalled the 1994 Dare To Vision conference in its title, scope, and structure (see SAMHSA News Volume II, No. 4, Autumn 1994). Both conferences sought to shed light on the prevalence of trauma, especially among persons with mental and addictive disorders, and to assure trauma survivors a voice in the development and implementation of services to address their needs.

The 1994 conference focused attention on revictimization by seclusion and restraint practices, which were not widely acknowledged within the treatment field at that time.

At the 2004 conference, topics addressed aspects of trauma and recovery, from assuring cultural competence in service delivery to addressing the needs of children of parents seeking integrated mental health, substance abuse, and trauma services.

According to Kathryn Power, M.Ed., Director of SAMHSA's Center for Mental Health Services (CMHS), the 1994 Dare To Vision conference was "the first time . . . national attention [was] focused on the effect of physical and sexual abuse in the lives of women with mental illnesses." Trauma survivors at the 2004 conference reported that one of their greatest hurdles was simply being believed when they spoke of the violence they had experienced, as well as having their trauma histories considered to be a significant factor in their illness and recovery.

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Trauma Awareness

In the 10 years since the Dare To Vision conference, a number of research studies have examined the question of prevalence and effects of trauma on the lives of persons with mental and substance abuse disorders. Many of the findings were compiled in a 2004 SAMHSA-funded report by the National Association of State Mental Health Program Directors, The Damaging Consequences of Violence and Trauma. At the conference, Ms. Power shared several of the findings summarized in the 2004 publication. For example, some estimates suggest that up to two-thirds of all those in substance abuse treatment report having been abused during childhood; the majority of homeless, mentally ill women experienced severe abuse as both children and adults.

Robert F. Anda, M.D., Ph.D., a senior research fellow at the Centers for Disease Control and Prevention, reported on the Adverse Childhood Experiences (ACE) Study. Published in 2003, the ACE Study found a consistent relationship between adverse childhood experiences including emotional, physical, or sexual abuse and increased risk for a variety of health problems among adults such as depressed affect, suicide attempts, and alcoholism. The data make a compelling case for addressing early traumatic childhood experiences.

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Progress in Treating Trauma

While these studies help to promote a greater awareness of the prevalence and effects of trauma on the individuals seen by service providers in the mental health and substance abuse fields, SAMHSA's Women, Co-Occurring Disorders, and Violence Study provides a base of data on the effectiveness of services designed to acknowledge and address the effects of trauma within mental health and substance abuse services.

A 5-year study from 1998 to 2003, funded by all three SAMHSA Centers, the Women, Co-Occurring Disorders, and Violence Study supported 14 sites in developing programs to provide integrated mental health, substance abuse, and trauma services to women. Nine sites were chosen to complete a 3-year implementation and evaluation, and four of these sites also participated in a Children's Subset Study—providing a group intervention for children of women enrolled in the Women, Co-Occurring Disorders, and Violence Study.

More than 2,000 women with co-occurring mental and substance abuse disorders and histories of trauma were enrolled in the study. Each study site conducted both an intervention and a comparison group, with the intervention focused on providing integrated counseling to address mental health, substance use, and trauma symptoms. After 6 months, women in all the intervention groups had, on average, significantly lower drug use and trauma symptoms compared to women in usual care.

Of women who reported using drugs at baseline, 50 percent of those who received integrated counseling reported not using drugs after 6 months versus 34 percent of women in the usual care group. More than half (54 percent) of women who reported using alcohol at baseline and participated in the integrated counseling reported alcohol use after 6 months, compared with 37 percent of women in usual care who reported using alcohol at baseline.

Among women with poor mental health status at baseline, 59 percent of those who received integrated counseling reported improved mental health symptoms after 6 months versus 49 percent of women in usual care. These improved outcomes were achieved at no greater service-use costs than usual care.

During 2005, numerous publications are planned based on data derived from both the Women, Co-Occurring Disorders, and Violence Study and the Children's Subset Study. With the end of SAMHSA funding of the study, members of the nine study sites formed the National Trauma Consortium to support and advance integrated services for women affected by trauma, mental illness, and substance abuse.

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Looking Forward, Reaching Out

The recent conference offered a wide variety of workshops. Trauma intervention models presented included those tested during the Women, Co-Occurring Disorders, and Violence Study and the Children's Subset Study. Additional workshops focused on the intersection of services to address trauma and alcohol abuse, strategies to support the involvement of persons with actual experiences of trauma in all aspects of programming, and the financing of trauma services.

The diversity among trauma survivors was recognized in workshops focused on providing appropriate services to Hispanics, African Americans, refugee and immigrant women, and members of groups affected by historical trauma, such as American Indians, Alaska Natives, Holocaust survivors, and those affected by the internment of Japanese Americans during World War II. Workshops also addressed particular symptoms and circumstances, such as self-inflicted violence or homelessness.

Overall, the need for wide and deep systems change threaded through many of the workshops and presentations. Conference participants—many of whom "dared to vision" a decade ago—are continuing to work with SAMHSA and other Federal agencies to effect these changes.

For more information on SAMHSA's efforts, visit www.mentalhealth.samhsa.gov/womenandtrauma.

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