Who Needs Trauma Initiatives? South Carolina!

In the June issue of Psychiatric Services, Sally Satel, M.D., questioned the need for "trauma initiatives" (1), such as we described in the same issue (2). In our article, we noted that trauma is highly prevalent among public mental health care consumers, that trauma and posttraumatic stress disorder are significantly underidentified and undertreated in the public mental health system, and that the impact on trauma survivors and society is significant. We then described the response of the South Carolina Department of Mental Health (SCDMH) to such findings in the form of an organized statewide trauma initiative. Although we concur with some of Dr. Satel's points, she makes several assumptions that do not fit with what we presented and then challenges us on the basis of these assumptions.

For instance, our guiding assumption is not that trauma "inevitably leads to serious problems that need specialized treatment," but rather that trauma often leads to serious problems that can benefit from specialized treatment, and that to ignore this fact is detrimental to the consumers we serve (3). Our trauma initiative attends to an issue that has been largely ignored. It is not, as Dr. Satel suggested, fitting one solution—so called trauma-sensitive services—to all problems.

In addition, we do not assume, as Dr. Satel suggests is common among trauma therapists, that "it is inevitably useful to talk about [traumatic] experiences." However, we do think it is important to acknowledge the empirical literature that supports the use of pharmacological interventions, such as selective serotonin reuptake inhibitors, and psychosocial interventions, such as exposure therapy, for many individuals who have posttraumatic stress disorder (4).

We agree with Dr. Satel that additional outcome research is needed, that there is a danger in using treatments that do not have empirical validation ("new-age fanciful therapies"), and that studies with public populations are especially lacking. Thus one of the four areas of emphasis in the South Carolina trauma initiative is to support and foster empirical research. We also agree that clinicians using existing treatment approaches, such as pharmacotherapy, cognitive-behavioral therapy, and case management, can provide appropriate care to trauma victims. However, relevant research and training opportunities are necessary and are supported by the initiative.

Finally, as Dr. Satel herself notes, assessment of trauma is an important component of any thorough evaluation. Before the trauma initiative, adequate assessments were not routinely conducted at any public mental health facility in South Carolina, which is consistent with findings in other public systems (5). Survey results of all SCDMH outpatient facilities at the start of the trauma initiative indicated that only 41 percent were routinely evaluating any aspect of trauma exposure among new patients. Furthermore, at the sites where trauma assessment was routine, virtually all assessments were inadequate. For example, patients were questioned about a very narrow range of traumas, and the questions were not consistent with factors that research has shown to be important.

We are confident that our trauma initiative, which aims to increase awareness, research, and training in empirically validated assessment and treatment protocols, is something other than a "risky fad." We believe it has the potential to produce significant long-term improvements in services for consumers with trauma-related difficulties and that our budget of $60,000 for the past year was funding well spent.