Commentary: Who Needs Trauma Initiatives?

In the preceding article, Dr. Frueh and his colleagues describe a statewide "trauma initiative" in South Carolina. More than a dozen states are now pouring precious mental health funds into this new cause. Often the guiding assumption behind such efforts is that early sexual or physical trauma inevitably leads to serious problems that need specialized treatment. Although well intentioned, trauma initiatives represent a dubious enterprise.

First, it is difficult to find a good description of "trauma-sensitive" services. Frueh's article is a case in point; after reading it one remains hard pressed to articulate the programmatic components of trauma treatment and to appreciate the ways in which it differs from competent treatment in general. Generally, however, the only clear thing I can divine is that trauma-sensitive practitioners spend a lot of time eliciting histories of abuse and engaging patients in discussions of what happened to them. Although some patients in public mental health settings may benefit from focusing on their past, to assume that this approach is useful for everyone, especially highly dysfunctional patients, is unwarranted.

Among other things, therapists cannot automatically assume that memories of abuse are true. This controversy is not new, but haven't we learned from the "false memory" debacle that relentless focus on ancient traumas can generate erroneous recollections? What's more, dwelling on victimhood tends to keep patients obsessing about how they were damaged—and some patients even regress—at the expense of getting on with their lives.

One must also keep in mind that even among patients who have been abused, past maltreatment is not necessarily the root of their current symptoms and life circumstances. For example, adults who are depressed might attribute their current misery to earlier stressful events, magnifying the significance of these events in retrospect. Also, formative—or deformative—experiences are vastly complex. Ongoing child abuse takes place in a developmental context that generally includes other forms of exploitation and family dysfunction, disruption, and deprivation.

Furthermore, the assumption that it is inevitably useful to talk about experiences is unwarranted. A number of studies have shown that many people who talk about their experiences do no better than those who are more contained (1,2,3). The same phenomenon has been observed among war veterans and Holocaust survivors (4).

The treatment of adults who have suffered childhood trauma is poorly researched. Before trauma initiatives are implemented, some outcomes data are needed. Most informative are studies of well-defined interventions among recently traumatized adults, such as the work by Foa on rape victims (5).

There is no reason that mentally ill adults with histories of childhood abuse cannot be cared for through existing disciplines, such as pharmacotherapy, cognitive-behavioral therapy, case management, and, in some cases, exploratory therapy. It is likely that most of the patients treated in public trauma initiatives will be chronically dysfunctional women with borderline personality disorder—like those I saw when I attended the 1998 annual meeting of the state's Office of Trauma Services in Portland, Maine. These patients in Portland were undergoing new-age fanciful "therapies" such as "body work"— aimed at identifying past trauma that is being expressed through bodily sensations—along with journaling and dream interpretation. Rather than receiving ill-defined, untested, and potentially regressive interventions—tax-payer funded interventions—these patients were obvious candidates for dialectical behavioral therapy—a well-researched and constructive treatment for borderline personality disorder.

All mental health professionals should, of course, be aware that a patient may have endured abuse; gathering such information is part of any thorough assessment. But implementation of a unique form of treatment for the sequelae of these experiences, if warranted, is something to be undertaken with great care. At a minimum, research on these interventions should be compared with the most promising treatment we now have: dialectical behavioral therapy. At present, the therapies that are part of "trauma initiatives" are unproven—risky fads that will siphon funds and attention away from established, effective treatments.