Carl C. Bell, MD

Most psychiatrists are trained to diagnose symptoms and treat patients with medication, psychotherapy, or a combination of both. Unfortunately, while we may have an appreciation of family, social, and cultural contexts, the understanding of these factors are not our strong suit. As physicians, we are focused on disease states and, unfortunately, are less familiar with issues of resiliency and strength- or asset-based approaches to patient care. In addition, we are less familiar with how protective factors minimize the impact of traumatic experiences.

Psychiatrists need to understand how living in violent families and neighborhoods increases the likelihood of trauma and the psychiatric sequelae associated with it as well as how to respond in the aftermath.



Prevalence of exposure to trauma and violence



Because interpersonal violence is a major problem in the African American community, it is not surprising that children are frequently exposed to violence in their homes and in their communities.

 Several epidemiological studies have shown a high prevalence of exposure to trauma in a variety of cultural, racial, and ethnic groups as well in various socioeconomic classes.

 In addition, because the contexts of epidemiological studies are often radically different, my colleagues and I have always thought it was a good idea to study patients in our clinical practice.

Of the 330 patients currently being seen for medication monitoring at the Community Mental Health Council, 18 (5.5%) have extensive histories of childhood trauma.

 Our center provides mental health services to both high– and low–collective efficacy communities; it is clear that there are either higher rates of trauma in the low–collective efficacy community and/or there are fewer protective factors in that type of community.

 Compared with patients from the high–collective efficacy community, those from the low–collective efficacy community are more likely to have been exposed to violence, either as victim or as witness-or both.

Not only are members of communities that have low collective efficacy more likely to see violence, but also families that are isolated and that lack access to social supports are more likely to be under stress and the children to be traumatized. Trauma has the potential to result in a variety of psychiatric sequelae no matter where it comes from-the family or the community. Accordingly, clinical psychiatrists need to be facile in talking to patients about childhood trauma during the initial psychiatric evaluation.

What new information does this article provide?


? The article places a great deal of emphasis of getting a trauma history from all patients and reminds us of the victimization questions that were developed by Jacobson and Bell/Jenkins. Advice is provided on how to help persons who have been traumatized-by treating them as people, not as neurochemical machines.

What are the implications for psychiatric practice?


? The information provided will help psychiatrists to be more responsive to issues of childhood trauma in adult patients. Although not all persons who experience childhood trauma automatically have a stress disorder as an adult, it is still important to include questions about childhood trauma when obtaining a history of an adult patient with a stress disorder.

Exploring childhood trauma in the initial psychiatric evaluation

Considering the prevalence of childhood and adult trauma, initial psychiatric evaluations should include a history of childhood and adult trauma but should take no longer than 30 minutes. Our experience is that childhood trauma histories are especially important in middle-aged women who have an early history of substance abuse or who present with generalized anxiety, panic attacks, and symptoms of depression.

The 30-minute investigation may need to be adjusted depending on the patient’s ability to relate his or her childhood and adult traumatic experiences (

). Wise and well-trained psychiatrists do not open “Pandora’s box” without knowing they can close it before the session is over, so the patient’s tolerance for these questions needs to be carefully gauged. You can always delve deeper in a future session-my experience is that the majority of patients tolerate these questions well and are relieved to finally meet someone who has enough compassion and courage to ask the questions in an empathetic manner.

A 51-year-old black woman has been taking multiple medications for depression, panic attacks, and anxiety for approximately 10 years. She has episodes of depression, but they never last longer than a few days and, thus, are not persistent enough to warrant a diagnosis of MDD. Before the onset of symptoms, she had a fairly decent life. She completed her requirements for a high school diploma and had many years of working in various blue-collar jobs. However, she has never really been happy, and in her mid-20s, she had an 8-year stint of cocaine use.

When asked about the cocaine use, she brushed the question aside, briefly stating that she had gotten into a “bad situation” early in her life. At that point, she was directly asked about exposure to childhood trauma (sexual assault, physical assault, witnessing violence) because it was the examiner’s experience that patients with her symptom pattern frequently had experiences with trauma as children. Only then did she report that her fifth grade teacher had sexually abused her the entire year she was in his class. She never told anyone, not even her mother. In addition, she reported several episodes of rape when she was using drugs.

She mused that she had always felt this was at the root of her problem but had never felt comfortable discussing it. She could not believe that something that had happened so long in the past could be affecting her life so many years later. On further reflection, she wondered whether this early childhood trauma had resulted in her lack of self-esteem, which caused her to sleep around when she was younger; whether her need to numb herself to the chronic memories of her abuse (that still haunted her) had resulted in her drug use; or whether this was the reason she was so overprotective of her 3 daughters when they were growing up.


Proposed criteria for developmental trauma disorder

During the 30-minute evaluation, we explained that she has been repeatedly traumatized and that the trauma had taken its toll on her. A psychiatric assessment indicates that she suffers from developmental trauma disorder (

 She was given a copy of the criteria to help her better understand the course her life had taken. In addition, we proposed that she shift her “learned helplessness” into “learned helpfulness.” This perspective will put her into a position of not letting the traumatic experiences define her.

 And it will give her a sense of mastery and allow her to develop a sense of power over the bad experiences.

She was also told about the Gift From Within Web site

 that she could use as a resource for further information. The patient was extraordinarily grateful for her new understanding of her problems. Lastly, she was told the story of a raped woman, who after receiving an apology on behalf of manhood for the reprehensible behavior of the man who raped her, said, “There is no reason to apologize. What happened to me does not define me. Only I define me.” The patient said she would have to work on adapting this view.

There is a growing recognition that traumatic experiences in childhood have the potential to strongly influence outcomes of children and adolescents. There is growing acknowledgment that children exposed to trauma grow up with psychiatric disorders that can be directly traced back to the initial exposure. Unfortunately, symptom checklists followed by matching psychotropic effects of medications to target symptoms often result in a medicalized patient. Although medications may rebalance neuropsychiatric structures and chemistries damaged by trauma, it is essential to provide the patient with practical information, education, and philosophical considerations. A good therapeutic bond between patient and psychiatrist will reassure the patient and result in better outcomes. Accordingly, the construction of a dynamic formulation of the origins of the patient’s symptoms and the ability to explain it to the patient in an understandable, commonsense manner is quite comforting and encouraging. The Dells had it right when they sang, “A little understanding goes a mighty long way.”

Introduction: Mental Health Correlates of Trauma

Understanding and Fostering Resilience in Persons Exposed to Trauma 

Articles

Psychiatrists need to understand how living in violent families and neighborhoods increases the likelihood of trauma and the psychiatric sequelae associated with it as well as how to respond in the aftermath.

Trauma Associated With Living in Violent Neighborhoods

As the United States becomes more culturally, racially, and ethnically diverse, psychiatry will be faced with the need to treat more diverse populations. This article focuses on challenges and obstacles encountered when treating black patients with mental illness. The black population in the United States is not a monolithic, homogeneous community. The heterogeneity of the population as a function of the African diaspora is complex and deserving of an understanding that goes beyond the phenotypic identification and assignment of individuals to what we believe to be "black."

 Language; ethnic culture (eg, Caribbean vs Southern-born); religious practices; socioeconomic status; immigration or refugee status; and the historical participation, or lack thereof, in the unique American experience of race relations defines how persons experience being "black" and express mental illness.


The first skill necessary to appropriately treat patients from the black community is to avoid stereotyping members of this diverse group.

 Such stereotyping is at the root of behaviors that result in the expression of microinsults and microaggression toward members of the African diaspora.

 For example, psychiatric services staff need to learn not to automatically ask black patients for their "Medicaid cards," but should rather ask, "How does the patient intend to pay for services?" 

Conversely, gratuitously attempting to overidentify with the black culture based on stereotypes is equally detrimental, (ie, a white therapist giving a black patient an unsolicited "soul" handshake at their first meeting). Alternatively, the supposition that leads a therapist to prematurely ask about substance abuse before eliciting relevant data to support this possibility may be offensive to a black patient. It is advisable to establish rapport and elicit data that more directly relate to the presenting problem before initiating this and other more sensitive types of inquiry.

 is an excellent primer that combats stereotyping by emphasizing the importance of recognizing the diversity that exists within black communities. Consideration of the individual patient's social context is important for avoidance of stereotyping and for understanding the context in which the patient's mental illness occurs. Middle-class, working-class, and poor blacks have different patterns of family membership, employment and continuity of employment, number of children, family functions, interaction (egalitarian, patriarchal, matriarchal), income and spending, social and leisure activities, involvement in community affairs, education, attitudes toward work, success,  self-reliance, and so on.

 Despite the myth that all black families are matriarchal, middle-class black families are often egalitarian, and those of Caribbean extraction may be very patriarchal; therefore, making assumptions about black family structure and function is a potential land mine. Factors that affect levels of cultural identity

 among persons of the African diaspora can be further understood by referring to the underused "Cultural Formulation" section of 

Central to recognizing the diversity within the black community is the development of skills of "cultural sensitivity."

 It is important to recognize and understand that different cultural, racial, and ethnic groups may require different medication prescribing practices.

 For example, because blacks have higher blood levels of the medication, they may be more predisposed to tardive dyskinesia given the same dose of a neuroleptic agent than a white counterpart.

 Simultaneously, while cultural sensitivity is important in the treatment of blacks with mental illness, it is equally important to recognize that there are universal principles of treatment that should apply to all patients.

 Clinicians must become astute in their ability to draw from both culturally specific and universal principles in their work with black patients.


Another aspect of cultural sensitivity is recognizing that many blacks have been subjected to various degrees of racism

 and have varying levels of recognition of this reality. Misconceptions on the part of blacks may stem from a number of causes.

There may be confusion on the part of blacks as to whether they are being tolerated or accepted by whites. Although some whites truly accept blacks, others may harbor negative stereotypes and only tolerate them. Rejecting the legitimate goodwill of whites is as big a mistake as trusting a white person who harbors racist attitudes. Many blacks have difficulty in recognizing who is who and consequently pay the price.

A second problem concerns the inability of blacks to distinguish between the supportive efforts of individual whites and the destructive actions of whites as a collective (eg, the long-standing and unaddressed health care disparities between blacks and whites). This confusion occurs when a black person is accepted by a white person and as a result, mistakenly believes that racism no longer exists.

Another problem is knowing when, where, and how to resist oppression (eg, microinsults or microaggression and overt discrimination) versus when, where, and how to accommodate it. There are occasions when racism should be fought bitterly but other times when the fight proves more detrimental than beneficial-for example, when a white psychiatrist stereotypes a black patient by diagnosing a psychotic spectrum disorder when an affective spectrum disorder is more suitable. Because of the power differential, the patient has a difficult choice to make regarding whether to challenge the treating psychiatrist's clinical acumen and authority.

Finally, there may be confusion about whether the locus of control is internal or external. An internal locus of control implies that you attribute your successes to yourself and your failures to your lack of effort. An external locus of control implies that you attribute your failures or successes to something outside of your control. A major problem for blacks is determining when they are in control of their destiny and when there are external factors imposed by racism. If blacks assume an external locus of control (ie, "the man" controls everything blacks do), then blacks will lack motivation to help themselves, and they will lack feelings of self-efficacy. Conversely, if blacks do not recognize the toxic external constraints imposed on them, they could erroneously attribute their failure to their own perceived shortcomings.

The first 3 of these areas of confusion can seriously disrupt the establishment of rapport between the patient and the treatment provider. The American Psychiatric Association's position statement on racism emphasizes the importance of being mindful of the existence and impact of racism and racial discrimination in the lives of patients and their families, in clinical encounters, and in the development of mental health services.

 The confusion about locus of control has a tremendous impact on feelings of self-efficacy, making it critically important to discuss these issues with African American patients early in treatment.


Blacks may harbor fear, distrust, lack of confidence, and anxiety over the prospects of stigmatization-all born of a historical recognition of failures of the health care system to adequately address disparities and exploitation (eg, Tuskegee syphilis experiments).

 In addition, because exposure to trauma is another common issue for black patients, they should be asked about their experiences with racism and trauma.

When treating black patients, it is critical to understand that risk factors are not necessarily predictive factors, since protective factors may intervene. Thus, psychiatrists must actively explore the protective factors surrounding blacks in risky contexts.

 In general, protective factors are the strength of social fabric surrounding the patient,

 the patient's access to state-of-the-art medical technology, the opportunities the patient has had for developing social skills (eg, the capacity for affect regulation), the patient's sense of self-efficacy and self-esteem,

 the protective shields in the patient's life (eg, family involvement, church), and the opportunity for the patient to develop a sense of self-efficacy by turning traumatic helplessness into learned helpfulness.

It is imperative that objective, empiric, evidence-based research guides how best to adapt current practices to mental health issues relevant to the diverse black community. Humanistic interventions geared toward using existing community resources and strengths (including family support, ethnic and spiritual values, education, and belief systems born of tradition) and an understanding of the black experience can be used to construct culturally sensitive and effective mental health services and interventions.

Dr Bell is president and CEO of the Community Mental Health Council and clinical professor in the department of psychiatry at the University of Illinois at Chicago. Dr Dove is interim head of psychiatry and associate professor of clinical psychiatry in the department of psychiatry at the University of Illinois in Chicago. Dr Williamson is a staff child psychiatrist at the Community Mental Health Council. They report that they have no conflicts of interest concerning the subject matter of this article.

http://encarta.msn.com/encyclopedia_761587467/African_Americans.html

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As the United States becomes more culturally, racially, and ethnically diverse, psychiatry will be faced with the need to treat more diverse populations. This article focuses on challenges and obstacles encountered when treating black patients with mental illness.

Challenges and Obstacles in Treating Mentally Ill Black Patients

Prior research on the impact of childhood abuse and trauma has been limited in scope. Previous studies have focused mainly on single forms of adversities. Stressful life events do not occur in pure forms, and research is needed to assess effects of multiple trauma and abuse on adult health risk outcomes. The Adverse Childhood Experiences (ACE) Study examined the association between multiple childhood trauma and health outcomes in adults (Felitti et al., 1998). Questionnaires on adverse childhood experiences were mailed to 13,494 adults who completed a standardized medical evaluation in a large California HMO, with the final sample consisting of 9,508 participants. Respondents and nonrespondents did not differ concerning gender or years of education. However, respondents were older than nonrespondents and were more likely to be white.

The questionnaire assessed seven categories of adverse experiences: 1) psychological abuse; 2) physical abuse; 3) sexual abuse; 4) violence against the respondent's mother; 5) living with household members who were substance abusers; 6) living with individuals who were mentally ill or suicidal; or 7) living with individuals who had ever been imprisoned. The researchers instructed respondents to limit their responses to events that occurred during the first 18 years of life. Additional health risk factors and disease conditions used to assess adult health status were: smoking, severe obesity, physical inactivity, depressed mood, suicide attempts, alcoholism, any drug abuse, parental drug abuse, high numbers of lifetime sexual partners, a history of having a sexually transmitted disease (STD), ischemic heart disease, cancer, stroke, chronic bronchitis, emphysema, diabetes, hepatitis or jaundice, and any skeletal fracture. 

Logistic regression was used to examine the association between adverse childhood experiences (range=0 to 7) and health outcomes controlling for significant demographic factors. Of the total sample, more than half (52%) of the respondents experienced one or more types of adverse childhood exposures, and 6.2% reported four or more exposures. Significant correlations were found among all categories of adverse childhood experiences; however, no multicollinearity existed between independent variables. Those with multiple categories of childhood exposure were more likely to have multiple health risk factors later in life. 

The graded relationship among the seven categories of adverse childhood exposures and each of the adult health risk factors and diseases studied was highly significant (p<0.001) (Figure 1). These data provide evidence that adverse childhood exposure to trauma and household dysfunctions are significantly associated with negative health outcomes in adults. Clearly, these issues warrant further study utilizing longitudinal designs. 

Public Health Care Implications for Children

Although this study is limited by its use of retrospective data, these findings have several important public health care implications for children exposed to trauma. Appropriate interventions could potentially address major health issues, such as drug abuse, depression, suicide attempts, STDs, obesity, ischemic heart disease and cancer, which sometimes occur in adult survivors of childhood trauma and abuse. These findings call for public health care interventions at the primary, secondary and tertiary levels.

Preventive programs need to target homes that are at high risk for family violence and dysfunction and where children are at an increased risk for exposure to abuse or trauma. Practitioners need to engage these individuals and their families in comprehensive home assessments and structured interventions that are aimed toward promoting more adaptive family functioning. Entire communities need to be educated regarding the potential harmful effects of prolonged exposure to family dysfunction and childhood trauma. Parental support groups, affordable day care services and greater access to community resources need to be offered to caretakers to reduce family disintegration and cumulative stress. Caretakers also need to be guided in connecting with their natural helping networks that will allow them to share child care responsibilities (reducing parental isolation) and modify harmful parenting practices that perpetuate increased exposure to family trauma. 

Children exposed to ongoing trauma at home need to be correctly assessed by trained public and mental health care practitioners to circumvent further possible psychological, behavioral and physical decline. Symptoms of chronic exposure to trauma include a lifetime history of major depressive disorders, alcohol/drug use/dependency and anxiety disorders (Briere and Runtz, 1990). Symptoms of hypervigilance and increased antisocial behaviors in children may be incorrectly attributed solely to attention-deficit/hyperactivity disorder and other behavioral diagnoses. Skillful assessments and interventions are treatment imperatives for children exposed to violence and disruption at home. Public health care workers should facilitate and encourage enrollment in drug treatment, primary care and mental health care programs for individuals exposed to chronic trauma who show early signs of drug use and poor biopsychosocial functioning. 

The developmental and behavioral consequences of repeated exposure to violence call for an effective assessment response by mental health care professionals. Curtailing poor health outcomes in adults requires a thorough assessment for family dysfunction and individual trauma in children. Such behaviors may manifest as extreme hopelessness or fatalistic behaviors later in life. 

We contend that evidence-based prevention strategies could prevent exposure to adverse childhood experiences or ameliorate the poor health and mental health outcomes of being exposed to adverse childhood experiences (Henggeler et al., 1992; Olds et al., 1998). Prevention strategies need to be nested within a comprehensive mental health care and wellness infrastructure to have effectiveness and wide dissemination.

Mental Health Care and Wellness Infrastructure

The Office of the Surgeon General has identified eight goals to improve the mental health care infrastructure for children in United States (Office of the Surgeon General, 2000) (Figure 2). This comprehensive infrastructure is necessary if we are to effectively address the languishing nature of mental health care services for children. The success of this project will depend on an unprecedented collaboration and commitment by three core federal and state departments that strongly shape the context in which children live: the U.S. Department of Health and Human Services (HHS), the U.S. Department of Education (DOE), and the U.S. Department of Justice (DOJ). Although children and adolescents with serious emotional disturbances are more likely to receive treatment from a program supported by the HHS, most children who receive mental health care in the United States are within the jurisdiction of the DOE (Burns et al., 1995). However, the greatest need for a mental health care services overhaul may be within the DOJ. For example, incarcerated children who have been traumatized as a victim and a perpetrator of violent offenses need extensive mental health care attention but are unlikely to receive adequate care (Simpatico et al., 2002). The multisystemic partnership proposed by the Surgeon General is the first step in addressing the crises in mental health care services for America's youth.

Goal 1: Promote public awareness of children's mental health care issues and reduce the stigma associated with mental illness

. Campaigns should help identify early indicators for mental health while promoting social, emotional and behavioral well-being.

Goal 2: Continue to develop, disseminate and implement scientifically proven prevention and treatment services

. Advancements in neurological, cognitive, social and psychological development will aid the design of better screening assessment and treatment tools. 

Goal 3: Improve the assessment and recognition of mental health care needs in children

. Increasing the understanding of policy-makers and practitioners may accomplish this goal by identifying early mental health care needs in preschool, child care, education, health care, welfare, juvenile justice and substance abuse treatment settings. Since most of the children with mental health care needs are under the purview of the DOE, promoting cost-effective and proactive systems of behavioral support within schools will be necessary.

Goal 4: Significant disparities exist between non-white and white use of mental health care services

. Increasing culturally competent white and non-white health care professionals and research on service delivery disparities will be extremely useful in attaining this difficult goal of reducing such disparities. Other avenues toward the elimination of the broad disparities include developing policies for uninsured children; encouraging alternative prevention/intervention strategies; and co-locating mental health care services with other key systems such as education, primary care, welfare, juvenile justice and substance abuse treatment.

Goal 5: Improve the infrastructure of children's mental health care services, including support for scientifically proven interventions across professions

. The primary objective for this goal is twofold: review incentives and disincentives for health care providers to assess the mental health needs of children; and provide incentives to agencies, programs and individual practitioners to use scientifically proven and cost-effective prevention and intervention strategies. 

Goal 6: Increase access to and coordination of quality mental health care services

. Health care professionals must develop a common language to describe children's mental health that considers cultural, ecological and familial context. There is an additional need for a universal measurement system across all major service sectors that is age-appropriate and culturally and gender sensitive. Improving access to services and involving key community stakeholders in the design and delivery of services to their communities are also critical. 

Goal 7: Train frontline providers to recognize and manage mental health care issues and educate mental health care providers in scientifically proven prevention and treatment services

Goal 8: Monitor the access to and coordination of quality mental health care services

. This goal may be maintained by establishing formal partnerships among federal research regulatory and service agencies, professional associations, and families/caregivers to transfer evidence-based knowledge. 

We have empirical evidence that exposure to adverse childhood experiences is cumulatively associated with negative health outcomes in adults. Following the U.S. Surgeon General's report on children's mental health, we propose developing public mental health care and wellness systems that will support prevention and intervention of children's exposure to adverse childhood experiences by using evidence-based strategies that can be widely disseminated (Bell, 2002).

Bell CC (2002), Connecting the Dots. In: Youth in Crisis-Uniting for Action. Proceedings of the Seventeenth Annual Rosalynn Carter Symposium on Mental Health Policy. Atlanta: Mental Health Program of The Carter Center, pp44-46. 
  

Briere J, Runtz M (1990), Differential adult symptomatology associated with three types of child abuse histories. Child Abuse Negl 14(3):357-364.
  

Burns BJ, Costello EJ, Angold A et al. (1995), Children's mental health service use across service sectors. Health Aff 14(3):147-159 [see comment].
  

Felitti VJ, Anda RF, Nordenberg D et al. (1998), Relationship of child abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 14(4):245-258 [see comments]. 
  

Henggeler SW, Melton GB, Smith LA (1992), Family preservation using multisystemic therapy: an effective alternative to incarcerating serious juvenile offenders. J Consult Psychol 60(6):953-961.
  

Office of the Surgeon General (2000), Report of the Surgeon General's Conference on Children's Mental Health: A National Action Agenda. HSS. Available at: www.surgeongeneral.gov/topics/cmh/childreport.htm. Accessed Feb. 13, 2003. 
  

Olds DL, Hill PL, Mihalic SF, O'Brien RA (1998), Blueprints for Violence Prevention; Book Seven: Prenatal and Infancy Home Visitation by Nurses. Boulder, Colo.: Center for the Study and Prevention of Violence. Institute of Behavioral Science, University of Colorado at Boulder.
  

Simpatico TA, Alaimo CJ, DeCarlo A et al. (2002), Cultural disparities in mental health service use for mentally ill offenders. Presented at the 54th Institute on Psychiatric Services. Chicago;Oct. 11.

This article reviews the Adverse Childhood Experiences (ACE) Study that examined the association between multiple childhood traumas and health outcomes in adults. These findings have significant public health implications for individuals exposed to childhood trauma, and the authors present a vision for a children's mental health care and wellness infrastructure in the United States derived from the Report of the Surgeon General's Conference on Children's Mental Health.

Carl C. Bell, MD

Articles

Trauma Associated With Living in Violent Neighborhoods

Challenges and Obstacles in Treating Mentally Ill Black Patients

Trauma and Violence in Childhood: A U.S. Perspective