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Day after day
Division seems
Beyond repair

And the floods
of biases declare
A national disaster

Hearts destroyed
By hubris
And breathless
Lung filled
with the smoke
of greed

Homes lose
their moral foundation
Windows stained
With inflexible thoughts

But the sun still rises
And hope shines
For another day
In a world seeking
Unity

Breaking news
Heightens trauma response
Fear lingers and plays
A game of fight
Flight or freeze

Centuries of despair
Moan for justice
And invite reform
At a hare’s pace

And evil does
Not surrender
It’s plight

But the sun still rises
And hope shines
For another day
In a world seeking
Unity

Some days
Humanity is dormant
And some days it
Erupts with pomp
And circumstance

Perhaps our current state
Will melt with raindrops of
Reconciliation

And just maybe
Dissonance will bend
Toward harmony

But the sun still rises
And hope shines
For another day
In a world seeking
Unity

is an outpatient psychiatrist at Prisma Health-Upstate and clinical associate professor at the University of South Carolina School of Medicine, Greenville. He served on the American Psychiatric Association’s Task Force to Address Structural Racism Throughout Psychiatry, and he currently serves as the Diversity and Inclusion section editor and advisory board member for

On this September 11th—and always—we strive for unity... 

Unity

Mass shootings continue, seemingly unabated. Perhaps we are becoming desensitized to them. Last night there was a deadly one in Memphis. What will be the aftermath of this one?

We are about 2 months past the Independence Day mass shooting in the Chicago suburb of Highland Park, Illinois. For self-disclosure: it is the community where my Rabbi son’s synagogue, Makom Solel Lakeside, is located. I also did a column on July 7th titled: “The Highland Park Mass Shooting: Sometimes You Just Want to be Proven Wrong.”

Grieving the losses and coming out of such trauma with posttraumatic growth and strength are the psychological goals. Can an artistic memorial help the recovery as a sort of collective art therapy?

This question is what the community is trying to answer as discussed in the September 4th 

 article, “Public art installation honoring Highland Park victims still draws a crowd 2 months after mass shooting, but it might be scaled back.”

 Often, memorials like this one are short-lived. However, this Highland Park one had a different genesis. It was begun by someone who had already done several public gun violence art projects.

By now, however, there is controversy of how long to leave this installation memorial up. One group wants it to continue as it evolves. Another feels it is traumatic in itself. Highland Park officials seem to be looking for a compromise. I wonder if those upset by the memorial are those who were triggered by the shooting or other prior traumatic events. Perhaps, paradoxically, this suggests that they need to talk to someone about their reaction, as they might be at continuing risk for some degree of PTSD.

Both because my son’s synagogue is located there and I am a native Chicagoan now living in Milwaukee, I had to go see it right away. And I did, on that dreary, drizzly Sunday evening. It is located downtown, right next to the railroad tracks, mainly in a corridor with arched ceilings. Trees and posts were wrapped by community members in shades of orange, the color associated with gun safety. Photos of the victims, and fresh flowers were there. Uplifting music played nearby. Quickly, I noticed instructions of a kind:

“Leave what you want. Take what you need.”

But what really got my attention is thousands of message-bearing luggage tags handing from the yarn. An anonymous person was quoted in the article

“I couldn’t grasp it all, so the first things I did was write a note and put it up there. It has given me a chance to start healing step by step. I come back to it, I grow a little more.”

Images of healing and horror flashed in my mind. The corridor reminded me of the tunnels that I have heard about in near-death experiences. The railroad tracks evoked thoughts of the railways that brought Jews to the concentration camps. Then I reacted like the visitor, so I left this tag and am processing my own reactions with you:

“This psychiatrist thinks this memorial is therapeutic. Better than Prozac for grief.”

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

1. Moffic HS. The Highland Park mass shooting: sometimes you just want to be proven wrong. 

https://www.psychiatrictimes.com/view/the-highland-park-mass-shooting-sometimes-you-just-want-to-be-proven-wrong

2. Keilman J. Public art installation honoring Highland Park victims still draws a crowd 2 months after mass shooting, but it might be scaled back. 

. September 4, 2022. Accessed September 8, 2022. 

https://www.chicagotribune.com/news/ct-highland-park-art-installation-mass-shooting-20220904-yvmjgan5sncjjerb2llk6jxntm-story.html

Can an artistic memorial help recovery from gun-violence trauma as a sort of collective art therapy?

Memorials to Mass Shootings: The Highland Park Model

The NCCHC Governance Board recently adopted a new position statement on the topic of trauma-responsive care for children and adolescents in correctional facilities.

“For corrections administrators, staff, and health professionals, trauma-responsive care is one of the most critical services we can provide to help youth who have been incarcerated restore their resilience,” said Jennifer Clifton, DNP, FNP-BC, CCHP-A, an associate professor and interim associate dean at the University of Utah College of Nursing.

According to Heather Forkey, MD; Jessica Griffin, PsyD; and Moira Szilagyi, MD, PhD, in their book 

Childhood Trauma and Resilience: A Practical Guide

published by the American Academy of Pediatrics, trauma-informed care is “a strength-based framework that is grounded in an understanding of and responsiveness to the impact of trauma: emphasizes physical, psychological, and emotional safety for both providers and survivors; and creates opportunities for survivors to build a sense of control and empowerment.”


Trauma-informed systems provide a framework that has been shown to contribute to improved client outcomes and decreased staff burnout in various settings.

“Trauma-responsive care takes trauma-informed care a step further,” Clifton said. “Trauma-responsive care involves an organizational commitment in the form of concrete policy and procedure changes; it has emerged as the most beneficial framework for treating traumatized individuals.”

The 5 core values of trauma-responsive care are:

By focusing on these values, clinicians can shift the paradigm from “What is wrong with them?” to “What happened to them?” This can create an environment aimed at rehabilitation rather than punishment for youth.

 directs all correctional facilities and auxiliary entities who serve youth to develop and maintain a trauma-responsive care model.

Facilities should also form Guide Teams of trauma experts, including residents from a target population, to lead and instruct staff, administrators, and health care providers on trauma-responsive care. Further, all employees of the juvenile correctional facility should be provided with the educational resources and mentors needed to help navigate a trauma-responsive approach. This includes a facility-wide cultural emphasis on employee self-care activities to combat compassion fatigue and burnout. 

The trauma-responsive approach may also involve cultural and policy shifts to support a therapeutic environment, including redesigning the facility setting to eliminate negative or threatening language and providing a calming and comfortable milieu, Clifton shared.

By taking into account the effects of stress, adversity, and trauma on an adolescent’s mental and physical health, correctional settings can best utilize a multifaceted trauma-responsive approach.

“One of the aspects of adolescent care I relish most is the ability to make a positive impact on the youth we serve through our words and actions,” said Clifton. “Learning the skills of trauma-responsive approaches to care helps us to help them—and isn’t that what it’s all about?”

1. Trauma-responsive care for youths in correctional facilities. National Commission on Correctional Health Care. August 2022. Accessed September 2, 2022. 

https://www.ncchc.org/trauma-responsive-care-for-youths-in-correctional-facilities/

2. Clifton J. Moving from “what’s wrong with them?” to “what happened to them?” National Commission on Correctional Health Care. August 22, 2022. Accessed September 2, 2022. 

https://www.ncchc.org/moving-from-what-is-wrong-with-them-to-what-happened-to-them/

The National Commission on Correctional Health Care has issued a new directive for trauma-responsive care for children and adolescents in correctional facilities. 

New Position Statement on Trauma-Responsive Care for Youth 

Tales From the Clinic: The Art of Psychiatry, 

we examine the case of posttraumatic stress disorder (PTSD) in the setting of homelessness and substance use. Most homeless individuals report experiencing significant trauma at some point in their lives. This discussion examines the correlation between trauma and homelessness, and touches on vicarious trauma endured by treating physicians as well. It is easy to fall into negative perceptions of patients with homelessness, trauma, and substance use. Successful treatment hinges on remaining humane in perspective, and viewing such cases as very high in comorbidity and needing additional psychosocial support.

“Ms Harris” is a middle-aged woman with a history of PTSD and alcohol use disorders who is currently receiving 

 at a local homeless shelter. She is engaged in a substance treatment program for the first time in her life.

Ms Harris was raped by an uncle at age 12 and advised by her mother to keep the incident a secret. After the rape, she started struggling with academic performance, and then she stopped attending school at age 16. She married at age 19 and quickly had 2 children. Her husband was physically and emotionally abusive in their marriage. She started drinking alcohol to cope with the abuse. She divorced her husband after 20 years of marriage when her youngest child turned 18. She received a small financial settlement after the divorce, but after 3 years, she had exhausted her savings. She was unable to sustain employment due to her 

 and discomfort interacting with strangers. During this time, her alcohol use escalated and her relationship with her children became strained. After exhausting her financial resources, Ms Harris experienced significant alcohol withdrawal and was subsequently admitted to the medical unit for treatment. Her apartment evicted her for nonpayment while inpatient, and she was subsequently discharged to a local shelter and substance use rehabilitation program.

Ms Harris is seen by a psychiatrist after completing the first 30 days of her sobriety. She is visibly anxious with significant psychomotor agitation. She reports difficulty with sleep initiation as well as sleep maintenance. She finds interacting with her peers uncomfortable and isolates herself when possible. During the visit, she reports significant irritability, primarily triggered by her peers and loud noises. She also reports having taken escitalopram in the past with poor effect.

Distrust of others is a well-known symptom of 

. Childhood maltreatment—including emotional abuse, emotional neglect, physical abuse, physical neglect, and sexual abuse—is also associated with increased distrust as well as interpersonal threat perception in adulthood.

 This often presents a challenge to the therapeutic alliance. Engaging in the principles of trauma-informed care is critical to both establishing trust and avoiding retraumatization.

During Ms Harris’s initial visit, she is reminded that her participation in the appointment is voluntary and confidential. Prior to obtaining a trauma history, she is advised that while she may be asked about broad categories of abuse, she can decline to answer any questions that make her uncomfortable and request that no trauma history be obtained at the initial visit. She is invited to provide any details that she does feel comfortable discussing, but is reassured that she will not be asked to divulge any painful details of her past. Ms Harris discusses that she had been 

 and physically abused as an adult, but declines to provide further details during the first few visits.

During the initial interview, Ms Harris has some ambivalence about her alcohol use. While she understands that her use had escalated to an unhealthy level, she also reports that it was her primary means of coping with her anxiety. Without it, she reports a significant escalation of her symptoms. She worries about her ability to tolerate a substance use treatment program.

Ms Harris is not alone in her difficulties with alcohol use. Some studies show the prevalence of alcohol dependence of homeless patients to be upwards of 55%, and similar rates of drug dependency.

 In emergency rooms, rates of substance use were significantly higher, sometimes doubled, in homeless patients as compared to those who did not report homelessness.

 While there are many hypotheses surrounding these findings, one cannot ignore the influence of trauma. Substance use disorders and PTSD often cooccur, with one study finding that up to 46% of patients with PTSD also meet criteria for a substance use disorder.

 Successful treatment of both disorders simultaneously is critical for patient improvement.

Ms Harris is initially started on sertraline for PTSD. Given her distrust of others and perceived failure of another selective serotonin reuptake inhibitor (SSRI), considerable time is spent in psychoeducation surrounding the role and effects of medications in her treatment plan. She is also started on naltrexone for 

. Trazodone is used for sleep initiation difficulties.

In subsequent visits, the patient reveals that she is having nightmares surrounding the physical abuse from her ex-husband. She reports that the dream frequency has not changed with the initiation of her other medications. Doxazosin is added. While more research is needed in patients with comorbid PTSD and alcohol use disorder, doxazosin has had some promising results when studying these illnesses separately.

Other treatment options aimed at addressing her anxiety such as hydroxyzine and gabapentin are discussed but declined by the patient due to a fear of daytime sedation. Topiramate is also discussed, as it has shown promise in patients with cooccurring PTSD and alcohol use disorder, although additional studies are needed.

 Ultimately, this medication is also omitted from the treatment plan due to the potential for cognitive deficits, which could impair her ability to participate fully in her substance use treatment program.

The shelter helps Ms Harris remain compliant with her medications with frequent reminders and scheduled medication times. She participates in cognitive behavioral therapy (CBT)-based substance use treatment classes, as well as group and individual therapy. She engages in prolonged exposure for her traumas. Over many weeks, Ms Harris begins to trust her psychiatrist and engage in more peer support activities. Her emotional and physical reactivity improve. With the help of the shelter’s case manager, Ms Harris is able to obtain work in the retail industry. As graduation approaches, she becomes more anxious. Her psychiatrist initiates a CBT-based model aimed at addressing her cognitive distortions surrounding her ability to be successful outside of a structured setting. Ms Harris graduates from the substance treatment program and moves into an apartment.

She is followed closely by her psychiatrist after graduation. Immediately following her transition out of the shelter, the patient reports a recurrence of anxiety and sleep disturbance. In addition, she reports a relapse after being offered alcohol by a well-meaning neighbor. While initially struggling with significant shame and guilt, the patient is able to abstain from further use. Trazodone is transiently increased, and Ms Harris continues to address her anxiety in therapy with positive effect.

After many months, Ms Harris becomes romantically involved with a neighbor at her apartment complex. She reports an improvement in her anxiety and continued sobriety in the weeks following the start of their relationship. She is lost to follow up.

Ms Harris returns to the clinic after 1 year. She reports that her boyfriend did not support her use of psychiatric medications and advised her to stop them. He soon became increasingly emotionally abusive, and the patient relapsed on alcohol. Two weeks ago, he sexually assaulted her after she declined to have intercourse. She has not yet told anyone about the assault, but ended the relationship. She reports feeling fearful, as he has remained a resident in her apartment complex.

Her psychiatrist provides emotional support while also encouraging the patient to report the assault to the police and consider seeking a restraining order in accordance with state law. She is also encouraged to obtain urgent gynecologic care and is given information about a local family violence shelter center. While the patient declines to report the incident to the police or seek resources from the family violence shelter, she does agree to seek gynecologic care. The patient restarts her medications and is able to taper off alcohol as an outpatient.

Working with homeless patients can be exceedingly rewarding. Patients such as Ms Harris can and do improve at a remarkable rate with the appropriate support and treatment. However, there are also challenges facing psychiatrists who work with homeless patients, notably vicarious trauma. Psychiatrists in this area are inherently exposed to personal reports of trauma repeatedly throughout the day. One study in Canada showed rates of PTSD in helping professions related to homelessness were 2 to 3 times higher than what were found in other frontline professions such as policework and emergency services.

 Therefore, it is imperative that those working with this patient population actively engage in their personal wellness and ensure they are receiving support from their institution.

is assistant professor at the Meninger Department of Psychiatry and Behavioral Sciences at the Baylor College of Medicine in Houston, Texas. She specializes in homeless populations with cooccurring psychiatric illnesses and serves as the Departmental Lead Medical Students Elective Officer and Associate Clerkship Director.

Childhood maltreatment in associated with distrust and negatively biased emotion processing.

Borderline Personal Disord Emot Dysregul. 

Trauma-Informed Care in Behavioral Health Services. 

Treatment Improvement Protocol (TIP) Series 57. Substance Abuse and Mental Health Services Administration; 2014.

The prevalence of mental disorders among the homeless in western countries: systematic review and meta-regression analysis.

4. Doran KM, Rahai N, McCormack RP, et al. 

Substance use and homelessness among emergency department patients.

5. Pietrzak R, Goldstein R, Southwick S, Grant B. 

Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: results from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions.

6. Back SE, Flanagan JC, Jones JL, et al. 

Doxazosin for the treatment of co-occurring PTSD and alcohol use disorder: design and methodology of a randomized controlled trial in military veterans.

7. Flanagan JC, Korte KJ, Killeen TK, Back SE. 

Concurrent treatment of substance use and PTSD.

PTSD symptoms, vicarious traumatization, and burnout in front line workers in the homeless sector.

More than 80% of homeless individuals report having experienced life-altering trauma at some point in their lives.

“I Have No One”: Understanding Homelessness and Trauma

It’s been a week since I first wrote about the recent 

. Sometimes, there is more to consider about such a traumatic episode as time goes on and our fight, freeze, or flight responses die down, such as what struck me over this past week.

 that we covered a week ago. The first time he was stabbed, really multiple times, was by the perpetrator at the usually tranquil Chautauqua Institute, resulting in injuries to his liver, an eye, an arm, and perhaps elsewhere according to early medical reports. These early reports said he was alert and talking, but nothing else has been updated in recent days.

Of course, after he was brought to the emergency room, a surgical knife, or knives, was used to begin to treat and heal his wounds. These knives have received much less media attention, as tends to happen in such traumatic events. We tend to be more attuned and absorbed in the dangers that have occurred and could happen to us, too.

This tale of the 2 knives parallels that of most any tool. We now pay much attention to harmful gun violence, but on occasion they are used for necessary self-defense, as in war or being attacked. Atomic energy can be used for benefits, as in safe energy production, or destruction, as in unnecessary nuclear bombing.

In medicine and psychiatry, medication can have harmful side effects at the same time as the benefits. It is up to us in psychiatry and in everyday life to use our tools—our knowledge and skills—for as much benefit and as little harm as possible. We, of course, operate without knives, but instead with words that can be therapeutic or cutting as we cut through various undue psychological defense mechanisms.

We have seen how harm can be medically helped in the Salman Rushdie injuries, and that is really the emphasis of the Hippocratic oath. There is a clause in the original oath that mentions the proper use of the knife on the human body, in that it should be left to those experts in its medical use:

“I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.”

Most likely, in the time of Hippocrates, Rushdie would have died. Gratefully, we often have the opportunity to redress the physical and psychological traumas we transmit to one another with therapeutic surgery and psychiatry.

Psychiatry’s tools: words, which can be as cutting as a knife. 

Remember Hippocrates: Salman Rushdie Was Stabbed with a Knife 2 Times

“Real true, posttraumatic stress disorder [PTSD] is going to have an impact, certainly on the next generation and maybe generations after that,” said Rachel Yehuda, PhD.

Yehuda, in the Educator of the Year Lecture at the 

2022 Annual Psychiatric Times™ World CME Conference

 in San Diego, shared her research on the potential of PTSD being passed genetically through the generations. Studying the Holocaust and 9/11 survivors showed fascinating results.

At a clinic for Holocaust survivors and their families at Mount Sinai School of Medicine, families reported feeling damaged, guilty, anxious, full of morbid grief, and had dysfunctional interpersonal relationships due to fear of loss. Overall, the children of survivors believed that parental Holocaust exposure was involved in their current mental health problems.

Previous research by Yehuda et al showed adult offspring of Holocaust survivors had differential effects of maternal and paternal PTSD in both glucocorticoid receptor sensitivity and vulnerability to psychiatric disorder. With both maternal and paternal PTSD, offspring had lower GR-1F promoter methylation; with just paternal PTSD, offspring had GR-1F promoter hypermethylation.

 Furthermore, Holocaust exposure induced intergenerational effects on FKBP5 methylation; specifically, Holocaust survivors and their adult children showed a nongenotype dependent change in methylation compared to their respective controls.

 This was the first demonstration of an association of preconception parental trauma with epigenetic alterations that is evident in both exposed parent and offspring.

Similar findings resulted from Yehuda’s work on the effects on 9/11. For example, in a post-9/11 program surveilling women who were pregnant, Yehuda and researchers collected salivary cortisol from mothers and babies.

 “What we found is that the mothers that felt PTSD, their cortisol levels were lower, but it’s also lower in babies, which was really wild,” said Yehuda. “But here’s the kicker: Both cortisol levels are lowest in the babies of mothers with PTSD who were exposed in the third trimester.”

This research suggests maternal PTSD may confer additional in utero effects, causing more anxiety for example.

 Trauma exposure during pregnancy directly affects the fetus and fetus germ cells, Yehuda shared.

How does trauma pass down? Yehuda explained that epigenetic changes could survive cell division associated with the formation of sperm and eggs; if the parent is exposed to trauma, their exposure could result in epigenetic changes that may affect their sperm or egg—meaning a single trauma could simultaneously affect multiple generations without direct exposure.

“This is inherited in our DNA,” said Yehuda. “Trauma is inherited.”

The biological remnants of parental experiences in our DNA can affect us in multiple ways, according to Yehuda. They can influence our response to stressors/challenges, make us better able to detect and respond to threats, increase vulnerability to mental health disorders, and increase our attunement to injustice. They are enduring, but not irreversible, Yehuda stressed.

1. Yehuda R, Daskalakis NP, Lehrner A, et al. 

Influences of maternal and paternal PTSD on epigenetic regulation of the glucocorticoid receptor gene in Holocaust survivor offspring.

2. Yehuda R, Daskalakis NP, Bierer LM, et al. 

Holocaust exposure induced intergenerational effects on FKBP5 methylation.

Transgenerational effects of posttraumatic stress disorder in babies of mothers exposed to the World Trade Center attacks during pregnancy.

Can we inherit our parents’ trauma? Research points to yes. 

Trauma in Your DNA: Educator of the Year Lecture

In his presentation, “How to Assess/Diagnose Childhood Trauma,” at the 

 in San Diego, Mark B. Hamner, MD pointed out that the Department of Health and Human Services data on child abuse underestimates traumatic exposure, given they only address abuse and not other traumas. “And abuse is often not reported,” he added.

Children can experience a number of traumatic experiences beyond physical, sexual, or psychological abuse and neglect, said Hamner, including: natural disasters or terrorism; family or community violence; the sudden or violent loss of a loved one; substance use disorder either personally or within their family; refugee and war experiences, including torture; serious accidents or life-threatening illness; military family related stressors, like deployment or parental loss, can all play a part in the child’s traumatic history.

Additionally, in the National Comorbidity Survey Replication Adolescent supplement, which looked at a national survey of adolescents aged 13 to 17, the lifetime prevalence of DSM-IV PTSD was 4.7% higher in girls.

Children and adolescents who identify as part of the LGBTQ+ community experience trauma at unique, higher rates. Common traumas include bullying, harassment, traumatic loss, intimate partner violence, physical and sexual abuse, stigma, and more.

“Somatization is a significant posttraumatic stress symptom,” said Hamner. “Some have argued this should be included in diagnostic criteria.”

An exemplifying study looked at the relationship between PTSD symptoms and somatization, and between intelligence and somatization in child sexual abuse victims to determine whether the type of abuse had an effect on the relationship between PTSD symptoms and somatization.

The study concluded that somatization in children who were sexually abused was influenced by the severity of PTSD symptoms and intelligence, and the effect of the PTSD symptoms on somatization was moderated by type of abuse.

When screening children and adolescents for trauma, Hamner shared a few tips that might help. 1. Make time in therapy sessions to complete screening measures with family members.

2. Allow the parent and child to choose the language in which the screen is completed.

3. Use developmentally appropriate strategies, like a chalk or dry erase board.

4. Let them decide the order in which they complete measures when possible.

6. If child is resistant, read aloud to them.

7. Offer to complete over 1 to 3 sessions.

8. Praise all children and parents for “hard work.”

9. Check endorsement of critical items like hurting oneself and develop safety plan.

10. Take time to explain what will happen next and clarify that you will readminister measures on an ongoing basis.

The National Child Traumatic Stress Network is an important resource, Hamner also noted. Specifically, he mentioned their Child and Adolescent Trauma Screen (CATS) instrument.

 It is downloadable and brief, taking only 5 to 10 minutes to complete. This could be a helpful tool in the screening arsenal, he said.

“There are the unique developmental considerations in this age range,” concluded Hamner. “It’s a vastly under researched area, not only in terms of epidemiology but also in terms of treatments.”

PTSD correlates with somatization in sexually abused children: type of abuse moderates the effect of PTSD on somatization.

2. Child and Adolescent Trauma Screen. International Society for Traumatic Stress Studies. Accessed August 12, 2022. 

https://istss.org/clinical-resources/child-trauma-assessments/child-and-adolescent-trauma-screen-(cats)

How do you screen for childhood trauma? One doctor at the 2022 Annual Psychiatric Times™ World CME Conference in San Diego, one doctor shared his most helpful tips.

Childhood Trauma: 10 Tips for Screening and More 

If anyone thought that trauma was settling down in the Middle East and the US, this weekend belied that assumption. Though these events otherwise seem separate and are of great social psychiatric concern in their own right, all occurring over the weekend may be more than coincidence. They are:

-After a year of relative “quiet,” rockets were launched from Israel to the Gaza Strip and from the Gaza Strip to Israel.

-The fourth Muslin man to be ambushed and killed in Albuquerque over the past 9 months occurred on Friday.

-Saturday night and Sunday was the Jewish commemoration of Tisha b’Av, an annual fast and study day related to several disasters in Jewish history.

-Saturday August 6th was “Hiroshima Day,” the day in 1945 when the first atomic bomb was dropped on Hiroshima.

In canvassing the members of SPIRIT, who have previously written about such traumas for 

™, there was a great diversity of opinion about whether it was the right time to respond, and what could we say of value, yet still be respectful of the mourning associated with these tragedies.

Then there are also the silent international traumas, such as in Lebanon. Two of our members recently visited Lebanon. Plagued with hunger and a lack of social services, they reported a sense of powerlessness, helplessness, resignation, and psychotic-like “zombies” walking the streets there. It seems that we in psychiatry have to avoid feelings of learned helplessness in reacting to these traumas.

Although hundreds of women dressed in white with their mouths taped shut marched in protest in downtown Chicago on Sunday, the invasion of Ukraine continues, with less attention by the media, psychiatry, and public.

Of course, the powers in the situation are beyond formal mental health, including the survival of countries and people. Oil money and politics are a major influence.

Nevertheless, we in psychiatry know how to sit, listen, and help address the harm we humans do to one another. Our trauma stories can be the source of wisdom, resilience, growth, and transformation. Our children and the continued intergenerational transmission of trauma is at stake. Trauma to children, regardless of whoever is responsible, is a psychiatric and global mental health issue.

We hope to make further comments in the near future and are always available to help and contribute our knowledge. In the meanwhile, we bear witness to these psychiatric tragedies of war and other violence.

 is a practicing psychiatrist with Providence Healthcare System in Portland, Oregon. He is the author of 

The Wounded Healer: The Pain and Joy of Caregiving

is clinical professor and chair of psychiatry and behavioral science at the University of North Dakota School of Medicine and Health Sciences. 

 is a professor of psychiatry at Cooper Medical School of Rowan University. He is active in several national and regional organizations and published and presented on international medical graduates, culture, religion, family psychiatry, gender issues, etc. 

 is a doctor working in frontline psychiatry for the National Health Service at South London and Maudsley NHS Foundation Trust in the United Kingdom. 

 serves as Kathleen & John Bricker Chair, Department of Psychiatry, LSUHSC. He also is chairman of the Board of Trustees of the Cobb Research Institute and is the 113th present of the National Medical Association. 

 is a clinical social worker, a visual storyteller, and a creativity consultant.

All these events that occurred over the weekend bear social psychiatric weight. 

SPIRIT (Social Psychiatry Interested in Recovery from International Trauma) Voices Some Current Concerns

It would be nearly impossible to peruse any media, engage in any conversation, or interact in any workplace without coming across the topic of the increased number of mass violence episodes (usually mass shootings) in the United States. With this in mind, I wanted to share evidence and thoughts surrounding myths about these episodes… as well as their corresponding truths. Although this is important in terms of accuracy, it is even more germane as it pertains to appropriate messaging by psychiatric professionals to our patients and our communities.

Myth #1: “We live in a more violent world than ever.”

Although the number of firearm deaths is increasing (please see Myth #7), we have seen decreases over time of other violent events. This is important to many of our patients suffering from anxiety or trauma-based illnesses. This myth and its messaging can lead to worries regarding lack of control, fatalistic projections, and learned helplessness. Additionally, it is important to note that most of the 

 in the United States is not categorized as mass shootings. For instance, approximately 70 women are killed with firearms every month in situations of domestic violence.

Myth #2: “All of these perpetrators are mentally ill.”

The truth is that the majority of the individuals acting as 

 do not possess diagnosable or treatable mental illnesses. In other words, mass shootings are not predominantly attributed to those with mental illness. In fact, it is much more common for those living with mental illness to be a victim of a crime, not the perpetrator.

 If you examine all violent events, only a very small percentage (3% to 4%) are committed by individuals with mental illness. Although that number rises a bit when looking solely at incidents of mass violence, it is still quite small when looking at the overall data set (15% to 20%).

Myth #3: “Patients with severe and persistent mental illness are routinely dangerous.”

Debunking this myth is massively important; we need to properly message this to decrease stigma, increase access, and provide a safe community for those with severe and persistent mental illness (SPMI). Longitudinal studies have demonstrated that the majority of those with mental illness are not violent,

 and even more so, there is little to no evidence that there are high rates of 

 directed to others. On the rare instances in which violence is seen in the SPMI population, it is not usually perpetrated with guns, and it is not directed toward strangers and the general public.

 The 3 main items that tend to correlate as predictive factors for homicidal violence (whether one has a mental illness or not) is anger, intoxication, and access to firearms.

Myth #4: “Mass shootings are the most prevalent violent issue facing society now.”

Although episodes of mass violence are low incidence events (compared to all violent events), they are very powerful in terms of emotion, victims, and media coverage. In fact, other violent acts occur much more frequently. For instance, there were approximately 500 deaths from mass shootings between 2000 and 2016. During that same time period, there were almost 320,000 suicide firearm deaths.

 Moreover, recent data has shown the suicide numbers to be at least twice that of all homicides.

 Thus, from a public health standpoint, the rise in 

 dwarf that of homicides and other violent deaths (not just mass shootings).

Myth #5: “Enacting legislation focused on the mentally ill will decrease mass shootings.”

Part and parcel to Myth #2, this makes mathematical sense as there would not be significant change by focusing on 15% of the cases. By falsely looking at mental health, we are missing characteristics that have been found to be markedly more common in assailants, including 

, misogyny, and feelings of isolation and alienation (with rumination on perceived slights, particularly in the workplace). Additionally, most individuals who commit these shootings exhibit planning/practicing and cognitive appraisal. These actions are not consistent with psychosis, which is associated with the inability for self-care, nor would these traits be detected by present civil commitment statutes.

Myth #6: “Mental health screening and risk factors are the best way to predict mass shooting events.”

Very similar in tone to Myth #5, Federal Bureau of Investigations data has shown perceived victimization, rumination, and premeditation amongst perpetrators is more indicative of intent than mental health status. Similarly, Secret Service data has noted personal grievances, past violence, and a history of felonious events as predictive.

 As such, the most common predictors are not symptom domains normally seen in psychiatric illness. That being said, we have a lot to offer the field given our skills in risk assessment, interviewing, and inter-agency collaboration.

Myth #7: “Access to firearms is not a risk factor for episodes of mass violence.”

With so much media surrounding mass violence in the US, we need to sort out fact from fiction.  

Trauma And Violence