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.
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
The 1994 conference focused attention on revictimization
by seclusion and restraint practices, which were not
widely acknowledged within the treatment field at that
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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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
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
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
For more information on SAMHSA's efforts, visit www.mentalhealth.samhsa.gov/womenandtrauma.
Jennings (1960–1992) expressed the trauma
of childhood sexual abuse in her life vividly and
poignantly through her sketches, oil paintings,
water colors, and writings.
Anna's work was exhibited
at the recent Dare To Act conference in Baltimore.
More than a decade ago, Anna's work was shown at
the 1994 Dare To Vision conference.
Since then, at many hospitals
and numerous conferences across the Nation, Anna's
images continue to tell her story. To see more
of her work and her story, visit www.AnnaFoundation.org.
artwork by Anna Caroline
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