Helga Thordarson and Tiffany Rector
This article explores how wide-ranging effects of exposure to psychological trauma in mentally ill individuals continue to be largely overlooked, contributing to poor outcomes and a flood of mentally ill individuals into the court system and correctional care. Even in state hospitals and community mental health settings, the consequences of trauma often go unrecognized and untreated in highly vulnerable individuals. The authors posit that a trauma-informed lens is needed to move “trauma-blind” systems forward to more enlightened, evidence-based care and treatment. The traditional criminalization hypothesis refers to the funneling of serious mental illness (SMI) individuals into the criminal justice system as a result of deinstitutionalization and inadequate community mental health resources. This article explores how expanding notions about criminalization that identify factors beyond SMI still miss the mark by underestimating or omitting the role of trauma. Chronic under-recognition of trauma-related disorders contributes to misattributions about the cause and meaning of behaviors that pose common management problems in prisons, state hospitals, conditional release and community-based mental health programs, homeless shelters, and communities. A trauma-informed perspective offers insight for care providers (and individuals) seeking to understand acts of aggression, self-injury, high risk medical refusals, impulsivity, substance abuse, medication nonadherence, rule-breaking, and heightened reactivity to perceived disrespect, shaming, coercion, and power differentials. The authors encourage providers to take a new look at clients who demonstrate these behaviors with the view that for many SMI individuals, these responses do not represent treatment resistance or reckless risk-taking, but rather, complex, adaptive behaviors that arise from traumatic life histories.
While trauma-informed care (TIC) is not the answer to all problems, it offers a more effective and compassionate approach to challenges facing SMI individuals and the systems that treat them. TIC fosters awareness of the lifelong effects of psychological trauma, shifting the clinical question from “What’s wrong with you?” to “What happened to you?” In trauma-informed systems, the impact of trauma is recognized at all levels and proactive policies and procedures are employed to mitigate harm and reduce retraumatization. TIC is associated with improved mental health outcomes, patient satisfaction, and significant reductions in violence, sexually risky behavior, substance abuse, containment-related injuries, seclusion and restraint, and use of sedative hypnotics in acute inpatient settings.1–3
TIC is a national standard promoted by public health agencies across the U.S. and beyond. Leaders in mental health care increasingly view trauma-informed perspectives as critical, and this paper serves as a call to action. TIC offers a roadmap for organizational change that supports safer environments for patients, inmates, and staff. A crucial first step is increasing awareness of trauma prevalence and impact among SMI individuals.