Pablo Stuart is a forensic psychiatrist. He specializes in capital cases and for the last 25 years he has been traveling around the country examining death row inmates, and reflecting on what he has found.
"Everyone I work with is mentally ill," he told me recently. "Every once in a while I'll have a new and different case, but there is a profile."
If one were to boil that profile down to a single word, it would be trauma.
Most of these death row inmates have some concoction of a range of predictable and horrific childhood and early adolescent experiences. Often it begins with sexual, physical or mental abuse. Second, in those families where abuse is rampant, it is most often the case that some form of substance abuse is present, too.
"Now you've got a kid with a traumatic history and a genetic predisposition for abuse and no parental supervision," Stuart says. Thirdly, there is often a pattern of multigenerational mental illness.
"So, mental illness, substance abuse and trauma-related disorder," he says, "that's the person who ends up charged with a capital crime."
Stuart works with the most extreme examples of this, but his observations are in line with a growing consensus about the need across the board to start integrating what's known as "trauma-informed therapy" into our health care system in a much more comprehensive way. Linda Rosenberg, the president of the National Council of Community Behavioral Healthcare, in a recently published letter called "Call to Arms" wrote: "(I)nstead of asking 'What's wrong with you?' we should be asking 'What happened to you?' "
The prevalence of trauma in behaviorally challenged or dysfunctional people is well established. The most comprehensive look at this phenomenon was documented in the Adverse Childhood Experiences Study, a joint collaboration between by Centers for Disease Control and Prevention and Kaiser Permanente, which provides a raft of fascinating data on how trauma develops, and what the long-term psychological consequences can be. What is less clear, however, is how best to incorporate that knowledge into a better system of care. The greater the exposure to trauma at an early age, the more likely a "negative outcome" can be expected later on in life. So treating it early and effectively requires agreement that the common denominator is likely trauma, which can serve as a starting point for further treatment.
"The fact that there is such consistency on these cases is significant," says Stuart. "Some of these people, they just never had a chance."
These dynamics are playing out right in our backyard. San Quentin, right up the road, has the biggest death row in the world -- excluding, of course, the de facto death rows that abound in dictatorial regimes like Libya. San Quentin inmates come from all around the country, of course. But there's no denying that the dynamics at work on Oakland's streets are producing large numbers of traumatized kids, many of whom will predictably go on to channel those experiences into a debilitating adulthood.
So what is "trauma informed care?"
"We must adopt a systemic approach which ensures that all people who come into contact with the behavioral health system will receive services that are sensitive to the impact of trauma," Rosenberg says. "They must be able to receive such services regardless of which 'door' they enter or whether they ever find their way to a trauma-specific treatment program. We can begin by recognizing the primacy of trauma as an overarching principle. Being trauma informed means realizing that the vast majority of people we come in contact have trauma histories. Trauma must be seen as the expectation, not the exception, in behavioral health treatment systems."
Source: Oakland Tribune, March 6, 2011
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