26 Helping Children Cast Off the Shackles of Trauma 42 Trauma-informed Care From the Field: Stories of Change We now approach trauma as a public.
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Published by the National Council for Community Behavioral Healthcare Breaking the SilenceTrauma-informed Behavioral Healthcare We Must Do More Linda RosenbergBreaking the SilenceKathryn Power The Invisible Suffering of War Jason SchiffmanCulture ShockRoger Fallot, Maxine Harris Intentional and Informed Connections Beth Filson, Shery Mead PLUS Trauma-informed Care from the Field Stories of Change Cover Art: Beth Filson ﬁWe Live Between the Cloudsﬂ 2011, I SSUE 2MAGAZINENationalCouncilSHARING BEST PRACTICES IN MENTAL HEALTH & ADDICTIONS TREATMENTwww.The NationalCouncil.org
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Questions about Meaningful Use Funding?Check out muadvisor.comMEANINGFUL USE FUNDING CHECKLISTRegister Providers at CMS websitePurchase Fully Certified EHR Apply for Funds at State websiteGet PaidHere at Echo, we think that last one is especially important. It™s why we™re proud that Grand Lake Mental Health Center in Nowata, OK was the first behavioral health provider in the country to get paid Meaningful Use funds. They™ve been an Echo customer since 1994. Learn how the most intuitive EHR for Behavioral Health can get you $63,750 per Provider too!www.echoman.com30 Years of Behavioral Health Solutionswww.echoman.com 800.635.8209 email@example.comGroupThe
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NationalCouncilNational Council Magazine is published by the National Council for Community Behavioral Healthcare, 1701 K Street, Suite 400, Washington, DC 20006. www.TheNationalCouncil.org ACKNOWLEDGMENTS In this issue of National Council Magazine focused on trauma-informed care, we are honored to feature art and stories from many persons recovering from trauma, mental illness, and substance use. We are indebted to each of them for agreeing to share their expressions in order to help others who are seeking the path to healing. We especially thank the following individuals for their support: Mike Drummond, CEO, Arundel Lodge Inc. Deede Miller, Gallery Director, Arundel Lodge, Inc. Marilyn Baker, Photographer for art at Open Eye Gallery Gayle Bluebird, RN, Peer Services Director, Delaware Psychiatric Center To view and purchase the works of various consumer artists, visit The Open Eye Gallery at www.openeyegallery.org Altered States of the Arts at www.alteredstatesofthearts.com President & CEO: Linda RosenbergEditor-in-Chief: Meena Dayak Specialty Editors, Trauma-informed Care Jeannie Campbell, Cheryl Sharp, Heather CobbEditorial Associate Nathan SprengerEditorial and Advertising Inquiries Communications@thenationalcouncil.org or 202.684.3740.Breaking the SilenceTrauma-informed Behavioral Healthcare National Council Magazine, 2011, Issue 2 INTRO DUCTION 4 We Must Do More Linda RosenbergEDITORIAL8 Breaking the Silence Kathryn Power 10 ACEing Trauma-informed Care Jeannie Campbell 13 Is Anyone Really Listening? Beth Filson 14 Shining the Light on Trauma-informed Care National Association of State Mental Health Program Directors 16 Sine Qua Non for Public Health Susan Salasin18 Virtual Veteran to Help Grad Students Learn Advertorial, University of Southern California School of Social Work 19 The Invisible Suffering of War Jason Schiffman22 Art Expressions Gayle Bluebird, Sharon Wise, Beth Filson 24 When Disaster Disrupts Linda Ligenza Cover Art: We Live Between the Clouds by Beth Filson PDF available at www.TheNationalCouncil.org (look under About Us/National Council Magazine) Pg 19The Invisible Suffering of War Shelly Netzer ﬁIdol and Eyesﬂ Questions about Meaningful Use Funding?Check out muadvisor.comMEANINGFUL USE FUNDING CHECKLISTRegister Providers at CMS websitePurchase Fully Certified EHR Apply for Funds at State websiteGet PaidHere at Echo, we think that last one is especially important. It™s why we™re proud that Grand Lake Mental Health Center in Nowata, OK was the first behavioral health provider in the country to get paid Meaningful Use funds. They™ve been an Echo customer since 1994. Learn how the most intuitive EHR for Behavioral Health can get you $63,750 per Provider too!www.echoman.com30 Years of Behavioral Health Solutionswww.echoman.com 800.635.8209 firstname.lastname@example.orgGroupThe
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4 / NATIONAL COUNCIL MAGAZINE 2011, ISSUE 2 4 / NATIONAL COUNCIL MAGAZINE 2010, ISSUE 1 26 Helping Children Cast Off the Shackles of Trauma Kelly Decker, Susan Ko 28 Culture Shock Roger Fallot, Maxine Harris 30 The Rest of the Story Anthony Salerno 32 Promises to Keep Interview with Ann Jennings 35 A Community Safety Net to Prevent Youth Suicide Advertorial, Hazelden Publishing 36 It™s All About Relationships Cheryl Sharp 38 Are You One of Us? Benedict Carey in the New York Times 41 Mobile Integrated Health Clinic Drives Recovery Advertorial, OptumHealth 42 Trauma-informed Care From the Field: Stories of Change Anchorage Community Mental Health, AK A New Leaf, AZ Beech Brook, OH Bridges to Recovery, CA Central Washington Comprehensive Mental Health, WA Community Care Behavioral Health Organization, PA Congreso de Latinos Unidos, PA Grafton Integrated Health Network, VA The Guidance Center, MI Institute for Health and Recovery, MA Kentucky River Community Care, KY King County Mental Health, Chemical Dependency Services Division, WA Livingston County Human Services Collaborative Body, MI Mental Health Center of Denver, CO Mental Health Connection, TX Peace4Tarpon, FL Seminole Behavioral Healthcare, FL Spectrum Health Systems, MA Star View Adolescent Center, CA Tri-County Mental Health Services, ME Truman Medical Center Behavioral Health, MO Interviews Almazar Consulting, IL The Kent Center, RI Massachusetts Correctional Institution, MA Naval Consolidated Brig Miramar, CA Redwood House at Caminar, CA Women™s Community Correctional Center, HI 64 Intentional and Informed Connections Beth Filson, Shery Mead 66 Peer Support Guides the Way Darby Penney 68 And That™s How They Do It In Brooklyn Jo Ann Ferdinand 70 The Healing WRAP Matthew Federici, Cheryl Sharp Interview with Walter Hudson 72 Seeking Safety: Coping Skills Lisa Najavits 72 A Matter of Faith Andrea Blanch75 A Sanctuary for Change Sandra Bloom76 Trauma-informed Care Training Resources Cheryl Sharp NationalCouncil42Trauma-informed Care from the Field : Stories of Change
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6 / NATIONAL COUNCIL MAGAZINE 2011, ISSUE 2 WE MUST DO MORELinda Rosenberg, MSW, President and CEO, National Council for Community Behavioral Healthcare Shelley Netzer ﬁMasksﬂ ﬁDuring every incarceration, every institution -alization, every court-ordered drug treatment program, it was always the same: I was always treated like a hopeless case. All people could see was the way I looked or the way I smelled. It wasn™t until I ˜nally entered a recovery-oriented, trauma- informed treatment program a little more than four years ago, where I felt safe and respected, that I could begin to heal–Someone ˜nally asked me ‚What happened to you?™ instead of ‚What™s wrong with you?™ﬂ Tonier Cain Tonier Cain is a success story. Today, she is a team leader with SAMHSA™s National Center for Trau -ma Informed Care. But for every Tonier Cain, there are hundreds of thousands of women and men who pass through our programs every day with painful histories of personal trauma Š including sexual as-sault, domestic violence, child abuse and neglect, and witnessing interpersonal violence Š that we all too often ignore. The good news is that people with behavioral health conditions and trauma histories can and do recover. But we can and must do more. It is important that we shift our focus from asking the people who seek our help what is wrong with them to asking what happened to them. Our suc -cess in helping to improve their health, the health of our organizations, and the health of the nation depends on it. WHY IS A FOCUS ON TRAUMA IMPORTANT? First, we know that violence is pervasive. In the United States, a woman is beaten every 15 seconds; a forcible rape occurs every 6 minutes. Trauma is now considered to be a near universal experience of individuals with behavioral health problems. Ac – cording to the U.S. Department of Health and Hu -man Services Of˜ce on Women™s Health, from 55 to 99 percent of women in substance use treatment and from 85 to 95 percent of women in the public mental health system report a history of trauma, with the abuse most commonly having occurred in childhood. More than 92 percent of women who are homeless have experienced severe physical and/or sexual abuse during their lifetime. Signi˜cant num -bers of women in the criminal justice system report physical and sexual abuse, and national surveys sug -gest that as many as one-third of women veterans have experienced rape during their military service. Second, we know the physical and psychological consequences of violence are highly disabling. The Adverse Childhood Experiences study, a general pop -ulation study conducted by the Centers for Disease Control and Prevention and Kaiser Permanente, is one of the largest investigations ever conducted to assess associations between childhood maltreat – ment and later-life health and wellbeing (http:// www.cdc.gov/ace/). Almost two-thirds of the study participants reported at least one adverse child – hood experience of physical or sexual abuse, ne -glect, or family dysfunction, and more than one of ˜ve reported three or more such experiences. ACE researchers discovered that the greater the number of adverse experiences, the greater the risk for negative outcomes. These include alcoholism and alcohol abuse, depression, illicit drug use, risk for intimate partner violence, sexually transmitted diseases, suicide attempts, and unintended preg – nancies. Heart disease, liver disease, and chronic obstructive pulmonary disease are also affected by adverse childhood experiences. We can™t begin to address the totality of an indi -vidual™s healthcare, or focus on promoting health and preventing disease Š both tenets of healthcare reform Š unless we address the trauma that pre-cipitates many chronic diseases. Nor can we begin to bring down the spiraling costs of healthcare. The ACE Study revealed that the economic costs of untreated trauma-related alcohol and drug abuse alone were estimated at $161 billion in 2000. The human costs are incalculable. Third, we know that trauma is shrouded in secrecy and denial and is often ignored. Nobody wants to talk about interpersonal violence. Both women and men who have been physically or sexually assaulted Someone ˜nally asked me ‚What happened to you?™ instead of ‚What™s wrong with you?™ Tonier Cain
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8 / NATIONAL COUNCIL MAGAZINE 2011, ISSUE 2 Colin Lacey ﬁOpen Eyesﬂ ﬁdoorﬂ they enter or whether they ever ˜nd their way to a trauma-speci˜c 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.Trauma-informed care means that regardless of the reasons an individual comes to our door, clinical staff asks them about their trauma history. We must ask respectfully, and we must be prepared to listen. In a trauma-informed system, services are designed to accommodate the needs of trauma survivors. Roger Fallot, clinical psychologist and director of re – search and evaluation at Community Connections, tells us that trauma-informed services:>> Incorporate knowledge about trauma in all aspects of service delivery. >> Are hospitable and engaging for survivors.>> Minimize revictimization. >> Facilitate recovery. As Roger and others have noted, in a trauma-in -formed human services system:>> Repeated trauma is viewed as a core life event around which subsequent development orga -nizes. Symptoms are understood not merely as complaints but as attempts to cope and survive.>> Treatment for individuals who have been trau – matized recognizes both their vulnerabilities and their strengths. By the very fact that the people we serve have experienced violence or the threat of violence and have come out on the other side, they are survivors, not victims. >> Services for trauma survivors are based on the principles of safety, voice, and choice as de˜ned by the people we serve. Our primary goals as helpers and healers must be the individual™s empowerment and recovery. The consumer must be an active planner and participant in services. Peer support can be lifesaving. >> Trauma services are ethnically, racially, and spirituality relevant to the individual and gender- speci˜c. Cultural competence is more than the latest buzzword in our ˜eld. It is the best way to ensure that the people we serve receive treat-ment that is meaningful to them.>> Finally, trauma treatment is coordinated across multiple service systems. The problems engen -dered by violence cut across emergency services, mental health care, primary healthcare, sub – stance abuse treatment, and domestic violence. But all too often trauma survivors cycle in and out of these various systems without ever receiving appropriate services. We can™t let that continue. HOW CAN NATIONAL COUNCIL MEMBERS DO MORE?The Kent Center, a National Council member in Warwick, RI, has been working to increase aware -ness about the impact of trauma throughout Rhode Island. They are partners with the state in a SAM -HSA grant to develop the Jail Diversion and Trauma Recovery Program, which aims to create trauma- informed criminal justice and behavioral health care systems. Many of you are already far down the road in offer-ing trauma-informed services and others are start -ing to think about how you step up. Here are some things you can do, beginning today, to make your services and systems more trauma informed:>> Engage leadership at the top. You must have top-down recognition of the importance of trau -ma for it to become embedded in the system. >> Make trauma recovery consumer-driven. The voice and participation of consumer/survivors should be at the core of all activities, from ser -vice development and delivery to evaluation. >> Emphasize early screening. Make early screen- ing for trauma, assessment of the impact of trau -ma, and referral for integrated trauma services common practice.>> Develop your workforce. Create workforce ori- entation, training, support, competencies, and job standards related to trauma. Don™t just train clinical staff Š train and educate everyone who comes into contact with consumers, from the re -ceptionist to the maintenance staff. >> Institute practice guidelines. Centralize clinical practice guidelines for working with people with trauma histories. Develop rules, regulations, and standards to support access to evidence-based and emerging best practices in trauma treatment. >> Avoid recurrence. Implement procedures to avoid retraumatization and reduce impacts of trauma.HOW WILL THE NATIONAL COUNCIL SUPPORT YOU? We believe we have much to contribute to leader -ship in the area of trauma-informed care and will work with you to raise awareness, educate our members and the general public, and, ultimately, improve client outcomes. As Kent Center president and CEO David Lauterbach points out, ﬁBecoming trauma informed is an ongoing process. We are all in the process of becoming more trauma informed each day, if we work at it.ﬂ Linda Rosenberg has more than 30 years of mental health policy and practice experience, focusing on the design, ˜nanc -ing, and management of behavioral health services. Under Rosenberg™s leadership since 2004, the National Council has more than doubled its membership; helped to secure the passage of the federal mental health and addiction parity law; expanded ˜nancing for integrated behavioral health/primary care services; and was instrumental in bringing behavioral health to the table in federal healthcare reform. Prior to joining the National Council, Rosenberg served as the Senior Deputy Commissioner for the New York State Of˜ce of Mental Health. The good news is that people with behavioral health conditions and trauma histories can and do recover. But we can and must do more.
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10 / NATIONAL COUNCIL MAGAZINE 2011, ISSUE 2 BREAKING THE SILENCEThe year was 1975. Armed with a freshly minted Master™s degree in counseling, I started work as victim services and volunteer coordinator at the Harrisburg Area Rape Crisis Center in Harrisburg, Pennsylvania. This was one of the ˜rst centers in the country to respond to the sexual assaults of women, men, and children as a public health issue and clinically signi˜cant traumatic event. Founded on a philosophy that the act of sexual assault was a crime of power, these centers began to spring up all over the state and the nation. The rape cri -sis movement worked hard to change protocols in police stations, emergency rooms, and courtrooms, successfully passing rape shield laws and changing the language we used, replacing the word ﬁvictimﬂ with ﬁsurvivor.ﬂ We called this work ﬁadvocacy,ﬂ from the Latin advocar Š to speak on behalf of another. But perhaps the most important contribution of these courageous women, who came together to share their stories of victimization, pain, and be -trayal, was their willingness to break their silence. Their stories were painful to listen to, but important to hear. They became self-advocates. As I listened, I heard again and again that a wom -an™s searing exposure to the raw trauma of physical or sexual assault put her overall emotional health at very high risk for both the short and long term. I heard how women learn not to trust their feelings or believe they are worth anyone™s time or help. I heard that the power of traumatic life events to destabilize individuals had been systematically missed by the mental health ˜eld altogether. I heard the depths of their pain, but I also saw the tremendous heights to which they could soar. I was a witness to resilience, hope, and recovery. As one abuse sur -vivor poignantly said, ﬁeven broken hearts can heal.ﬂ I have never forgotten those voices. For over 40 years, they have inspired me to work tirelessly to help open the nation™s eyes to the impact of violence and trauma and the need to promote emotional wellness and recovery for every man, woman, and child who has been affected by traumatic events. Trauma occurs when an external threat overwhelms a person™s coping resources. Interpersonal violence Š including physical and sexual assault such as rape, incest, battering, and murder Š shatters trust and safety, fragments relationships, narrows hope, and impedes recovery. Untreated trauma that be -gins in childhood Š which is often intentional, pro – longed, and repeated Š exerts a powerful impact on adult emotional health, physical health, and major causes of mortality in the United States. Interpersonal violence is so common for women, regardless of cultural af˜liation and socioeconomic class, that it has been described as a ﬁnormativeﬂ part of female experience in the United States to – day. It is widely accepted to be a near universal ex – perience of individuals with mental and substance use disorders and those involved in the criminal justice system. Our children are witnesses to and victims of violence themselves. Military sexual trau – ma affects as many as one-third of our women in uniform. We cannot hope to rein in healthcare costs and improve healthcare quality if we don™t attend to trauma and its consequences. I began to do so as director of the Rhode Island Department of Mental Health, Retardation, and Hospitals by instituting screening for trauma across the behavioral health system and in my role as President of the National Association of State Men – tal Health Program Directors. In 1998, NASMHPD membership unanimously passed a policy state-ment about the presence and effects of trauma for individuals with mental and substance use condi- tions. The statement said in part, ﬁIt should be a matter of best practice to ask persons who enter mental health systems, at an appropriate time, if they are experiencing or have experienced trauma in their lives.ﬂ We must have these conversations. The focus is not on what went wrong in the individual™s life. The focus is on what allows them to bend rather than break in the face of life™s adversities. This is the very de˜ni -tion of resilience. As Richard Mollica, MD, author of Healing Invisible Wounds , has written, ﬁUltimately, traumatized people heal themselves, and what™s more, their experience can teach the rest of us how to deal with the tragedies of life.ﬂ For nearly 20 years, the Substance Abuse and Mental Health Services Administration, in the U.S. Department of Health and Human Services, has recognized the need to address trauma as a funda-mental obligation for effective public mental health and substance abuse services delivery. Through demonstration projects, national conferences, and services grant programs focused on trauma, A. Kathryn Power, M Ed, Director, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services Dawn Jackson ﬁMusic Manﬂ
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NATIONAL COUNCIL MAGAZINE 2011, ISSUE 2 / 11SAMHSA is the leader in the development and dissem -ination of trauma-informed principles and practices. Technical assistance activities such as the National Center for Trauma-Informed Care and the National Child Traumatic Stress Initiative have provided tools for states and communities to promote recovery and healing for trauma survivors. Since 1994, SAMHSA™s Center for Mental Health Ser -vices has sponsored conferences that have helped shape the national agenda for women with mental and substance use conditions who are trauma survi-vors. The conference titles, Dare to Vision, Dare to Act, and Dare to Transform, speak to the evolution of our understanding and our goals for the future. The ˜rst conference in 1994 focused attention on the fact that many individuals who sought our help were revictimized in the mental health, substance abuse, and criminal justice systems by the dangerous prac- tices of forced medication, seclusion, and restraint. We are perpetrating violence ourselves when, in the words of a woman subjected to forced treatment, we ﬁlock them up, shock them up, tie them up, or drug them up.ﬂ Seclusion and restraint are not treatment options Š they are treatment failures. They cannot co-exist with a recovery-oriented system. SAMHSA has been a leader in promoting the reduction and elimination of seclusion and restraint, helping psychi -atric hospitals, emergency rooms, nursing homes, and schools understand how to promote an individual™s ability to provide self-care to prevent the possibility of violence. The elimination of seclusion and restraint saves money and improves outcomes for individuals and staff working conditions.In the past decade, a new understanding of the im -pact of trauma stemming from violence has begun to fundamentally alter the way services are delivered. In 1998, SAMHSA launched a ˜ve-year study on Women, Co-occurring Disorders, and Violence that highlighted the extent to which trauma can become the cen-tral organizing principle in a person™s life, affecting her ability to form relationships, keep a job, or live in stable housing. This study made clear that many individuals previously labeled as ﬁmentally ill,ﬂ ﬁsub -stance abusers,ﬂ or ﬁcriminalsﬂ were coping with the results of severe trauma histories. This understand -ing helps us view much of what we once considered pathological Š such as IV drug use or self-injury Š as coping mechanisms that have allowed individuals to survive some of the most horri˜c experiences a per- son can endure. We now approach trauma as a public health issue that can be addressed by creating safe, stable, and nurturing environments for children, youth, and families; in fact, preventing abuse and trauma before they occur. Based on what we know about the prevalence and impact of trauma in individuals™ lives, any assistance we offer Š in the community, in jails and prisons, and to our women and men in uniform Š must be characterized both by trauma-speci˜c diagnostic and treatment services, and by a trauma-informed environment capable of sustaining these services. In a trauma-informed environment, everyone Š clinical staff, support staff, and service recipients Š is edu -cated about trauma and its consequences. Individu -als and organizations are alert for ways to make their environments more healing and less retraumatizing for both staff and the individuals they serve. No one organization or federal agency can do this work alone. The effects of trauma spill over into our hospitals, our jails, and our social welfare systems, and these organizations also must be part of a com -prehensive solution. The Women and Trauma Federal Partners Committee is an outgrowth of the voluntary Federal Partners for Mental Health Transformation. It consists of representatives from more than 20 federal agencies and operating divisions. In April 2010, the committee held a Roundtable on Women and Trauma to begin a dialogue on the behavioral health impacts of trauma affecting women and girls and to develop recommendations for a comprehensive agenda for systems change, integration, and collaboration. A collective momentum emerged from the meeting and agencies have followed up with concrete actions designed to promote trauma-informed services and systems. A second roundtable planned for December 2011 will focus on effective strategies for prevention and intervention as we implement trauma-informed approaches across the service spectrum.As we go forward, our work is about bringing to scale the visibility, understanding, and response to trauma throughout the lifespan and across multiple experi -ences (e.g., maternal depression, combat exposure, etc.). Healing and integrated care must respect, hon – or, and validate survivors™ experiences in a positive way. Above all, we must follow the wisdom of Winston Churchill, who reminded us, ﬁCourage is what it takes to stand up and speak; courage is also what it takes to sit down and listen.ﬂ I learned long ago that when trauma survivors have the courage to speak about their fear, their isolation, and their pain, we must have the courage to listen. Together, we will be healed. A. Kathryn Power, M.Ed. is the director of the Center for Mental Health Services at the Substance Abuse and Mental Health Ser -vices Administration, an operating division of the U.S. Department of Health and Human Services. Prior to federal appointments, Power served for over 10 years as the as president of the Na -tional Association of State Mental Health Program Directors and director of the Rhode Island Department of Mental Health, Retar -dation and Hospitals. Power previously directed substance abuse prevention and policy programs including the Rhode Island Of˜ce of Substance Abuse, the Governor™s Drug Policy Of˜ce, the Rhode Island Anti-Drug Coalition, and the Rhode Island Council of Com -munity Mental Health Centers. Earlier professional experiences include teaching at elementary, secondary, and university levels; providing counseling, leadership, and advocacy for rape crisis and domestic violence service systems and agencies; and working as a computer systems analyst at the Department of Defense. Power is a graduate of the Toll Fellowship program of the Council of State Governments. She completed programs in senior executive leadership development, mental health leadership, and substance abuse leadership at the John F. Kennedy School of Government. Ms. Power is a retired Captain in the U.S. Navy Reserve. When trauma survivors have the courage to speak about their fear, their isolation, and their pain, we must have the courage to listen. Together, we will be healed. Christian McCarroll ﬁShower Room at Dachauﬂ Leading Change: A Plan for SAMHSA™s Roles and Actions 2011Œ2014Trauma & Justice ( Initiative #2) Purpose Reducing the pervasive, harmful, and costly health impact of violence and trauma by integrating trauma-informed approaches throughout health, behavioral health, and related systems and addressing the behavioral health needs of people involved in or at risk of involvement in the criminal and juvenile justice systems.
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