Mapping “Trauma-Informed” Legislative Proposals in U.S. Congress

Abstract

Despite calls for translation of trauma-informed practice into public policy, no empirical research has investigated how the construct has been integrated into policy proposals. This policy mapping study identified and analyzed every bill introduced in US Congress that mentioned “trauma-informed” between 1973 and 2015. Forty-nine bills and 71 bill sections mentioned the construct. The number of trauma-informed bills introduced annually increased dramatically, from 0 in 2010 to 28 in 2015. Trauma-informed bill sections targeted a range of sectors, but disproportionally focused on youth (73.2%). Only three bills defined “trauma-informed.” Implications within the context of a changing political environment are discussed.

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Adm Policy Ment Health
DOI 10.1007/s10488-017-0799-9
ORIGINAL ARTICLE
Mapping “Trauma-Informed” Legislative Proposals inU.S.
Congress
JonathanPurtle1· MichaelLewis2
© Springer Science+Business Media New York 2017
1998; Shonkoff et al. 2012), academic difficulties (Stein
et al. 2003), arrest and incarceration (Abram et al. 2004;
Messina and Grella 2006), food insecurity (Chilton et al.
2015; Sun et al. 2016), and homelessness (Hopper et al.
2010; Kim et al. 2010). In response to the far-reaching
effects of trauma, the construct of trauma-informed prac-
tice emerged in the 1990s to better meet the needs of
trauma survivors (Baker etal. 2016; Bloom 2013; Bowen
and Murshid 2016; Harris and Fallot 2001; Ko etal. 2008;
Treatment, 2014).
Although many definitions of trauma-informed practice
exist (Branson etal. 2017; Marsac etal. 2016), the core ten-
ets of a trauma-informed approach are captured by the Sub-
stance abuse and mental health services administration’s
(SAMHSA 2016) Four “Rs” of: realizing the widespread
impact of trauma and pathways to recovery, recognizing the
signs and symptoms of trauma among consumers of ser-
vices and staff, responding by integrating knowledge about
trauma into practice and policy; and proactively resisting
re-traumatization. Trauma-informed approaches to prac-
tice have demonstrated effectiveness in reducing the use
of seclusion and restraint (Azeem et al. 2011; Boel-Studt
2015; Hodgdon etal. 2013), improving substance use and
mental health outcomes (Gatz etal. 2007; Greenwald etal.
2012; Morrissey etal. 2005), and enhancing the quality of
treatment environments (Rivard etal. 2005).
Trauma-informed practice initially gained traction in
human and mental health service sectors at the local-
level, but has recently been embraced by a wide array of
sectors at multiple levels of government (Becker-Blease
2017). For example, federal initiatives such as the White
House’s My Brother’s Keeper and the Department of Jus-
tice’s (DOJ) Defending Childhood Taskforce encouraged
the widespread implementation of trauma-informed inter-
ventions. States (e.g., Washington) (Kagi and Regala 2012)
Abstract Despite calls for translation of trauma-informed
practice into public policy, no empirical research has
investigated how the construct has been integrated into
policy proposals. This policy mapping study identified and
analyzed every bill introduced in US Congress that men-
tioned “trauma-informed” between 1973 and 2015. Forty-
nine bills and 71 bill sections mentioned the construct.
The number of trauma-informed bills introduced annu-
ally increased dramatically, from 0 in 2010 to 28 in 2015.
Trauma-informed bill sections targeted a range of sectors,
but disproportionally focused on youth (73.2%). Only three
bills defined “trauma-informed.” Implications within the
context of a changing political environment are discussed.
Introduction
Traumatic stress has profound impacts on multiple domains
of life and increases the risk of many adverse outcomes—
such as mental and physical health problems (Felitti etal.
The results of this study were presented at the International
Society for Traumatic Stress Studies’ Annual Meeting in Dallas,
TX on November 10, 2016.
Electronic supplementary material The online version of this
article (doi:10.1007/s10488-017-0799-9) contains supplementary
material, which is available to authorized users.
* Jonathan Purtle
JPP46@drexel.edu
1 Department ofHealth Management & Policy, Drexel
University Dornsife School ofPublic Health, 3215 Market
St., 3rd floor, Philadelphia, PA, USA
2 Department ofPsychology, Virginia Tech College ofScience,
Blacksburg, VA, USA

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and cities (e.g., Philadelphia, PA) (Beidas etal. 2016) have
made commitments to promoting trauma-informed prac-
tice in their public systems. Major philanthropies, such as
the Robert Wood Johnson Foundation and The California
Endowment, have established trauma-informed practice
as a funding priority. Interest in trauma-informed practice
has also increased in academic discourses. The number of
new entries to PubMed annually that mentioned “trauma-
informed” in the title or abstract increased from only 7 in
2010, to 46 in 2014, 81 in 2015, and 83 in 2016 (search
conducted on February 22, 2017).
Within this context of growing interest in trauma-
informed practice, mental health researchers and practition-
ers have called for the translation of trauma-informed prac-
tice into public policy (Ardino 2014; Bloom 2016; Bowen
and Murshid 2016; Fairbank and Gerrity 2007; Gerrity
2007; ISTSS, 2010; NCTSN; Shern etal. 2016; Shonkoff
and Fisher 2013). As Bowen and Murshid (2016) describe,
“Now, therefore, is an opportune time for public health and
allied fields to expand on the shift toward trauma-informed
care already underway in the service system and promote a
parallel transformation in social policy.” (p.228) Despite
enthusiasm about the notion of trauma-informed policy—
and its potential to maximize the public health impact of
traumatic stress research (Sorenson 2002; Thoits 2010)—
no empirical studies have investigated if and how the con-
struct of trauma-informed practice has been integrated
into public policy proposals. Consequently, little is known
about the current status of trauma-informed public policy
and limited guidance exists to guide trauma-informed pol-
icy advocacy efforts.
Policy Mapping
We conducted a policy mapping study to begin to address
this knowledge gap. Policy mapping is a methodology in
which policies and/or policy proposals related to an issue
are systematically identified and then analyzed using con-
tent analysis (Burris 2015; Burris et al. 2010; Tremper
etal. 2010). By cataloguing the policies ‘on the books,’
mapping studies can identify policy gaps and provide a
foundation for future research on policy implementation,
enforcement, and impact (Burris et al. 2010). Through
categorizing policy proposals according to their charac-
teristics, mapping studies can inform policy development
activities (Burris etal. 2016). By assessing trends in the
volume of policy proposals to address an issue, mapping
studies can provide indication of changes in the amount
of attention an issue is receiving from policymakers
(Tremper et al. 2010; Wagenaar et al. 2006). Mapping
studies are frequently conducted for policies related to
physical health (e.g., air quality and food safety), but
are underutilized in the field of mental health (Peck
and Scheffler 2002; Purtle 2014; Rowan et al. 2015).
For example, The Policy Surveillance Program at Tem-
ple University conducts ongoing mapping studies for 58
health-related policies and only one is focused on mental
health (i.e., involuntary commitment laws) (The Policy
Surveillance Program, Temple University 2016).
Study Purpose
This article presents the results of a policy mapping study
of legislative proposals introduced in US Congress with
the explicit intent of advancing trauma-informed practice.
The objectives of the study were to: (1) determine if the
volume of federal legislative proposals making explicit
reference to trauma-informed practice has increased, (2)
identify the sectors and populations targeted by these
proposals, and (3) catalogue the policy instruments used
to promote trauma-informed practice.
It is important to emphasize the parameters of our
study and justify the rationale for our approach. First, we
limited our study to legislative proposals that explicitly
mentioned trauma-informed practice. Thus, we did not
attempt to determine if tenets of trauma-informed prac-
tice (e.g., screening for trauma exposure, preventing re-
traumatization) were implicit in legislative proposals that
did not explicitly mention the term. We operationalized
trauma-informed narrowly to ensure construct validity
and adhere to the recommendation that policy mapping
studies focus “on measuring the apparent characteristics
of legal texts, rather than interpreting their meaning.”
(Burris 2015) (p.119).
Second, we limited our study to legislative propos-
als at the federal-level. Our study was not designed to
capture trauma-informed policy activity in the execu-
tive branch of government (e.g., policies of SAMHSA or
the Administration for Children and Families), judiciary
decisions related to trauma-informed practice, or identify
state or local policy proposals that mentioned the con-
struct. We limited our study to federal legislation because
state policies are often modeled after federal legislative
proposals (Goodman 2007) and because federal legisla-
tion served as a logical starting point given the paucity of
trauma policy research. In summary, our study was not an
exhaustive review of how public policy has been used to
address the needs of trauma survivors; but rather begins
to map the uncharted territory “trauma-informed” federal
legislation to provide direction for future research and
policy development activities.

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Method
Data Collection
Congress.gov—a comprehensive, publically available data-
base containing information about all bills introduced in US
Congress since 1973—was used to identify legislative pro-
posals introduced between January 1, 1973 and December
31, 2015 that included mention of trauma-informed prac-
tice. The Word and Phrase option within the Congress.gov
Advanced Search function was used to identify all bills that
contained the terms(s) “trauma-informed” and/or “trauma
informed” in the Title or Text fields. An Excel sheet was
created that listed the title and bill number of each legisla-
tive proposal and a hyperlink to where its full text could
be accessed on Congress.gov. For many of the bills, multi-
ple versions existed because the text was iteratively revised
through the legislative processes. In these instances, only
the most recent version of each bill was analyzed.
Coding Categories
Both entire bills and the individual sections of bills that
included trauma-informed language were units of analy-
sis. The boundaries of bill sections were delineated by
the headings “Sec.” before and after the mentions trauma-
informed practice. In this article, bills that included trauma-
informed language are referred to as “trauma-informed
bills” and bill sections that included trauma-informed lan-
guage referred to as “trauma-informed sections.” Prelimi-
nary coding categories and sub-categories were established
a priori based on an earlier policy mapping study of federal
legislative proposals to address post-traumatic stress dis-
order (PTSD) (Purtle 2014) and scholarship about trauma-
informed policy (Ardino 2014; Bloom 2016; Bowen and
Murshid 2016; Fairbank and Gerrity 2007; Gerrity 2007;
ISTSS, 2010; Shern etal. 2016; Shonkoff and Fisher 2013).
Trauma-informed bills were coded according to the
mutually exclusive categories of: the Congressional cham-
ber (i.e., House or Senate) in which the bill was introduced,
the name of the congressperson who introduced the bill and
their political party, the congressional committee to which
the bill was first referred, the date when the bill was intro-
duced, whether or not the bill became law, and whether or
not the bill included a definition of “trauma-informed.”
Trauma-informed sections were coded according to the
non-mutually exclusive categories of: the population that
the trauma-informed practice targeted (e.g., youth in fos-
ter care, college students), the sector in which the trauma-
informed practice was intended to be implemented (e.g.,
juvenile justice, health care), and the policy instruments
used to promote trauma-informed practice. Policy instru-
ments are the means by which public policy can be used to
achieve goals; and policy instrument typologies are often
used in mapping studies to describe how policies have
been used to address issues (Howlett 2010; Howlett etal.
1995). Trauma-informed sections were coded as contain-
ing symbolic and/or material policy instruments. Symbolic
policy instruments codify the perceived importance of an
issue (e.g., designating an issue awareness day) whereas
material instruments allocate resources or alter processes.
Trauma-informed sections that contained material instru-
ments were also coded as substantive and/or procedural.
Substantive instruments affect the delivery of goods and
services, whereas procedural instruments affect pro-
cesses. Trauma-informed sections that contained material
instruments were also coded according to the governing
resources being used (i.e., treasury, which allocates finan-
cial resources, authority, which mandates behaviors and
practices; information/knowledge, which educate policy
targets; and organizational structure, which requires gov-
ernment employees to provide services).
Each trauma-informed section was also coded according
to whether or not it exclusively targeted youth populations
(i.e., did not target adults) because youth and adults are
often served by separate systems that are affected by differ-
ent policies. We defined ‘youth’ as people between the ages
of 0 and 18 and thus did not include college students in this
category. Trauma-informed sections that targeted families
(i.e., both children and adults) were not coded as exclu-
sively targeting youth. Trauma-informed sections were
not coded according to the extent that they were evidence-
supported because the details needed to make such assess-
ments (e.g., the specific trauma-informed interventions that
would be implemented) were typically not provided in the
legislative texts.
Coding Process
First, two coders independently read all of the trauma-
informed bills, wrote notes about themes observed in the
legislative texts, and then revised the preliminary coding
categories and definitions through discussions in which
notes were compared. All of the bills were then indepen-
dently coded again by the two coders using Qualtrics (a
web-based survey platform; Provo, Utah). The two coded
datasets were then exported, compared, and incongruent
coding decisions (which did not exceed ten percent for any
coding sub-category) were resolved through discussions.
This produced the final legislative dataset.
Analysis
The dataset was imported into SPSS 24.0 (IBM, Armonk,
NY) for analysis. Univariate statistics were generated
to describe the proportion of trauma-informed bills and

Adm Policy Ment Health
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sections coded at each sub-category, with the total num-
ber of trauma-informed bills and sections as the denomi-
nators. Each bill and section was counted as a single unit
regardless of the number of times that it referenced trauma-
informed practice. The data were stratified to examine dif-
ferences in trauma-informed bills and sections with varying
characteristics. Fisher exact and χ2 tests were conducted to
determine the statistical significance of differences between
trauma-informed sections that did and did not exclusively
target youth.
Results
The first bill in US Congress that made explicit reference
to trauma-informed practice was the Domestic Minor Sex
Trafficking Deterrence and Victims Support Act of 2010 (S
2925) and was introduced on December 22, 2009. Between
then and December 31, 2015, 49 bills were introduced
that mentioned “trauma-informed” or “trauma informed”
(complete list of bills available in online appendix). These
bills contained 71 sections of legislative text that included
trauma-informed language (per bill mean: 1.4, mode: 1,
range 1–4). Of the 49 bills, 40 (81.6%) were introduced by
Democrats, nine (18.4%) were introduced by Republicans,
27 (55.1%) were introduced in the Senate, and 22 (44.9%)
were introduced in the House (Table 1). Thirty-nine dif-
ferent congresspersons introduced the 49 trauma-informed
bills.
Two trauma-informed bills, containing two trauma-
informed sections, became law. The Justice for Victims of
Trafficking Act of 2015 (Public Law No: 114–22), signed
into law on May 29, 2015, requires states and local gov-
ernments to have a plan to provide “trauma-informed,
gender-responsive rehabilitative care to victims of child
human trafficking” [Sec. 203(k)(4) (C)(ii)] to be eligible
for funding from DOJ’s Victim-centered child human traf-
ficking deterrence block grant program. The Every Student
Succeeds Act (Public Law No: 114–95), signed into law on
December 10, 2015, identifies training school personnel
in “trauma-informed practices in classroom management”
[Sec. 4107(5)(D)(ii)] and school-based mental health ser-
vices that are “based on trauma-informed practices that are
evidence-based” [Sec. 4107(5)(B)(ii)(II)(aa)] as two of the
many activities that agencies can perform with funds allo-
cated by the law.
Only three bills (S 2999, S 1169, and HR 2728) included
a definition of “trauma-informed.” This definition was
identical in each of these bills and read:
The term ‘trauma-informed’ means—(A) understand-
ing the impact that exposure to violence and trauma
have on a youth’s physical, psychological, and psy-
chosocial development; (B) recognizing when a youth
has been exposed to violence and trauma and is in
need of help to recover from the adverse impacts of
trauma; and (C) responding by helping in ways that
reflect awareness of the adverse impacts of trauma.
Trend inVolume ofTrauma-Informed Bills andBill
Sections
The volume of trauma-informed bills and sections intro-
duced in US Congress increased dramatically between
when the first bill was introduced and December 31, 2015
(Fig. 1). The number of trauma-informed bills introduced
annually ranged from 0 in 2010, 2011, and 2012 to 28 in
2015. The most trauma-informed sections were intro-
duced in 2015 when 28 bills contained 39 trauma-informed
sections.
Target Populations andSectors ofTrauma-Informed
Bill Sections
The majority of trauma-informed sections exclusively tar-
geted youth (52 sections, 73.2%) (Table 2). The specific
youth populations targeted included those in primary and
secondary schools (16 sections, 22.5%), juvenile justice
facilities (ten sections, 14.1%), and foster care settings
(seven sections, 9.9%) and those that were victims of sex
trafficking (six sections, 8.5%) or experiencing homeless-
ness (four sections, 5.6%). For example, the Youth Justice
Table 1 Characteristics of legislative proposals introduced in US
congress between December 22, 2009 and December 31, 2015 that
mentioned “trauma-informed” and/or “trauma informed.”
Bill characteristic n%
Congressional chamber introduced
House 22 44.9
Senate 27 55.1
Congressional committee first referred
Senate health, education, labor, and pensions 14 28.6
House energy and commerce 9 18.4
House education and the workforce 8 16.3
Senate judiciary 7 14.3
Senate finance 5 10.2
House judiciary 4 8.2
Senate banking, housing, and urban affairs 1 2.0
House ways and means 1 2.0
Political party of congressperson
Democrat 40 81.6
Independent 0 0
Republican 9 18.4

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Act of 2015 [HR 2728, Sec. 101(4)] was introduced with
the purpose “to support a trauma-informed continuum of
programs (including delinquency prevention, intervention,
mental health, behavioral health, and substance abuse treat-
ment, and aftercare) to address the needs of at-risk youth
and youth who come into contact with the justice system.”
College students (14 sections, 19.7%) were the most com-
mon population targeted in trauma-informed sections that
did not exclusively target youth. For example, the Campus
Accountability and Safety Act [HR 1310, Sec. 2(5)] pro-
posed to amend the Higher Education Act of 1965 (Pub-
lic Law No: 101–542, i.e., ‘the Cleary Act’) to develop and
administer an online survey for students about their expe-
riences with sexual violence that uses “trauma-informed
language to prevent retraumatization.” None of the trauma-
informed sections targeted active duty military personnel or
veterans.
Trauma-informed sections targeted a range of sectors.
Sixteen Section(22.5%) targeted agencies in the child wel-
fare and/or primary/secondary education sector, 14 (19.7%)
targeted institutions of higher education and/or crimi-
nal justice (e.g., juvenile justice facilities, courts), and 10
(14.1%) targeted clinical health care settings. For example,
the SOAR to Health and Wellness Act of 2015 [S 1446,
Sec. 3(b)(4)(H)] proposed to establish a pilot program to
train health care providers to identify potential victims of
human trafficking and “provide such victims care that is…
trauma-informed.” All of the trauma-informed sections
that targeted the criminal justice sector exclusively targeted
youth.
Policy Instruments Used toPromote Trauma-Informed
Practice
Twenty-eight (39.4%) trauma-informed sections contained
at-least one symbolic policy instrument (Table 3). Sym-
bolic instruments were often used to make proclamations
about the potential of trauma-informed practice, such as
the Improving the Juvenile Justice System for Girls Act
of 2013 [HR 1833, Sec. 1(b)(6)], which stated that “Cur-
rent research and data have shown that gender-responsive,
strength-based programming providing trauma-informed
care and trauma-specific services is the most effective
means of preventing juvenile offenses.”
Fifty (70.4%) trauma-informed sections contained at
least one material instrument, with 40 (56.3%) contain-
ing at least one substantive instrument and 32 (45.0%)
containing at least one procedural instrument. Many
substantive instruments targeted the SAMHSA National
Child Traumatic Stress Initiative (NCTSI), such as the
Gun Violence Prevention and Reduction Act of 2013 [HR
2910, Sec. 223(4)] which directed NCTSI to dissemi-
nate “evidence-based and trauma-informed interventions,
treatments, products, and other resources to appropriate
stakeholders.” Procedural instruments required executive
branch agencies perform activities such as prepare reports
for Congress about the provision of trauma-informed ser-
vices and consider grant applicants’ trauma-informed
service capacity when making funding decisions. For
example, The Family Unification, Preservation, and
100
10 10
28
100 0
12
19
39
0
5
10
15
20
25
30
35
40
2009 2010 2011 2012 2013 2014 2015
Number of trauma-informed bills/secons
Year
Number of bills menoning "trauma-informed"
Number of bill secons menoning "trauma-…
Fig. 1 Trend in legislative proposals introduced in US Congress
between December 22, 2009 and December 31, 2015 that mentioned
“trauma-informed” and/or “trauma informed”
Table 2 Target sectors
of legislative proposals
introduced in US Congress
between December 22, 2009
and December 31, 2015 that
mentioned “trauma-informed”
and/or “trauma informed.”
Chi square and Fisher’s exact tests used to compare differences in the proportion of trauma-informed sec-
tions with the characteristic according to whether or not the section exclusively targeted youth populations.
df = 1
Target sector All sections
N=71
Did not exclu-
sively target youth
n=19
Exclusively targeted youth
n=52
n%n%n% pa
Child welfare 16 22.5 3 15.8 13 25.0 0.410
Primary/secondary education 16 22.5 0 0 16 30.8 0.003
Higher education 14 19.7 14 73.7 0 0 ≥0.0001
Criminal justice 14 19.7 0 0 14 26.9 0.007
Health care 10 14.1 1 5.3 9 17.3 0.151
Public health 1 1.40 1 5.3 0 0 0.267

Adm Policy Ment Health
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Modernization Act of 2015 [S 2289, Sec. 201], required
that consideration be given to “whether an eligible
applicant utilizes evidence-based practices and trauma-
informed care models to serve families” when evaluating
grant applicants.
Treasury governing resources were most frequently
used to promote trauma-informed practice (42 sections,
59.2%). Treasury resources were primarily used in pro-
posals that would have provided grants to deliver trauma-
informed services, such as the Strengthening Mental
Health in Our Communities Act of 2014 [HR 4574, Sec.
601(b)(2)] which proposed to “provide financial support
to enable local communities to implement a comprehen-
sive culturally and linguistically appropriate, trauma-
informed, and age-appropriate, school mental health
program.” Authority resources were used in 25 (35.2%)
sections and mandated trauma-informed practices. For
example, the Campus Accountability and Safety Act [S
2692, Sec. 4(a)] required that any institution of higher
education that receives federal funds designate a con-
fidential advisor for victims of crime and that they “be
trained to perform a victim-centered, trauma-informed
(forensic) interview, which shall focus on the experience
of the victim.” Information/knowledge resources were
used in 14 (19.7%) of sections and provided trainings on
trauma-informed practice, such as the Children’s Recov-
ery from Trauma Act (HR 2632, Sec. 2) that proposed to
provide funding for NCTSI to “oversee the continuum of
interprofessional training initiatives in evidence-based
and trauma-informed treatments, interventions, and prac-
tices offered to NCTSI grantees.”
Discussion
The volume of federal legislative proposals making explicit
reference to trauma-informed practice increased dramati-
cally between when the first bill was introduced on Decem-
ber 22, 2009 and December 31, 2015. This increase, cou-
pled with the fact that these proposals were introduced by
many different congresspersons on both sides of the aisle,
is an indicator of heightened interest in trauma-informed
practice within US Congress (Tremper etal. 2010; Wage-
naar etal. 2006). This finding is consistent with evidence
that traumatic stress is increasingly recognized as a prob-
lem in mainstream public and political discourses (Hou-
ston et al. 2016; Purtle et al. 2016; Wu 2016). Increases
in legislative attention to trauma-informed practice signal
a need for a trauma-informed workforce and integration of
knowledge about trauma into the core curricula of clinical
(e.g., psychology, psychiatry, primary care social work)
and non-clinical (e.g., public health, education, criminal
justice) training programs (DePrince and Newman 2011;
Ko etal. 2008). Increased enthusiasm for trauma-informed
legislation also reinforces the importance of strategies to
ensure that trauma-informed initiatives are implemented
with fidelity when they are adopted across different sectors
(Becker-Blease 2017).
Trends in legislative proposals to promote trauma-
informed practice should be considered within the politi-
cal context in which they occurred; and implications of
our study should be considered within context of the cur-
rent political environment. Increases in legislative attention
towards trauma-informed practiced occurred during the
Table 3 Policy instruments
used in sections of legislative
proposals introduced in US
Congress between December
22, 2009 and December 31,
2015 that mentioned “trauma-
informed” and/or “trauma
informed.”
Chi square and Fisher’s exact tests used to compare differences in the proportion of trauma-informed sec-
tions with the characteristic according to whether or not the section exclusively targeted youth populations.
df = 1
Section characteristic All sections
N = 71
Did not exclu-
sively target youth
n = 19
Exclusively tar-
geted youth n = 52
pa
n%n%n%
Instrument used
Symbolic only 21 29.6 3 15.8 18 34.6 0.151
Material only 43 60.6 10 52.6 33 63.5 0.152
Both symbolic and material 7 9.9 6 31.6 1 1.9 ≥0.0001
Material substantive only 28 39.4 15 78.9 13 25.0 ≥0.0001
Material procedural only 10 14.1 1 5.3 9 17.3 0.151
Both material substantive and
material procedural
12 16.9 0 0 12 23.1 0.028
Governing resource used
Treasury 42 59.2 9 47.4 33 63.5 0.103
Authority 25 35.2 6 31.6 19 36.5 0.207
Information/knowledge 14 19.7 5 26.3 9 17.3 0.177
Organizational/structure 0 0 0 0.0 0 0.0 –

Adm Policy Ment Health
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presidency of Barack Obama, a Democrat whose admin-
istration overtly supported trauma-informed practice (Jar-
rett and Lhamon 2016). In contrast, the agenda of Presi-
dent Donald Trump—a Republican whose administration
plans to drastically reduce the size of the federal workforce
(Trump 2017) —raises questions about the extent to which
trauma-informed bills could be effectively implemented if
they become law during his presidency.
Despite changes in federal leadership, there are at least
three reasons why attention to trauma-informed prac-
tice might be sustained in US Congress during the Trump
presidency. First, it should be noted that the most trauma-
informed bills were introduced in 2015 when Republicans
had majority control of both the House of Representa-
tives and the Senate—as they will until at least January 3,
2019. Furthermore, both of the trauma-informed bills that
became law were introduced in 2015. Second, it should be
reiterated that nine (18.4%) of the trauma-informed bills
were introduced by Republicans, suggesting some bi-par-
tisan support for trauma-informed practice. Also, a search
of Congress.gov reveals that eight trauma-informed bills
were already introduced in US Congress as of February 22,
2017—one (12.5%) by a Republican congressperson.
Third, although Democrats and Republicans are deeply
divided on several health policy issues (Gollust, 2016; Kin-
dig 2015; Purtle etal. 2017), bi-partisan support exists for
mental health and substance abuse issues—which are the
focus of many trauma-informed initiatives (Gatz etal. 2007;
Greenwald etal. 2012; Morrissey etal. 2005). For example,
a survey of US state legislators found that a similar pro-
portion of Democrats and Republicans identified behavio-
ral health a top policy priority (46.4 vs. 52.8%, p = 0.795)
(Purtle etal. 2016). A 2016 survey of US adults found that
a similar proportion of Democrats and Republicans felt that
government spending on opioid addiction treatment was
too low (45 vs. 37%, p > 0.05) (Blendon etal. 2016). Advo-
cacy efforts to promote trauma-informed legislation might
be successful if they frame trauma-informed initiatives as
a strategy to address issues for which bi-partisan support
exists.
Although the volume of trauma-informed bills intro-
duced in US Congress increased dramatically, only two of
these bills (4.1%) became law—slightly less than the pro-
portion of bills (9.3%) that became law in a mapping study
of federal legislative proposals to address PTSD (Purtle
2014). By identifying these two trauma-informed bills,
however, our study raises empirical questions about their
implementation, enforcement, and potential impacts. One
of the trauma-informed sections, Sec. 103 of The Justice
for Victims of Trafficking Act of 2015 (Public Law No:
114 − 22), requires that grant recipients have a plan to pro-
vide “trauma-informed, gender-responsive rehabilitative
care to victims of child human trafficking” to be eligible
for funding from DOJ’s Victim-centered child human traf-
ficking deterrence block grant program. policy monitoring
activities should evaluate whether the criteria used by DOJ
to assess this are aligned with evidence-supported recom-
mendations for trauma-informed practice with victims of
human trafficking (Ahn etal. 2013; Clawson etal. 2007;
Macy and Johns 2010) and whether these plans are actually
implemented by grant recipients.
The other trauma-informed section that became law,
Sec. 4108 of The Every Student Succeeds Act (Public Law
No: 114–95), lists training school personnel in “trauma-
informed practices in classroom management” and men-
tal health services that are “based on trauma-informed
practices” as two of the many options that local education
agencies can choose from to comply with requirements for
the receipt of funds. Future studies could evaluate the pro-
portion of funded agencies that selected these options, the
trauma-informed training curricula school personnel have
completed to satisfy these requirements, and the extent to
which these practices have been implemented and are con-
sistent with evidence about trauma-informed practice in
school settings (Ngo etal. 2008; Perry and Daniels 2016;
Walkley and Cox 2013; Wiest-Stevenson and Lee 2016).
The sectors and populations that were the targets of
trauma-informed sections should be considered within the
context of research about the epidemiology of traumatic
stress and evidence on trauma-informed interventions.
The finding that trauma-informed sections targeted a wide
range of sectors is consistent with evidence on the effects
of trauma across multiple domains of life and that trauma-
informed interventions offer promise in these areas (Baker
etal. 2016; Bowen and Murshid 2016; Marsac etal. 2016).
However, the finding that youth were the exclusive target
population of the majority (73.2%) of trauma-informed sec-
tions does not reflect research on the incidence of trauma
exposure over the life course and potential of trauma-
informed interventions for adult military populations (Din-
nen etal. 2014; Kelly etal. 2014; Norman etal. 2014) and
civilian populations (Endres etal. 2015; Machtinger etal.
2015; Sun etal. 2016).
The finding that explicit mentions of “trauma-informed”
were largely absent from legislative proposals targeting
adults should not be interpreted as a lack of legislative
attention to the needs of adult trauma survivors, as many
bills have targeted these populations—such as the Violence
Against Women Reauthorization Act of 2013 (Public Law
No: 113–4) and the Veterans Access, Choice, and Account-
ability Act of 2014 (Public Law No: 113–146). Rather, this
finding suggests that trauma-informed practice has largely
been defined as a youth-specific construct in US Congress.
Political science research indicates that this often hap-
pens as issues become defined in policy discourse within
the context of a specific population (Schneider and Ingram

Adm Policy Ment Health
1 3
1993, 2005). For example, an ethnographic content analy-
sis of the language used in federal legislative proposals to
address PTSD found that the disorder had been defined as
a military-specific problem (Purtle 2016). Advocates might
consider engaging in activities to increase congresspersons’
awareness about the potential of trauma-informed interven-
tions for adult populations.
We found that only three (6.1%) of the trauma-informed
bills provided a definition of the construct. Given that
trauma-informed practice is a relatively new construct
and open to a range of interpretations (Baker etal. 2016),
advocates might try to ensure that a definition of trauma-
informed is included in legislative proposals to increase the
likelihood that “trauma-informed” mandates are operation-
alized as intended when implemented by executive branch
agencies (Becker-Blease 2017). It should also be noted
that over one-quarter (29.6%) of trauma-informed sections
were symbolic and did not include provisions that would
have instrumental impacts on trauma survivors. This is
more than twice the proportion of bill sections that were
symbolic in the mapping study of federal legislative pro-
posals to address PTSD (13.7%) (Purtle 2014). This find-
ing could reflect the fact that trauma-informed practice is
a newer construct than PTSD and that these symbolic sec-
tions served to educate congresspersons about the notion of
trauma-informed practice.
Limitations
It should be re-emphasized that our study was limited
to federal legislative proposals that explicitly mentioned
trauma-informed practice. Future studies that map explic-
itly trauma-informed policy proposals across the execu-
tive and judiciary branches of federal government and at
state and local-levels would enhance understanding of the
trauma-informed policy landscape. There would also be
benefits to research that mapped policy proposals that were
implicitly trauma-informed—such as those that promoted
safety, transparency, and empowerment (Bowen and Mur-
shid 2016). We did not categorize trauma-informed bills
or sections according to the extent that they were likely to
produce positive impacts for trauma survivors. As noted
above, we were unable to assess the extent to which trauma-
informed sections were evidence-supported because the
legislative language was typically too broad to make such
assessments.
Conclusion
Trauma-informed practice has received an increasing
amount of attention in US Congress. Trauma-informed bills
have been introduced by a diversity of congresspersons,
refereed to an assortment of congressional committees, and
targeted a range of sectors. These findings indicate political
will and signal an opportunity to institutionalize trauma-
informed practice through federal legislation. The policy
instruments and legislative language identified in this map-
ping study offer guidance for mental health researchers
and practitioners who seek to advance trauma-informed
policies.
Funding National Institute of Mental Health 5R25MH080916-07;
National Institute of Mental Health 1R21MH111806-01.
Compliance with Ethical Standards
Conflict of interest Jonathan Purtle declares that he has no conflict
of interest. Michael Lewis declares that he has no conflict of interest.
Ethical Approval This article does not contain any studies with
human participants or animals performed by any of the authors.
References
Abram, K. M., Teplin, L. A., Charles, D. R., Longworth, S. L.,
McClelland, G. M., & Dulcan, M. K. (2004). Posttraumatic
stress disorder and trauma in youth in juvenile detention.
Archives of general psychiatry, 61(4), 403–410.
Ahn, R., Alpert, E. J., Purcell, G., Konstantopoulos, W. M., McGa-
han, A., Cafferty, E., & Burke, T. F. (2013). Human trafficking:
review of educational resources for health professionals. Ameri-
can Journal of Preventive Medicine, 44(3), 283–289.
Ardino, V. (2014). Trauma-informed care: is cultural competence a
viable solution for efficient policy strategies. Clin Neuropsychia-
try, 11(1), 45–51.
Azeem, M. W., Aujla, A., Rammerth, M., Binsfeld, G., & Jones, R.
B. (2011). Effectiveness of six core strategies based on trauma
informed care in reducing seclusions and restraints at a child and
adolescent psychiatric hospital. Journal of Child and Adolescent
Psychiatric Nursing, 24(1), 11–15.
Baker, C. N., Brown, S. M., Wilcox, P. D., Overstreet, S., & Arora,
P. (2016). Development and psychometric evaluation of the atti-
tudes related to trauma-informed care (ARTIC) scale. School
Mental Health, 8(1), 61–76.
Becker-Blease, K. A. (2017). As the world becomes trauma–informed,
work to do. Journal of Trauma & Dissociation, 18(2), 131–138.
Beidas, R. S., Adams, D. R., Kratz, H. E., Jackson, K., Berkowitz, S.,
Zinny, A., Evans, A. (2016). Lessons learned while building a
trauma-informed public behavioral health system in the City of
Philadelphia. Evaluation and Program Planning, 59, 21–32.
Blendon, R.C., McMurty, C., Benson, J. & Sayde, J. (2016).
The Opioid Abuse crisis is a rare area of bipartisan con-
sensus. Health Affairs Blog. Retrieved February 24,
2017, from http://healthaffairs.org/blog/2016/09/12/
the-opioid-abuse-crisis-is-a-rare-area-of-bipartisan-consensus/.
Bloom, S. L. (2013). Creating sanctuary: Toward the evolution of
sane societies: Routledge, Abingdon
Bloom, S. L. (2016). Advancing a national cradle-to-grave-to-cradle
public health agenda. Journal of Trauma & Dissociation, 17(4),
383–396.
Boel-Studt, S. M. (2015). A Quasi-experimental study of trauma-
informed psychiatric residential treatment for children and ado-
lescents. Research on Social Work Practice, 1049731515614401.

Adm Policy Ment Health
1 3
Bowen, E. A., & Murshid, N. S. (2016). Trauma-informed social pol-
icy: A conceptual framework for policy analysis and advocacy.
American journal of public health, 106(2), 223–229.
Branson, C., Baetz, C., Horwitz, S., & Hoagwood, K. (2017).
Trauma-informed juvenile justice systems: A systematic review
of definitions and core components. Psychological Trauma: The-
ory, Research, Practice and Policy. doi:10.1037/tra0000255
Burris, S. (2015). Public health law monitoring and evaluation in a
big data future. ISJLP, 11, 115.
Burris, S., Hitchcock, L., Ibrahim, J., Penn, M., & Ramanathan,
T. (2016). Policy surveillance: A vital public health practice
comes of age. Journal of Health Politics, Policy and Law, 41(6),
1151–1173.
Burris, S., Wagenaar, A. C., Swanson, J., Ibrahim, J. K., Wood, J.,
& Mello, M. M. (2010). Making the case for laws that improve
health: A framework for public health law research. Milbank
Quarterly, 88(2), 169–210.
Children’s Mental Health: Traumatic Stress/Child Welfare, 3(1),
27–30.
Chilton, M., Knowles, M., Rabinowich, J., & Arnold, K. T. (2015).
The relationship between childhood adversity and food
insecurity:‘It’s like a bird nesting in your head’. Public Health
Nutrition, 18(14), 2643–2653.
Clawson, H. J., Salomon, A., & Grace, L. G. (2007). Treating the hid-
den wounds: Trauma treatment and mental health recovery for
victims of human trafficking: Department of Health and Human
Services, Office of the Assistant Secretary for Planning and
Evaluation Washington, DC.
DePrince, A., & Newman, E. (2011). Special issue editorial: The art
and science of trauma-focused training and education. Psycho-
logical Trauma: Theory, Research, Practice, and Policy, 3(3),
213–214.
Dinnen, S., Kane, V., & Cook, J. M. (2014). Trauma-informed care: A
paradigm shift needed for services with homeless veterans. Pro-
fessional case management, 19(4), 161–170.
Endres, M. J., Keller, S., Wong, S. Y., & Krahn, K. (2015). Insights in
public health: toward a trauma-informed system of care in Hawai
‘i’s adult mental health division. Hawai’i Journal of Medicine &
Public Health, 74(6), 213.
Fairbank, J. A., & Gerrity, E. T. (2007). Making trauma intervention
principles public policy. Psychiatry, 70(4), 316–319.
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz,
A. M., Edwards, V., & Marks, J. S. (1998). Relationship of child-
hood abuse and household dysfunction to many of the leading
causes of death in adults: The adverse childhood experiences
(ACE) Study. American Journal of Preventive Medicine, 14(4),
245–258.
Gatz, M., Brown, V., Hennigan, K., Rechberger, E., O’Keefe, M.,
Rose, T., & Bjelajac, P. (2007). Effectiveness of an integrated,
trauma-informed approach to treating women with co-occurring
disorders and histories of trauma: The Los Angeles site experi-
ence. Journal of Community Psychology, 35(7), 863–878.
Gerrity, E. T. (2007). Child trauma: The role of public policy. Focal
Point: Research, Policy, and Practice in Children’s Mental
Health: Traumatic Stress/Child Welfare, 21(1), 27–30.
Gollust SE. Improving population health in a politicized World:
Understanding and overcoming communication barriers 2016.
Retrieved February 24, 2017, from https://www.isr.umich.edu/
cps/events/Gollust_20160610.pdf.rs.
Goodman, R. A. (2007). Law in public health practice: Oxford Uni-
versity Press, Oxford
Greenwald, R., Siradas, L., Schmitt, T. A., Reslan, S., Fierle, J., &
Sande, B. (2012). Implementing trauma-informed treatment for
youth in a residential facility: First-year outcomes. Residential
Treatment for Children & Youth, 29(2), 141–153.
Harris, M. E., & Fallot, R. D. (2001). Using trauma theory to design
service systems: Jossey-Bass, San Francisco
Hodgdon, H. B., Kinniburgh, K., Gabowitz, D., Blaustein, M. E.,
& Spinazzola, J. (2013). Development and implementation of
trauma-informed programming in youth residential treatment
centers using the ARC framework. Journal of Family Violence,
28(7), 679–692.
Hopper, E. K., Bassuk, E. L., & Olivet, J. (2010). Shelter from the
storm: Trauma-informed care in homelessness services settings.
The Open Health Services and Policy Journal, 3(2), 80–100.
Houston, J. B., Spialek, M. L., & Perreault, M. F. (2016). Coverage
of posttraumatic stress disorder in the New York Times, 1950–
2012. Journal of health communication, 21(2), 240–248.
Howlett, M. (2010). Designing public policies: Principles and instru-
ments: Routledge, Abingdon
Howlett, M., Ramesh, M., & Perl, A. (1995). Studying public policy:
Policy cycles and policy subsystems. 3: Cambridge University
Press, Cambridge
International Society for Traumatic Stress Studies. (2010). Strategic
Plan. Retrieved February 24, 2017, from https://www.istss.org/
ISTSS_Main/media/Documents/ISTSSStrategicPlanPrioritiesFI-
NAL1.pdf.
Jarrett, V. L., Lhamon, C. (2016). Trauma-informed school discipline
and preventing sexual assault. The White House. https://oba-
mawhitehouse.archives.gov/blog/2016/09/19/trauma-informed-
school-discipline-and-k-12-checklist-and-toolkit.
Kagi, R., & Regala, D. (2012). Translating the Adverse Childhood
Experiences (ACE) study into public policy: Progress and possi-
bility in Washington State. Journal of Prevention & Intervention
in the Community, 40(4), 271–277.
Kelly, U., Boyd, M. A., Valente, S. M., & Czekanski, E. (2014).
Trauma-informed care: Keeping mental health settings safe for
veterans. Issues in Mental Health Nursing, 35(6), 413–419.
Kim, M. M., Ford, J. D., Howard, D. L., & Bradford, D. W. (2010).
Assessing trauma, substance abuse, and mental health in a sam-
ple of homeless men. Health & Social Work, 35(1), 39–48.
Kindig, D. A. (2015). Can there be political common ground for
improving population health? Milbank Quarterly, 93(1), 24–27.
Ko, S. J., Ford, J. D., Kassam-Adams, N., Berkowitz, S. J., Wilson, C.,
Wong, M., ... Layne, & C, M. (2008). Creating trauma-informed
systems: Child welfare, education, first responders, health care,
juvenile justice. Professional Psychology: Research and Prac-
tice, 39(4), 396.
Machtinger, E. L., Cuca, Y. P., Khanna, N., Rose, C. D., & Kimberg,
L. S. (2015). From treatment to healing: The promise of trauma-
informed primary care. Women’s Health Issues, 25(3), 193–197.
Macy, R. J., & Johns, N. (2010). Aftercare services for international
sex trafficking survivors: Informing US service and program
development in an emerging practice area. Trauma, Violence, &
Abuse, 1524838010390709.
Marsac, M. L., Kassam-Adams, N., Hildenbrand, A. K., Nicholls, E.,
Winston, F. K., Leff, S. S., & Fein, J. (2016). Implementing a
trauma-informed approach in pediatric health care networks.
JAMA Pediatrics, 170(1), 70–77.
Messina, N., & Grella, C. (2006). Childhood trauma and women’s
health outcomes in a California prison population. American
Journal of Public Health, 96(10), 1842–1848.
Morrissey, J. P., Jackson, E. W., Ellis, A. R., Amaro, H., Brown, V. B.,
& Najavits, L. M. (2005). Twelve-month outcomes of trauma-
informed interventions for women with co-occurring disorders.
Psychiatric Services, 55(10), 1213–1222
Ngo, V., Langley, A., Kataoka, S. H., Nadeem, E., Escudero, P., &
Stein, B. D. (2008). Providing evidence based practice to ethni-
cally diverse youth: Examples from the Cognitive Behavioral
Intervention for Trauma in Schools (CBITS) program. Journal

Adm Policy Ment Health
1 3
of the American Academy of Child and Adolescent Psychiatry,
47(8), 858.
Norman, S. B., Wilkins, K. C., Myers, U. S., & Allard, C. B. (2014).
Trauma informed guilt reduction therapy with combat veterans.
Cognitive and Behavioral Practice, 21(1), 78–88.
Peck, M. C., & Scheffler, R. M. (2002). An analysis of the definitions
of mental illness used in state parity laws. Psychiatric Services,
53(9), 1089–1095.
Perry, D. L., & Daniels, M. L. (2016). Implementing trauma—
informed practices in the school setting: A pilot study. School
Mental Health, 8(1), 177–188.
Purtle, J. (2014). The legislative response to PTSD in the United
States (1989–2009): A content analysis. Journal of Traumatic
Stress, 27(5), 501–508.
Purtle, J. (2016). “Heroes’ invisible wounds of war:” constructions of
posttraumatic stress disorder in the text of US federal legislation.
Social Science & Medicine, 149, 9–16.
Purtle, J., Dodson, E. A., & Brownson, R. C. (2016). Uses of research
evidence by State legislators who prioritize behavioral health
issues. Psychiatric Services, 67(12), 1355–1361.
Purtle, J., Goldstein, N. D., Edson, E., & Hand, A. (2017). Who votes
for public health? US senator characteristics associated with vot-
ing in concordance with public health policy recommendations
(1998–2013). SSM-Population Health, 3, 136–140.
Purtle, J., Lynn, K., & Malik, M. (2016). “Calculating the toll of
trauma” in the headlines: Portrayals of posttraumatic stress dis-
order in the New York Times (1980–2015). American Journal of
Orthopsychiatry. 2016;86(6):632–638.
Rivard, J. C., Bloom, S. L., McCorkle, D., & Abramovitz, R. (2005).
Preliminary results of a study examining the implementation and
effects of a trauma recovery framework for youths in residential
treatment. Therapeutic Community: The International Journal
for Therapeutic and Supportive Organizations, 26(1), 83–96.
Rowan, P. J., Duckett, S. A., & Wang, J. E. (2015). State mandates
regarding postpartum depression. Psychiatric Services, 66(3),
324–328.
Schneider, & Ingram (1993). Social construction of target popula-
tions: Implications for politics and policy. American Political
Science Review, 87(02), 334–347.
Schneider, &amp, & Ingram. (2005). Deserving and entitled: Social
constructions and public policy: SUNY Press, Albany
Shern, D. L., Blanch, A. K., & Steverman, S. M. (2016). Toxic stress,
behavioral health, and the next major era in public health. Ameri-
can Journal of Orthopsychiatry, 86(2), 109.
Shonkoff, J. P., & Fisher, P. A. (2013). Rethinking evidence-based
practice and two-generation programs to create the future of
early childhood policy. Development and Psychopathology,
25(4pt2), 1635–1653.
Shonkoff, J. P., Garner, A. S., Siegel, B. S., Dobbins, M. I., Earls, M.
F., McGuinn, L., Wood, & D, L. (2012). The lifelong effects of
early childhood adversity and toxic stress. Pediatrics, 129(1),
e232–e246.
Sorenson, S. B. (2002). Preventing traumatic stress: Public health
approaches. Journal of Taumatic Stress, 15(1), 3–7.
Stein, B. D., Jaycox, L. H., Kataoka, S. H., Wong, M., Tu, W., Elli-
ott, M. N., & Fink, A. (2003). A mental health intervention for
schoolchildren exposed to violence: A randomized controlled
trial. JAMA, 290(5), 603–611.
Substance Abuse and Mental Health Services Adminstration.
(2016). SAMHSA’s Efforts to Address Trauma and Violence.
Retrieved February 24, 2017, from http://www.samhsa.gov/
trauma-violence/samhsas-efforts.
Sun, J., Knowles, M., Patel, F., Frank, D. A., Heeren, T. C., & Chil-
ton, M. (2016). Childhood adversity and adult reports of food
insecurity among households with children. American Journal of
Preventive Medicine, 50(5), 561–572.
Sun, J., Patel, F., Kirzner, R., Newton-Famous, N., Owens, C., Welles,
S. L., & Chilton, M. (2016). The Building wealth and health net-
work: Methods and baseline characteristics from a randomized
controlled trial for families with young children participating in
temporary assistance for needy families (TANF). BMC Public
Health, 16(1), 1.
The Policy Surveillance Program, Temple University. (2016). The
Policy Surveillance Program. Topics. Retrieved February 24,
2017, from http://lawatlas.org/topics.
Thoits, P. A. (2010). Stress and health major findings and policy
implications. Journal of Health and Social Behavior, 51(1
suppl), S41–S53.
Tremper, C., Thomas, S., & Wagenaar, A. C. (2010). Measuring law
for evaluation research. Evaluation Review, 34(3), 242–266.
Trump, D. (2017). Presidential memorandum regard-
ing the hiring freeze. The White House. January 23,
2017. Retrieved February 24, 2017, from https://
www.whitehouse.gov/the-press-office/2017/01/23/
presidential-memorandum-regarding-hiring-freeze.
Wagenaar, A. C., Erickson, D. J., Harwood, E. M., & O’Malley, P. M.
(2006). Effects of state coalitions to reduce underage drinking:
A national evaluation. American Journal of Preventive Medicine,
31(4), 307–315.
Walkley, M., & Cox, T. L. (2013). Building trauma-informed schools
and communities. Children & Schools, cdt007.
Wiest-Stevenson, C., & Lee, C. (2016). Trauma-informed schools.
Journal of Evidence-Informed Social Work, 1–6.
Wu, L. (2016). US media representation of post-traumatic stress dis-
order: a comparative study of regional newspapers and national
newspapers. Journal of Mental Health, 6, 1–7.