Gov. Hogan Proclamation Supporting Mental Health

youth violence
Youth violence is preventable

For Mental Health awareness week, Gov. Hogan issued a proclamation recognizing the association of trauma with mental and behavioral health issues.  He stated that all mental health services should identify any trauma which requires treatment to support the treatment of any mental health issues.

I recommend that the ACE’s Questionnaire in any of its variants be filled out on all clients so that if Trauma-informed care is needed, it can be provided.

The various types of trauma include:

  •  child abuse and neglect
  • exposure to violence
  • bullying
  • treating someone with disrespect or harshness
  • a child’s parents or caregivers being arrested or incarcerated for illegal activity
  • Being belittled or treated with emotional harshness
  • Substance abuse by parents or caregivers resulting in neglect of youth in their care

The results of childhood maltreatment are:

  • functioning at a developmental level less than would be expected given one’s age
  • neurological disruption of ability to self soothe when upset and exercise emotional dyscontrol when upset
  • cognitive disruption resulting in learning problems
  • Difficulty getting along with others
  • Aggression toward others
  • lack of rule-following
  • Getting in trouble with the law or school authorities
  • Association with peers that get into trouble with school or law enforcement authorities.

Ways to Reduce the Risk of aggression toward others, breaking school rules, and law-breaking includes a combination of:

  • trauma-informed care
  • Neuro and biofeedback
  • family therapy
  • Skill building
  • CBT
  • Increase in structure and rule enforcement
  • Behavior modification and use of behavior contracts
  • Accountability contracts
  • Relationship building with a trusted adult
  • Positive attention from trusted adults
  • engagement in healthy activities

Thanks for reading.

Dr. Kathy

2020 had significant increase over 2019 in murders

Youth violence is preventable

The New Your Times reported, “The United States experienced its biggest one-year increase on record in murders in 2020, according to new figures released Monday by the F.B.I., with some cities hitting record highs.”

I am sure that the pandemic had some effect on the US violence rate in 2020.  However, prevention and treatment of those at higher risk for violence is a solution-focused view of this problem.

Trauma-informed treatment can be very effective in reducing the potential risk of violence. Another solution-focused intervention based on research would be to ensure that child maltreatment is eliminated and that traumatized children get effective treatment which often includes family treatment.  It is important that children are properly cared for in homes where violence is a recurring event.  Additionally, many children in foster care have been maltreated. This is a population that needs effective trauma-informed care.



Copy of a Letter of Inquiry on Disallowed Mental Health Diagnoses

I have a copy of a list of non-allowed MH diagnoses in Maryland that I find disturbing.  I do not know if Optum or BHA make these decisions. I want to raise the issue of re-evaluation of these non-allowed diagnoses such as post-partum depression (F53) and eating disorders (F50.01 & F50.02) and Bulemia (F50.2).  I think at least one of these (Post-partum depression, F50..0) raises a women’s rights issue and a clinical issue and I think it needs to be re-evaluated. I certainly think that Autism and Aspergers as a disallowed diagnosis need re-evaluation. This method of coding reduces the number of services that can be provided for these diagnoses in rural areas, where specialty services are less likely to be found.
 These restrictions come from conventions that result from a view of mental health which does not take into account trauma or the reality that very few people have only one diagnosis.  Many people have multiple diagnoses and all
problem areas need to be treated and resiliency strengthened.
Let me begin by saying that it is very clear from the research on CCBHC’s that multidisciplinary integrated care works best for clients.  These are diagnoses that can be approached from multiple angles for better care.  Research has also made it very clear that childhood trauma is at the root of some of these diagnoses such as eating disorders.  Without treating the root, it is very difficult to help people heal.
My question is that if behavioral health agencies cannot bill to treat post-partum depression, who treats the mental health part of postpartum depression.    Postpartum depression has at least 1 mental health symptom, depression. If Behavioral Health does not treat postpartum depression, who treats it? The physician? The physician is not trained to treat a mental health disorder.
The other one that stands out to me is eating disorders.  Eating disorders are often related to trauma and have multiple mental health symptoms.  If behavioral health does not treat eating disorders, who does treat this? The physician?  They are not trained to treat mental health disorders.  This is also a diagnosis where coordination between the physician and the mental health therapist is essential.  There is not systemic means for mental health professionals to coordinate with physicians here in Maryland.
What this comes back to is coordinated care for better outcomes instead of the silos of the past.
I have one other issue to raise.  Registered Psychology Associates are allowed to refer clients to PRP. I have verified this through Optum’s staff.  However, that credential is not on the drop-down menus allowing for those credentialed in this way to refer clients to PRP. We have reported this to Optium, as well. I supervise a registered Psychology Associate and I review and used to sign for all referrals she makes to PRP, but when she put me as a co-signer on the referral, she was told that I cannot refer to myself.  That makes no sense and has been partially corrected.  It is still not in the drop-down menu.

Approaching Violence Prevention Through a Public Health Lens

See how the CDC is pushing for a health approach to violence prevention.  I received this email from cure violence global at
“We continue to witness the shifting of the paradigm related to treating violence as a health issue. Most recently, we see this in the Centers for Disease Control’s (CDC’s) prioritization of funding for studies on gun violence prevention through a public health lens:  “I’m not here about gun control. I’m here about preventing gun violence and gun death.” said CDC Director, Dr. Rochelle Walensky. CVG applauds Dr. Walensky and the CDC for their continued recognition of violence as a public health issue and for Congress’s renewal of funding for research on gun violence prevention after a 20-year lapse.”
Dr. Kathy
On a Mission To Prevent Violence
Prevent Violence Through Healthy Communitiesd be well

Mindfulness apps help teens with depression and anxiety

Youth are very attuned to phone apps.  I found the following on Linked In.
Brain & Behavior Research Foundation (BBRF)20,380 followers2 hours ago

A free #smartphone app providing brief #mindfulness training sessions helped young teens ruminate less. Repetitive and negative self-focused thinking, often concerning stressful or negative past events, is often seen in #anxiety and #depression
I (Dr. Kathy) have found that the CALM app works well for some of my clients.
Thanks for reading,
Dr. Kathy

Public Comment on Civil Committment in Maryland

Comments on Civil Commitment Changes being considered in Maryland.

By Dr. Kathryn Seifert, CEO of ESPS, Salisbury, MD

Civil commitment due to dangerousness has three concepts that must be fully defined and understood before making decisions about what should be included in any related regulatory or legislative changes.  These concepts are dangerousness, civil commitment, the rights of the potential perpetrators vs. the rights of the public to be protected from harm, and the connection between mental illness substance abuse, and dangerousness.

The changes being considered are increases in the clarity of the definition of dangerousness and widespread education of healthcare providers on the issues surrounding dangerousness, mental illness, substance abuse and civil commitment.  Much can be learned by reviewing the research literature on these topics.


A discussion on these issues should include an understanding and communication of the risk factors for dangerousness.  The new definition of dangerousness also needs to inform healthcare providers of the importance of accuracy in determining who might be at risk for dangerousness and thus subject to the restrictions of their liberty engendered by being placed under a civil commitment order.  To discuss risk factors for dangerousness, it is important to review the extensive research available on this topic.   There are four categories of dangerousness toward others discussed here. These are perpetration of harm to others in a mass violence event, domestic violence within intimate relationships, workplace violence, and harm perpetrated as apart of criminal activity.  The research on the risk factors for each of these categories is extensive.

For domestic violence in the home, the risk factors include (1) an emotionally volatile person (likely to have emotional dysregulation due to a history of trauma (ACES faST Fact) and likely to be diagnosed with Borderline or other Personality Disorder; (2) Suicide attempts which may be diagnosed as Major Depressive Disorder, a trauma related disorder,  or Borderline or other Personality Disorder (3) A history of aggression toward others; (4) Heavy substance abuse; (5) Poor anger management; (6) A history of experiencing or witnessing childhood violence, particularly within the family which can be diagnosed as a trauma related mental health disorder or an Axis II Personality Disorder (The Anna Institute, 2006); (7) Poor non-violent problem-solving skills which may be a result of a history of developmental delays arising out of a history of childhood trauma (Van der Kolk, 2009); and (8) past violence toward others which can also be related to a history of childhood trauma and exposure to violence as a child (Van der Kolk, 2009) (Center for Substance Abuse Treatment (US)., 2014)

For workplace multiple victim violence, the risk factors include: (1) Highly impatient and hypersensitive behaviors which may include emotional dysregulation which may be a trauma related disorder (Van der Kolk, 2009)or a personality disorder; (2) High suspiciousness; (3) A person that intimidates, ridicules, and demeans others; (4) A history of violence toward others which may be related to a trauma history and exposure to violence as a child and a trauma related diagnosis, a substance abuse disorder which is often associated with a history of trauma and a trauma related diagnosis and trauma related mental health issues, and (5) problems dealing in a healthy way with authority figures, which can also be related to a history of trauma (Lee, 2007).

The risk factors for perpetration of events of mass violence have been described by Professors Peterson and Densley in an unprecedented study of mass murderers in the US since 1966 ( ). They have identified the common factors associated with mass violence. Drs Peterson and Densley have determined that the majority of mass violence perpetrators had the following characteristics: nearly all mass shooters experienced early childhood trauma and exposure to violence at a young age (Densley, 2021); one out of three mass murderers were suicidal; greater than 80% of mass murderers in Peterson and Densley’s database were in psychological crisis without adequate services and supports when they harmed others; 60% had histories of mental health problems; and 67% showed increasing agitation or emotional dysregulation leading up to the mass violence event.  They also determined that many mass murderers had a fascination or obsession with other mass murderers and firearms.  Additionally, having 4 or more of the risk factors for violence was more highly related to commission of mass murder than having just one of these factors.

Among those committing criminal violence, commonalities include childhood trauma, mental illness, substance abuse, living in poorly resourced communities, past violence toward others, involvement in deviant peer groups and personality disorders among adults with criminal justice involvement.

Looking across groups, the connection between childhood trauma, mental illness, and substance abuse stand out as prime factors in the perpetration of all kinds of violence. This is also well documented in the research literature in this topic (Bloom, 2007). Childhood trauma is also highly associated with mental illness and substance abuse as has been established by the research on aversive childhood experiences (ACE’s,  If we look at trauma related mental health disorders, we return to the connection between mental illness and dangerousness to self and others.  Additionally, persons with substance abuse and mental health problems are 7 times more likely to commit violence toward another person.

Risk Assessment

Validated risk assessments have become the standard of care in determining high, moderate, and low risk of violence emphasizing the need for treatment in moderate to high-risk cases. This emphasizes the need to include the research literature on risk assessments in this discussion. Quinsy, et al, established that clinical judgement without a knowledge of violence risk factors in determining the risk of dangerousness is no better than chance (ROC <50% correct classification probability). The most highly validated risk assessments have been established with 75-80% correct classification probability through an ROC analysis. To use clinical judgement alone without knowledge of established risk factors for violence is insufficient. Additionally, not abiding by the established standards of care are increasingly becoming the topic of civil liability lawsuits when an at risk person without sufficient services commits a violent act. Therefore, any civil commitment regulations should consider applying this literature to any decision making.  Additionally, the standard for deciding cases of potential civil commitment should reduce the risk of false positives and false negatives by using the highest (ROC) standard of probability of committing a future violent act.  This must be the standard that is used when addressing risk reduction planning.  Validated risk assessments have been the standard in Canada for decades but is still in its infancy in the US. This needs to be addressed in these changes of regulations.

Civil Commitment

There must be a careful balance between the consideration of the rights of a person at risk to commit violence while protecting the rights of the public to not be harmed by another.  In making these decisions, we must be careful, judicious, and as accurate as possible. One does not restrict another’s rights without just cause and the highest level of accuracy, nor does one knowingly place others in harm’s way.

The best way to stop violence is through prevention (Seifert K. , Connecting Child Maltreatment and Behavioral Health Problems. , 2016).  Many persons at risk for future violence have had contact with the criminal or juvenile justice system or are under disciplinary action in the workplace.  Many of these at-risk persons have been identified due to emotionally out of control behaviors that often fly below the radar of official or legal accountability but are recognized by supervisors or community members (Seifert K. ). Legal and workplace actions can be used to refer persons at risk for violence to treatment to reduce the risk of future violence before there is a need for civil commitment. The case being made here is that interventions to stop childhood trauma, and to provide treatment for trauma, mental illness and substance abuse throughout the lifespan should be widely available. This may reduce the need for civil commitment.


  1. Improving the clarity of the definition of dangerousness through a literature review is supported
  2. Using the highest standards of accuracy with validated risk assessments and risk reduction planning in determining less restrictive treatment options before civil commitment is supported
  3. Extensive training for healthcare providers on dangerousness, risk factors for dangerousness and the changes in regulation is supported.
  4. Using effective trauma treatment and skill building as an interim step before the use of civil commitment
  5. Training all Emergency department and crisis intervention personnel of the risk factors for violence and changes in regulation is supported.
  6. Making needed treatment readily available to all. There is sufficient literature that the CCBHC model supports the inter-agency coordination needed to increase the effectiveness of mental health and substance abuse services.
  7. Payment for improved client outcomes as a standard to improve behavioral health services and outcomes throughout Maryland
  8. Civil commitment should be a last resort and should be done thoughtfully and carefully to balance the rights of at-risk clients and the public.  A civil commitment for outpatient therapy by a provider that understands these issues and has a proven track record of serving this population is to be considered before involuntary commitment to an inpatient facility.



ACES faST Fact. (n.d.). Retrieved from Centers for Disease control and Prevention:

Bloom, H. &. (2007). Essential Writings in Violence Rissk Assessment and management. Toronto: Center for Addiction and Menytal Health.

Braaten, S. (1998). Behavior Objective Sequence. Champaign, Ill: Research Press.

BURNS, B. S. (2004). Mental health need and access to mental health services by youths Involved with child welfare: A national survey. J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY,. (n.d.). aces About. Retrieved from Centers for Disease Control and Prevention:

Center for Substance Abuse Treatment (US). (2014). Trauma-Informed Care in Behavioral Health Services. Retrieved from (Treatment Improvement Protocol (TIP) Series, No. 57.) Exhibit 1.3-4, DSM-5 Diagnostic Criteria for PTSD. :

Herrenkohl, T. I. (2000). Developmental Risk factors for Youth violence. Journal of Adolescent Health, 176-186.

Hurlburt, M. L. (2004). Contextual predictors of mental health service use among children open to child welfare. ARCH GEN PSYCHIATRY, 1217-1224.

Kaplan, K. B. (2019). Child Protective Service Disparities and Serious Mental Illnesses: Results From a National Survey. American Psychiatric Association.

Lee, V. a. (2007). Cognitive, emotional, and neurobiological developoment: Mediating the relationship between maltreatment and aggression. Child maltreatment, 281-298.

Lipskey, M. W. (2000, April). Effective Intervention for Serious Juvenile Offenders. Retrieved from Office of Justice Programs :

NAMI. (2020, may). Substance Abuse Disorders. Retrieved from Nami:

Seifert, K. (2006). How Children Become Violent: Keeping your kids out of gangs, terrorist organizations, and cults. Boston: Acanthus.

Seifert, K. (2016). Connecting Child Maltreatment and Behavioral Health Problems. . Retrieved from Psychology Today:

Seifert, K. (n.d.). Youth Violence. Springer.

Seifert, M. K. (2003 – 2018). CARE-2b Assessment. Boston, MASS: Acanthus Publishing.

The Anna Institute. (2006, 10 24). Adverse Childhood Experience (ACE) Questionnaire. Retrieved from

Tremblay, R. (. (2005). Developmental Origins of Aggression. NY, NY: The Guilford Press.


Walsh, C. (2003). The relationship between parental substance abuse and child maltreatment: findings from the Ontario Health Supplement. Child Abuse and Neglect, 1409-1425.

Sincerely Submitted

Dr. Kathryn Seifert



Description and Purpose of Levels and Domains of CARE


youth violence

The social determinants of health are now well recognized by practitioners and scientists.  Additionally, the relationship between childhood trauma and negative behavioral and physical health outcomes in adults was established by the ACE’s research ( (Felitti, 1998)) on 17,000 American adults.  It was a retrospective study comparing childhood trauma and adult health outcomes.  In the “Levels of CARE,” the complexity of problems and strengths is matched with the complexity of treatment which includes addressing the social determinants of health.    This model is fashioned after ASAM criteria but adds health across SAMHSA Eight Dimensions of Health ( (SAMHSA, 2016).

The Eight Dimensions of Wellness include physical, emotional, social, intellectual, environmental, spiritual, vocational, and financial health.  These eight were clustered into the 4 Domains of Health: Health (physical, emotional, social, intellectual, and Spiritual), Home (safety, stability, and attachment), community (social, and environmental), and purpose (vocational, community, and financial).

The ”Levels of CARE” uses principles of holistic and integrated care.  This instrument uses the level of health in the 4 Domains of overall Health: Health, Home, Community, and Purpose (SAMHSA) to categorize the complexity of problems, skills, and treatment planning that a client may need.  The health of each of these domains will impact a person’s overall health.  If help is needed to improve the health in any of these domains, they should be addressed in the treatment plan to improve overall health.  This is based on the concept that all types of health are interrelated and can affect other domains of health.   The intensity/health of problem areas and coping skills can help determine what services are needed. The health/problems of each domain of health will inform the state of overall health.  This, in turn, will inform the intensity, complexity, and multidisciplinary treatments that are needed.  In like fashion, the treatment plan should match the needs of the client.   In this way, all contributing factors to health can be addressed.

The Integrated Levels and Domains of care will be available on this site soon, so stay tuned.

School Shooting today in Winston Salem, NC

Sadly 1 student has been killed in a school shooting in Winston-Salem, NC. Thankfully, all staff and other students are safe. Now that schools are back in session across the country, I encourage all schools to consider establishing Threat Assessment Teams and Risk Reduction Planning.  Threat Assessment Teams include personnel from education, social work, psychology, psychiatry, law enforcement, and representatives of the medical community.  The team meets regularly to create risk reduction plans for any students that may be at risk to harm themselves or others.  In order to provide interventions to reduce the risk of harm to self or others, members of the Threat assessment team must have certain information:

  1. Know the risk factors and effective interventions for anyone with behaviors that place them at risk to harm themselves or others.
  2. Learn which students need to be screened.
  3. Explore the local resources for interventions
  4. Have a process for referring youth to adequate services
  5. Gain an understanding that harm to self and others is driven primarily by trauma histories, inadequate treatment, stress, and crisis.  Those at risk need supports and services, not punishment to help youth solve problems, reduce toxic stress, build coping skills, and change behavior.

For more information go to

Bullying and trauma