A TREATMENT IMPROVEMENT PROTOCOL

A TREATMENT IMPROVEMENT PROTOCOL

Trauma-Informed Care in Behavioral Health Services

TIP 57

 

 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment

1 Choke Cherry Road Rockville, MD 20857

A TREATMENT IMPROVEMENT PROTOCOL

Trauma-Informed Care in Behavioral Health Services

TIP 57

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services

Acknowledgments This publication was produced under contract numbers 270-99-7072, 270-04-7049, and 270­ 09-0307 by the Knowledge Application Program (KAP), a Joint Venture of The CDM Group, Inc., and JBS International, Inc., for the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). Andrea Kopstein, Ph.D., M.P.H., Karl D. White, Ed.D., and Christina Currier served as the Contracting Officer’s Representatives.

Disclaimer The views, opinions, and content expressed herein are the views of the consensus panel members and do not necessarily reflect the official position of SAMHSA or HHS. No official support of or endorsement by SAMHSA or HHS for these opinions or for the instruments or resources described are intended or should be inferred. The guidelines presented should not be considered substitutes for individualized client care and treatment decisions.

Public Domain Notice All materials appearing in this volume except those taken directly from copyrighted sources are in the public domain and may be reproduced or copied without permission from SAMHSA or the authors. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, HHS.

Electronic Access and Copies of Publication This publication may be ordered or downloaded from SAMHSA’s Publications Ordering Web page at http://store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726­ 4727) (English and Español).

Recommended Citation Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

Originating Office Quality Improvement and Workforce Development Branch, Division of Services Improvement, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857.

HHS Publication No. (SMA) 14-4816 First Printed 2014

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………………………………………………………….. …………………………………………………………………….

 

61 Sequence of Trauma Reactions …………………………………………………………………………………… 60 Common Experiences and Responses to Trauma Subthreshold Trauma-Related Symptoms 75 Specific Trauma-Related Psychological Disorders…………………………………………………………. 77 Other Trauma-Related and Co-Occurring Disorders ……………………………………………………. 85

Contents

Consensus Panel………………………………………………………………………………………………. vii KAP Expert Panel and Federal Government Participants ……………………………………………ix What Is a TIP? …………………………………………………………………………………………………..xi Foreword……………………………………………………………………………………………………….. xiii How This TIP Is Organized ……………………………………………………………………………….. xv

Terminology……………………………………………………………………………………………………………..xvi PART 1: A PRACTICAL GUIDE FOR THE PROVISION OF BEHAVIORAL HEALTH SERVICES ……………………………………………………………………………………….. 1 Chapter 1—Trauma-Informed Care: A Sociocultural Perspective ………………………………… 3

Scope of the TIP ………………………………………………………………………………………………………… 4 Intended Audience……………………………………………………………………………………………………… 4 Before You Begin ……………………………………………………………………………………………………….. 4 Structure of the TIP……………………………………………………………………………………………………. 6 What Is Trauma?………………………………………………………………………………………………………… 7 Trauma Matters in Behavioral Health Services………………………………………………………………. 7 Trauma-Informed Intervention and Treatment Principles……………………………………………… 11 As You Proceed ………………………………………………………………………………………………………… 32

Chapter 2—Trauma Awareness …………………………………………………………………………….33 Types of Trauma……………………………………………………………………………………………………….. 33 Characteristics of Trauma ………………………………………………………………………………………….. 46 Individual and Sociocultural Features………………………………………………………………………….. 52

Chapter 3—Understanding the Impact of Trauma …………………………………………………….59

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Strategy #8: Develop Policies and Procedures To Ensure Trauma-Informed Practices and To Prevent Retraumatization ………………………………………………………………………………… 166

Concluding Note…………………………………………………………………………………………………….. 110

Trauma-Informed Care in Behavioral Health Services

Chapter 4—Screening and Assessment …………………………………………………………………..91

……………………….. 99 Screening and Assessment …………………………………………………………………………………………. 92 Barriers and Challenges to Trauma-Informed Screening and Assessment Cross-Cultural Screening and Assessment…………………………………………………………………. 103 Choosing Instruments……………………………………………………………………………………………… 104 Trauma-Informed Screening and Assessment…………………………………………………………….. 106

Chapter 5—Clinical Issues Across Services……………………………………………………………111 Trauma-Informed Prevention and Treatment Objectives …………………………………………….. 111 Treatment Issues …………………………………………………………………………………………………….. 127 Making Referrals to Trauma-Specific Services……………………………………………………………. 135

Chapter 6—Trauma-Specific Services ………………………………………………………………….137 Introduction …………………………………………………………………………………………………………… 137 Trauma-Specific Treatment Models ………………………………………………………………………….. 139 Integrated Models for Trauma………………………………………………………………………………….. 147 Emerging Interventions …………………………………………………………………………………………… 153 Concluding Note…………………………………………………………………………………………………….. 155

PART 2: AN IMPLEMENTATION GUIDE FOR BEHAVIORAL HEALTH PROGRAM ADMINISTRATORS……………………………………………………………………157 Chapter 1—Trauma-Informed Organizations ……………………………………………………….159

Strategy #1: Show Organizational and Administrative Commitment to TIC…………………. 161 Strategy #2: Use Trauma-Informed Principles in Strategic Planning …………………………….. 162 Strategy #3: Review and Update Vision, Mission, and Value Statements……………………….. 162 Strategy #4: Assign a Key Staff Member To Facilitate Change …………………………………….. 163 Strategy #5: Create a Trauma-Informed Oversight Committee ……………………………………. 163 Strategy #6: Conduct an Organizational Self-Assessment of Trauma-Informed Services … 164 Strategy #7: Develop an Implementation Plan……………………………………………………………. 164

Strategy #9: Develop a Disaster Plan…………………………………………………………………………. 166 Strategy #10: Incorporate Universal Routine Screenings ……………………………………………… 167 Strategy #11: Apply Culturally Responsive Principles …………………………………………………. 167 Strategy #12: Use Science-Based Knowledge……………………………………………………………… 169 Strategy #13: Create a Peer-Support Environment……………………………………………………… 169 Strategy #14: Obtain Ongoing Feedback and Evaluations …………………………………………… 170 Strategy #15: Change the Environment To Increase Safety………………………………………….. 171 Strategy #16: Develop Trauma-Informed Collaborations …………………………………………….. 171

Chapter 2—Building a Trauma-Informed Workforce ………………………………………………173 Introduction …………………………………………………………………………………………………………… 173 Workforce Recruitment, Hiring, and Retention………………………………………………………….. 174

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Contents

………………………………………………………………. 181 Training in TIC ……………………………………………………………………………………………………… 177 Trauma-Informed Counselor Competencies Counselor Responsibilities and Ethics……………………………………………………………………….. 182 Clinical Supervision and Consultation ………………………………………………………………………. 191 Secondary Traumatization ……………………………………………………………………………………….. 193 Counselor Self-Care………………………………………………………………………………………………… 205

APPENDICES……………………………………………………………………………………………….215 Appendix A—Bibliography ………………………………………………………………………………..215 Appendix B—Trauma Resource List…………………………………………………………………….247 Appendix C—Historical Account of Trauma………………………………………………………….267 Appendix D—Screening and Assessment Instruments …………………………………………….271 Appendix E—Consumer Materials………………………………………………………………………285 Appendix F—Organizational Assessment for Trauma-Informed Care…………………………287 Appendix G—Resource Panel …………………………………………………………………………….289 Appendix H—Field Reviewers ……………………………………………………………………………293 Appendix I—Cultural Competence and Diversity Network Participants ……………………..299 Appendix J—Acknowledgments ………………………………………………………………………….300 EXHIBITS

Exhibit 1.1-1: TIC Framework in Behavioral Health Services—Sociocultural Perspective ….. 6 Exhibit 1.1-2: A Social-Ecological Model for Understanding Trauma and Its Effects ………. 15 Exhibit 1.1-3: Understanding the Levels Within the Social-Ecological Model of

Trauma and Its Effects…………………………………………………………………………………………… 16 Exhibit 1.1-4: Cross-Cutting Factors of Culture…………………………………………………………… 26 Exhibit 1.2-1: Trauma Examples ………………………………………………………………………………… 35 Exhibit 1.3-1: Immediate and Delayed Reactions to Trauma …………………………………………. 62 Exhibit 1.3-2: Cognitive Triad of Traumatic Stress ……………………………………………………….. 67 Exhibit 1.3-3: DSM-5 Diagnostic Criteria for ASD …………………………………………………….. 78 Exhibit 1.3-4: DSM-5 Diagnostic Criteria for PTSD…………………………………………………… 82 Exhibit 1.3-5: ICD-10 Diagnostic Criteria for PTSD ………………………………………………….. 85 Exhibit 1.3-6: Important Treatment Facts About PTSD and Substance Use Disorders…….. 89 Exhibit 1.4-1: Grounding Techniques …………………………………………………………………………. 98 Exhibit 1.4-2: Key Areas of Trauma Screening and Assessment……………………………………. 105 Exhibit 1.4-3: SLE Screening…………………………………………………………………………………… 107 Exhibit 1.4-4: STaT: Intimate Partner Violence Screening Tool …………………………………… 108 Exhibit 1.4-5: PC-PTSD Screen………………………………………………………………………………. 108 Exhibit 1.4-6: The SPAN ………………………………………………………………………………………… 108 Exhibit 1.4-7: The PTSD Checklist………………………………………………………………………….. 109 Exhibit 1.4-8: Resilience Scales ………………………………………………………………………………… 110 Exhibit 1.5-1: OBSERVATIONS: A Coping Strategy………………………………………………… 119

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Trauma-Informed Care in Behavioral Health Services

Exhibit 2.1-1: TIC Planning Guidelines ……………………………………………………………………. 165 Exhibit 2.2-1: Clinical Practice Issues Relevant to Counselor Training in Trauma-

Informed Treatment Settings………………………………………………………………………………… 179 Exhibit 2.2-2: Guidelines for Training in Mental Health Interventions for Trauma­

…………………………… 183 Exposed Populations……………………………………………………………………………………………. 180

Exhibit 2.2-3: Trauma-Informed Counselor Competencies Checklist Exhibit 2.2-4: Sample Statement of the Client’s Right to Confidentiality From a

Client Bill of Rights…………………………………………………………………………………………….. 185 Exhibit 2.2-5: Green Cross Academy of Traumatology Ethical Guidelines for the

Treatment of Clients Who Have Been Traumatized ……………………………………………….. 186 Exhibit 2.2-6: Boundaries in Therapeutic Relationships………………………………………………. 189 Exhibit 2.2-7: Counselor Strategies To Prevent Secondary Traumatization ……………………. 198 Exhibit 2.2-8: Secondary Traumatization Signs ………………………………………………………….. 199 Exhibit 2.2-9: ProQOL Scale …………………………………………………………………………………… 201 Exhibit 2.2-10: Your Scores on the ProQOL: Professional Quality of Life Screening……… 202 Exhibit 2.2-11: What Is My Score and What Does It Mean?………………………………………. 203 Exhibit 2.2-12: Clinical Supervisor Guidelines for Addressing Secondary Traumatization……. 205 Exhibit 2.2-13: Comprehensive Self-Care Plan Worksheet………………………………………….. 208 Exhibit 2.2-14: Comprehensive Self-Care Plan Worksheet Instructions………………………… 209 Exhibit 2.2-15: The Ethics of Self-Care…………………………………………………………………….. 210

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Consensus Panel

Note: Each panelist’s information reflects his or her affiliation at the time of the Consensus Panel meeting and may not reflect that person’s most current affiliation.

Chair Lisa M. Najavits, Ph.D. Research Psychologist Veterans Affairs Boston Healthcare System Professor of Psychiatry Boston University School of Medicine Boston, MA

Co-Chair Linda B. Cottler, Ph.D., M.P.H. Professor of Epidemiology in Psychiatry Department of Psychiatry Washington University–St. Louis St. Louis, MO

Workgroup Leaders Stephanie S. Covington, Ph.D., LCSW,

MFCC Co-Director Center for Gender and Justice Institute for Relational Development La Jolla, CA

Margaret Cramer, Ph.D. Clinical Psychologist/Clinical Instructor Harvard Medical School Boston, MA

Anne M. Herron, M.S. Director Treatment Programming New York State Office of Alcoholism and Substance Abuse Services

Albany, NY

Denise Hien, Ph.D. Research Scholar Social Intervention Group School of Social Work Columbia University New York, NY

Dee S. Owens, M.P.A. Director Alcohol-Drug Information Indiana University Bloomington, IN

Panelists Charlotte Chapman, M.S., LPC, CAC Training Director Division of Addiction Psychiatry Mid-Atlantic Addiction Technology Transfer

Center Virginia Commonwealth University Richmond, VA

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Trauma-Informed Care in Behavioral Health Services

Scott F. Coffey, Ph.D. Associate Professor Department of Psychiatry and Human

Behavior University of Mississippi Medical Center Jackson, MS

Renee M. Cunningham-Williams, M.S.W., M.P.E., Ph.D.

Research Assistant/Professor of Social Work Department of Psychiatry Washington University St. Louis, MO

Chad D. Emrick, Ph.D. Administrative Director Substance Abuse Treatment Program Denver VA Medical Center (116A1) Denver, CO

Charles R. Figley, Ph.D. Professor Director of the Traumatology Institute Florida State University Tallahassee, FL

Larry M. Gentilello, M.D., FACS Professor and Chairman Division of Burn, Trauma, and Critical Care University of Texas Southwestern Medical

School Dallas, TX

Robert Grant, Ph.D. Trauma Consultant Oakland, CA

Anthony (Tony) Taiwai Ng, M.D. Disaster Psychiatrist Washington, DC

Pallavi Nishith, Ph.D. Associate Research Professor Center for Trauma Department of Psychology University of Missouri–St. Louis St. Louis, MO

Joseph B. Stone, Ph.D., CACIII, ICADC Program Manager and Clinical Supervisor Confederated Tribes of Grand Ronde

Behavioral Health Program Grand Ronde, OR

Michael Villanueva, Ph.D. Research Professor Center on Alcoholism, Substance Abuse, and

Addiction Albuquerque, NM

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KAP Expert Panel and Federal Government Participants

Barry S. Brown, Ph.D. Adjunct Professor University of North Carolina–Wilmington Carolina Beach, NC

Jacqueline Butler, M.S.W., LISW, LPCC, CCDC III, CJS

Professor of Clinical Psychiatry College of Medicine University of Cincinnati Cincinnati, OH

Deion Cash Executive Director Community Treatment and Correction

Center, Inc. Canton, OH

Debra A. Claymore, M.Ed.Adm. Owner/Chief Executive Officer WC Consulting, LLC Loveland, CO

Carlo C. DiClemente, Ph.D. Chair Department of Psychology University of Maryland–Baltimore County Baltimore, MD

Catherine E. Dube, Ed.D. Independent Consultant Brown University Providence, RI

Jerry P. Flanzer, D.S.W., LCSW, CAC Chief, Services Division of Clinical and Services Research National Institute on Drug Abuse Bethesda, MD

Michael Galer, D.B.A. Independent Consultant Westminster, MA

Renata J. Henry, M.Ed. Director Division of Alcoholism, Drug Abuse and

Mental Health Delaware Department of Health and Social

Services New Castle, DE

Joel Hochberg, M.A. President Asher & Partners Los Angeles, CA

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Trauma-Informed Care in Behavioral Health Services

Jack Hollis, Ph.D. Associate Director, Center for Health

Research Kaiser Permanente Portland, OR

Mary Beth Johnson, M.S.W. Director Addiction Technology Transfer Center University of Missouri–Kansas City Kansas City, MO

Eduardo Lopez Executive Producer EVS Communications Washington, DC

Holly A. Massett, Ph.D. Academy for Educational Development Washington, DC

Diane Miller Chief Scientific Communications Branch National Institute on Alcohol Abuse and

Alcoholism Bethesda, MD

Harry B. Montoya, M.A. President/Chief Executive Officer Hands Across Cultures Española, NM

Richard K. Ries, M.D. Director/Professor Outpatient Mental Health Services Dual Disorder Programs Seattle, WA

Gloria M. Rodriguez, D.S.W. Research Scientist Division of Addiction Services New Jersey Department of Health and

Senior Services Trenton, NJ

Everett Rogers, Ph.D. Center for Communications Programs Johns Hopkins University Baltimore, MD

Jean R. Slutsky, P.A., M.S.P.H. Senior Health Policy Analyst Agency for Healthcare Research & Quality Rockville, MD

Nedra Klein Weinreich, M.S. President Weinreich Communications Canoga Park, CA

Clarissa Wittenberg Director Office of Communications and Public

Liaison National Institute of Mental Health Bethesda, MD

Consulting Members of the KAP Expert Panel Paul Purnell, M.A Social Solutions, LLC Potomac, MD

Scott Ratzan, M.D., M.P.A., M.A. Academy for Educational Development Washington, DC

Thomas W. Valente, Ph.D. Director Master of Public Health Program Department of Preventive Medicine School of Medicine University of Southern California Los Angeles, CA

Patricia A. Wright, Ed.D. Independent Consultant Baltimore, MD

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What Is a TIP?

Treatment Improvement Protocols (TIPs) are developed by the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services (HHS). Each TIP involves the development of topic-specific best practice guidelines for the prevention and treatment of substance use and mental disorders. TIPs draw on the experience and knowledge of clinical, research, and administrative experts of various forms of treatment and prevention. TIPs are distributed to facilities and individuals across the country. Published TIPs can be accessed via the Internet at http://store.samhsa.gov.

Although each consensus-based TIP strives to include an evidence base for the practices it rec­ ommends, SAMHSA recognizes that behavioral health is continually evolving, and research fre­ quently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey “front-line” information quickly but responsibly. If research supports a particular approach, cita­ tions are provided.

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Foreword

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA’s mission is to reduce the impact of sub­ stance abuse and mental illness on America’s communities.

The Treatment Improvement Protocol (TIP) series fulfills SAMHSA’s mission to improve pre­ vention and treatment of substance use and mental disorders by providing best practices guidance to clinicians, program administrators, and payers.TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and imple­ mentation requirements. A panel of non-Federal clinical researchers, clinicians, program admin­ istrators, and patient advocates debates and discusses their particular area of expertise until they reach a consensus on best practices. This panel’s work is then reviewed and critiqued by field reviewers.

The talent, dedication, and hard work that TIP panelists and reviewers bring to this highly par­ ticipatory process have helped bridge the gap between the promise of research and the needs of practicing clinicians and administrators to serve, in the most scientifically sound and effective ways, people in need of behavioral health services. We are grateful to all who have joined with us to contribute to advances in the behavioral health field.

Pamela S. Hyde, J.D. Administrator Substance Abuse and Mental Health Services Administration

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM

Director

Frances M. Harding Director Center for Substance Abuse

Paolo del Vecchio, M.S.W. Director Center for Mental Health

Center for Substance Abuse Prevention Services Treatment Substance Abuse and Mental Substance Abuse and Mental

Substance Abuse and Mental Health Services Administration Health Services Administration Health Services Administration

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How This TIP Is Organized

This Treatment Improvement Protocol (TIP) is divided into three parts: • Part 1: A Practical Guide for the Provision of Behavioral Health Services • Part 2: An Implementation Guide for Behavioral Health Program Administrators • Part 3: A Review of the Literature

Part 1 is for behavioral health service providers and consists of six chapters. Recurring themes include the variety of ways that substance abuse, mental health, and trauma interact; the im­ portance of context and culture in a person’s response to trauma; trauma-informed screening and assessment tools, techniques, strategies, and approaches that help behavioral health professionals assist clients in recovery from mental and substance use disorders who have also been affected by acute or chronic traumas; and the significance of adhering to a strengths-based perspective that acknowledges the resilience within individual clients, providers, and communities.

Chapter 1 lays the groundwork and rationale for the implementation and provision of trauma- informed services. It provides an overview of specific trauma-informed intervention and treat­ ment principles that guide clinicians, other behavioral health workers, and administrators in becoming trauma informed and in creating a trauma-informed organization and workforce. Chapter 2 provides an overview of traumatic experiences. It covers types of trauma; distinguishes among traumas that affect individuals, groups, and communities; describes trauma characteristics; and addresses the socioecological and cultural factors that influence the impact of trauma. Chap­ ter 3 broadly focuses on understanding the impact of trauma, trauma-related stress reactions and associated symptoms, and common mental health and substance use disorders associated with trauma. Chapter 4 provides an introduction to screening and assessment as they relate to trauma and is devoted to screening and assessment processes and tools that are useful in evaluating trauma exposure, its effects, and client intervention and treatment needs. Chapter 5 covers clini­ cal issues that counselors and other behavioral health professionals may need to know and ad­ dress when treating clients who have histories of trauma. Chapter 6 presents information on specific treatment models for trauma, distinguishing integrated models (which address substance use disorders, mental disorders, and trauma simultaneously) from those that treat trauma alone.

Advice to Counselors and/or Administrators boxes in Part 1 provide practical information for providers. Case illustrations, exhibits, and text boxes further illustrate information in the text by offering practical examples.

Part 2 provides an overview of programmatic and administrative practices that will help behav­ ioral health program administrators increase the capacity of their organizations to deliver

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Trauma-Informed Care in Behavioral Health Services

trauma-informed services. Chapter 1 examines the essential ingredients, challenges, and processes in creating and implementing trauma-informed services within an organization. Chapter 2 focuses on key development activities that support staff members, including trauma-informed training and supervision, ethics, and boundaries pertinent to responding to traumatic stress, secondary trauma, and counselor self-care.

Advice to Administrators and/or Supervisors boxes in Part 2 highlight more detailed information that supports the organizational implementation of trauma-informed care (TIC). In addition, case illustrations, organizational activities, and text boxes reinforce the material presented within this section.

Part 3 is a literature review on TIC and behavioral health services and is intended for use by clin­ ical supervisors, interested providers, and administrators. Part 3 has three sections: an analysis of the literature, links to select abstracts of the references most central to the topic, and a general bibliography of the available literature. To facilitate ongoing updates (performed periodically for up to 3 years from first publication), the literature review is only available online at the Substance Abuse and Mental Health Services Administration (SAMHSA) Publications Ordering Web page (http://store.samhsa.gov).

Terminology Behavioral health: Throughout the TIP, the term “behavioral health” is used. Behavioral health refers to a state of mental/emotional being and/or choices and actions that affect wellness. Be­ havioral health problems include substance abuse or misuse, alcohol and drug addiction, serious psychological distress, suicide, and mental and substance use disorders. This includes a range of problems from unhealthy stress to diagnosable and treatable diseases like serious mental illness and substance use disorders, which are often chronic in nature but from which people can and do recover. The term is also used in this TIP to describe the service systems encompassing the pro­ motion of emotional health, the prevention of mental and substance use disorders, substance use and related problems, treatments and services for mental and substance use disorders, and recov­ ery support. Because behavioral health conditions, taken together, are the leading causes of disa­ bility burden in North America, efforts to improve their prevention and treatment will benefit society as a whole. Efforts to reduce the impact of mental and substance use disorders on Ameri­ ca’s communities, such as those described in this TIP, will help achieve nationwide improvements in health.

Client/consumer: In this TIP, the term “client” means anyone who seeks or receives mental health or substance abuse services. The term “consumer” stands in place of “client” in content areas that address consumer participation and determination. It is not the intent of this docu­ ment to ignore the relevance and historical origin of the term “consumer” among individuals who have received, been subject to, or are seeking mental health services. Instead, we choose the word “client,” given that this terminology is also commonly used in substance abuse treatment services. Note: This TIP also uses the term “participant(s)” instead of “client(s)” for individuals, families, or communities seeking or receiving prevention services.

Complex trauma: This manual adopts the National Child Traumatic Stress Network (NCTSN) definition of complex trauma. The term refers to the pervasive impact, including developmental

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How This TIP Is Organized

consequences, of exposure to multiple or prolonged traumatic events. According to the NCTSN Web site (http://www.nctsn.org/trauma-types), complex trauma typically involves exposure to sequential or simultaneous occurrences of maltreatment, “including psychological maltreatment, neglect, physical and sexual abuse, and domestic violence…. Exposure to these initial traumatic experiences—and the resulting emotional dysregulation and the loss of safety, direction, and the ability to detect or respond to danger cues—often sets off a chain of events leading to subsequent or repeated trauma exposure in adolescence and adulthood” (NCTSN, 2013).

Co-occurring disorders: When an individual has one or more mental disorders as well as one or more substance use disorders (including substance abuse), the term “co-occurring” applies. Although people may have a number of health conditions that co-occur, including physical prob­ lems, the term “co-occurring disorders,” in this TIP, refers to substance use and mental disorders.

Cultural responsiveness and cultural competence: This TIP uses these terms interchangeably, with “responsiveness” applied to services and systems and “competence” applied to people, to refer to “a set of behaviors, attitudes, and policies that…enable a system, agency, or group of profes­ sionals to work effectively in cross-cultural situations” (Cross, Bazron, Dennis, & Isaacs, 1989, p. 13). Culturally responsive behavioral health services and culturally competent providers “honor and respect the beliefs, languages, interpersonal styles, and behaviors of individuals and families receiving services…. [C]ultural competence is a dynamic, ongoing developmental process that requires a long-term commitment and is achieved over time” (U.S. Department of Health and Human Services, 2003, p. 12).

Evidence-based practices: There are many different uses of the term “evidence-based practices.” One of the most widely accepted is that of Chambless and Hollon (1998), who say that for a treatment to be considered evidence based, it must show evidence of positive outcomes based on peer-reviewed randomized controlled trials or other equivalent strong methodology. A treatment is labeled “strong” if criteria are met for what Chambless and Hollon term “well-established” treatments. To attain this level, rigorous treatment outcome studies conducted by independent investigators (not just the treatment developer) are necessary. Research support is labeled “mod­ est” when treatments attain criteria for what Chambless and Hollon call “probably efficacious treatments.”To meet this standard, one well-designed study or two or more adequately designed studies must support a treatment’s efficacy. In addition, it is possible to meet the “strong” and “modest” thresholds through a series of carefully controlled single-case studies. An evidence- based practice derived from sound, science-based theories incorporates detailed and empirically supported procedures and implementation guidelines, including parameters of applications (such as for populations), inclusionary and exclusionary criteria for participation, and target interventions.

Promising practices: Even though current clinical wisdom, theories, and professional and expert consensus may support certain practices, these practices may lack support from studies that are scientifically rigorous in research design and statistical analysis; available studies may be limited in number or sample size, or they may not be applicable to the current setting or population. This TIP refers to such practices as “promising.”

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Trauma-Informed Care in Behavioral Health Services

Recovery: This term denotes a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. Major dimen­ sions that support a life in recovery, as defined by SAMHSA, include: • Health: overcoming or managing one’s disease(s) as well as living in a physically and emo­

tionally healthy way. • Home: a stable and safe place to live. • Purpose: meaningful daily activities, such as a job, school, volunteerism, family caretaking, or

creative endeavors, and the independence, income, and resources to participate in society. • Community: relationships and social networks that provide support, friendship, love, and hope.

Resilience: This term refers to the ability to bounce back or rise above adversity as an individual, family, community, or provider. Well beyond individual characteristics of hardiness, resilience includes the process of using available resources to negotiate hardship and/or the consequences of adverse events. This TIP applies the term “resilience” and its processes to individuals across the life span.

Retraumatization: In its more literal translation, “retraumatization” means the occurrence of traumatic stress reactions and symptoms after exposure to multiple events (Duckworth & Follette, 2011). This is a significant issue for trauma survivors, both because they are at increased risk for higher rates of retraumatization, and because people who are traumatized multiple times often have more serious and chronic trauma-related symptoms than those with single traumas. In this manual, the term not only refers to the effect of being exposed to multiple events, but also implies the process of reexperiencing traumatic stress as a result of a current situation that mir­ rors or replicates in some way the prior traumatic experiences (e.g., specific smells or other senso­ ry input; interactions with others; responses to one’s surroundings or interpersonal context, such as feeling emotionally or physically trapped).

Secondary trauma: Literature often uses the terms “secondary trauma,” “compassion fatigue,” and “vicarious traumatization” interchangeably. Although compassion fatigue and secondary trauma refer to similar physical, psychological, and cognitive changes and symptoms that behav­ ioral health workers may encounter when they work specifically with clients who have histories of trauma, vicarious trauma usually refers more explicitly to specific cognitive changes, such as in worldview and sense of self (Newell & MacNeil, 2010). This publication uses “secondary trauma” to describe trauma-related stress reactions and symptoms resulting from exposure to another individual’s traumatic experiences, rather than from exposure directly to a traumatic event. Sec­ ondary trauma can occur among behavioral health service providers across all behavioral health settings and among all professionals who provide services to those who have experienced trauma (e.g., healthcare providers, peer counselors, first responders, clergy, intake workers).

Substance abuse: Throughout the TIP, the term “substance abuse” has been used to refer to both substance abuse and substance dependence. This term was chosen partly because behavioral health professionals commonly use the term substance abuse to describe any excessive use of ad­ dictive substances. In this TIP, the term refers to the use of alcohol as well as other substances of abuse. Readers should attend to the context in which the term occurs to determine what possible range of meanings it covers; in most cases, it will refer to all varieties of substance-related

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How This TIP Is Organized

disorders as found in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American Psychiatric Association, 2013a).

Trauma: In this text, the term “trauma” refers to experiences that cause intense physical and psy­ chological stress reactions. It can refer to “a single event, multiple events, or a set of circumstances that is experienced by an individual as physically and emotionally harmful or threatening and that has lasting adverse effects on the individual’s physical, social, emotional, or spiritual well­ being” (SAMHSA, 2012, p. 2). Although many individuals report a single specific traumatic event, others, especially those seeking mental health or substance abuse services, have been ex­ posed to multiple or chronic traumatic events. See the “What Is Trauma” section in Part 1, Chap­ ter 1, for a more indepth definition and discussion of trauma.

Trauma-informed: A trauma-informed approach to the delivery of behavioral health services includes an understanding of trauma and an awareness of the impact it can have across settings, services, and populations. It involves viewing trauma through an ecological and cultural lens and recognizing that context plays a significant role in how individuals perceive and process traumatic events, whether acute or chronic. In May 2012, SAMHSA convened a group of national experts who identified three key elements of a trauma-informed approach: “(1) realizing the prevalence of trauma; (2) recognizing how trauma affects all individuals involved with the program, organi­ zation, or system, including its own workforce; and (3) responding by putting this knowledge into practice” (SAMHSA, 2012, p 4).

Trauma-informed care: TIC is a strengths-based service delivery approach “that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psy­ chological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment” (Hopper, Bassuk, & Olivet, 2010, p. 82). It also involves vigilance in anticipating and avoiding institutional processes and individual practices that are likely to retraumatize individuals who already have histories of trauma, and it upholds the importance of consumer participation in the development, delivery, and evaluation of services.

Trauma-specific treatment services: These services are evidence-based and promising practices that facilitate recovery from trauma. The term “trauma-specific services” refers to prevention, intervention, or treatment services that address traumatic stress as well as any co-occurring disor­ ders (including substance use and mental disorders) that developed during or after trauma.

Trauma survivor: This phrase can refer to anyone who has experienced trauma or has had a traumatic stress reaction. Knowing that the use of language and words can set the tone for recov­ ery or contribute to further retraumatization, it is the intent of this manual to put forth a message of hope by avoiding the term “victim” and instead using the term “survivor” when appropriate.

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Part 1: A Practical Guide for the Provision of Behavioral

Health Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IN THIS CHAPTER • Scope of the TIP • Intended Audience • Before You B egin • Structure of the TIP • What Is Trauma? • Trauma Matters in

Behavioral Health Services

• Trauma -Informed Intervention and Treatment Principles

• As You P roceed

Trauma-Informed Care:1 A Sociocultural Perspective

Many individuals who seek treatment in behavioral health settings have histories of trauma, but they often don’t recognize the signifi­ cant effects of trauma in their lives; either they don’t draw connec­ tions between their trauma histories and their presenting problems, or they avoid the topic altogether. Likewise, treatment providers may not ask questions that elicit a client’s history of trauma, may feel unprepared to address trauma-related issues proactively, or may struggle to address traumatic stress effectively within the con­ straints of their treatment program, the program’s clinical orienta­ tion, or their agency’s directives.

By recognizing that traumatic experiences and their sequelae tie closely into behavioral health problems, front-line professionals and community-based programs can begin to build a trauma- informed environment across the continuum of care. Key steps include meeting client needs in a safe, collaborative, and compas­ sionate manner; preventing treatment practices that retraumatize people with histories of trauma who are seeking help or receiving services; building on the strengths and resilience of clients in the context of their environments and communities; and endorsing trauma-informed principles in agencies through support, consulta­ tion, and supervision of staff.

This Treatment Improvement Protocol (TIP) begins by introducing the scope, purpose, and organization of the topic and describing its intended audience. Along with defining trauma and trauma- informed care (TIC), the first chapter discusses the rationale for addressing trauma in behavioral health services and reviews trauma- informed intervention and treatment principles.These principles serve as the TIP’s conceptual framework.

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Trauma-Informed Care in Behavioral Health Services

Scope of the TIP Many individuals experience trauma during their lifetimes. Although many people exposed to trauma demonstrate few or no lingering symptoms, those individuals who have experi­ enced repeated, chronic, or multiple traumas are more likely to exhibit pronounced symp­ toms and consequences, including substance abuse, mental illness, and health problems. Subsequently, trauma can significantly affect how an individual engages in major life areas as well as treatment.

This TIP provides evidence-based and best practice information for behavioral health service providers and administrators who want to work more effectively with people who have been exposed to acute and chronic traumas and/or are at risk of developing traumatic stress reactions. Using key trauma-informed principles, this TIP addresses trauma-related prevention, intervention, and treatment issues and strategies in behavioral health services. The content is adaptable across behavioral health settings that service individuals, fami­ lies, and communities—placing emphasis on the importance of coordinating as well as inte­ grating services.

Intended Audience This TIP is for behavioral health service pro­ viders, prevention specialists, and program administrators—the professionals directly re­ sponsible for providing care to trauma survi­ vors across behavioral health settings, including substance abuse and mental health services. This TIP also targets primary care professionals, including physicians; teams working with clients and communities who have experienced trauma; service providers in the criminal justice system; and researchers with an interest in this topic.

Before You Begin This TIP endorses a trauma-informed model of care; this model emphasizes the need for behavioral health practitioners and organiza­ tions to recognize the prevalence and pervasive impact of trauma on the lives of the people they serve and develop trauma-sensitive or trauma-responsive services. This TIP provides key information to help behavioral health practitioners and program administrators be­ come trauma aware and informed, improve screening and assessment processes, and im­ plement science-informed intervention strate­ gies across settings and modalities in behavioral health services. Whether provided by an agency or an individual provider, trauma- informed services may or may not include trauma-specific services or trauma specialists (individuals who have advanced training and education to provide specific treatment inter­ ventions to address traumatic stress reactions). Nonetheless,TIC anticipates the role that trauma can play across the continuum of care— establishing integrated and/or collaborative processes to address the needs of traumatized individuals and communities proactively.

Individuals who have experienced trauma are at an elevated risk for substance use disorders, including abuse and dependence; mental health problems (e.g., depression and anxiety symptoms or disorders, impairment in rela­ tional/social and other major life areas, other distressing symptoms); and physical disorders and conditions, such as sleep disorders. This TIP focuses on specific types of prevention (Institute of Medicine et al., 2009): selective prevention, which targets people who are at risk for developing social, psychological, or other conditions as a result of trauma or who are at greater risk for experiencing trauma due to behavioral health disorders or conditions; and indicated prevention, which targets people who display early signs of trauma-related

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Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective

symptoms. This TIP identifies interventions, including trauma-informed and trauma- specific strategies, and perceives treatment as a means of prevention—building on resilience, developing safety and skills to negotiate the impact of trauma, and addressing mental and substance use disorders to enhance recovery.

This TIP’s target population is adults. Beyond the context of family, this publication does not examine or address youth and adolescent responses to trauma, youth-tailored trauma- informed strategies, or trauma-specific inter­ ventions for youth or adolescents, because the developmental and contextual issues of these populations require specialized interventions. Providers who work with young clients who have experienced trauma should refer to the resource list in Appendix B. This TIP covers TIC, trauma characteristics, the impact of traumatic experiences, assessment, and inter­ ventions for persons who have had traumatic experiences. Considering the vast knowledge base and specificity of individual, repeated, and chronic forms of trauma, this TIP does not provide a comprehensive overview of the unique characteristics of each type of trauma (e.g., sexual abuse, torture, war-related trauma, murder). Instead, this TIP provides an over­ view supported by examples. For more infor­ mation on several specific types of trauma, please refer to TIP 36, Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues (Center for Substance Abuse Treatment [CSAT], 2000b), TIP 25, Substance Abuse Treatment and Domestic Violence (CSAT, 1997b), TIP 51, Substance Abuse Treatment: Addressing the Specif ic Needs of Women (CSAT, 2009d), and the planned TIP, Reintegration-Related Behavioral Health Issues in Veterans and Military Families (Substance Abuse and Mental Health Services Administration [SAMHSA], planned f).

This TIP, Trauma-Informed Care in Behavioral Health Services, is guided by SAMHSA’s Stra­ tegic Initiatives described in Leading Change: A Plan for SAMHSA’s Roles and Actions 2011– 2014 (SAMHSA, 2011b). Specific to Strate­ gic Initiative #2, Trauma and Justice, this TIP addresses several goals, objectives, and actions outlined in this initiative by providing behav­ ioral health practitioners, supervisors, and ad­ ministrators with an introduction to culturally responsive TIC.

Specifically, the TIP presents fundamental concepts that behavioral health service provid­ ers can use to: • Become trauma aware and knowledgeable

about the impact and consequences of traumatic experiences for individuals, fami­ lies, and communities.

• Evaluate and initiate use of appropriate trauma-related screening and assessment tools.

• Implement interventions from a collabora­ tive, strengths-based approach, appreciating the resilience of trauma survivors.

• Learn the core principles and practices that reflect TIC.

• Anticipate the need for specific trauma- informed treatment planning strategies that support the individual’s recovery.

• Decrease the inadvertent retraumatization that can occur from implementing standard organizational policies, procedures, and in­ terventions with individuals, including cli­ ents and staff, who have experienced trauma or are exposed to secondary trauma.

• Evaluate and build a trauma-informed or­ ganization and workforce.

The consensus panelists, as well as other con­ tributors to this TIP, have all had experience as substance abuse and mental health counselors, prevention and peer specialists, supervisors, clinical directors, researchers, or administrators working with individuals, families, and

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Trauma-Informed Care in Behavioral Health Services

communities who have experienced trauma. The material presented in this TIP uses the wealth of their experience in addition to the available published resources and research relevant to this topic. Throughout the consen­ sus process, the panel members were mindful of the strengths and resilience inherent in in­ dividuals, families, and communities affected by trauma and the challenges providers face in addressing trauma and implementing TIC.

Structure of the TIP Using a TIC framework (Exhibit 1.1-1), this TIP provides information on key aspects of trauma, including what it is; its consequences; screening and assessment; effective

prevention, intervention, and treatment ap­ proaches; trauma recovery; the impact of trauma on service providers; programmatic and administrative practices; and trauma re­ sources.

Note: To produce a user-friendly but in­ formed document, the first two parts of the TIP include minimal citations. If you are in­ terested in the citations associated with topics covered in Parts 1 and 2, please consult the review of the literature provided in Part 3 (available online at http://store.samhsa.gov). Parts 1 and 2 are easily read and digested on their own, but it is highly recommended that you read the literature review as well.

Exhibit 1.1-1: TIC Framework in Behavioral Health Services—Sociocultural Perspective

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See Appendix C to read about the history of trauma and trauma

interventions.

Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective

What Is Trauma? According to SAMHSA’s Trauma and Justice Strategic Initiative, “trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physi­ cally or emotionally harmful or threatening and that has lasting adverse effects on the in­ dividual’s functioning and physical, social, emotional, or spiritual well-being” (SAMHSA, 2012, p. 2). Trauma can affect people of every race, ethnicity, age, sexual ori­ entation, gender, psychosocial background, and geographic region. A traumatic experience can be a single event, a series of events, and/or a chronic condition (e.g., childhood neglect, domestic violence). Traumas can affect indi­ viduals, families, groups, communities, specific cultures, and generations. It generally over­ whelms an individual’s or community’s re­ sources to cope, and it often ignites the “fight, flight, or freeze” reaction at the time of the event(s). It frequently produces a sense of fear, vulnerability, and helplessness.

Often, traumatic events are unex­ pected. Individuals may experience the traumatic

event directly, witness an event, feel threat­ ened, or hear about an event that affects someone they know. Events may be human- made, such as a mechanical error that causes a disaster, war, terrorism, sexual abuse, or vio­ lence, or they can be the products of nature (e.g., flooding, hurricanes, tornadoes). Trauma can occur at any age or developmental stage, and often, events that occur outside expected life stages are perceived as traumatic (e.g., a child dying before a parent, cancer as a teen, personal illness, job loss before retirement).

It is not just the event itself that determines whether something is traumatic, but also the

individual’s experience of the event. Two peo­ ple may be exposed to the same event or series of events but experience and interpret these events in vastly different ways. Various biopsychosocial and cultural factors influence an individual’s immediate response and long­ term reactions to trauma. For most, regardless of the severity of the trauma, the immediate or enduring effects of trauma are met with resili­ ence—the ability to rise above the circum­ stances or to meet the challenges with fortitude.

For some people, reactions to a traumatic event are temporary, whereas others have pro­ longed reactions that move from acute symp­ toms to more severe, prolonged, or enduring mental health consequences (e.g., posttrau­ matic stress and other anxiety disorders, sub­ stance use and mood disorders) and medical problems (e.g., arthritis, headaches, chronic pain). Others do not meet established criteria for posttraumatic stress or other mental disor­ ders but encounter significant trauma-related symptoms or culturally expressed symptoms of trauma (e.g., somatization, in which psycho­ logical stress is expressed through physical concerns). For that reason, even if an individu­ al does not meet diagnostic criteria for trauma-related disorders, it is important to recognize that trauma may still affect his or her life in significant ways. For more infor­ mation on traumatic events, trauma character­ istics, traumatic stress reactions, and factors that heighten or decrease the impact of trau­ ma, see Part 1, Chapter 2, “Trauma Aware­ ness,” and Part 1, Chapter 3, “Understanding the Impact of Trauma.”

Trauma Matters in Behavioral Health Services The past decade has seen an increased focus on the ways in which trauma, psychological distress, quality of life, health, mental illness,

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Two Influential Studies That Set the Stage for the Development of TIC

The Adverse Childhood Experiences Study (Centers for Disease Control and Prevention, 2013) was a large epidemiological study involving more than 17,000 individuals from United States; it analyzed the long-term effects of childhood and adolescent traumatic experiences on adult health risks, mental health, healthcare costs, and life expectancy.

The Women, Co-Occurring Disorders and Violence Study (SAMHSA, 2007) was a large multisite study focused on the role of interpersonal and other traumatic stressors among women; the interre­ latedness of trauma, violence, and co-occurring substance use and mental disorders; and the incorpo­ ration of trauma-informed and trauma-specific principles, models, and services.

Trauma-Informed Care in Behavioral Health Services

and substance abuse are linked. With the at­ tacks of September 11, 2001, and other acts of terror, the wars in Iraq and Afghanistan, disas­ trous hurricanes on the Gulf Coast, and sexual abuse scandals, trauma has moved to the fore­ front of national consciousness.

Trauma was once considered an abnormal experience. However, the first National Comorbidity Study established how prevalent traumas were in the lives of the general popu­ lation of the United States. In the study, 61 percent of men and 51 percent of women re­ ported experiencing at least one trauma in their lifetime, with witnessing a trauma, being involved in a natural disaster, and/or experi­ encing a life-threatening accident ranking as the most common events (Kessler et al., 1999). In Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions, 71.6 percent of the sample reported witnessing trauma, 30.7 percent experienced a trauma that resulted in injury, and 17.3 percent expe­ rienced psychological trauma (El-Gabalawy, 2012). For a thorough review of the impact of trauma on quality of life and health and among individuals with mental and substance use disorders, refer to Part 3 of this TIP, the online literature review.

Rationale for TIC Integrating TIC into behavioral health ser­ vices provides many benefits not only for cli­ ents, but also for their families and communities, for behavioral health service

organizations, and for staff. Trauma-informed services bring to the forefront the belief that trauma can pervasively affect an individual’s well-being, including physical and mental health. For behavioral health service providers, trauma-informed practice offers many oppor­ tunities. It reinforces the importance of ac­ quiring trauma-specific knowledge and skills to meet the specific needs of clients; of recog­ nizing that individuals may be affected by trauma regardless of its acknowledgment; of understanding that trauma likely affects many clients who are seeking behavioral health ser­ vices; and of acknowledging that organizations and providers can retraumatize clients through standard or unexamined policies and practices. TIC stresses the importance of addressing the client individually rather than applying gen­ eral treatment approaches.

TIC provides clients more opportunities to engage in services that reflect a compassionate perspective of their presenting problems. TIC can potentially provide a greater sense of safe­ ty for clients who have histories of trauma and a platform for preventing more serious conse­ quences of traumatic stress (Fallot & Harris, 2001). Although many individuals may not identify the need to connect with their histo­ ries, trauma-informed services offer clients a chance to explore the impact of trauma, their strengths and creative adaptations in manag­ ing traumatic histories, their resilience, and the relationships among trauma, substance use, and psychological symptoms.

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Advice to Counselors: The Importance of TIC

The history of trauma raises various clinical issues. Many counselors do not have extensive training in treating trauma or offering trauma-informed services and may be uncertain of how to respond to clients’ trauma-related reactions or symptoms. Some counselors have experienced traumas them­ selves that may be triggered by clients’ reports of trauma. Others are interested in helping clients with trauma but may unwittingly cause harm by moving too deeply or quickly into trauma material or by discounting or disregarding a client’s report of trauma. Counselors must be aware of trauma- related symptoms and disorders and how they affect clients in behavioral health treatment.

Counselors with primary treatment responsibilities should also have an understanding of how to rec­ ognize trauma-related reactions, how to incorporate treatment interventions for trauma-related symptoms into clients’ treatment plans, how to help clients build a safety net to prevent further trauma, how to conduct psychoeducational interventions, and when to make treatment referrals for further evaluations or trauma-specific treatment services. All treatment staff should recognize that traumatic stress symptoms or trauma-related disorders should not preclude an individual from mental health or substance abuse treatment and that all co-occurring disorders need to be addressed on some level in the treatment plan and setting. For example, helping a client in substance abuse treat­ ment gain control over trauma-related symptoms can greatly improve the client’s chances of sub­ stance abuse recovery and lower the possibility of relapse (Farley, Golding, Young, Mulligan, & Minkoff, 2004; Ouimette, Ahrens, Moos, & Finney, 1998). In addition, assisting a client in achieving abstinence builds a platform upon which recovery from traumatic stress can proceed.

Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective

Implementing trauma-informed services can improve screening and assessment processes, treatment planning, and placement while also decreasing the risk for retraumatization. The implementation may enhance communication between the client and treatment provider, thus decreasing risks associated with misun­ derstanding the client’s reactions and present­ ing problems or underestimating the need for appropriate referrals for evaluation or trauma- specific treatment. Organizational investment in developing or improving trauma-informed services may also translate to cost effective­ ness, in that services are more appropriately matched to clients from the outset. TIC is an essential ingredient in organizational risk management; it ensures the implementation of decisions that will optimize therapeutic out­ comes and minimize adverse effects on the client and, ultimately, the organization. A key principle is the engagement of community, clients, and staff. Clients and staff are more apt to be empowered, invested, and satisfied if they are involved in the ongoing development and delivery of trauma-informed services.

An organization also benefits from work de­ velopment practices through planning for, attracting, and retaining a diverse workforce of individuals who are knowledgeable about trauma and its impact. Developing a trauma- informed organization involves hiring and promotional practices that attract and retain individuals who are educated and trained in trauma-informed practices on all levels of the organization, including board as well as peer support appointments. Trauma-informed or­ ganizations are invested in their staff and adopt similar trauma-informed principles, including establishing and providing ongoing support to promote TIC in practice and in addressing secondary trauma and implement­ ing processes that reinforce the safety of the staff. Even though investing in a trauma- informed workforce does not necessarily guar­ antee trauma-informed practices, it is more likely that services will evolve more profi­ ciently to meet client, staff, and community needs.

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Trauma-Informed Care in Behavioral Health Services

Trauma and Substance Use Disorders Many people who have substance use disor­ ders have experienced trauma as children or adults (Koenen, Stellman, Sommer, & Stellman, 2008; Ompad et al., 2005). Sub­ stance abuse is known to predispose people to higher rates of traumas, such as dangerous situations and accidents, while under the in­ fluence (Stewart & Conrod, 2003; Zinzow, Resnick, Amstadter, McCauley, Ruggiero, & Kilpatrick, 2010) and as a result of the lifestyle associated with substance abuse (Reynolds et al., 2005). In addition, people who abuse sub­ stances and have experienced trauma have worse treatment outcomes than those without histories of trauma (Driessen et al., 2008; Najavits et al., 2007). Thus, the process of re­ covery is more difficult, and the counselor’s role is more challenging, when clients have histories of trauma. A person presenting with both trauma and substance abuse issues can have a variety of other difficult life problems that commonly accompany these disorders, such as other psychological symptoms or men­ tal disorders, poverty, homelessness, increased risk of HIV and other infections, and lack of social support (Mills, Teesson, Ross, & Peters, 2006; Najavits, Weiss, & Shaw, 1997). Many individuals who seek treatment for substance use disorders have histories of one or more traumas. More than half of women seeking substance abuse treatment report one or more lifetime traumas (Farley, Golding, Young, Mulligan, & Minkoff, 2004; Najavits et al., 1997), and a significant number of clients in inpatient treatment also have subclinical traumatic stress symptoms or posttraumatic stress disorder (PTSD; Falck, Wang, Siegal, &

Carlson, 2004; Grant et al., 2004; Reynolds et al., 2005).

Trauma and Mental Disorders People who are receiving treatment for severe mental disorders are more likely to have histo­ ries of trauma, including childhood physical and sexual abuse, serious accidents, homeless­ ness, involuntary psychiatric hospitalizations, drug overdoses, interpersonal violence, and other forms of violence. Many clients with severe mental disorders meet criteria for PTSD; others with serious mental illness who have histories of trauma present with psycho­ logical symptoms or mental disorders that are commonly associated with a history of trauma, including anxiety symptoms and disorders, mood disorders (e.g., major depression, dys­ thymia, bipolar disorder; Mueser et al., 2004), impulse control disorders, and substance use disorders (Kessler, Chiu, Demler, & Walters, 2005).

Traumatic stress increases the risk for mental illness, and findings suggest that traumatic stress increases the symptom severity of men­ tal illness (Spitzer, Vogel, Barnow, Freyberger & Grabe, 2007). These findings propose that traumatic stress plays a significant role in per­ petuating and exacerbating mental illness and suggest that trauma often precedes the devel­ opment of mental disorders. As with trauma and substance use disorders, there is a bidirec­ tional relationship; mental illness increases the risk of experiencing trauma, and trauma in­ creases the risk of developing psychological symptoms and mental disorders. For a more comprehensive review of the interactions among traumatic stress, mental illness, and substance use disorders, refer to Part 3 of this TIP, the online literature review.

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Advice to Counselors: Implementing Trauma-Informed Services

Recognizing that trauma affects a majority of clients served within public health systems, the National Center for Trauma-Informed Care (NCTIC) has sought to establish a comprehensive framework to guide systems of care in the development of trauma-informed services. If a system or program is to support the needs of trauma survivors, it must take a systematic approach that offers trauma-specific diagnostic and treatment services, as well as a trauma-informed environment that is able to sustain such services, while fostering positive outcomes for the clients it serves. NCTIC also offers technical assistance in the implementation of trauma-informed services. For specific administrative information on TIC implementation, refer to Part 2, Chapters 1 and 2, of this TIP.

“A program, organization, or system that is trauma -informed realizes the widespread impact of trauma and under -stands poten – tial paths for healing; recognizes the signs and symptoms of trauma in staff, clients, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures,

practices, and settings.”

(SAMHSA, 2012, p. 4)

Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective

Trauma-Informed Intervention and Treatment Principles TIC is an intervention and organizational approach that focuses on how trauma may affect an individual’s life and his or her re­ sponse to behavioral health services from pre­ vention through treatment. There are many definitions of TIC and various models for incorporating it across organizations, but a “trauma-informed approach incorporates three key elements: (1) realizing the prevalence of trauma; (2) recognizing how trauma affects all individuals involved with the program, organi­ zation, or system, including its own workforce; and (3) responding by putting this knowledge into practice” (SAMHSA, 2012, p. 4).

TIC begins with the first contact a person has with an agency; it requires all staff members (e.g., receptionists, intake personnel, direct care staff, supervisors, administrators, peer supports, board members) to recognize that the individual’s experience of trauma can greatly influence his or her receptivity to and engagement with services, interactions with staff and clients, and responsiveness to pro­ gram guidelines, practices, and interventions. TIC includes program policies, procedures, and practices to protect the vulnerabilities of those who have experienced trauma and those who provide trauma-related services. TIC is created through a supportive environment and by redesigning organizational practices, with

consumer participation, to prevent practices that could be retraumatizing (Harris & Fallot, 2001c; Hopper et al., 2010). The ethical prin­ ciple, “first, do no harm,” resonates strongly in the application of TIC.

TIC involves a commitment to building com­ petence among staff and establishing pro­ grammatic standards and clinical guidelines that support the delivery of trauma-sensitive services. It encompasses recruiting, hiring, and retaining competent staff; involving consum­ ers, trauma survivors, and peer support special­ ists in the planning, implementation, and evaluation of trauma-informed services; devel­ oping collaborations across service systems to streamline referral processes, thereby securing trauma-specific services when appropriate; and building a continuity of TIC as consumers move from one system or service to the next. TIC involves reevaluating each service deliv­ ery component through a trauma-aware lens.

The principles described in the following sub­ sections serve as the TIP’s conceptual

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“Trauma -informed care embraces a per­ spective that highlights adaptation over

symptoms and resilience over pathology.”

(Elliot, Bjelajac, Fallot, Markoff, & Reed, 2005, p. 467)

Trauma-Informed Care in Behavioral Health Services

framework. These principles comprise a com­ pilation of resources, including research, theo­ retical papers, commentaries, and lessons learned from treatment facilities. Key elements are outlined for each principle in providing services to clients affected by trauma and to populations most likely to incur trauma. Although these principles are useful across all prevention and intervention services, settings, and populations, they are of the utmost im­ portance in working with people who have had traumatic experiences.

Promote Trauma Awareness and Understanding Foremost, a behavioral health service provider must recognize the prevalence of trauma and its possible role in an individual’s emotional, behavioral, cognitive, spiritual, and/or physical development, presentation, and well-being. Being vigilant about the prevalence and po­ tential consequences of traumatic events among clients allows counselors to tailor their presentation styles, theoretical approaches, and intervention strategies from the outset to plan for and be responsive to clients’ specific needs. Although not every client has a history of trauma, those who have substance use and mental disorders are more likely to have expe­ rienced trauma. Being trauma aware does not mean that you must assume everyone has a history of trauma, but rather that you antici­ pate the possibility from your initial contact and interactions, intake processes, and screen­ ing and assessment procedures.

Even the most standard behavioral health practices can retraumatize an individual ex­

posed to prior traumatic experiences if the provider implements them without recogniz­ ing or considering that they may do harm. For example, a counselor might develop a treat­ ment plan recommending that a female cli­ ent—who has been court mandated to substance abuse treatment and was raped as an adult—attend group therapy, but without con­ sidering the implications, for her, of the fact that the only available group at the facility is all male and has had a low historical rate of female participation. Trauma awareness is an essential strategy for preventing this type of retraumatization; it reinforces the need for providers to reevaluate their usual practices.

Becoming trauma aware does not stop with the recognition that trauma can affect clients; instead, it encompasses a broader awareness that traumatic experiences as well as the im­ pact of an individual’s trauma can extend to significant others, family members, first re­ sponders and other medical professionals, be­ havioral health workers, broader social networks, and even entire communities. Fami­ ly members frequently experience the trau­ matic stress reactions of the individual family member who was traumatized (e.g., angry outbursts, nightmares, avoidant behavior, other symptoms of anxiety, overreactions or underre­ actions to stressful events). These repetitive experiences can increase the risk of secondary trauma and symptoms of mental illness among the family, heighten the risk for externalizing and internalizing behavior among children (e.g., bullying others, problems in social rela­ tionships, health-damaging behaviors), in­ crease children’s risk for developing posttraumatic stress later in life, and lead to a greater propensity for traumatic stress reac­ tions across generations of the family. Hence, prevention and intervention services can pro­ vide education and age-appropriate program­ ming tailored to develop coping skills and support systems.

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Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective

So too, behavioral health service providers can be influenced by exposure to trauma-related affect and content when working with clients. A trauma-aware workplace supports supervi­ sion and program practices that educate all direct service staff members on secondary trauma, encourages the processing of trauma- related content through participation in peer- supported activities and clinical supervision, and provides them with professional develop­ ment opportunities to learn about and engage in effective coping strategies that help prevent secondary trauma or trauma-related symp­ toms. It is important to generate trauma awareness in agencies through education across services and among all staff members who have any direct or indirect contact with clients (including receptionists or intake and admission personnel who engage clients for the first time within the agency). Agencies can maintain a trauma-aware environment through ongoing staff training, continued su­ pervisory and administrative support, collabo­ rative (i.e., involving consumer participation) trauma-responsive program design and im­ plementation, and organizational policies and practices that reflect accommodation and flex­ ibility in attending to the needs of clients af­ fected by trauma.

Recognize That Trauma-Related Symptoms and Behaviors Originate From Adapting to Traumatic Experiences A trauma-informed perspective views trauma- related symptoms and behaviors as an individ­ ual’s best and most resilient attempt to man­ age, cope with, and rise above his or her experience of trauma. Some individuals’ means of adapting and coping have produced little difficulty; the coping and adaptive strategies of others have worked in the past but are not working as well now. Some people have diffi­

culties in one area of life but have effectively negotiated and functioned in other areas.

Individuals who have survived trauma vary widely in how they experience and express traumatic stress reactions.Traumatic stress reactions vary in severity; they are often meas­ ured by the level of impairment or distress that clients report and are determined by the mul­ tiple factors that characterize the trauma itself, individual history and characteristics, devel­ opmental factors, sociocultural attributes, and available resources. The characteristics of the trauma and the subsequent traumatic stress reactions can dramatically influence how indi­ viduals respond to the environment, relation­ ships, interventions, and treatment services, and those same characteristics can also shape the assumptions that clients/consumers make about their world (e.g., their view of others, sense of safety), their future (e.g., hopefulness, fear of a foreshortened future), and themselves (e.g., feeling resilient, feeling incompetent in regulating emotions). The breadth of these effects may be observable or subtle.

Once you become aware of the significance of traumatic experiences in clients’ lives and begin to view their presentation as adaptive, your identification and classification of their presenting symptoms and behaviors can shift from a “pathology” mindset (i.e., defining cli­ ents strictly from a diagnostic label, implying that something is wrong with them) to one of resilience—a mindset that views clients’ pre­ senting difficulties, behaviors, and emotions as responses to surviving trauma. In essence, you will come to view traumatic stress reactions as normal reactions to abnormal situations. In embracing the belief that trauma-related reac­ tions are adaptive, you can begin relationships with clients from a hopeful, strengths-based stance that builds upon the belief that their responses to traumatic experiences reflect creativity, self-preservation, and determination.

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Trauma-Informed Care in Behavioral Health Services

This will help build mutual and collaborative therapeutic relationships, help clients identify what has worked and has not worked in their attempts to deal with the aftermath of trauma from a nonjudgmental stance, and develop intervention and coping strategies that are more likely to fit their strengths and resources. This view of trauma prevents further retrau­ matization by not defining traumatic stress reactions as pathological or as symptoms of pathology.

View Trauma in the Context of Individuals’ Environments Many factors contribute to a person’s response to trauma, whether it is an individual, group, or community-based trauma. Individual at­ tributes, developmental factors (including pro­ tective and risk factors), life history, type of trauma, specific characteristics of the trauma, amount and length of trauma exposure, cultur­ al meaning of traumatic events, number of losses associated with the trauma, available resources (internal and external, such as coping skills and family support), and community reactions are a few of the determinants that influence a person’s responses to trauma across time. Refer to the “View Trauma Through a Sociocultural Lens” section later in this chap­ ter for more specific information highlighting the importance of culture in understanding and treating the effects of trauma.

Trauma cannot be viewed narrowly; instead, it needs to be seen through a broader lens—a contextual lens integrating biopsychosocial, interpersonal, community, and societal (the degree of individualistic or collective cultural values) characteristics that are evident preced­ ing and during the trauma, in the immediate and sustained response to the event(s), and in the short- and long-term effects of the trau­ matic event(s), which may include housing availability, community response, adherence to

or maintenance of family routines and struc­ ture, and level of family support.

To more adequately understand trauma, you must also consider the contexts in which it occurred. Understanding trauma from this angle helps expand the focus beyond individu­ al characteristics and effects to a broader sys­ temic perspective that acknowledges the influences of social interactions, communities, governments, cultures, and so forth, while also examining the possible interactions among those various influences. Bronfenbrenner’s (1979) and Bronfenbrenner and Ceci’s (1994) work on ecological models sparked the devel­ opment of other contextual models. In recent years, the social-ecological framework has been adopted in understanding trauma, in implementing health promotion and other prevention strategies, and in developing treat­ ment interventions (Centers for Disease Con­ trol and Prevention, 2009). Here are the three main beliefs of a social-ecological approach (Stokols, 1996): • Environmental factors greatly influence

emotional, physical, and social well-being. • A fundamental determinant of health ver­

sus illness is the degree of fit between indi­ viduals’ biological, behavioral, and sociocultural needs and the resources avail­ able to them.

• Prevention, intervention, and treatment approaches integrate a combination of strategies targeting individual, interperson­ al, and community systems.

This TIP uses a social-ecological model to explore trauma and its effects (Exhibit 1.1-2). The focus of this model is not only on nega­ tive attributes (risk factors) across each level, but also on positive ingredients (protective factors) that protect against or lessen the im­ pact of trauma. This model also guides the inclusion of certain targeted interventions in this text, including selective and indicated

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Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective

Exhibit 1.1-2: A Social-Ecological Model for Understanding Trauma and Its Effects

prevention activities. In addition, culture, de­ velopmental processes (including the devel­ opmental stage or characteristics of the individual and/or community), and the specific era when the trauma(s) occurred can signifi­ cantly influence how a trauma is perceived and processed, how an individual or community engages in help-seeking, and the degree of accessibility, acceptability, and availability of individual and community resources.

Depending on the developmental stage and/or processes in play, children, adolescents, and adults will perceive, interpret, and cope with traumatic experiences differently. For example, a child may view a news story depicting a traumatic event on television and believe that

the trauma is recurring every time they see the scene replayed. Similarly, the era in which one lives and the timing of the trauma can greatly influence an individual or community re­ sponse. Take, for example, a pregnant woman who is abusing drugs and is wary of receiving medical treatment after being beaten in a do­ mestic dispute. She may fear losing her chil­ dren or being arrested for child neglect. Even though a number of States have adopted poli­ cies focused on the importance of treatment for pregnant women who are abusing drugs and of the accessibility of prenatal care, other States have approached this issue from a crim­ inality standpoint (e.g., with child welfare and criminal laws) in the past few decades. Thus, the traumatic event’s timing is a significant

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Trauma-Informed Care in Behavioral Health Services

component in understanding the context of trauma and trauma-related responses.

The social-ecological model depicted in Ex­ hibit 1.1-2 provides a systemic framework for looking at individuals, families, and communi­ ties affected by trauma in general; it highlights the bidirectional influence that multiple con­ texts can have on the provision of behavioral health services to people who have experi­ enced trauma (see thin arrow). Each ring rep­ resents a different system (refer to Exhibit 1.1-3 for examples of specific factors within each system). The innermost ring represents the individual and his or her biopsychosocial characteristics. The “Interpersonal” circle em­ bodies all immediate relationships including family, friends, peers, and others. The “Com­ munity/Organizational” band represents social support networks, workplaces, neighborhoods, and institutions that directly influence the individual and his/her relationships. The “So­ cietal” circle signifies the largest system—State

and Federal policies and laws, such as eco­ nomic and healthcare policies, social norms, governmental systems, and political ideologies. The outermost ring, “Period of Time in His­ tory,” reflects the significance of the period of time during which the event occurred; it influ­ ences each other level represented in the circle. For example, making a comparison of society’s attitudes and responses to veterans’ homecom­ ings across different wars and conflicts through time shows that homecoming envi­ ronments can have either a protective or a negative effect on healing from the psycholog­ ical and physical wounds of war, depending on the era in question. The thicker arrows in the figure represent the key influences of culture, developmental characteristics, and the type and characteristics of the trauma. All told, the context of traumatic events can significantly influence both initial and sustained responses to trauma; treatment needs; selection of pre­ vention, intervention, and other treatment

Exhibit 1.1-3: Understanding the Levels Within the Social-Ecological Model of Trauma and Its Effects

Individual Factors

Interpersonal Factors

Community and Organizational

Factors Societal Factors

Cultural and Developmen­

tal Factors

Period of Time in History

Age, biophysi­ cal state, men­ tal health status, temper­ ament and other personal­ ity traits, edu­ cation, gender, coping styles, socioeconomic status

Family, peer, and significant other interac­ tion patterns, parent/family mental health, parents’ histo­ ry of trauma, social network

Neighborhood quality, school system and/or work environ­ ment, behavioral health system quality and acces­ sibility, faith- based settings, transportation availability, com­ munity socioeco­ nomic status, community em­ ployment rates

Laws, State and Federal economic and social policies, media, societal norms, judicial system

Collective or individualistic cultural norms, eth­ nicity, cultural subsystem norms, cogni­ tive and mat­ urational development

Societal atti­ tudes related to military service mem­ bers’ home­ comings, changes in diagnostic understanding between DSM­ III-R* and DSM-5**

*Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (American Psychiatric Association [APA], 1987)

**Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (APA, 2013a)

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Marisol is a 28-year-old Latina woman working as a barista at a local coffee shop. One evening, she was driving home in the rain when a drunk driver crossed into her lane and hit her head on. Marisol remained conscious as she waited to be freed from the car and was then transported to the hospital. She sustained fractures to both legs. Her recovery involved two surgeries and nearly 6 months of rehabilitation, including initial hospitalization and outpatient physical therapy.

She described her friends and family as very supportive, saying that they often foresaw what she needed before she had to ask. She added that she had an incredible sense of gratitude for her em­ ployer and coworkers, who had taken turns visiting and driving her to appointments. Although she was able to return to work after 9 months, Marisol continued experiencing considerable distress about her inability to sleep well, which started just after the accident. Marisol describes repetitive dreams and memories of waiting to be transported to the hospital after the crash. The other driver was charged with driving under the influence (DUI), and it was reported that he had been convicted two other times for a DUI misdemeanor.

Answering the following questions will help you see how the different levels of influence affect the impact and outcome of the traumatic event Marisol experienced, as well as her responses to that event: 1. Based on the limited information provided in this illustration, how might Marisol’s personality

affect the responses of her family and friends, her coworkers, and the larger community? 2. In what ways could Marisol’s ethnic and cultural background influence her recovery? 3. What societal factors could play a role in the car crash itself and the outcomes for Marisol and

the other driver?

Explore the influence of the period of time in history during which the scenario occurs—compare the possible outcomes for both Marisol and the other driver if the crash occurred 40 years ago versus in the present day.

Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective

strategies; and ways of providing hope and promoting recovery.

Minimize the Risk of Retraumatization or Replicating Prior Trauma Dynamics Trauma-informed treatment providers acknowledge that clients who have histories of trauma may be more likely to experience par­ ticular treatment procedures and practices as negative, reminiscent of specific characteristics of past trauma or abuse, or retraumatizing— feeling as if the past trauma is reoccurring or as if the treatment experience is as dangerous and unsafe as past traumas. For instance, cli­ ents may express feelings of powerlessness or being trapped if they are not actively involved in treatment decisions; if treatment processes or providers mirror specific behavior from the

clients’ past experiences with trauma, they may voice distress or respond in the same way as they did to the original trauma. Among the potentially retraumatizing elements of treat­ ment are seclusion or “time-out” practices that isolate individuals, mislabeling client symp­ toms as personality or other mental disorders rather than as traumatic stress reactions, in­ teractions that command authority, treatment assignments that could humiliate clients (such as asking a client to wear a sign in group that reflects one of their treatment issues, even if the assignment centers on positive attributes of the client), confronting clients as resistant, or presenting treatment as conditional upon conformity to the provider’s beliefs and defini­ tions of issues.

Clients’ experiences are unique to the specific traumas they have faced and the surrounding

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How often have you heard “We aren’t equipped to handle trauma” or “We don’t have time to deal with reactions that surface if traumatic experiences are discussed in treatment” from counselors and administrators in behavioral health services? For agencies, staff members, and clients, these state­ ments present many difficulties and unwanted outcomes. For a client, such comments may replicate his or her earlier encounters with others (including family, friends, and previous behavioral health professionals) who had difficulty acknowledging or talking about traumatic experiences with him or her. A hands-off approach to trauma can also reinforce the client’s own desire to avoid such discus­ sions. Even when agencies and staff are motivated in these sentiments by a good intention—to con­ tain clients’ feelings of being overwhelmed—such a perspective sends strong messages to clients that their experiences are not important, that they are not capable of handling their trauma- associated feelings, and that dealing with traumatic experiences is simply too dangerous. Statements like these imply that recovery is not possible and provide no structured outlet to address memories of trauma or traumatic stress reactions.

Nevertheless, determining how and when to address traumatic stress in behavioral health services can be a real dilemma, especially if there are no trauma-specific philosophical, programmatic, or procedural processes in place. For example, it is difficult to provide an appropriate forum for a client to address past traumas if no forethought has been given to developing interagency and intra- agency collaborations for trauma-specific services. By anticipating the need for trauma-informed services and planning ahead to provide appropriate services to people who are affected by trauma, behavioral health service providers and program administrators can begin to develop informed inter­ vention strategies that send a powerful, positive message: • Both clients and providers can competently manage traumatic experiences and reactions. • Providers are interested in hearing clients’ stories and attending to their experiences. • Recovery is possible.

Trauma-Informed Care in Behavioral Health Services

circumstances before, during, and after that trauma, so remember that even seemingly safe and standard treatment policies and proce­ dures, including physical plant operations (e.g., maintenance, grounds, fire and safety proce­ dures), may feel quite the contrary for a client if one or more of those elements is reminiscent of his or her experience of trauma in some way. Examples include having limited privacy or personal space, being interviewed in a room that feels too isolating or confining, undergo­ ing physical examination by a medical profes­ sional of the same sex as the client’s previous perpetrator of abuse, attending a group session in which another client expresses anger appro­ priately in a role play, or being directed not to talk about distressing experiences as a means of deescalating traumatic stress reactions.

Although some treatment policies or proce­ dures are more obviously likely to solicit dis­

tress than others, all standard practices should be evaluated for their potential to retraumatize a client; this cannot be done without knowing the specific features of the individual’s history of trauma. Consider, for instance, a treatment program that serves meals including entrees that combine more than one food group. Your client enters this program and refuses to eat most of the time; he expresses anger toward dietary staff and claims that food choices are limited. You may initially perceive your cli­ ent’s refusal to eat or to avoid certain foods as an eating disorder or a behavioral problem. However, a trauma-aware perspective might change your assumptions; consider that this client experienced neglect and abuse sur­ rounding food throughout childhood (his mother forced him to eat meals prepared by combining anything in the refrigerator and cooking them together).

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From the first time you provide outpatient counseling to Mike, you explain that he can call an agency number that will put him in direct contact with someone who can provide further assistance or sup­ port if he has emotional difficulty after the session or after agency hours. However, when he attempts to call one night, no one is available despite what you’ve described. Instead, Mike is directed by an operator to either use his local emergency room if he perceives his situation to be a crisis or to wait for someone on call to contact him. The inconsistency between what you told him in the session and what actually happens when he calls makes Mike feel unsafe and vulnerable.

Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective

As a treatment provider, you cannot consist­ ently predict what may or may not be upset­ ting or retraumatizing to clients. Therefore, it is important to maintain vigilance and an atti­ tude of curiosity with clients, inquiring about the concerns that they express and/or present in treatment. Remember that certain behaviors or emotional expressions can reflect what has happened to them in the past.

Foremost, a trauma-informed approach begins with taking practical steps to reexamine treat­ ment strategies, program procedures, and or­ ganizational polices that could solicit distress or mirror common characteristics of traumatic experiences (loss of control, being trapped, or feeling disempowered). To better anticipate the interplay between various treatment ele­ ments and the more idiosyncratic aspects of a particular client’s trauma history, you can: • Work with the client to learn the cues he or

she associates with past trauma. • Obtain a good history. • Maintain a supportive, empathetic, and

collaborative relationship. • Encourage ongoing dialog. • Provide a clear message of availability and

accessibility throughout treatment.

In sum, trauma-informed providers anticipate and respond to potential practices that may be perceived or experienced as retraumatizing to clients; they are able to forge new ways to re­ spond to specific situations that trigger a trauma-related response, and they can provide clients with alternative ways of engaging in a particularly problematic element of treatment.

Create a Safe Environment The need to create a safe environment is not new to providers; it involves an agency-wide effort supported by effective policies and pro­ cedures. However, creating safety within a trauma-informed framework far exceeds the standard expectations of physical plant safety (e.g., facility, environmental, and space-related concerns), security (of staff members, clients, and personal property), policies and proce­ dures (including those specific to seclusion and restraint), emergency management and disaster planning, and adherence to client rights. Providers must be responsive and adapt the environment to establish and support cli­ ents’ sense of physical and emotional safety.

Beyond anticipating that various environ­ mental stimuli within a program may generate strong emotions and reactions in a trauma survivor (e.g., triggers such as lighting, access to exits, seating arrangements, emotionality within a group, or visual or auditory stimuli) and implementing strategies to help clients cope with triggers that evoke their experiences with trauma, other key elements in establish­ ing a safe environment include consistency in client interactions and treatment processes, following through with what has been re­ viewed or agreed upon in sessions or meetings, and dependability. Mike’s case illustration de­ picts ways in which the absence of these key elements could erode a client’s sense of safety during the treatment process.

Neither providers nor service processes are always perfect. Sometimes, providers

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Case Illustration: Jane

Jane, a newly hired female counselor, had a nephew who took his own life. The program that hired her was short of workers at the time; therefore, Jane did not have an opportunity to engage suffi­ ciently in orientation outside of reviewing the policies and procedure manual. In an attempt to pre­ sent well to her new employer and supervisor, she readily accepted client assignments without considering her recent loss. By not immersing herself in the program’s perspective and policies on staff well-being, ethical and clinical considerations in client assignments, and how and when to seek supervision, Jane failed to engage in the practices, heavily supported by the agency, that promoted safety for herself and her clients. Subsequently, she felt emotionally overwhelmed at work and would often abruptly request psychiatric evaluation for clients who expressed any feelings of hopelessness out of sheer panic that they would attempt suicide.

Trauma-Informed Care in Behavioral Health Services

unintentionally relay information inaccurately or inconsistently to clients or other staff mem­ bers; other times, clients mishear something, or extenuating circumstances prevent provid­ ers from responding as promised. Creating safety is not about getting it right all the time; it’s about how consistently and forthrightly you handle situations with a client when cir­ cumstances provoke feelings of being vulnera­ ble or unsafe. Honest and compassionate communication that conveys a sense of han­ dling the situation together generates safety. It is equally important that safety extends be­ yond the client. Counselors and other behav­ ioral health staff members, including peer support specialists, need to be able to count on the agency to be responsive to and maintain their safety within the environment as well. By incorporating an organizational ethos that recognizes the importance of practices that promote physical safety and emotional well­ being, behavioral health staff members may be more likely to seek support and supervision when needed and to comply with clinical and programmatic practices that minimize risks for themselves and their clients.

Beyond an attitudinal promotion of safety, organizational leaders need to consider and create avenues of professional development and assistance that will give their staff the means to seek support and process distressing circumstances or events that occur within the agency or among their clientele, such as case

consultation and supervision, formal or infor­ mal processes to debrief service providers about difficult clinical issues, and referral pro­ cesses for client psychological evaluations and employee assistance for staff. Organizational practices are only effective if supported by unswerving trauma awareness, training, and education among staff. Jane’s case illustration shows the impact of a minor but necessary postponement in staff orientation for a new hire—not an unusual circumstance in behav­ ioral health programs that have heavy case­ loads and high staff turnover.

Identify Recovery From Trauma as a Primary Goal Often, people who initiate or are receiving mental health or substance abuse services don’t identify their experiences with trauma as a significant factor in their current challenges or problems. In part, this is because people who have been exposed to trauma, whether once or repeatedly, are generally reluctant to revisit it. They may already feel stuck in repetitive memories or experiences, which may add to their existing belief that any intervention will make matters worse or, at least, no better. For some clients, any introduction to their trauma- related memories or minor cues reminiscent of the trauma will cause them to experience strong, quick-to-surface emotions, supporting their belief that addressing trauma is danger­ ous and that they won’t be able to handle the

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Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective

emotions or thoughts that result from at­ tempting to do so. Others readily view their experiences of trauma as being in the past; as a result, they engage in distraction, dissociation, and/or avoidance (as well as adaptation) due to a belief that trauma has little impact on their current lives and presenting problems. Even individuals who are quite aware of the impact that trauma has had on their lives may still struggle to translate or connect how these events continue to shape their choices, behav­ iors, and emotions. Many survivors draw no connection between trauma and their mental health or substance abuse problems, which makes it more difficult for them to see the value of trauma-informed or trauma-specific interventions, such as creating safety, engaging in psychoeducation, enhancing coping skills, and so forth.

As a trauma-informed provider, it is important that you help clients bridge the gap between their mental health and substance-related is­ sues and the traumatic experiences they may have had. All too often, trauma occurs before substance use and mental disorders develop; then, such disorders and their associated symptoms and consequences create opportuni­ ties for additional traumatic events to occur. If individuals engage in mental health and sub­ stance abuse treatment without addressing the role that trauma has played in their lives, they are less likely to experience recovery in the long run. For example, a person with a history of trauma is more likely to have anxiety and depressive symptoms, use substances to self- medicate, and/or relapse after exposure to trauma-related cues. Thus, collaboration with­ in and between behavioral health agencies is necessary to make integrated, timely, trauma- specific interventions available from the be­ ginning to clients/consumers who engage in substance abuse and mental health services.

Support Control, Choice, and Autonomy Not every client who has experienced trauma and is engaged in behavioral health services wants, or sees the need for, trauma-informed or trauma-specific treatment. Clients may think that they’ve already dealt with their trauma adequately, or they may believe that the effects of past trauma cause minimal dis­ tress for them. Other clients may voice the same sentiments, but without conviction— instead using avoidant behavior to deter dis­ tressing symptoms or reactions. Still others may struggle to see the role of trauma in their presenting challenges, not connecting their past traumatic experiences with other, more current difficulties (e.g., using substances to self-medicate strong emotions). Simply the idea of acknowledging trauma-related experi­ ences and/or stress reactions may be too frightening or overwhelming for some clients, and others may fear that their reactions will be dismissed. On the other hand, some individu­ als want so much to dispense with their trau­ matic experiences and reactions that they hurriedly and repeatedly disclose their experi­ ences before establishing a sufficiently safe environment or learning effective coping strat­ egies to offset distress and other effects of re­ traumatization.

As these examples show, not everyone affected by trauma will approach trauma-informed services or recognize the impact of trauma in their lives in the same manner. This can be challenging to behavioral health service pro­ viders who are knowledgeable about the im­ pact of trauma and who perceive the importance of addressing trauma and its ef­ fects with clients. As with knowing that dif­ ferent clients may be at different levels of awareness or stages of change in substance abuse treatment services, you should acknowledge that people affected by trauma

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Trauma-Informed Care in Behavioral Health Services

present an array of reactions, various levels of trauma awareness, and different degrees of urgency in their need to address trauma.

Appreciating clients’ perception of their pre­ senting problems and viewing their responses to the impact of trauma as adaptive—even when you believe their methods of dealing with trauma to be detrimental—are equally important elements of TIC. By taking the time to engage with clients and understand the ways they have perceived, adjusted to, and responded to traumatic experiences, providers are more likely to project the message that clients possess valuable personal expertise and knowledge about their own presenting prob­ lems. This shifts the viewpoint from “Provid­ ers know best” to the more collaborative “Together, we can find solutions.”

How often have you heard from clients that they don’t believe they can handle symptoms that emerge from reexperiencing traumatic cues or memories? Have you ever heard clients state that they can’t trust themselves or their reactions, or that they never know when they are going to be triggered or how they are go­ ing to react? How confident would you feel about yourself if, at any time, a loud noise could initiate an immediate attempt to hide, duck, or dive behind something? Traumatic experiences have traditionally been described as exposure to events that cause intense fear, helplessness, horror, or feelings of loss of con­ trol. Participation in behavioral health services should not mirror these aspects of traumatic experience. Working collaboratively to facili­ tate clients’ sense of control and to maximize clients’ autonomy and choices throughout the treatment process, including treatment plan­ ning, is crucial in trauma-informed services.

For some individuals, gaining a sense of con­ trol and empowerment, along with under­ standing traumatic stress reactions, may be pivotal ingredients for recovery. By creating

opportunities for empowerment, counselors and other behavioral health service providers help reinforce, clients’ sense of competence, which is often eroded by trauma and pro­ longed traumatic stress reactions. Keep in mind that treatment strategies and procedures that prioritize client choice and control need not focus solely on major life decisions or treatment planning; you can apply such ap­ proaches to common tasks and everyday inter­ actions between staff and consumers. Try asking your clients some of the following questions (which are only a sample of the types of questions that could be useful): • What information would be helpful for us

to know about what happened to you? • Where/when would you like us to call you? • How would you like to be addressed? • Of the services I’ve described, which seem

to match your present concerns and needs? • From your experience, what responses from

others appear to work best when you feel overwhelmed by your emotions?

Likewise, organizations need to reinforce the importance of staff autonomy, choice, and sense of control. What resources can staff members access, and what choices are availa­ ble to them, in processing emotionally charged content or events in treatment? How often do administrators and supervisors seek out feed­ back on how to handle problematic situations (e.g., staff rotations for vacations, case consul­ tations, changes in scheduling)? Think about the parallel between administration and staff members versus staff members and clients; often, the same philosophy, attitudes, and behaviors conveyed to staff members by ad­ ministrative practices are mirrored in staff– client interactions. Simply stated, if staff members do not feel empowered, it will be a challenge for them to value the need for client empowerment. (For more information on administrative and workforce development issues, refer to Part 2, Chapters 1 and 2.)

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members cannot make decisions pertaining to interventions or involvement in community services autocratically; instead, they should develop trauma-informed, individualized care plans and/or treatment plans collaboratively with the client and, when appropriate, with family and caregivers. The nonauthoritarian approach that characterizes TIC views clients

Mina initially sought counseling after her husband was admitted to an intensive outpatient drug and alcohol program. She was self-referred for low-grade depression, resentment toward her spouse, and codependency. When asked to define “codependency” and how the term applied to her, she responded that she always felt guilty and responsible for everyone in her family and for events that occurred even when she had little or no control over them.

After the intake and screening process, she expressed interest in attending group sessions that fo­ cused primarily on family issues and substance abuse, wherein her presenting concerns could be explored. In addition to describing dynamics and issues relating to substance abuse and its impact on her marriage, she referred to her low mood as frozen grief. During treatment, she reluctantly began to talk about an event that she described as life changing: the loss of her father. The story began to unfold in group; her father, who had been 62 years old, was driving her to visit a cousin. During the ride, he had a heart attack and drove off the road. As the car came to stop in a field, she remembered calling 911 and beginning cardiopulmonary resuscitation while waiting for the ambu­ lance. She rode with the paramedics to the hospital, watching them work to save her father’s life; however, he was pronounced dead soon after arrival.

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