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Trauma Informed Care: Applications in Mental health and Substance Use Disorder Treatment


Trauma Informed Care: Applications in Mental health and Substance Use Disorder Treatment February 10, 2016 Andrea Winkler, LCSW, LCAS Duke University – PowerPoint PPT presentation

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Title: Trauma Informed Care: Applications in Mental health and Substance Use Disorder Treatment

Trauma Informed Care Applications in Mental
health and Substance Use Disorder Treatment
  • February 10, 2016
  • Andrea Winkler, LCSW, LCAS
  • Duke University

This product is supported by Florida Department
of Children and Families Substance Abuse and
Mental Health Program Office funding.
  1. Understand the nature and prevalence of trauma
    among mental health (MH) and substance use
    disorder (SUD) populations.
  2. Describe the need for trauma informed care in
    MH/SUD treatment settings and articulate 5
    general tenants of the approach.
  3. Identify existing screening tools and
    evidence-based practices for TIC in MH/SUD
  4. Consider the role of trauma and trauma informed
    care for special population groups.

  • A little bit about me
  • A little bit about you

  • A disordered psychic or behavioral state
    resulting from mental or emotional stress or
    physical injury. Merriam-Webster Dictionary
  • An extremely distressing experience that causes
    severe emotional shock and may have long-lasting
    psychological effects.
  • Encarta Dictionary

Trauma via DSM-5
  • Exposure to actual or threatened death, serious
    injury, or sexual violence via
  • Direct exposure
  • Witnessing the event as it occurred to others
  • Learning that the event occurred to a close
    family member or friend (if death, must have been
    violent or accidental)
  • Experiencing repeated or extreme exposure to
    aversive details of the traumatic event (not
    exposure through electronic media, TV, movies,
    pictures, unless work related)

Types of Trauma
  • Acute Trauma a single event that lasts for a
    limited time.
  • Chronic Trauma the experience of multiple
    traumatic events, often over a longer period of
  • Complex Trauma multiple traumatic events that
    begin at a very young age, caused by adults who
    should have been caring for and protecting the

Examples of Trauma
  • Domestic violence
  • Sexual abuse and assault
  • Physical abuse and assault
  • Community violence
  • Historical /Intergenerational
  • Serious accidents
  • Unexpected loss of a loved one
  • Medical procedures or conditions
  • War and/or terrorist attacks
  • Institutional abuse
  • Secondhand exposure

Response to Trauma Varies
  • Nature of the trauma
  • How close the person was to the event
  • Previous trauma experience(s)
  • Relationship to the abuser or victim
  • Perception of the person involved about the
  • Chronicity and severity of the trauma itself
  • Coping skills of the person prior to the
  • Response of support system
  • Level of life stressors at time of experience

Potential Impacts of Trauma
  • Neurological
  • Biological
  • Emotional
  • Psychological
  • Behavioral
  • Social

Neurological Effects
  • Some traumatic events have a direct impact on
    brain function and structure.
  • Trauma activates stress hormones and
  • Acutely this results in flight, fight, or freeze.
  • Chronically this results in /- changes to brain
    functioning and/or /- changes to brain
    structure due to neuroendocrine system impacts.
  • Chronic trauma can cause over-activation of
    HPA axis in the brain, and constant production
    of stress hormone, cortisol.
  • The amygdala (emotion and fear response) and
    hippocampus (memory) are also impacted.
  • Brain changes can include reduced cerebral
    volume, associated ventricular enlargement,
    alterations in pituitary and hippocampus.

Biological Effects
  • Somatic complaints
  • Sleep disturbance
  • Fatigue
  • Forgetfulness, confusion, and concentration
  • Flashbacks or Dissociation
  • Sexual numbing
  • Increased flight, fight, or freeze (submit)
  • Gastrointestinal, cardiovascular,
    musculoskeletal, respiratory, and dermatological

Emotional Effects
  • Depression
  • Impatience
  • Lack of trust
  • Unsafe
  • Inner turmoil and pain
  • Restricted range of affect
  • Self-blame, self-doubt
  • Shame, secrecy
  • Shock, numbness
  • Disconnectedness
  • Fear
  • Anger, rage
  • Worry, anxiety
  • Sadness, grief
  • Powerless, ineffective
  • Overwhelm

Psychological Effects
  • Cognitions are especially impacted by trauma
  • Distrust of others or expectations that they
    might be harmed by everyone
  • Overestimation of and preoccupation with danger
  • Low self-esteem and self-blame
  • Helplessness and hopelessness about the future
  • Shame and/or stigma
  • Survivor guilt

Behavioral Effects
  • Crying
  • Agitation, irritability, rage
  • Passiveness
  • Diminished interest in activities
  • Self-injurious behaviors
  • Suicidality
  • Reenactments
  • Dissociation
  • Risky, impulsive behaviors
  • Compulsive behaviors
  • Problems with eating
  • Rigid behaviors
  • Increased use of substances
  • Panic, phobia

Social Effects
  • Isolating, detaching from others
  • Over working
  • Relationship strains, dysfunction
  • Neglect of responsibilities
  • Poor parenting
  • Feeling unlikeable or strange in social
  • Assuming malevolence
  • Avoidance of sexual activity or trauma related
  • High rates of re-victimization

Trauma- and Stressor-Related Disorders (DSM 5)
  • Acute Stress Disorder (3 days to 1 month)
  • Post Traumatic Stress Disorder (PTSD) (gt 1 month)
  • Other Specified trauma-related disorder
  • Co-occurring SA/MH disorders are also common
    including major depressive disorder, generalized
    anxiety disorder, obsessive compulsive disorder
    and other anxiety disorders, substance use
    disorders (SUD), sleep disorders

Post-Traumatic Growth
  • After exposure to trauma most people will
    experience some of the effects noted above, but
    will not develop chronic symptoms or psychiatric
  • They will garner their resilience via internal
    strengths and external supports, and make
    constructive meaning of what has happened.
  • People may reflect that trauma offered them
    opportunity to develop important coping
    strategies or other positive outcomes.

Prevalence of Trauma70 of U.S. adults have
experienced at least one traumatic event in their
  • Among Men
  • Among Women
  • 61 experience trauma in lifetime
  • 5 develop PTSD
  • More likely to suffer crime victimization or war
  • Robbery victimization rate is higher for males
    (2.4 per 1,000 males age 12 or older) than for
    females (1.4 per 1,000)
  • Aggravated assault rate is also higher for males
    (3.4 per 1,000) than for females (2.3 per 1,000)
  • Males (0.1 per 1,000) are less likely than
    females (1.3 per 1,000) to be victims of rape or
    sexual assault.
  • 51 experience in lifetime
  • 10 develop PTSD
  • 92 of homeless women have experienced severe
    physical and/or sexual abuse
  • 1/3 of women veterans experienced sexual assault
    during military service
  • 9-44 experience domestic violence in lifetime
  • More likely to have experienced childhood
    physical and/or sexual abuse
  • 91 of incarcerated women in state prison

Prevalence of Trauma
  • Among MH and SA Populations
  • 90 of public mental health clients exposed to
  • 75 of women AND men in SUD treatment report
  • 55-99 of women in SUD Treatment (TX)
  • 85-95 of women in MH TX
  • 11-38 of men SUD TX have PTSD SUD diagnosis
  • 33-59 of women in SUD TX have PTSD SUD

What is Trauma-Informed Care?
  • Changing the question from What is wrong with
  • to What happened to you?

Trauma Informed Care
  • To understand the role that violence and
    victimization play in the lives of most of our
    consumers of mental health and substance abuse
    services and to use that understanding to design
    service systems that accommodate the
    vulnerabilities of trauma survivors and allow
    services to be delivered in a way that will
    facilitate consumer participation in treatment.
  • Source Harris Fallot, 2001)

Core Principles of T-I Care
  1. Safety Ensure physical and emotional safety
  2. Trustworthiness Maximize trustworthiness, making
    expectations clear, and maintaining appropriate
  3. Choice Prioritize consumer choice and control
  4. Collaboration Maximize collaboration and sharing
    of power with clients
  5. Empowerment Prioritize client empowerment and

General Recommendations
  • Recognize the primacy of trauma in MH/SA.
  • Incorporate knowledge about trauma in all aspects
    of service delivery.
  • Be hospitable and engaging for trauma survivors -
    ask respectfully and be prepared to respond.
  • See symptoms as attempts to cope and survive.
  • See both vulnerabilities and strengths.
  • Recognize our primary goal as helpers is the
    clients empowerment and recovery.
  • Coordinate care across multiple service systems.
  • Avoid re-traumatization.

Identifying Trauma
  • Identifying trauma history early in the treatment
    process is an important aspect of T-I Care.
  • Identifying trauma via screening and assessment
    can be complicated by
  • Lack of preparation or discomfort of the
  • Challenge of delineation or rule-out of
    symptoms for diagnostic categories (i.e.,
    symptoms mimic anxiety, depression, etc.)
  • Subthreshold symptoms do not trigger assessment
  • Clients shame, secrecy, or denial of traumatic
  • Co-occurring substance use disorders often noted
    as primary

  • Universal Screening administered as quickly as is
    feasible relatively brief and nonthreatening.
  • Brief explanation of prevalence data as rationale
    can help remove the sense of isolation and shame.
  • Screening must be trauma-informed do not request
    details of trauma, know how to respond to
  • Tools for screening are available online and in
    the slide below

Screening Tools Include
  • Stressful Life Experiences (SLE) screen provided
    in SAMHSA TIP 57 Trauma-Informed Care in
    Behavioral Health Services
  • Others available via SAMHSA TIP 57 Appendix D
  • Those in public domain include
  • Clinician Administered PTSD Scale (CAPS)
  • Evaluation of Lifetime Stressors (ELS)
  • Impact of Events Scale (IES also Revised-R)
  • Penn Inventory for PTSD
  • PTSD Symptom Scale-Interview or Self-Report
  • Trauma History Questionnaire (THQ)

  • An ongoing process of getting to know an
  • Established rapport and trust.
  • Clinician must remain non-judgmental, sensitive,
    and patient.
  • Identifies symptoms and behaviors and
    conceptualizes a clients risk behavior through
    the lens of what happened to them.
  • Provides input for the development of treatment
    goals with objectives designed to reduce the
    negative impacts of trauma on clients life.
  • Even those who do not meet full criteria for PTSD
    may suffer symptoms that strongly impact
    behavior, judgment, education/work performance,
    and ability to connect with others.

How to Support Client Engagement
  • Be aware of ambivalence with regard to addressing
    trauma issues, use motivational interviewing to
    explore ambivalence.
  • Be aware of pacing of disclosures and track level
    of intensity of sessions. Discuss the need to
    pace disclosures with the client directly.

Strategies to Establish Appropriate Pacing and
  1. Frequently discuss and request feedback from
    clients about pacing and timing
  2. Use the subjective units of distress (SUD) scale
  3. Slowly increase the speed of intervention and
    adjust the intensity
  4. Monitor clients to track whether they are
    internally overwhelmed or moving into avoidance
  5. Be alert to signs that things are moving to fast
  6. Slow down the process and seek consultation if
    symptoms increase or other problems develop
  7. Use caution and avoid confrontations/interpretatio
    ns that are challenging avoid stressful
    interventions such as role plays, group
    confrontation, or guided imagery

Source SAMHSA, 2014
Trauma Specific Interventions or Services
  • Services designed specifically to address
    violence, trauma, and related symptoms and
  • Intent of activities is to increase skills and
    strategies that allow survivors to manage their
    symptoms and reactions.
  • Goal is to eventually reduce or eliminate
    debilitating symptoms and prevent further
    traumatization or violence.
  • Services that address the impact of trauma on
    womens lives and facilitate trauma recovery.
  • Source Harris Fallot, 2001

When to Start Trauma Treatment
Evidence-Based Practices (EBP) for Trauma
  • FROM
  • National Registry of Evidence-based Programs and
  • SAMHSA TIP 57 Trauma-Informed Care in Behavioral
    Health Settings

Trauma Specific Treatment Models
  • Cognitive Processing Therapy (CPT)
  • Exposure Therapy
  • Eye Movement Desensitization and Reprocessing
  • Skills Training in Affective and Interpersonal
  • Stress Inoculation Training
  • Narrative Therapy

A Note on Psychopharmacology Treatment of PTSD
  • Evidence suggests CBT has greater impact on PTSD
    than medications some see medications as an
    addition to therapy
  • Selective serotonin reuptake inhibitors (SSRI)
    have the strongest evidence base
  • Only Zoloft and Paxil are approved by FDA for
  • Strong evidence for Prozac and Effexor (SNRI) as
    well and are sometimes used off label
  • Medications will minimize symptoms though will
    not likely entirely eliminate them
  • There are exceptions to use of SSRI as 1st line
    treatment (i.e., co-morbid bipolar disorder)
  • Maximum benefit depends on dosage and duration

Source Jeffreys, 2015
EBPs for Integrated Trauma Substance Use
Disorder Treatment
  • FROM
  • National Registry of Evidence-based Programs and

Integrated Trauma Informed Interventions
  • A Womans Path to Recovery (Based on A Womans
    Addiction Workbook)
  • Boston Consortium Model Trauma-Informed
    Substance Abuse Treatment for Women
  • Forever Free
  • Helping Women Recover and Beyond Trauma
  • Interactive Journaling
  • Seeking Safety
  • Trauma Recovery and Empowerment Model
  • Bold options have also shown evidence with men in
    substance use disorder treatment.

How to Shift to a TraumaInformed Model
  • Administrative commitment to change
  • Universal screening
  • Training and education
  • Consumer-driven
  • Hiring practices
  • Review of policies and procedures
  • Shared philosophy that reflects a sensitivity to

Plan for Implementation?
  • What are your Challenges?
  • Lets brainstorm Solutions!

A Note Regarding Special Populations
  • Being trauma informed includes being culturally
    competent through cultural relevance to clients.

Some Special Populations to Consider
  • Gay, Lesbian, Bisexual and Transgender
  • People with Intellectual/Developmental Disability
  • Women in the Perinatal Period
  • Veterans
  • Immigrants
  • African Americans
  • And many, many more.

Case Study Traumatic Web
  • Alice is a 36 year old African American woman
    that presents for care at an outpatient substance
    use disorder program for pregnant and parenting
    women. Shes been referred by child protective
    services who have cited her ongoing use of
    cocaine as problematic for her ability to
    maintain custody and care for her youngest child.
    Alice has been diagnosed with cocaine use
    disorder and bipolar disorder. She has a history
    of minimal treatment engagement, with
    intermittent courses with other outpatient
    providers, no history of inpatient care.
  • Alice presents with acute distress regarding the
    possible loss of custody of her youngest child.
    She has a history of loss of custody of 3 older
    children. Patient reports that her twins were
    removed from her care in the context of
    unemployment and marijuana use her rights were
    terminated to these twins about 7 years
    previously and this has been a significant loss
    for the patient. Her eldest daughter, now in her
    early adolescence was also removed from the
    patients care at the same time and chose to
    remain in the custody of another family member.
    They continue to have some contact. Alices
    youngest child, now age 6, has been neglected by
    the patient during her transition from marijuana
    use to cocaine use.

Case Study Traumatic Web (contd.)
  • In discussion of drug use experience Alice
    reports that she was introduced to cocaine by a
    male boyfriend and that she continued to increase
    use in the context of this relationship. The
    patient reports that she began to experience the
    need for cocaine to support engagement in sexual
    relations with this man. Patient describes
    feeling out-of-control of her desire for drugs
    and sexual contact. She began to neglect her
    child in the context of this relationship and
    relied on the childs father and other family
    members to care for her. Upon entering treatment
    patient expressed doubt in the childs fathers
    ability to provide full-time care due to his
    history with the child. The patient expressed
    great shame related to being back in a situation
    where she might lose custody of another child.
  • In discussion of her mental health experience
    Alice reports that she was diagnosed with bipolar
    disorder due to periods of depressed/disengaged
    mood as well as risk-taking behavior resulting in
    legal consequences. Episodes have rarely been
    isolated from drug and alcohol use patterns, but
    patient asserts that she experiences an obvious
    shift in mood state regardless of circumstances
    or substance use. Patient has a history of mood
    stabilizer use and reports improvements in mood
    and cognition she opts for psychiatric consult
    for this purpose.

Case Study Traumatic Web (contd.)
  • As treatment progresses, patient shares more
    about her history. Alice shares with the
    therapist about her childhood sexual trauma which
    included being sold by her drug addicted mother
    to various men for sexual acts as early as 3
    years old. Alice shares about additional sexual
    trauma incidents that recurred throughout her
    life. She began to describe the shame and
    self-loathing associated with this history. Alice
    begins to discuss how out-of-control she has felt
    about her sexual behavior as well as her
    experience of various pregnancies.
  • Clinician initiates treatment with use of
    motivational interviewing to understand why the
    patient wants to change her pattern of behavior
    or may not want to change it. As motivation is
    clarified and expressed the clinician shifts to a
    discussion of what has historically gotten in the
    way of change.

Case Study Traumatic Web (contd.)
  • Clinician provides an integrated explanation of
    Alices pattern that acknowledges the role that
    sexual trauma has played in her behavioral
    patterns. Clinician provides psychoeducation
    about trauma and its possible effects. Clinician
    attempts to reduce shame and self-loathing by
    ascribing legitimate blame for her traumatic past
    while balancing this with Alices deep love and
    respect for her mother. Clinician provides a
    simple construct for the patient to understand
    both her substance use and sexual behavior
    pattern a difficulty with safety.
  • Clinician role models choices in maintaining
    safety during sessions by pacing disclosures of
    sexual details, again providing psychoeducation
    about the value of developing skills to preserve
    safety prior to getting into the hardest
    memories. Clinician introduces patient to the
    Seeking Safety curriculum and elicits patient

Case Study Traumatic Web (contd.)
  • Clinician guides Alice through the manual
    handouts weekly with supplemental discussion of
    applicability to the patients experience as well
    as her week-to-week effort to enhance her safety.
    She is encouraged to choose a new path for her
    recovery as means towards healing her childhood
    wounds. Alice chooses to live in a 30 day, then
    90 day recovery house, and begins to engage in
    12-Step programs. During all new situations,
    clinician maintains a focus on Alices choices
    that might support safety. Whenever she
    experiences a set-back, an unsafe choice or
    exposure, we explore it for opportunities and
    understand it in the context of her change.
  • Clinician supports all of Alices next steps
    through the lens of safety and choices. Decisions
    are reviewed in this regard with increased
    deferral to Alice in order to support her ability
    to trust herself. Direct feedback is given with
    regard to unsafe choice without any confrontation
    or shaming. Emotion regulation skills and support
    is provided when Alice hits the inevitable walls
    of early recovery and grief associated with
    traumatic losses.

Case Study Traumatic Web (contd.)
  • Through this long-term process Alice transitions
    from supportive recovery housing, to independent
    living, she seeks employment, later determining
    she wants to help others and completing peer
    support training. She begins to date and reviews
    this relationship for safety and trust. Alice
    regains full custody of her youngest daughter and
    continues to review and discuss parenting choices
    through the lens of safety for self and child.
  • Alice reduces her contact in care, though she
    hesitates to fully transition to independence she
    is consistently empowered by the clinician to do
    so. With time, Alice feels prepared for
    termination and an intentional closing is
    offered, with a reminder that a return to therapy
    is always a future choice.

  • Thank You!
  • Contact Information
  • Andrea Winkler, LCSW, LCAS
  • 919-660-0528 office
  • 919-681-8627 fax

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