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

1
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.
2
Objectives

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
   treatment.
4. Consider the role of trauma and trauma informed
   care for special population groups.

3
Introductions

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

4
Trauma

• 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

5
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)

6
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
  time.
• Complex Trauma multiple traumatic events that
  begin at a very young age, caused by adults who
  should have been caring for and protecting the
  child.

7
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

8
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
  experience
• Chronicity and severity of the trauma itself
• Coping skills of the person prior to the
  experience
• Response of support system
• Level of life stressors at time of experience

9
Potential Impacts of Trauma

• Neurological
• Biological
• Emotional
• Psychological
• Behavioral
• Social

10
Neurological Effects

• Some traumatic events have a direct impact on
  brain function and structure.
• Trauma activates stress hormones and
  neurochemicals
• 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.

11
Biological Effects

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

12
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

13
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

14
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

15
Social Effects

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

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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

17
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
  illness.
• 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.

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Prevalence of Trauma70 of U.S. adults have
experienced at least one traumatic event in their
lifetime

• Among Men

• Among Women

• 61 experience trauma in lifetime
• 5 develop PTSD
• More likely to suffer crime victimization or war
  trauma
• 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

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Prevalence of Trauma

• Among MH and SA Populations

• 90 of public mental health clients exposed to
  multiple
• 75 of women AND men in SUD treatment report
  histories
• 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
  diagnosis

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What is Trauma-Informed Care?

• Changing the question from What is wrong with
  you?
• to What happened to you?

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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)

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Core Principles of T-I Care

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

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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.

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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
  clinician
• 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
  experiences
• Co-occurring substance use disorders often noted
  as primary

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Screening

• 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
  answers.
• Tools for screening are available online and in
  the slide below

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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
  Version
• Trauma History Questionnaire (THQ)
• AND MANY MORE!

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Assessment

• An ongoing process of getting to know an
  individual.
• 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.

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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.

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Strategies to Establish Appropriate Pacing and
Timing

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
   strategies
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
30
Trauma Specific Interventions or Services

• Services designed specifically to address
  violence, trauma, and related symptoms and
  reactions.
• 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

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When to Start Trauma Treatment
32
Evidence-Based Practices (EBP) for Trauma
Treatment

• FROM
• National Registry of Evidence-based Programs and
  Practices nrepp.samhsa.gov
• SAMHSA TIP 57 Trauma-Informed Care in Behavioral
  Health Settings

33
Trauma Specific Treatment Models

• Cognitive Processing Therapy (CPT)
• Exposure Therapy
• Eye Movement Desensitization and Reprocessing
  (EMDR)
• Skills Training in Affective and Interpersonal
  Regulation
• Stress Inoculation Training
• Narrative Therapy

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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
  PTSD
• 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
35
EBPs for Integrated Trauma Substance Use
Disorder Treatment

• FROM
• National Registry of Evidence-based Programs and
  Practices nrepp.samhsa.gov

36
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.

37
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
  trauma

38
Plan for Implementation?

• What are your Challenges?
• Lets brainstorm Solutions!

39
A Note Regarding Special Populations

• Being trauma informed includes being culturally
  competent through cultural relevance to clients.

40
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.

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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.

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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.

43
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.

44
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
  buy-in.

45
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.

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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.

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Questions
48

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

49
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