Creating Trauma Informed
Systems of Care for Human
Service Settings
Robert W. Glover, Ph.D.
Executive Director
Brian Sims, M.D.
NASMHPD Consultant
National Association of State
Mental Health Program
Directors
Represents the $36.7 Billion Public Mental
Health System serving 6.4 million people
annually in all 50 states, 4 territories, and
the District of Columbia.
An affiliation with the approximately 220
State Psychiatric Hospitals: Serve 200,000
people per year and 50,000 people served
at any point in time.
Vision:
Mental health is universally
perceived as essential to
overall health and well-being
with services that are
available, accessible, and of
high quality.
Mission:
NASMHPD serves as the
national representative and
advocate for state mental
health agencies and their
directors and supports
effective stewardship of
state mental health systems.
NASMHPD informs its
members on current and
emerging public policy
issues, educates on research
findings and best practices,
provides consultation and
technical assistance,
collaborates with key
stakeholders, and facilitates
state to state sharing.
Priorities for NASMHPD
Transforming Mental Health
Introduction

Some of the Presentation Content May
Describe Traumatic Experiences
– Please Take Care of Yourself

Word Choice Translation
– Examples: “Consumer” versus “User”;
“Provider” versus “Caregiver”

Consumer Voice – “In Their Own Words”
4
Content
Introduction
I.
What is Trauma and Why Must We
Address It? (Bob Glover)
II. Understanding the Bio-Psychosocial
Impact of Trauma (Brian Sims)
III. Trauma Sensitive Tools
(Bob Glover and Brian Sims)
IV. DVD – “Healing Neen”
(Bob Glover – Introduction)
V.
Peer Panel and Next Steps
8
I. What is Trauma and
Why Must We Address It?
Creating Trauma Informed Systems of
Care for Human Service Settings
Seclusion and Restraint “In Their Own Words”
What is Trauma?


Definition (NASMHPD, 2006)
– The experience of violence and victimization
including sexual abuse, physical abuse, severe
neglect, loss, domestic violence and/or the
witnessing of violence, terrorism or disasters
DSM IV-TR (APA, 2000)
– Person’s response involves intense fear, horror
and helplessness
– Extreme stress that overwhelms the person’s
capacity to cope
13
Types of trauma resulting in serious
and persistent mental health
problems:

Are usually not a “single blow” event e.g.
rape, natural disaster

Are interpersonal in nature: intentional,
prolonged, repeated, severe

Occur in childhood and adolescence and
may extend over an individual’s life span
(Terr, 1991; Giller, 1999)
14
Definition of Trauma
Informed Care

Mental Health Treatment that incorporates:
– An appreciation for the high prevalence of
traumatic experiences in persons who receive
mental health services
–
A thorough understanding of the profound
neurological, biological, psychological and
social effects of trauma and violence on the
individual
(Jennings, 2004)
15
Prevalence of Trauma
Mental Health Population – United States

90% of public mental health
clients have been exposed to
trauma (Mueser et al., 2004, Mueser et al.,
1998)

Most have multiple experiences of
trauma (Mueser et al., 2004, Mueser et al.,
1998)

Anna Jennings
97% of homeless women with
SMI have experienced severe
physical & sexual abuse – 87%
experience this abuse both in
childhood and adulthood
(Goodman et al., 1997)
16
Prevalence of Trauma
Child Mental Health/Youth Detention
Population - U.S.

American study of 100 adolescent
inpatients; 93% had trauma histories and
32% had PTSD

70-90% incarcerated girls – sexual,
physical, emotional abuse
(DOC, 1998, Chesney & Sheldon, 1991)

Canadian study of 187 adolescents
reported 42% had PTSD
17
Prevalence of Trauma
Substance Abuse Population – U.S.

Up to two-thirds of men and women in SA
treatment report childhood abuse & neglect
(SAMSHA CSAT, 2000)

Study of male veterans in SA inpatient unit
– 77% exposed to severe childhood trauma
– 58% history of lifetime PTSD (Triffleman et al., 1995)

50% of women in SA treatment have history of
rape or incest
(Governor's Commission on Sexual and Domestic Violence, Commonwealth
of MA, 2006)
18
Seclusion and Restraint:
The Disgraceful Reality
Other Critical Trauma Correlates: The
Relationship of Childhood Trauma to Adult Health




Adverse Childhood Events (ACEs) have serious
health consequences
Adoption of health risk behaviors as coping
mechanisms
– eating disorders, smoking, substance abuse,
self harm, sexual promiscuity
Severe medical conditions: heart disease,
pulmonary disease, liver disease, STDs, GYN
cancer
Early Death
(Felitti et al., 1998)
20
Adverse Childhood
Experiences
– Recurrent and severe physical abuse
– Recurrent and severe emotional abuse
– Sexual abuse

Growing up in household with:
– Alcohol or drug user
– Member being imprisoned
– Mentally ill, chronically depressed, or
institutionalized member
– Mother being treated violently
– Both biological parents absent
– Emotional or physical abuse
(Fellitti et al, 1998)
21
ACE Study

“Male child with an ACE score of 6 has a
4600% increase in likelihood of later
becoming an IV drug user when compared
to a male child with an ACE score of 0.
Might heroin be used for the relief of
profound anguish dating back to childhood
experiences? Might it be the best coping
device that an individual can find?”
(Felitti et al, 1998)
22
ACE Study

Is drug abuse self-destructive or is it a
desperate attempt at self-healing, albeit
while accepting a significant future risk?”
(Felitti, et al, 1998)
23
ACE Study

“Addiction is best viewed as an understandable,
unconscious, compulsive use of psychoactive
materials in response to abnormal, prior life
experiences, most of which are concealed by
shame, secrecy, and social taboo.”
(Felitti et al, 1998)
24
Sexual Trauma and Addiction



208 African-American Women with
histories of crack cocaine use
Of those Women, those with history of
sexual trauma (n=134) reported being
addicted to more substances than those who
had not been sexually traumatized (n=74)
The Women with trauma histories reported
more prior treatment failures than those
without.
(Young & Boyd, 2000)
25
What does the prevalence data tell us?



The majority of adults and children in psychiatric
treatment settings have trauma histories
A sizable percentage of people with substance use
disorders have traumatic stress symptoms that
interfere with achieving or maintaining sobriety
A sizable percentage of adults and children in the
prison or juvenile justice system have trauma
histories
(Hodas, 2004, Cusack et al., Mueser et al., 1998, Lipschitz et al., 1999,
NASMHPD, 1998)
26
Prevalence of Trauma
“Many providers may assume that abuse
experiences are additional problems for the
person, rather than the central problem…”
(Hodas, 2004)
27
What does the prevalence data tell us?



Growing body of research on the
relationship between victimization and later
offending
Many people with trauma histories have
overlapping problems with mental health,
addictions, physical health, and are victims
or perpetrators of crime
Victims of trauma are found across all
systems of care
(Hodas, 2004, Cusack et al., Muesar et al., 1998,
Lipschitz et al., 1999, NASMHPD, 1998)
28
Therefore……
We need to presume the clients we
serve have a history of traumatic
stress and exercise “universal
precautions” by creating systems
of care that are trauma-informed
(Hodas, 2005)
29
Trauma Informed Care
Systems
30
Trauma Informed Care Systems
Key Principles





Integrate philosophies of care that guide all
clinical interventions
Are based on current literature
Are inclusive of the survivor's perspective
Are informed by research and evidence of
effective practice
Recognize that coercive interventions cause
traumatization and re-traumatization and are to
be avoided
(Fallot & Harris, 2002; Ford, 2003; Najavits, 2003)
31
Trauma Informed Care Systems
Key Features

Valuing the individual in all aspects of care

Neutral, objective and supportive language

Individually flexible plans and approaches

Avoid shaming or humiliation at all times
(Fallot & Harris, 2002; Cook et al., 2002; Ford, 2003; Cusack et al. 2003;
Jennings, 1998; Prescott, 2000)
32
Trauma Informed Care Systems
Key Features

Focusing on what happened to you in place of
what is wrong with you
(Bloom, 2002)

Asking questions about current abuse
– Addressing the current risk and developing a
safety plan for discharge

One person sensitively asking the questions

Noting that people who are psychotic and
delusional can respond reliably to trauma
assessments if questions are asked appropriately
(Rosenburg, 2001)
33
Trauma Informed Non Trauma Informed

Recognition of high
prevalence of trauma

Lack of education on
trauma prevalence &
“universal” precautions
Over-diagnosis of
Schizophrenia & Bipolar
D., Conduct D. & singular
addictions

Recognition of
primary and cooccurring trauma
diagnoses


Assess for traumatic
histories & symptoms

Cursory or no trauma
assessment

Recognition of culture
and practices that are
re-traumatizing

“Tradition of Toughness”
valued as best care
approach
34
Trauma Informed
Non Trauma Informed

Power/control minimized
- constant attention to
culture


Caregivers/supporters –
collaboration
Address training needs
of staff to improve
knowledge & sensitivity



Keys, security
uniforms, staff
demeanor, tone of
voice
Rule enforcers –
compliance
“Patient-blaming” as
fallback position
without training
35
Trauma Informed



Non Trauma Informed
Staff understand
function of behavior
(rage, repetitioncompulsion, self-injury)
Objective, neutral
language

Behavior seen as
intentionally
provocative

Transparent systems
open to outside parties

Labeling language:
manipulative, needy,
“attention-seeking”
Closed system –
advocates discouraged
(Fallot & Harris, 2002; Cook et al., 2002, Ford, 2003, Cusack et al., Jennings, 1998,
36
Prescott, 2000)
Organizational Commitment to
Trauma Informed Care
37
Organizational Commitment to
Trauma Informed Care

Adoption of a trauma informed policy to include:
– commitment to appropriately assess trauma
– avoidance of re-traumatizing practices

Key administrators get on board

Resources available for system modifications and
performance improvement processes

Education of staff is prioritized
(Fallot & Harris, 2002; Cook et al., 2002)
38
Organizational Commitment to
Trauma Informed Care

Unit staff can access expert trauma
consultation

Unit staff can access trauma-specific
treatment if indicated
(Fallot & Harris, 2002; Cook et al., 2002)
39
Organizational Commitment to
Trauma Informed Care

Assessment data informs treatment
planning in daily clinical work

Advance directives, safety plans and deescalation preferences are
communicated and used

Power & Control are minimized by
attending constantly to unit culture
(Fallot & Harris, 2002; Cook et al., 2002)
40
Summary / Take Home

Train/Supervise Staff in Prevalence, Impact,
Treatment Philosophy, and Interventions

Thorough and Sensitive Trauma Assessments

Organizational Culture: Physical, Treatment &
Support Environments Infused with Recovery
Focus (e.g., Respect/Kindness/Collaboration &
Empowerment/Hope)
41
New Zealand and Trauma Informed Care

Best Practice in the Reduction and Elimination of
Seclusion and Restraint
Seclusion: Time for Change
O’HaganM, Divis M, Long J. (2008)

Action Plan
developing alternatives to the use of seclusion and
restraint in new zealand mental health inpatient settings
seclusion: time for change (December 2008)

The Journey Forward
Discussion Paper: Trauma and Service Response to
Trauma (Dr. Emily Street, Consultant Clinical Psychologist -December 2007)
Joan Gillece, Ph.D.
NASMHPD Project
Manager
National Center for Trauma
Informed Care (NCTIC)
Joan.gillece@nasmhpd.org
703-739-9333
SAMHSA Funded
“I have learned that
people will forget
what you said,
people will forget
what you did, but
people will never
forget how you made
them feel.”
3/23/2016
-Maya Angelou
Novelist, Poet
46