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.
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 evidencebased practices for TIC in MH/SUD treatment.
4. Consider the role of trauma and trauma
informed care for special population groups.
Introductions
• A little bit about me
• A little bit about you
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
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 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.
Examples of Trauma
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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
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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
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
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.
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
Emotional Effects
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Shock, numbness
Disconnectedness
Fear
Anger, rage
Worry, anxiety
Sadness, grief
Powerless, ineffective
Overwhelm
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Depression
Impatience
Lack of trust
Unsafe
Inner turmoil and pain
Restricted range of
affect
• Self-blame, self-doubt
• Shame, secrecy
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
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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
Trauma- and Stressor-Related
Disorders (DSM 5)
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Acute Stress Disorder (3 days to 1 month)
Post Traumatic Stress Disorder (PTSD) (> 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
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.
Prevalence of Trauma
70% of U.S. adults have experienced at least one traumatic event in their lifetime
Among Men
• 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.
Among Women
 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 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
Changing the question from “What is wrong with you?”
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 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
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 client’s
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 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
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
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:
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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!
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 client’s 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
client’s 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 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/interpretations 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
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
women’s lives and
facilitate trauma
recovery.”
Source: Harris & Fallot, 2001
When to Start “Trauma Treatment”
FROM:
National Registry of Evidence-based Programs and Practices
nrepp.samhsa.gov
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 (EMDR)
• Skills Training in Affective and Interpersonal
Regulation
• 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 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
FROM
National Registry of Evidence-based Programs and Practices
nrepp.samhsa.gov
Integrated Trauma Informed Interventions
• A Woman’s Path to Recovery (Based on A Woman’s
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 Trauma
Informed 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
Plan for Implementation?
What are your Challenges?
Let’s 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. She’s 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 patient’s care at the same time and chose to remain in
the custody of another family member. They continue to have some contact.
Alice’s youngest child, now age 6, has been neglected by the patient during
her transition from marijuana use to cocaine use.
Case Study: Traumatic Web (cont’d.)
• 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 outof-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 child’s father and other family
members to care for her. Upon entering treatment patient expressed doubt in the
child’s father’s 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 risktaking 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 (cont’d.)
• 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 selfloathing associated with this history. Alice begins to discuss how out-ofcontrol 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 (cont’d.)
• Clinician provides an integrated explanation of Alice’s 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 Alice’s
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.
Case Study: Traumatic Web (cont’d.)
• Clinician guides Alice through the manual handouts weekly with
supplemental discussion of applicability to the patient’s 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 Alice’s 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 Alice’s 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 (cont’d.)
• 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.
Questions
Thank You!
Contact Information:
Andrea Winkler, LCSW, LCAS
919-660-0528 office
919-681-8627 fax
andrea.winkler@duke.edu
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