Insert Workshop Title

1
Trauma Issues with Specific Populations
Adolescents Transition Age Youth WORKSHOP
Michael Dennis, Ph.D. and Janet C. Titus,
Ph.D. Chestnut Health Systems, Normal, IL
Presentation at Substance Abuse and Mental Health
Services Administrations Pre- Conference
Training Session, Trauma-Informed Care An
Essential Element of Recovery Training.
Hollywood, FL, June 18, 2011
2
Acknowledgements and Contact Information

• Analysis performed with support from SAMHSA
  contrac t no. 270-07-0191 using data from
  SAMHSA/CSAT GAIN Data set from 182 grantees
  (17534, 16386, 16400, 16414, 16904, 16915, 16928,
  16939, 16961, 16984, 16992, 17046, 17070, 17071,
  17334, 17433, 17434, 17446, 17475, 17476, 17484,
  17486, 17490, 17517, 17523, 17534, 17535, 17547,
  17589, 17604, 17605, 17638, 17646, 17648, 17673,
  17702, 17719, 17724, 17728, 17742, 17744, 17751,
  17755, 17761, 17763, 17765, 17769, 17775, 17779,
  17786, 17788, 17812, 17817, 17821, 17825, 17830,
  17831, 17847, 17864, 18406, 18587, 18671, 18723,
  18735, 18849, 19313, 19323, 19942, 20084, 20085,
  20086, 20100, 20117, 20200, 20300, 20400, 20759,
  20781, 20798, 20806, 20827, 20828, 20847, 20848,
  20849, 20852, 20865, 20870, 20910, 20921, 20941,
  21551, 21580, 21585, 21597, 21624, 21632, 21682,
  21688, 21705, 21714, 21774, 21788, 21815, 21874,
  21883, 21890, 21892, 21948, 30100, 30200, 30300,
  30400, 30500, 30600, 30700, 31000, 31100, 31200,
  110000, 130000, 140000, 150000, 160000, 190000,
  200000, 210000, 220000, 230000, 240000, 250000,
  260000, 270000, 280000, 290000, 300000, 310000,
  320000, 330000, 340000, 350000, 360000, 370000,
  380000, 390000, 400000, 410000, 420000, 430000,
  440000, 450000, 460000, 470000, 480000, 500000,
  510000, 520000, 540000, 570000, 580000, 590000,
  600000, 610000, 620000, 630000, 640000, 655372,
  655373, 655374, 660000, 670000, 680000,, 690000,
  700000, 820000, 830000, 840000, 850000, 860000,
  870000, 880000, 910000, 920000)
• Dr. Liza Suárez and the Adolescent Trauma and
  Substance Abuse Committee of the National Child
  Traumatic Stress Network (NCTSN)
• Opinions are those of the author and not official
  positions of the government
• Available from www.chestnut.org/li/posters
• Please direct comments to Michael Dennis,
  Chestnut Health Systems, 448 Wylie Drive, Normal,
  IL 61761, 309-451-7801, mdennis_at_chestnut.org .

3
Goals of Afternoon Breakout

1. To compare the effectiveness of several evidence
   based approaches to adolescent treatment in terms
   of changes in victimization, trauma, emotional
   problems, substance use, abuse dependence, HIV
   risk behaviors and crime
2. To review some of the promising trauma-informed
   or integrated treatments for co-occurring trauma
   and substance abuse

4
Change Over Time in Selected NOMS Outcomes
Source CSAT 2010 SA Dataset Subset to
Adolescents and Young Adults (n24,091)
5
Change in Selected NOMS Outcomes by Severity of
Victimization
On average higher trauma associated with being
worse at intake but also more change
Low Severity
Mod Severity
High Severity
Source CSAT 2010 SA Dataset Subset to
Adolescents and Young Adults (n24,091)
6
Which general outpatient approaches address
co-occurring trauma issues?

• Nine Treatment Outpatient Approaches
• Seven Challenges (Schwebel, 2004) (n114)
• Chestnut Health Systems (CHS Godley et al. 2002)
  Treatment (n192)
• Adolescent Community Reinforcement Approach
  (A-CRA Godley et al., 2001) -CYT/AAFT (n2144)
  and -Other (n276)
• Multi-Systemic Therapy (MST Henggeler et al.,
  1998) (n85)
• Multi-Dimensional Family Therapy (MDFT Liddle,
  2002) (n258)
• Motivational Enhancement Therapy-Cognitive
  Behavior Therapy (METCBT Sampl Kadden,
  2001)-CYT/EAT (n5262) and -Other (n878)
• Family Support Network (FSN Hamilton et al.,
  2001) (n369)

6
7
Two sets of outcomes

• Mental Health
• Emotional Problems Scale
• Days of Traumatic Memories
• Days of Victimization
• Other Outcomes
• Substance Problems Scale
• Substance Frequency Scale
• Illegal Activities Scale
• HIV Risk Change Index
• Average Across

7
8
Change (post-pre) in Effect Size for Emotional
Problems by Type of Treatment
Four best on mental health outcomes include 7
challenges, CHS, A-CRA, MST
9
Change (post-pre) in Effect Size for Core
Treatment Outcomes by Type of Treatment
Four best on treatment outcomes include A-CRA,
MST, MDFT, FSN
10
Summary of Findings

• All programs reduced mental health / trauma
  problems with 4 doing particularly well 7
  challenges, CHS, A-CRA, MST
• All programs reduced general outcomes on average,
  with 4 doing particularly well A-CRA, MST, MDFT,
  FSN
• All more assertive/family/systemic programs
• All have formal training, quality assurance,
  monitoring technical assistance
• Where we could break in two (A-CRA MET/CBT),
  programs with more training, quality assurance,
  monitoring and technical assistance did better
  than those with less
• A-CRA with a mix of BA/MA did as well as MST
  which targets MA level therapists and family
  therapists that are often in short supply
• While it is not as effective, the shortest
  least expensive (MET/CBT5) still has positive
  effects

10
11
Both Trauma and Substance Use Follow Classical
Conditioning Models
Bad coping/ Avoidant response or Seeking relief
Emotional/Physical Reaction
Original Signal Trigger/Reminder
Pain, anxiety, anger, anxiety, guilt, sadness
Substance use
Craving, drug seeking anxiety, guilt, shame
12
The two main reasons for continued use are to
seek pleasure and to avoid physical or
psychological pain
Adolescent Brain Development Occurs from the
Inside to Out and from Back to Front
Photo courtesy of the NIDA Web site. From A Slide
Teaching Packet The Brain and the Actions of
Cocaine, Opiates, and Marijuana.
13
Characteristics of Individuals with Traumatic
Stress and Substance Abuse

• Emotional and behavioral dysregulation
• Coping deficits
• Family strain
• Environmental stress
• Academic vocational difficulties
• Health problems
• Involvement with multiple service systems (legal
  system, social services, mental health, substance
  abuse, special education)

14
Trauma Exposure vs. PTSD

• Lifetime exposure to trauma is common.
• Only a fraction of trauma-exposed individuals
  will go on to develop PTSD or a sub-clinical
  variation of it (complex trauma response, DESNOS,
  partial PTSD).
• Strongest risks for exposure turning into PTSD
• Unexpected death of someone close
• Sexual assault or physical assault that involved
  fearing for own life
• If they do not get help right away or are not
  believed
• As demonstrated earlier, trauma associated with a
  wide range of consequences
• PTSD is just a subset

15
Posttraumatic Stress Disorder

• A set of characteristic symptoms that can develop
  when a PAST trauma overwhelms the persons
  ability to cope
• Re-Experiencing the traumatic event through
  intrusive thoughts or dreams of the event, or
  intense psychological distress when exposed to
  reminders of the event
• Avoidance of thoughts, feelings, images, or
  locations that remind one of or are associated
  with the traumatic event
• Increased arousal such as hyper-vigilance,
  irritability, exaggerated startle response, and
  sleeping difficulties

Child maltreatment often does not meet criteria
for PTSD because it happened multiple ways or
times and is often on going.
16
The Whole is Greater than the Sum of its Parts

• The presence of traumatic stress or PTSD greatly
  complicates the recovery process in individuals
  with substance use disorders.
• Exposure to trauma or trauma triggers has been
  shown to increase drug cravings and relapse in
  people with co-occurring trauma and substance
  abuse.
• When substance abuse and traumatic stress are
  treated separately, individuals with co-occurring
  disorders are more likely to relapse and revert
  to previous maladaptive coping strategies..

17
Common Components of Trauma-Informed Care

• Cognitive restructuring such as recognizing,
  challenging, and correcting negative cognitions
• Emotion regulation skills such as the
  identification, expression, and modulation of
  negative affect like anxiety and panic
• Stress management skills such as relaxation and
  positive self-talk
• Gradual exposure to achieve desensitization to
  trauma reminders while practicing relaxation

Adapted from Cohen, Mannarino, Zhitova, Capone
(2003)
18
Some Specific Models of Trauma Informed Care for
Adolescents and Emerging Adults

• Cognitive Behavioral Intervention for Trauma in
  Schools (CBITS)
• Structured Psychotherapy for Adolescents
  Responding to Chronic Stress (SPARCS)
• Integrated Care for Adolescents Struggling with
  Traumatic Stress and Substance Abuse (I-CARE)
• Trauma Recovery and Empowerment Model (TREM)
• Seeking Safety

19
Cognitive Behavioral Intervention for Trauma in
Schools (CBITS)

• CBITS is a skills-based group intervention aimed
  at relieving symptoms of PTSD, depression, and
  anxiety among children exposed to trauma.
• Skills are learned through use of drawings and
  talking in both group and individual sessions.
• Skills are reinforced by completing assignments
  and participating in activities.
• There are parent and teacher education sessions
  as well.

20
CBITS Facts

• Population girls boys, 10-15 yrs, exposed to
  trauma AND suffering moderate symptoms diverse
  groups
• Sessions 10 weekly group sessions (5-8 youths),
  1-3 individual (exposure), 2 parent, 1 teacher
• Setting - school
• Components 6 cognitive behavioral skills
• Education on reactions to trauma
• Relaxation training
• Cognitive therapy
• Exposure to trauma reminders
• Stress or trauma exposure
• Social problem-solving

21
Support for CBITS

• Quasi-experiment with control group (Kataoka et
  al., 2003)
• Latino immigrant children exposed to community
  violence
• Children in the CBITS group had significantly
  greater improvement in PTSD and depressive
  symptoms compared to those on a wait-list at 3
  months.
• Randomized controlled trial (Stein, Jaycox, Wong,
  Tu, Elliott Fink, 2003)
• Largely Latino 6th graders exposed to community
  violence.
• Children in the CBITS group had significantly
  greater improvement in PTSD and depressive
  symptoms compared to those on a wait-list at 3
  months.
• Parents of the children in the CBITS group
  reported significant improvements in functioning.
• Improvements in symptoms and functioning
  continued to be seen at 6 months.

22
Implementing CBITS

• Staff - ideal person has prior training and
  experience with mental health and CBT.
• CBITS manual available from http//www.sopriswest
  .com
• Jaycox, L. (2003). CBITS Cognitive-Behavioral
  Intervention for Trauma in Schools. New York
  Sopris West.
• Training available contact Dr. Audra Langley
  (alangley_at_mednet.ucla.edu)
• trainees read background materials and the manual
  and watch a training video prior to training,
  attend a 2-day training, receive ongoing
  supervision from a local clinician with expertise
  in CBT
• www.cbitsprogram.org.
• More info on CBITS
• Contact Sheryl Kataoka (skataoka_at_ucla.edu)

23
Structured Psychotherapy for Adolescents
Responding to Chronic Stress (SPARCS)

• SPARCS is a skills-based group intervention for
  chronically traumatized adolescents who may still
  be living with ongoing stress and are
  experiencing problems in several areas of
  functioning
• Emotional and behavioral regulation
• Attention/Consciousness
• Self-perception
• Interpersonal relationships
• Somatization and physical health problems
• Systems of meaning

24
Structured Psychotherapy for Adolescents
Responding to Chronic Stress (SPARCS)

• SPARCS components are based on three empirically
  validated interventions.
• Dialectical Behavior Therapy for Adolescents
  (mindfulness and interpersonal skills)
• Trauma Adaptive Recovery Group Education and
  Therapy (TARGET) (problem solving skills)
• UCLA Trauma/Grief Program (enhancing social
  support and planning for future)
• Cognitive-behavioral, present-focused,
  strength-based
• Overall goals (the 4 Cs)
• Cultivate awareness
• Cope more effectively
• Connect with others
• Create meaning

25
SPARCS Facts

• Population girls boys, 12-19 yrs, who have
  problems in functioning related to chronic
  interpersonal trauma
• Sessions 16 weekly 1 hour group sessions (6-10
  youths)
• Setting outpatient clinics, schools, group
  homes, boarding schools, residential treatment,
  foster care programs
• Components (Core Skills)
• Mindfulness
• Problem Solving
• Meaning-making
• Relationship building and communication skills
• Distress Tolerance
• Psychoeducation on stress and trauma

26
Support for SPARCS

• Quasi-experiment with comparison group (Lyons et
  al., in press)
• Adolescents in foster care who received were half
  as likely to run away and a fourth as likely to
  experience treatment disruptions (e.g., arrests,
  hospitalization) than those assigned to a
  standard care intervention.
• Pilot study (Habib Ross, 2006)
• Adolescent girls in a 22 session SPARCS group
  showed significant improvement in overall
  functioning on level of behavioral dysfunction,
  interpersonal relationships, and interpersonal
  coping (support seeking behavior).

27
Implementing SPARCS

• Staff prior training and experience in
  counseling
• SPARCS manual available from treatment developers
  (Dr. Ruth DeRosa)
• DeRosa, R., Habib, M., Pelcovitz, D., Rathus, J.,
  Sonnenklar, J., Ford, J., et al. (2006).
  Structured Psychotherapy for Adolescents
  Responding to Chronic Stress. Unpublished
  manual.
• Training available http//sparcstraining.com/index
  .php
• Initial two day training, later two day training,
  frequent consultations
• Learning Collaborative
• More info on SPARCS
• Dr. Victor Labruna (vlabruna_at_nshs.edu)
• Dr. Mandy Habib (mhabib_at_nshs.edu)

28
Integrated Care for Adolescents Struggling with
Traumatic Stress and Substance Abuse (I-CARE)

• I-CARE is a community-based program for youths
  who are having difficulties regulating emotions
  resulting from traumatic experiences and
  environmental stress and who are also having
  problems with substance abuse.
• Acknowledges the role of the social ecology on
  youth and family functioning.
• The intervention provides a framework for
  coordinating care.
• Following assessment, a multidisciplinary team
  chooses from a series of interventions based on
  the youths needs.

29
Integrated Care for Adolescents Struggling with
Traumatic Stress and Substance Abuse (I-CARE)

• I-CARE is based on Trauma Systems Therapy (TST),
  which is based on several approaches
• Systems-of-Care approach (overall framework)
• Multisystemic Therapy (MST) (home-based services)
• Dialectical Behavior Therapy (emotional
  regulation skills training)
• Trauma Focused Cognitive Behavioral Therapy
  (cognitive processing skills training)
• Psychopharmacology
• I-CARE was previously known as Trauma Systems
  Therapy Substance Abuse (TST-SA)

30
I-CARE Facts

• Population girls boys, 13-17 yrs, with
  co-occurring trauma and substance abuse who are
  having problems with emotional regulation in an
  environment that cannot contain it.
• Sessions length of treatment is variable, can
  last from 3 to 9 months depending on severity of
  youths situation individual and parent/family
  components
• Setting community-based program - delivered in
  clinic, at home, in the social environment

31
I-CARE Modules
Ready Set Go Building alliance and enhancing motivation, Psychoeducation, Troubleshooting Practical Barriers, Treatment Planning
Stabilization on Site Home Based Care, Family Communication, Behavior Management, Community Integration Strategies
Services Advocacy Connecting the youth and family with needed resources
Psychopharmacology Coordinated psychiatric evaluation and medication management
Emotion Regulation Psychoeducation and Skill Building (Affect Management, Competency building, Emotion Identification and Acceptance)
Cognitive Processing Cognitive Restructuring, Exposure to the Trauma Narrative
Meaning Making Enacting meaning, future orientation, relapse prevention
32
Support for I-CARE

• TST open trial (Saxe, Ellis, Fogler, Hansen,
  Sorkin, 2005)
• ? trauma symptoms, ? emotional and behavioral
  regulation
• More stable social environment
• Transitioning from more intensive to less
  intensive phases of treatment
• Dissemination Ulster County Program Evaluation
• ? trauma symptoms, ? family stability
• ? hospitalization rates and length of hospital
  stay
• ? length for need of services
• TST controlled trial (preliminary findings)
• Reduced drop out rates (10/10 vs. 1/10 retention
• after 3 months)

33
Implementing I-CARE

• Staff M.A. level counselors staff with less
  formal training can deliver components in
  collaboration with counselors
• Materials
• I-CARE manual available from treatment developer,
  Dr. Liza Suárez (lsuarez_at_psych.uic.edu)
• Adolescent and parent workbook, assessments
• Training available
• Two days basic training
• Weekly conference call
• One day follow-up training at 6 months
• More info on I-CARE
• Contact Dr. Suárez

34
Trauma Recovery and Empowerment (TREM)

• TREM is a comprehensive group intervention for
  women survivors of physical, sexual, and/or
  emotional abuse who may use substances and for
  whom traditional recovery work has been
  unavailable or ineffective.
• Draws on cognitive restructuring, skill-building,
  and psychoeducational techniques
• Teaches techniques for self-soothing, boundary
  maintenance, and current problem solving
• Emphasizes development of coping skills and
  social support.

35
TREM Facts

• Population women trauma survivors with
  substance abuse and/or mental health problems a
  mens group and an adolescent girls group have
  been implemented 18-25, 26-55 yrs diverse
  ethnic groups
• Sessions 24 to 29 to 33 weekly group sessions
  (6-8 members), 75 minutes per session, over a 9
  month period
• Setting substance abuse and mental health
  programs (residential and non-residential),
  correctional institutions, welfare-to-work
  programs, homeless shelters

36
TREM Components

• Empowerment learn strategies for
• Self-comfort and accurate self-monitoring
• Setting physical and emotional boundaries
• Increasing self-esteem
• Trauma Education
• Explore and reframe the connection between their
  experiences of abuse and consequences of abuse
  (other current difficulties), including substance
  use, mental health symptoms, interpersonal
  problems
• Provided with tools and skills with which they
  can combat the repercussions of trauma

37
TREM Components

• Advanced Trauma Recovery
• Explore practical coping, problem solving, and
  skill-building strategies
• Topics include communication style,
  decision-making, managing out-of-control
  feelings, developing safer relationships
• TREM addresses substance abuse throughout the
  intervention. Skills such as self-awareness,
  self-soothing, emotional modulation, development
  of safe and mutual relationships, and consistent
  problem solving are aimed at active substance
  abuse treatment and relapse prevention.

38
Support for TREM

• Quasi-experimental studies (Amaro et. al., n.d.
  Fallot, McHugo, Harris, 2005 Toussaint,
  VanDeMark, Bornemann, Graber, 2007)
• Severity of problems related to substance abuse
• TREM participants showed significantly greater
  decreases in drug addiction severity at 6- and
  12-month follow-ups than those receiving usual
  care significant improvements in alcohol
  addiction severity
• Mean alcohol and drug problem severity scores
  decreased from baseline to 1-year follow-up,
  relative to recipients of alternative care
• Psychological problems/symptoms
• TREM participants showed significantly reduced
  symptoms of psychological problems 1 year after
  the intervention
• Trauma symptoms
• At 12-month follow-up, trauma symptoms were
  significantly reduced among TREM participants
  compared with recipients of alternative care.

39
Implementing TREM

• Female co-leaders (male leaders in mens group)
• TREM manual available from Community Connections
  or in bookstores
• Harris, M. (1998). Trauma Recovery and
  Empowerment A Clinicians Guide for working with
  women in groups. New York The Free Press.
• Training available from developers, designed for
  2 trainers and up to 40 participants
• More info on TREM
• Rebecca Wolfson Berley, M.S.W. rwolfson_at_community
  connectionsdc.org www.communityconnectionsdc.org
  

40
Seeking Safety

• Seeking Safety is a present-focused therapy
  designed to promote safety and recovery for
  individuals with PTSD and substance abuse as well
  as those who have trauma histories but who do not
  meet clinical criteria for PTSD.
• Based on 5 key principles
• Safety is the primary goal
• Work on PTSD/trauma and substance abuse at the
  same time
• Focus on ideals to counteract the loss of ideals
  from the experiences of PTSD/trauma and substance
  abuse
• Address cognitive, behavioral, interpersonal, and
  case management areas of client functioning
• Focus on clinician processes (e.g., helping
  clinicians work with countertransference issues)

41
Seeking Safety Facts

• Population adults and adolescents (male and
  female) with PTSD/trauma and substance abuse
  disorders
• Sessions 25 weekly 50-90 minute sessions (or
  twice weekly), group or individual formats
• Setting substance abuse treatment (OP,
  residential), correctional facilities, health and
  mental health centers

42
Seeking Safety Components

• There are 25 components roughly equally divided
  between cognitive, behavioral, and interpersonal
  domains. Below is a sample of topics

Safety Recovery thinking
Taking back your power Creating meaning
Grounding Community resources
When substances control you Setting boundaries in relationships
Asking for help Coping with triggers
Self-nurturing Healing from anger
43
Seeking Safety Components

• No exposure
• considered later stage of treatment
• risk of painful memories triggering substance use
  in misguided attempt to cope
• could trigger others if in group format

44
Support for Seeking Safety

• Evidence base of published studies - 6 pilot
  studies, 4 randomized controlled trials (RCTs), 1
  controlled nonrandomized trial, 2 multisite
  controlled trials, and 1 dissemination study
• Populations - men, women, veterans, adolescents,
  homeless, and criminal justice
• All outcome studies evidenced positive outcomes
  (decreased trauma symptoms, decreased substance
  abuse, improvements in other areas such as HIV
  risk, suicidal symptoms, problem solving, social
  functioning, and sense of meaning).
• In the controlled trials, Seeking Safety
  typically outperformed the comparison condition.

45
Implementing Seeking Safety

• Seeking Safety has been implemented by counselors
  (M.A. level, B.A. level, case managers), social
  workers, and psychologists
• Seeking Safety manual
• Najavits, L.M. (2002). Seeking Safety A
  Treatment Manual for PTSD and Substance Abuse.
  New York Guildford.
• Training
• Individualized to specific needs of clinic
• Via videos, on-site, existing training, telephone
  consultation
• More info on Seek Safety
• Contact Lisa Najavits (info_at_seekingsafety.org)
• http//www.seekingsafety.org

46
Information on Other Models

• National Child Traumatic Stress Network
  http//www.nctsn.org
• National Center for Trauma-Informed Care
  http//www.samhsa.gov/nctic/
• Models for Developing Trauma-Informed Behavioral
  Health Systems and Trauma-Specific Services
  2008 Update http//www.theannainstitute.org/Models
  20for20Developing20Traums-Report201-09-0920_F
  INAL_.pdf