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Trauma-Informed Treatment: Best Practices


Trauma-Informed Treatment: Best Practices James A. Peck, Psy.D. Los Angeles County Annual Drug Court Conference May 15, 2009 * * * * * In each realm of one s life ... – PowerPoint PPT presentation

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Title: Trauma-Informed Treatment: Best Practices

Trauma-Informed Treatment Best Practices
  • James A. Peck, Psy.D.
  • Los Angeles County Annual Drug Court Conference
  • May 15, 2009

Trauma-Informed and Trauma-Specific Services
  • The provision of trauma-informed care is a
    seminal concept in emerging efforts to address
    trauma in the lives of children, youth and
  • In a trauma-informed system, trauma is viewed as
    a defining and organizing experience that forms
    the core of an individuals identity.

Source Harris, M. and Fallot, R.D. (Eds), 2001
What are Trauma-Informed Services?
  • Characteristics of trauma-informed services
  • Incorporate knowledge about traumaprevalence,
    impact, and recoveryin all aspects of service
  • Hospitable and engaging for survivors
  • Minimize re-victimization
  • Facilitate recovery and empowerment

Comparing Traditional and Trauma-Informed
  • Understanding of Trauma
  • Understanding of the Consumer/Survivor
  • Understanding of Services
  • Understanding of the Service Relationship

Trauma-Informed Human Services Paradigm
  • Understanding of Trauma
  • Traumatic events are not rare experiences of
    life disruption are pervasive and common
  • The impact of trauma is seen in multiple,
    apparently unrelated life domains
  • Repeated trauma is viewed as a core life event
    around which subsequent development organizes
  • Trauma begins a complex pattern of actions and
    reactions which have a continuing impact over the
    course of ones life

Trauma-Informed Human Services Paradigm
  • Understanding of the Consumer/Survivor
  • An integrated, whole person view of individuals
    and their problems and resources
  • Symptoms are understood not as pathology but
    primarily as attempts to cope and survive what
    seem to be symptoms may more accurately be
  • A contextual, relational view of both problems
    and solutions
  • Appropriate and collaborative responsibility

Trauma-Informed Human Services Paradigm
  • Understanding of Services
  • Primary goals are empowerment and recovery
  • Survivors are survivors their strengths need to
    be recognized
  • Service priorities are prevention driven
  • Service time limits are determined by survivor
    self-assessment and recovery/healing needs
  • Risk to the consumer is considered along with
    risk to the system and the provider

Trauma-Informed Human Services Paradigm
  • Understanding of the Service Relationship
  • A collaborative relationship between the consumer
    and the provider of her or his choice
  • Both the consumer and the provider are assumed to
    have valid and valuable knowledge bases
  • The consumer is an active planner and participant
    in services
  • The consumers safety must be guaranteed and
    trust must be developed over time

A Culture Shift Core Principles of a
Trauma-Informed System
  • Safety Ensuring physical and emotional safety
  • Trustworthiness Maximizing trustworthiness,
    making tasks clear, and maintaining appropriate
  • Choice Prioritizing consumer choice and control
  • Collaboration Maximizing collaboration and
    sharing of power with consumers
  • Empowerment Prioritizing consumer empowerment
    and skill-building

Trauma-Specific Interventions
  • Services designed specifically to address
    violence, trauma, and related symptoms and
  • The intent of the activities is to increase
    skills and strategies that allow survivors to
    manage their symptoms and reactions with minimal
    disruption to their daily obligations and to
    their quality of life, and eventually to reduce
    or eliminate debilitating symptoms and to prevent
    further traumatization and violence.

  • Screening Assessment

  • Trauma-informed care refers not only to the
    recognition of the pervasiveness of trauma, but
    also to a commitment to identify and address it
    early, whenever possible.
  • Numerous assessment/diagnostic issues complicate
    the identification treatment of trauma.

What is the Difference between
Screening/Diagnosis Issues
  • Identification of PTSD or sub-threshold PTSD
    symptoms is complicated by the fact that these
    symptoms mimic symptoms of anxiety and depression
  • Many individuals with PTSD also abuse alcohol and
  • If trauma screening isnt conducted, these
    individuals are usually treated as people with
    just depression, or just anxiety, or just AOD

Screening/Diagnosis Issues PTSD Diagnostic
  • Individual is exposed to traumatic event in
  • They experienced, witnessed, or were confronted
    with event/events that involved actual or
    threatened death or serious injury to themselves
    or others
  • Response to event included intense fear,
    helplessness, or horror
  • Combat-related PTSD vs. non-combat related

Screening/Diagnosis Issues PTSD Diagnostic
  • Three categories of symptoms
  • 1. Re-experiencing 2. Avoidance 3. Arousal
  • Re-experiencing
  • Recurrent re-experiencing of trauma, i.e.
    flashbacks, nightmares, intrusive thoughts or
  • Intense psychological and/or physiological
    reactions to external or internal cues that
    represent some aspect of the traumatic event(s)

Screening/Diagnosis Issues PTSD Diagnostic
  • 2. Avoidance Symptoms
  • Persistent avoidance of stimuli associated with
    the trauma, i.e.
  • Thoughts, feelings, conversations
  • Activities, people, places
  • Impaired memory of aspects of trauma
  • Reduced interest or participation in usual
  • Feeling detached/estranged from others
  • Restricted range of affect (i.e. unable to feel
  • Sense of shortened lifespan

Screening/Diagnosis Issues PTSD Diagnostic
  • 3. Persistent symptoms of increased arousal
  • Difficulty falling asleep or staying asleep
  • Frequent irritability or angry outbursts
  • Impaired concentration/focus
  • Hypervigilance
  • Exaggerated startle response

What is COJAC?
  • Summer of 2005 State Co-Occurring Disorders
    Workgroup/COD Policy Academy members, along with
    representatives from the County Alcohol and Drug
    Program Administrators Association of California
    (CADPAAC) and the California Mental Health
    Directors Association (CMHDA), formed the
    Co-Occurring Joint Action Council (COJAC) to
    develop and implement the States COD Action

The COJAC Screening Committee
  • Major objectives identify screening protocols
    designed to meet the needs of a variety of
    populations served by both AOD and Mental Health
    Systems, including
  • adolescents
  • women with children
  • adults
  • transition age youth with trauma histories

The COJAC Screening Committee
  • Committee was charged with identifying the best
    screening tool(s) for COD.
  • Committee reviewed all instruments being utilized
    across the country found that the most widely
    used instruments were those designed for
    identification of either substance abuse or
    mental illness.

The COJAC Screening Committee
  • Screening Committee therefore decided to design a
    California screening tool that would
  • Identify potential co-occurring disorders
  • Identify potential trauma histories
  • Be short enough to not burden clients/staff
  • Be simple enough to be utilized in a wide range
    of settings, i.e. law enforcement/ criminal
    justice, primary care, emergency departments,
    mental health clinics, etc.

(No Transcript)
The COJAC Screener
  • COJAC Screener currently being implemented in
    mental health departments in a number of
    California counties including LA
  • CA Alcohol and Drug Programs (ADP) is
    simultaneously implementing a two-year pilot test
    of the Screener
  • Goal is to increase capacity to detect
    consumers/clients with potential mental health,
    substance use, or trauma-related problems

Comprehensive Assessment
  • Assessment identifies risk behaviors (i.e. danger
    to self, danger to others) and suggests
    interventions that ultimately reduce risk.
  • Assessment can also help explain a consumer/
    clients behavior, the behaviors connection to
    his/her experience of trauma, and whether
    substance use is a means to cope with distress.
  • Assessment provides input for the development of
    treatment goals with measurable objectives
    designed to reduce the negative effects of trauma
    and substance use.

Trauma Assessment
  • Not all individuals who have experienced trauma
    need trauma-specific interventions.
  • Unfortunately, many individuals exposed to trauma
    lack natural support systems and need the help of
    trauma-informed care systems.
  • Many people who do not meet the full criteria for
    PTSD still suffer significant posttraumatic
    symptoms that can strongly affect behavior,
    judgment, education/work performance, and ability
    to connect with family/caregivers.
  • These individuals may benefit from comprehensive
    trauma assessment to determine most effective

Importance of Trauma Assessment
  • Trauma assessment typically involves conducting a
    thorough trauma history
  • Identify all forms of traumatic events
    experienced directly or witnessed by the
    consumer/client, to inform the choice of
  • Supplement trauma history with trauma-specific
    standardized clinical measures to assist in
    identifying the type and severity of symptoms the
    individual is experiencing

  • Interventions

Recommendations for Integrated Treatment For
Trauma and Substance Abuse
  • Cross training in mental health and substance
  • Utilize screening and assessment tools that
    identify needs in both areas
  • Provide more intense treatment options to address
    the magnitude of difficulties often experienced
    by this population
  • Emphasize management and reduction of both
    substance use and PTSD symptoms early in the
    recovery process
  • Be aware that reducing substance use may
    initially increase PTSD symptoms
  • Provide relapse prevention efforts, targeting
    both substance and trauma-related cues, early in

Sources Back et al., 2000 Giaconia, et al.,
2003 Ouimette Brown, 2003
Common Elements of Evidence-Based Trauma and
Substance Abuse Treatments
  • Starting treatment
  • Psychoeducation
  • Strategies to promote client engagement
  • Cognitive behavioral approaches
  • Skill building to improve ability to cope with
  • Skill building to improve ability to cope with
  • Family interventions (adolescent clients)
  • Improve parental monitoring and limit setting
  • Improve communication

A Cognitive-Behavioral Model of the Relapse
Confronts a high-risk situation
Response does not use adequate coping
Chooses and makes use of appropriate coping
Experiences decrease in self-efficacy, with a
resulting sense of helplessness or passivity and
decreased self control
Has expectation that a drink would help the
situation (positive outcome expectancies)
Experiences a sense of mastery and an ability to
cope with the situation
These perceptions and expectancies lead to
initial use of alcohol
Results in abstinence violation effect
These perceptions decrease the likelihood of
Feels guilt and loss of control
These feelings increase probability of relapse
Source Adapted from Alan Kadden, 1995
Core Components of Trauma-Informed
Evidence-Based Treatment
  • Trauma-informed approaches incorporate some or
    all of the following elements
  • Building a strong therapeutic relationship
  • Psychoeducation about normal responses to trauma
  • Family support or conjoint therapy
  • Emotional expression and regulation skills
  • Anxiety management and relaxation skills
  • Cognitive processing or reframing

Core Treatment Components
  • Additional elements of trauma-informed treatment
  • Construction of a coherent trauma narrative
  • Strategies that allow exposure to traumatic
    memories and feelings in tolerable doses so that
    they can be mastered and integrated into the
    consumer/clients experience
  • Personal safety training and other important
    empowerment activities
  • Resilience and closure

Core Treatment ComponentsCognitive
  • Traumatized individuals often show negative
    patterns of thinking as a result of their
    traumatic experiences
  • Distrust of others or expectations that they
    might be harmed by others
  • Overestimation of and preoccupation with danger
  • Low self-esteem and self-blame (feeling
    responsible for the trauma or what happened as a
  • Helplessness and hopelessness about the future
  • Shame and/or stigma
  • Survivor guilt

Core Treatment ComponentsCognitive
  • Polarized thinkingframing things in black/white,
    good/bad terms, either they achieve perfection or
    they have failed
  • Control fallaciesfeeling externally controlled
    and helpless or a victim of fate, or feeling
    internally controlled and responsible for the
    pain and happiness of everyone around them
  • Blamingholding other people responsible for your
    pain or blaming yourself for every problem
    (externalizing or internalizing to the extreme)

Core Treatment Components
  • Cognitive processing/reframing/restructuring can
    help consumers/clients identify these faulty
    patterns of thinking and practice using healthier
    cognitive coping strategies

Core Treatment ComponentsCognitive Processing
  • Learn about thoughts, feelings, and behavior
  • Distinguish between accurate and inaccurate
    cognitions, or helpful and unhelpful cognitions
  • Understand relationship between feelings,
    thoughts, and behavior
  • Learn how to identify and correct unhelpful
  • Identify Identifying the thought related to the
  • Challenge Evaluating the thought based on the
    evidence and logic
  • Replace Choosing alternative, more accurate,
    adaptive or helpful thoughts. Changing the
    emotion or the behavior by changing thoughts

Core Treatment ComponentsThe Trauma Narrative
  • Developing a trauma narrative involves
  • Reviewing details of traumatic experience to
    achieve habituation to distress (reduce
    association between memories and overwhelming
  • Identifying and challenging distortions in
    thinking associated with the trauma
  • Generating a trauma narrative helps a
    consumer/client to
  • Control intrusive and upsetting trauma-related
  • Reduce avoidance of trauma-related cues
  • Identify unhelpful cognitions about traumatic
  • Recognize and prepare for reminders of trauma

Core Treatment ComponentsMotivational
  • Motivational Interviewing strategies
  • Taking an empathic, non-judgmental stance and
    listening reflectively
  • Developing discrepancy between the clients goals
    and their current behaviors
  • Rolling with the clients resistance and avoiding
  • Supporting/building self-efficacy

Source Miller Rollnick, 2002
Stages of Change
Precontem- plation
Source Prochaska DiClemente, 1982
Motivational Interviewing Decisional Balance
  • Seeking Safety An Intervention for PTSD and
    Substance Abuse

Seeking Safety
  • Developed by
  • Lisa M. Najavits, PhD
  • VA Boston Health Care System
  • 150 South Huntington, 1168-3
  • Belmont, MA 02130
  • E-Mail or

Source Najavits, L.M., 2002
Seeking Safety
  • Evidence-based, present-focused therapy designed
    to promote safety and recovery for individuals
    with trauma histories.
  • Relevant for individuals with PTSD and those with
    trauma histories who do not meet criteria for
  • Based on 4 key content areas cognitive,
    behavioral, interpersonal and case management.
  • Able to be delivered in a variety of settings
    (inpatient, outpatient, field-based) and formats
    (group, individual).
  • Integrates both Trauma and Substance Abuse

Source Najavits, L.M., 2002
Seeking SafetyTreatment Topics
  • Introduction to Treatment and Case Management
  • Safety
  • PTSD Taking Back Your Power
  • Detaching from Emotional Pain (Grounding)
  • When Substances Control You
  • Asking for Help
  • Taking Good Care of Yourself
  • Compassion
  • Red and Green Flags

Seeking SafetyTreatment Topics
  • Honesty
  • Recovery Thinking
  • Integrating the Split Self
  • Commitment
  • Creating Meaning
  • Community Resources
  • Setting Boundaries in Relationships
  • Discovery

Seeking SafetyTreatment Topics
  • Getting Others to Support Your Recovery
  • Coping with Triggers
  • Respecting Your Time
  • Healthy Relationships
  • Self-Nurturing
  • Healing From Anger
  • Life Choices Game (review)
  • Termination

Adapting Seeking Safety to Different Contexts
  • 12 Sessions (original CTN Study)
  • Introduction to Treatment
  • Safety
  • PTSD Taking Back Your Power
  • Detaching from Emotional Pain (Grounding)
  • When Substances Control You
  • Taking Good Care of Yourself
  • Compassion
  • Red and Green Flags
  • Honesty
  • Integrating the Split Self
  • Creating Meaning
  • Setting Boundaries in Relationships
  • Healing from Anger
  • 5 Sessions
  • Safety
  • PTSD Taking Back Your Power
  • When Substances Control You
  • Detaching from Emotional Pain (Grounding)
  • Asking for Help

Seeking Safety 5-Session Module
Seeking Safety 5-Session Module
  • Session 1 SAFETY
  • Although the world is full of suffering, it is
    full also of the overcoming of it.
  • Safety as the first stage of healing from PTSD
    and SA
  • Empower the patient to regain control
  • Help the patient to identify cues (who, what,
    when) that are safe
  • Teach coping skills that may never have been
    learned in childhood
  • Assess the impact of SA and develop a plan for
    harm reduction/abstinence
  • Provide psychoeducation about SA and PTSD

Seeking Safety 5-Session Module
  • Session 1 SAFETY
  • DO
  • Be active and directive
  • Give the patient control
  • Seek to understand the patients self-destructive
    behaviors as symbolic or literal reenactment of
    the initial abuse.
  • DO NOT
  • Do not offer dynamic interpretations
  • Do not confront defenses
  • Do not focus on therapist-patient relationship

Seeking Safety 5-Session Module
  • Session 2 PTSD Taking Back Your Power
  • You are not responsible for being down, but you
    are responsible for getting up
  • Define PTSD
  • Explore the relationship between PTSD and SA
  • Help clients to take back their power by viewing
    PTSD and SA with compassion
  • Help clients understand the long-term impact of
    severe trauma
  • Intervention includes handouts for all of the
    above topics

Seeking Safety 5-Session Module
  • Session 3 When Substances Control You
  • Not to laugh, not to lament, not to judge, but
    to understand
  • Help patients honestly evaluate whether they have
    a substance use disorder
  • Raise patients awareness of how substance abuse
    prevents healing from PTSD
  • Identify an immediate plan to relinquish
    substance use that is REALISTIC and ACCEPTABLE to
    the patient (quit at once, try an experiment, cut
    down gradually)
  • Conduct an imaginative exercise, Climbing Mount
    Recovery, to help patients realistically prepare
    to stop using substances
  • Help patients recognize that it is normal to have
    mixed feelings about giving up substances, as
    long as their actions remain safe
  • Discuss the role of self-help groups and
    encourage patients to attend

Seeking Safety 5-Session Module
  • Session 4 Detaching from Emotional Pain
  • No feeling is final
  • Teach grounding as a set of simple but powerful
    techniques to detach from emotional pain
  • Conduct an in-session experiential exercise on
    grounding (record for clients to take home)
  • Explore how grounding can be applied to clients
    day-to-day problems

Seeking Safety 5-Session Module
  • Session 5 Asking for Help
  • And the trouble is, if you dont risk anything,
    you risk even more
  • Discuss effective ways to ask for help
  • Rehearse/roleplay how to ask for help
  • Explore clients experiences of asking for help,
    i.e. were people willing to help, were they
    rejected, etc

A Trauma-Informed ApproachIncludes a
Trauma-Informed Team
  • A trauma-informed team integrates mental health,
    substance abuse, and trauma work
  • A trauma-informed team working with adolescents
    integrates youth interventions with parent/family
  • A trauma-informed team coordinates efforts with
    the multiple systems affecting the consumer/client

The Team Approach is Essentialto Effective
Service Provision
  • It allows us to assemble expertise packages to
    provide the highest quality services (i.e., we
    can assemble the best group of individuals with
    varying expertise, including trauma work)
  • It allows us to use staffing patterns that permit
    backup and sharing of clinical responsibilities
    and coverage
  • It allows us to treat the child(ren), in the case
    of adolescent clients, and parents/caregivers and
    also work with the multiple systems affecting the
    child and family

Managing Professional and Personal Stress When
Working with Trauma Victims
Professional/Personal Stress
  • Providing services for traumatized individuals
    increases the potential for secondary traumatic
  • Clinicians/criminal justice professionals may
    empathize with their clients experiences
    feelings of helplessness, anger, and fear are
  • Clinicians/criminal justice professionals who are
    parentsor who have their own histories of
    traumamay be at particular risk for experiencing
    such reactions.

Professional/Personal Stress
  • Clinician self-care is an important aspect of a
    trauma-informed system.
  • Working with trauma survivors reminds us of our
    own vulnerability to traumatic events, the
    dangerousness of the world we live in, and the
    way in which the things that matter to us (e.g.,
    our loved ones, our health, our sense of meaning)
    can be suddenly affected.
  • The term vicarious traumatization was first
    used in 1990 to describe secondary traumatic
    stress (in the helper).

Impact of Working with Victims of Trauma
  • Trauma experienced while working in
    healthcare/criminal justice roles has been
    described as
  • Compassion fatigue
  • Countertransference
  • Secondary traumatic stress (STS)
  • Vicarious traumatization
  • Unlike other forms of job burnout STS is
    precipitated not by work load and institutional
    stress, but by exposure to clients trauma.
  • STS can disrupt clinicians lives, feelings,
    personal relationships and overall view of the

Recognizing Signs of Secondary Traumatic Stress
  • Secondary traumatic stress manifests as reactions
    of grief, rage, and outrage, which grow as we
    repeatedly hear about and see our
    consumers/clients pain and loss. It is also
    evident in our own emotional numbing and our wish
    not to know.
  • Other signs include
  • Feeling off balance
  • Being easily flooded by negative feelings and
    having to limit exposure to violence (e.g., by
    avoiding TV or movies)
  • Being easily moved to tears
  • Feelings of burnout
  • Feelings of despair and hopelessness
  • Reduced productivity

Managing Personal and Professional Stress
Strategies for Healthcare/Criminal Justice
  • Request and expect regular supervision and
    supportive consultation.
  • Utilize peer support.
  • Consider your own therapy for unresolved trauma,
    which your professional work may be activating.
  • Practice stress management through meditation,
    prayer, conscious relaxation, deep breathing, and
  • Develop a written plan focused on work-life
  • Participate in community-building activities and
    system change. We need to collaborate with our
    consumers/clients, co-workers, and communities to
    bring about lasting change in our society.

Managing Professional/Personal Stress
  • Attend to your health physical, emotional,
    psychological, and spiritual
  • Try to eat healthy
  • Exercise
  • Take mini-vacations
  • Practice receiving from others
  • Spend time with important people in your life
  • Identify comforting/relaxing activities
  • Take time to eat lunch and chat with co-workers

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