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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 – PowerPoint PPT presentation

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Title: Insert Workshop Title

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
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
  • Please direct comments to Michael Dennis,
    Chestnut Health Systems, 448 Wylie Drive, Normal,
    IL 61761, 309-451-7801, .

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

Change Over Time in Selected NOMS Outcomes
Source CSAT 2010 SA Dataset Subset to
Adolescents and Young Adults (n24,091)
Change in Selected NOMS Outcomes by Severity of
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)
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)

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

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
Change (post-pre) in Effect Size for Core
Treatment Outcomes by Type of Treatment
Four best on treatment outcomes include A-CRA,
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,
  • 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

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
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.
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)

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
  • As demonstrated earlier, trauma associated with a
    wide range of consequences
  • PTSD is just a subset

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.
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
  • 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..

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
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

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.

  • Population girls boys, 10-15 yrs, exposed to
    trauma AND suffering moderate symptoms diverse
  • 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

Support for CBITS
  • Quasi-experiment with control group (Kataoka et
    al., 2003)
  • Latino immigrant children exposed to community
  • Children in the CBITS group had significantly
    greater improvement in PTSD and depressive
    symptoms compared to those on a wait-list at 3
  • Randomized controlled trial (Stein, Jaycox, Wong,
    Tu, Elliott Fink, 2003)
  • Largely Latino 6th graders exposed to community
  • Children in the CBITS group had significantly
    greater improvement in PTSD and depressive
    symptoms compared to those on a wait-list at 3
  • 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.

Implementing CBITS
  • Staff - ideal person has prior training and
    experience with mental health and CBT.
  • CBITS manual available from http//www.sopriswest
  • Jaycox, L. (2003). CBITS Cognitive-Behavioral
    Intervention for Trauma in Schools. New York
    Sopris West.
  • Training available contact Dr. Audra Langley
  • 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
  • More info on CBITS
  • Contact Sheryl Kataoka (

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
  • Emotional and behavioral regulation
  • Attention/Consciousness
  • Self-perception
  • Interpersonal relationships
  • Somatization and physical health problems
  • Systems of meaning

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,
  • Overall goals (the 4 Cs)
  • Cultivate awareness
  • Cope more effectively
  • Connect with others
  • Create meaning

  • 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
  • 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

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).

Implementing SPARCS
  • Staff prior training and experience in
  • 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
  • Training available http//
  • Initial two day training, later two day training,
    frequent consultations
  • Learning Collaborative
  • More info on SPARCS
  • Dr. Victor Labruna (
  • Dr. Mandy Habib (

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.

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)

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
  • Setting community-based program - delivered in
    clinic, at home, in the social environment

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
Support for I-CARE
  • TST open trial (Saxe, Ellis, Fogler, Hansen,
    Sorkin, 2005)
  • ? trauma symptoms, ? emotional and behavioral
  • 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
  • ? length for need of services
  • TST controlled trial (preliminary findings)
  • Reduced drop out rates (10/10 vs. 1/10 retention
  • after 3 months)

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 (
  • 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

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.

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

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
  • Provided with tools and skills with which they
    can combat the repercussions of trauma

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.

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.

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

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
  • Address cognitive, behavioral, interpersonal, and
    case management areas of client functioning
  • Focus on clinician processes (e.g., helping
    clinicians work with countertransference issues)

Seeking Safety Facts
  • Population adults and adolescents (male and
    female) with PTSD/trauma and substance abuse
  • 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

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
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

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.

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
  • More info on Seek Safety
  • Contact Lisa Najavits (
  • http//

Information on Other Models
  • National Child Traumatic Stress Network
  • National Center for Trauma-Informed Care
  • Models for Developing Trauma-Informed Behavioral
    Health Systems and Trauma-Specific Services
    2008 Update http//