SAMHSA’s Strategic

Initiative

Focus on Trauma

A. Kathryn Power, M. Ed.

Senior Lead – Military Service

Members, Veterans & their Families

SAMHSA Regional Administrator

Region I

Teens on the Edge: Fostering Connection, Resilience and Hope

Crowne Plaza Hotel

Warwick, RI

October 17, 2014

1

SAMHSA’s Strategic

Initiatives 2011 – 2014

1. Prevention

2. Trauma and Justice

3. Military Families

4. Recovery Support

5. Health Reform

6. Health Information

Technology

7. Data, Outcomes &

Quality

8. Public Awareness &

Support

Bu

sin

ess

Op

era

tio

ns

Da

ta

Co

mm

unic

ation

s

He

alth

Fin

an

cin

g

Po

licy

Reso

urc

e

Inve

stm

en

t

Sta

ff

Deve

lop

ment

SAMHSA’s Strategic

Initiatives 2015 – 2018

1. Prevention

2. Health Care and

Health Systems

Integration

3. Trauma and Justice

4. Recovery Support

5. Health Information

Technology

6. Workforce

SAMHSA OF THE FUTURE – FY 2014 AND BEYOND

SAMHSA’s

INTERNAL

OPERATING

STRATEGIES

3

3

SAMHSA’s Mission and Roles

Mission: To reduce the impact of substance abuse and mental illness on America’s communities

Roles:

● Voice and leadership

● Funding - service capacity development

● Information and communications

● Regulation and standard setting

● Practice improvement

3

SAMHSA’s Trauma and Justice Strategic Initiative

• Integrating a trauma informed approach throughout health, behavioral health and related systems in order to reduce the harmful effects of trauma and violence on individuals, families and communities.

• Utilizing innovative strategies to reduce the involvement of individuals with trauma and behavioral health issues in the criminal and juvenile justice systems.

5

Reported Prevalence of Trauma in Behavioral

Health

• Majority of adults and children in inpatient

psychiatric and substance use disorder treatment

settings have trauma histories (Lipschitz et al, 1999; Suarez, 2008; Gillece, 2010)

• 43% to 80% of individuals in psychiatric hospitals

have experienced physical or sexual abuse

• 51%-90% public mental health clients exposed to

trauma (Goodman et al, 1997; Mueser et al, 2004)

• 2/3 adults in SUD treatment report child abuse and

neglect (SAMHSA, CSAT, 2000)

• Survey of adolescents in SU treatment > 70% had

history of trauma exposure (Suarez, 2008)

6

SAMHSA Trauma Measures

60.55%

FY 2013: TRAC Crosstabulation/Frequency Report- Trauma Measures

7

SAMHSA Trauma Measures

22.14%

77.86%

72.61%

27.39% 23.65%

76.35%

16.88%

83.12%

FY 2013: TRAC Crosstabulation/Frequency Report- Trauma Measures

8

Severity of Victimization by Age

SAMHSA 2011 GAIN Summary Analytic Data Set (n=29,501)

9

Severity of Victimization Scale

*n=3,230

**Mean of 15 items Source: SAMSHA CSAT 2011 GAIN AT Summary Analytic Data Set subset to AAFT (n=5,321)

10

Count of Major Clinical Problems* at Intake by Severity of Victimization

11

Source: SAMHSA CSAT 2011 GAIN AT Summary Analytic Data Set subset to AAFT (n=5,489)

Based on count of self reporting criteria to suggest alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity

Homelessness and Trauma Statistics

• Over 95% of homeless parents are women.

• Homeless women with childhood abuse histories report

higher rates of violence exposure as adults.

• 70% of homeless women report a history of childhood

emotional, physical, and sexual abuse.

• 63% of homeless women report experiencing violence as

adults.

• Two-thirds of homeless mothers in the United States have

a history of domestic violence.

• Homeless mothers are three times as likely as low-income

but stably housed women to suffer post-traumatic stress

and twice as likely to be drug- or alcohol-dependent.

12

How Does Trauma Enter the Lives of

Homeless Children?

• Homelessness results from combined effects of: • Extreme poverty

• Lack of affordable housing

• Decreased government supports

• Challenge of raising children alone

• Domestic violence

• Fractured social supports

• This experience of homelessness results multiple

losses: • Community

• Routine

• Possessions

• Privacy

• Security

13

Trauma and Homelessness

• Homelessness makes children and youth more

vulnerable to: • Physical and sexual assault

• Witnessing violence

• Abrupt separation

• The stress associated with homelessness can

exacerbate other trauma-related difficulties and

interfere with recovery due to ongoing traumatic

reminders and challenges.

14

Characteristics of Individuals with Traumatic Stress and Substance Abuse

• Emotional and behavioral dysregulation

• Coping deficits

• Family strain

• Challenges navigating environmental stress

• Academic & vocational difficulties

• Health problems

• Involvement with multiple service systems (legal system, social services, mental health, substance abuse, special education)

15

Post-traumatic Stress Disorder

• A set of characteristic symptoms that can develop when a PAST trauma overwhelms the person’s 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

16

Trauma Exposure vs. PTSD

• Lifetime exposure to trauma is common

• Only a fraction of trauma-exposed individuals will go on to develop 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

• Trauma associated with a wide range of consequences (e.g. health and behavioral health, etc.)

• PTSD is just a subset of trauma responses

17

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.

18

Common Components of

Trauma-Informed Intervention

• 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)

19

Some Specific Models of Trauma Interventions for Adolescents & Emerging Adults

• Trauma Focused Cognitive Behavioral Treatment

(TF-CBT)

• Structured Psychotherapy for Adolescents

Responding to Chronic Stress (SPARCS)

• Integrated Care for Adolescents Struggling with

Traumatic Stress and Substance Abuse (I-CARE)

• Seeking Safety

20

SAMHSA’s Comprehensive Public Health

Approach to Trauma

21

22

23

SAMHSA’s Concept of Trauma

3-E’s

Trauma: Individual trauma results from an

event, series of events, or set of circumstances

that is

experienced by an individual as physically and/or

emotionally harmful or threatening and that has

lasting adverse

effects on the individual’s functioning and mental,

physical, social, emotional, and/or spiritual well-

being

24

SAMHSA’s Concept of a Trauma-Informed Approach 4R’s

A program, organization or system that is trauma-informed

(1) realizes the prevalence of trauma and taking a universal precautions position;

(2) recognizes how trauma affects all individuals involved with the program, organization, or system, including its own workforce;

(3) responds by putting this knowledge into practice; and

(4) resists retraumatization.

25

Principles of a Trauma-Informed Approach

• Safety: Throughout the organization, staff and the people they serve, whether children or adults, feel physically and psychologically safe; the physical setting is safe and interpersonal interactions promote a sense of safety.

• Trustworthiness and transparency: Organizational operations and decisions are conducted with transparency and the l goal of building and maintaining trust among clients, family members, staff, and others involved with the organization.

• Peer support: Peers refers to individuals with lived experiences of trauma, or in the case of children this may be family members of children who have experienced traumatic events and are key caregivers in their recovery) and mutual self help re key vehicles for establishing safety, building trust, enhancing collaboration, and maximizing a sense of empowerment

• Collaboration and mutuality: Partnering and leveling of power differences between staff and clients and among organizational staff from direct care staff to administrators; demonstrates that healing happens in relationships and in the meaningful sharing of power and decision-making. The organization recognizes that everyone has a role to play in a trauma-informed approach; one does not have to be a therapist to be therapeutic.

• Empowerment, Voice and Choice: Throughout the organization and among the clients served, individuals’ strengths and experiences are recognized and built upon; the experience of having a voice and choice is validated and new skills developed.. The organization fosters a belief in resilience and in the ability of individuals, organizations, and communities to heal and promote recovery from trauma; building on strengths and not just addressing perceived deficits.

• Cultural, historical, and gender issues: The organization actively moves past cultural stereotypes and biases (e.g. based on race, ethnicity, sexual orientation, age, geography, etc.), offers gender responsive services, leverages the healing value of traditional cultural connections, and recognizes and addresses historical trauma.

26

Guidance for a Trauma-Informed Approach

1. Governance and leadership

2. Policy

3. Physical environment of the organization

4. Engagement and involvement of people in recovery,

trauma survivors, consumers, and family members of

children receiving services

5. Cross sector collaboration

6. Screening, assessment, and interventions

7. Training and workforce development

8. Progress Monitoring and Quality assurance

9. Financing

10.Evaluation

27

Recovery Principles

• Person-Driven

• Many Pathways

• Holistic

• Peer Support

• Relational

• Culture

• Addresses Trauma

• Strengths/

Responsibility

• Respect

• Hope

Practices

Supports

Services

Measures

Impacts

28

Resilience

Resilience is the ability to adapt well to stress, adversity, trauma or tragedy. It means that, overall, you remain stable and maintain healthy levels of psychological and physical functioning in the face of disruption or chaos

The key is to not try to avoid stress altogether, but to manage the stress in our lives in such a way that we avoid the negative consequences of stress!

Accept the fact that there will be certain levels of stress in your life, and work to manage it in a way that you avoid or minimize the negative consequences of the stress

(Daniel, 2007)

29

Ten Strategies for Building Resilience

1. Make connections ─ Family, friends, civic groups, faith-based

organizations, other local groups

2. Avoid seeing crises as insurmountable problems. You can change

how you interpret and respond to stressful events

3. Accept that change is a part of living. The only thing that is

constant in life is change

4. Do something regularly, even if it seems small, which enables

you to move toward your goals

5. Take decisive actions rather than detaching completely and

wishing problems and stresses would go away.

(Daniel, 2007)

30

Ten Strategies for Building Resilience

6. Look for opportunities for self-discovery. People often grow in some

respect as a result of their struggle with loss.

7. Nurture a positive view of yourself. Develop confidence in your ability to

solve problems; trust your instincts.

8. Keep things in perspective. Keep a long-term perspective--avoid blowing

things out of proportion.

9. Maintain a hopeful outlook. Expect that good things will happen in your

life; visualize what you want rather than worrying about what you fear

10. Take care of yourself. Pay attention to your own needs and feelings.

Engage in activities you enjoy and find relaxing.

(Daniel, 2007)

31

Person

Served

Trauma Sensitive

Trauma Assessment

and TX

Trauma Informed System of

Care

Non-

Coercive

Non-

Controlling

Partnerships Collaboration

Resiliency

Hope Healing

almazarconsulting@yahoo.com

Recovery

32

Programs and Services for Families Exposed to Trauma

• Support groups focusing on the dynamics of trauma and its impacts on family members’ emotional and physical health, parenting, and coping.

• Culturally appropriate services.

• Supporting caregivers’ roles in restoring a sense of stability to the family.

• Screening caregivers for histories of trauma.

• Assessing whether a child’s development is progressing appropriately or has been interrupted.

• Screening for children’s history of traumatic experiences

• Creating administrative infrastructure to support training that will assist staff in addressing the trauma.

• Creating partnerships between shelters and community-based trauma recovery services.

• Promoting wider awareness of the role of trauma in precipitating and extending family homelessness.

33

Lessons Learned from Grantees

• The behavioral health impacts of trauma are a key focus

in the national discourse about child and youth mental health services

• Growing evidence of effective trauma-focused services (e.g. TF-CBT)

• Lack of sufficient training for practitioners on trauma screening and interventions

• Need broader response to trauma

• Even if excellent treatment provided others in setting close to child/youth can negate good work of treatment interventions.

34

Resources

• Resource:

NCTSN, National Child Traumatic Stress Initiative

• http://www.NCTSN.org

• Resource:

NCTIC, National Center for Trauma-Informed Care

• http://www.samhsa.gov/NCTIC

25

http://www.nctsn.org/http://www.samhsa.gov/NCTIC

THANK YOU! QUESTIONS??

A. Kathryn Power M.Ed. Regional Administrator - Region 1

Substance Abuse and Mental Health Services

Administration

U.S. Department of Health and Human Services

JFK Federal Building

15 New Sudbury Street, Room 1826

Boston, MA 02203

617.565.1482

kathryn.power@samhsa.hhs.gov

31

mailto:kathryn.power@samhsa.hhs.gov