Presentation on theme: "Trauma-Informed Treatment: Best Practices"— Presentation transcript:
1 Trauma-Informed Treatment: Best Practices James A. Peck, Psy.D.Los Angeles County Annual Drug Court ConferenceMay 15, 2009
2 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 adults.In a trauma-informed system, trauma is viewed as “a defining and organizing experience that forms the core of an individual’s identity.”Source: Harris, M. and Fallot, R.D. (Eds), 2001
3 What are Trauma-Informed Services? Characteristics of trauma-informed servicesIncorporate knowledge about trauma—prevalence, impact, and recovery—in all aspects of service deliveryHospitable and engaging for survivorsMinimize re-victimizationFacilitate recovery and empowerment
4 Comparing Traditional and Trauma-Informed Paradigms Understanding of TraumaUnderstanding of the Consumer/SurvivorUnderstanding of ServicesUnderstanding of the Service Relationship
5 Trauma-Informed Human Services Paradigm Understanding of TraumaTraumatic events are not rare; experiences of life disruption are pervasive and commonThe impact of trauma is seen in multiple, apparently unrelated life domainsRepeated trauma is viewed as a core life event around which subsequent development organizesTrauma begins a complex pattern of actions and reactions which have a continuing impact over the course of one’s life
6 Trauma-Informed Human Services Paradigm Understanding of the Consumer/SurvivorAn 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 solutionsA contextual, relational view of both problems and solutionsAppropriate and collaborative responsibility allocation
7 Trauma-Informed Human Services Paradigm Understanding of ServicesPrimary goals are empowerment and recoverySurvivors are survivors; their strengths need to be recognizedService priorities are prevention drivenService time limits are determined by survivor self-assessment and recovery/healing needsRisk to the consumer is considered along with risk to the system and the provider
8 Trauma-Informed Human Services Paradigm Understanding of the Service RelationshipA collaborative relationship between the consumer and the provider of her or his choiceBoth the consumer and the provider are assumed to have valid and valuable knowledge basesThe consumer is an active planner and participant in servicesThe consumer’s safety must be guaranteed and trust must be developed over time
9 A Culture Shift: Core Principles of a Trauma-Informed System Safety: Ensuring physical and emotional safetyTrustworthiness: Maximizing trustworthiness, making tasks clear, and maintaining appropriate boundariesChoice: Prioritizing consumer choice and controlCollaboration: Maximizing collaboration and sharing of power with consumersEmpowerment: Prioritizing consumer empowerment and skill-building
10 Trauma-Specific Interventions Services designed specifically to address violence, trauma, and related symptoms and reactions.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.
12 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.
13 What is the Difference between… ScreeningAssessment
14 Screening/Diagnosis Issues Identification of PTSD or sub-threshold PTSD symptoms is complicated by the fact that these symptoms mimic symptoms of anxiety and depressionMany individuals with PTSD also abuse alcohol and drugsIf trauma screening isn’t conducted, these individuals are usually treated as people with just depression, or just anxiety, or just AOD
15 Screening/Diagnosis Issues PTSD Diagnostic Criteria Individual is exposed to traumatic event in which:They experienced, witnessed, or were confronted with event/events that involved actual or threatened death or serious injury to themselves or othersResponse to event included intense fear, helplessness, or horrorCombat-related PTSD vs. non-combat related
16 Screening/Diagnosis Issues PTSD Diagnostic Criteria Three categories of symptoms:1. Re-experiencing; 2. Avoidance; 3. ArousalRe-experiencing:Recurrent re-experiencing of trauma, i.e. flashbacks, nightmares, intrusive thoughts or imagesIntense psychological and/or physiological reactions to external or internal cues that represent some aspect of the traumatic event(s)
17 Screening/Diagnosis Issues PTSD Diagnostic Criteria 2. Avoidance SymptomsPersistent avoidance of stimuli associated with the trauma, i.e.Thoughts, feelings, conversationsActivities, people, placesImpaired memory of aspects of traumaReduced interest or participation in usual activitiesFeeling detached/estranged from othersRestricted range of affect (i.e. unable to feel loving/loved)Sense of shortened lifespan
18 Screening/Diagnosis Issues PTSD Diagnostic Criteria 3. Persistent symptoms of increased arousalDifficulty falling asleep or staying asleepFrequent irritability or angry outburstsImpaired concentration/focusHypervigilanceExaggerated startle response
19 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 State’s COD Action Plan.
20 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:adolescentswomen with childrenadultstransition age youth with trauma histories
21 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.
22 The COJAC Screening Committee Screening Committee therefore decided to design a California screening tool that would:Identify potential co-occurring disordersIdentify potential trauma historiesBe short enough to not burden clients/staffBe 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.
24 The COJAC ScreenerCOJAC Screener currently being implemented in mental health departments in a number of California counties including LACA Alcohol and Drug Programs (ADP) is simultaneously implementing a two-year pilot test of the ScreenerGoal is to increase capacity to detect consumers/clients with potential mental health, substance use, or trauma-related problems
25 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/ client’s behavior, the behavior’s 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.
26 Trauma AssessmentNot 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 interventions.
27 Importance of Trauma Assessment Trauma assessment typically involves conducting a thorough trauma historyIdentify all forms of traumatic events experienced directly or witnessed by the consumer/client, to inform the choice of interventionSupplement trauma history with trauma-specific standardized clinical measures to assist in identifying the type and severity of symptoms the individual is experiencing
29 Recommendations for Integrated Treatment For Trauma and Substance Abuse Cross training in mental health and substance abuseUtilize screening and assessment tools that identify needs in both areasProvide more intense treatment options to address the magnitude of difficulties often experienced by this populationEmphasize management and reduction of both substance use and PTSD symptoms early in the recovery processBe aware that reducing substance use may initially increase PTSD symptomsProvide relapse prevention efforts, targeting both substance and trauma-related cues, early in treatmentadolescent substance abuse treatment literature suggests that that traumatized youth do not do well in treatment focusing only on substance useSources: Back et al., 2000; Giaconia, et al., 2003; Ouimette & Brown, 2003
30 Cognitive behavioral approaches Common Elements of Evidence-Based Trauma and Substance Abuse TreatmentsStarting treatmentPsychoeducationStrategies to promote client engagementCognitive behavioral approachesSkill building to improve ability to cope with distressSkill building to improve ability to cope with cravingsFamily interventions (adolescent clients)Improve parental monitoring and limit settingImprove communication
31 A Cognitive-Behavioral Model of the Relapse Process CLIENTConfronts a high-risk situationResponse does not use adequate copingChooses and makes use of appropriate coping responseExperiences decrease in self-efficacy, with a resulting sense of helplessness or passivity and decreased self controlHas expectation that a drink would help the situation (positive outcome expectancies)Experiences a sense of mastery and an ability to cope with the situationThese perceptions and expectancies lead to initial use of alcoholResults in “abstinence violation effect”These perceptions decrease the likelihood of relapseFeels guilt and loss of controlThese feelings increase probabilityof relapseSource: Adapted from Alan & Kadden, 199531
32 Core Components of Trauma-Informed Evidence-Based Treatment Trauma-informed approaches incorporate some or all of the following elements:Building a strong therapeutic relationshipPsychoeducation about normal responses to traumaFamily support or conjoint therapyEmotional expression and regulation skillsAnxiety management and relaxation skillsCognitive processing or reframingBuilding a strong therapeutic relationshipPsychoeducation about normal responses to trauma: clarify inappropriate information children may have obtained directly from the perpetrator or on their own and also helps to clarify safety issues. Normalize thoughts and feelings about the traumatic experience(s). This can include general information about the type of trauma experienced and normal reactions to trauma. In some cases it may also be important to include information about sex education, risk reduction and personal safety skillsParent support, conjoint therapy, or parent trainingEmotional expression and regulation skills: Teaching children to manage their emotions and deal with their anxiety, help children understand that their difficulties are a normal response to a traumatic event. Skills: how to label a wide range of emotions, how to identify different levels of emotional intensity, strategies for expressing these emotions appropriately.Anxiety management and relaxation skills:Controlled breathing: proper breathing, slow exhalation, practiceRelaxation: Alternating between tensing and relaxing muscles. Focusing attention on the difference between feeling tense and feeling relaxed in order to teach children how to recognize tense feelings and neutralize themthought stopping: To help children disrupt their intrusive thoughts. Gain a sense of control over negative thoughts that interfere with their school work, their homework, relationships and sleep. Thought can be stopped verbally (saying: go away) or physically (snapping rubber band worn around writs) and replaced with a happy thought.Cognitive processing or reframing:Learn about the relationships among thoughts, feels, and behaviorHow to identify and correct unhelpful thoughts.32
33 Core Treatment Components Additional elements of trauma-informed treatment:Construction of a coherent trauma narrativeStrategies that allow exposure to traumatic memories and feelings in tolerable doses so that they can be mastered and integrated into the consumer/client’s experiencePersonal safety training and other important empowerment activitiesResilience and closureWording change, top lines/GH
34 Core Treatment Components Cognitive Traumatized individuals often show negative patterns of thinking as a result of their traumatic experiencesDistrust of others or expectations that they might be harmed by othersOverestimation of and preoccupation with dangerLow self-esteem and self-blame (feeling responsible for the trauma or what happened as a result)Helplessness and hopelessness about the futureShame and/or stigmaSurvivor guiltChildren often have unhelpful and inaccurate thoughts and beliefs about traumatic events or about the impact the trauma is likely to have on their lives. Some of these beliefs may have developed as a direct result of the traumatic experience, but some probably existed even before the trauma happened. Regardless of when they developed, it's important to try to help children and parents identify and change these thoughts.
35 Core Treatment Components Cognitive Polarized thinking—framing things in black/white, good/bad terms, either they achieve perfection or they have failedControl fallacies—feeling externally controlled and helpless or a victim of fate, or feeling internally controlled and responsible for the pain and happiness of everyone around themBlaming—holding other people responsible for your pain or blaming yourself for every problem (externalizing or internalizing to the extreme)35
36 Core Treatment Components Cognitive processing/reframing/restructuring can help consumers/clients identify these faulty patterns of thinking and practice using healthier cognitive coping strategies
37 Core Treatment Components Cognitive Processing Learn about thoughts, feelings, and behaviorDistinguish between accurate and inaccurate cognitions, or helpful and unhelpful cognitionsUnderstand relationship between feelings, thoughts, and behaviorLearn how to identify and correct unhelpful thoughtsIdentify: Identifying the thought related to the emotionChallenge: Evaluating the thought based on the evidence and logicReplace: Choosing alternative, more accurate, adaptive or helpful thoughts. Changing the emotion or the behavior by changing thoughtsCognitive processing skills taught prior to conducting exposure to trauma narrative should address general negative cognitions. These skills can be revisited after completion of the trauma narrative to address more specific negative thoughts about the traumatic event, once all the trauma details and associated negative cognitions have been identified
38 Core Treatment Components The Trauma Narrative Developing a trauma narrative involves:Reviewing details of traumatic experience to achieve habituation to distress (reduce association between memories and overwhelming emotion)Identifying and challenging distortions in thinking associated with the traumaGenerating a trauma narrative helps a consumer/client to:Control intrusive and upsetting trauma-related imageryReduce avoidance of trauma-related cuesIdentify unhelpful cognitions about traumatic eventsRecognize and prepare for reminders of trauma“Exposure” techniques involve eliciting distress while facing situations, sensations or memories in order to decrease arousal over time
39 Core Treatment Components Motivational Interviewing Motivational Interviewing strategiesTaking an empathic, non-judgmental stance and listening reflectivelyDeveloping discrepancy between the client’s goals and their current behaviorsRolling with the client’s resistance and avoiding argumentationSupporting/building self-efficacySource: Miller & Rollnick, 200239
40 Stages of Change Source: Prochaska & DiClemente, 1982 Precontem-plationContemplationPreparationRecurrenceMaintenanceActionPrecontemplation StageDefinition: Not yet considering change or is unwilling or unable to changePrimary task: Raising AwarenessContemplation StageIn this stage the client sees the possibility of change but is ambivalent and uncertain about beginning the processPrimary task: Resolving ambivalence and helping the client choose to make the changeDetermination StageIn this stage the client is committed to changing but is still considering exactly what to do and how to doPrimary task: Help client identify appropriate change strategiesAction StageIn this stage the client is taking steps toward change but hasn’t stabilized in the processPrimary task: Help implement the change strategies and learn to limit or eliminate potential relapsesRecurrence StageDefinition: Client has experienced a recurrence of the symptomsPrimary task: Must cope with the consequences and determine what to do nextHow Can I Help Clients Move through These Stages of Change?Use the microskillsOpen-ended questionsAffirmationsReflectionsSummariesto elicit and reinforce self-motivational statements (Change Talk)Source: Prochaska & DiClemente, 1982
41 Motivational Interviewing Decisional Balance Exercise Good things about no change (continuing to use)I don’t have to deal with my problems.I feel more confident.I have something to do when I am bored.It helps me avoid thinking about (the trauma).I have more fun at parties.It helps me calm down and relax.Not-so-good things about no change (continuing to use)I feel guilty or ashamed.I don’t like the way I look and feel after use.It is a source of conflict between me and my family.It is a source of conflict between me and my friends.I will have money problems.I will continue to feel anxious and depressed.I will harm my health.Not-so-good things about changing (reducing or stopping use)I will feel more depressed and/or anxious.I won’t have anything to do when I’m bored.I won’t have any way to relax.I will be more anxious.I won’t be able to interact with people.I don’t know if I can make change stick.Good things about changing (reducing or stopping use)I will feel more in control over my life.I will gain more self-esteem.It will improve my relationship with my family.I will have more money.I will have fewer problems at work and/or school.It will help make my counseling/therapy more effective.
42 Seeking Safety: An Intervention for PTSD and Substance Abuse
43 Seeking Safety Developed by: VA Boston Health Care System Lisa M. Najavits, PhDVA Boston Health Care System150 South Huntington,Belmont, MAorSource: Najavits, L.M., 2002
44 Seeking SafetyEvidence-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 PTSD.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 AbuseSource: Najavits, L.M., 2002
45 Seeking Safety Treatment Topics Introduction to Treatment and Case ManagementSafetyPTSD: Taking Back Your PowerDetaching from Emotional Pain (Grounding)When Substances Control YouAsking for HelpTaking Good Care of YourselfCompassionRed and Green Flags
46 Seeking Safety Treatment Topics HonestyRecovery ThinkingIntegrating the Split SelfCommitmentCreating MeaningCommunity ResourcesSetting Boundaries in RelationshipsDiscovery
47 Seeking Safety Treatment Topics Getting Others to Support Your RecoveryCoping with TriggersRespecting Your TimeHealthy RelationshipsSelf-NurturingHealing From AngerLife Choices Game (review)Termination
48 Adapting Seeking Safety to Different Contexts 12 Sessions (original CTN Study)Introduction to TreatmentSafetyPTSD: Taking Back Your PowerDetaching from Emotional Pain (Grounding)When Substances Control YouTaking Good Care of YourselfCompassionRed and Green FlagsHonestyIntegrating the Split SelfCreating MeaningSetting Boundaries in RelationshipsHealing from Anger5 Sessions:SafetyPTSD: Taking Back Your PowerWhen Substances Control YouDetaching from Emotional Pain (Grounding)Asking for Help
50 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 SAEmpower the patient to regain controlHelp the patient to identify cues (who, what, when) that are safeTeach coping skills that may never have been learned in childhoodAssess the impact of SA and develop a plan for harm reduction/abstinenceProvide psychoeducation about SA and PTSD
51 Seeking Safety 5-Session Module Session 1: SAFETYDO:Be active and directiveGive the patient controlSeek to understand the patient’s self-destructive behaviors as “symbolic or literal reenactment of the initial abuse.”DO NOT:Do not offer dynamic interpretationsDo not confront defensesDo not focus on therapist-patient relationship
52 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 PTSDExplore the relationship between PTSD and SAHelp clients to take back their power by viewing PTSD and SA with compassionHelp clients understand the long-term impact of severe traumaIntervention includes handouts for all of the above topics
53 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 disorderRaise patient’s awareness of how substance abuse prevents healing from PTSDIdentify 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 substancesHelp patients recognize that it is normal to have mixed feelings about giving up substances, as long as their actions remain safeDiscuss the role of self-help groups and encourage patients to attend
54 Seeking Safety 5-Session Module Session 4: Detaching from Emotional Pain (Grounding)“No feeling is final”Teach grounding as a set of simple but powerful techniques to detach from emotional painConduct 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
55 Seeking Safety 5-Session Module Session 5: Asking for Help“And the trouble is, if you don’t risk anything, you risk even more”Discuss effective ways to ask for helpRehearse/roleplay how to ask for helpExplore clients’ experiences of asking for help, i.e. were people willing to help, were they rejected, etc
56 A Trauma-Informed Approach Includes a Trauma-Informed Team A trauma-informed team integrates mental health, substance abuse, and trauma workA trauma-informed team working with adolescents integrates youth interventions with parent/family interventionsA trauma-informed team coordinates efforts with the multiple systems affecting the consumer/client
57 The Team Approach is Essential to 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 coverageIt 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
58 Managing Professional and Personal Stress When Working with Trauma Victims 58
59 Professional/Personal Stress Providing services for traumatized individuals increases the potential for secondary traumatic stress.Clinicians/criminal justice professionals may empathize with their clients’ experiences; feelings of helplessness, anger, and fear are common.Clinicians/criminal justice professionals who are parents—or who have their own histories of trauma—may be at particular risk for experiencing such reactions.59
60 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).
61 Impact of Working with Victims of Trauma Trauma experienced while working in healthcare/criminal justice roles has been described as:Compassion fatigueCountertransferenceSecondary traumatic stress (STS)Vicarious traumatizationUnlike 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 world.
62 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 tearsFeelings of “burnout”Feelings of despair and hopelessnessReduced productivity
63 Managing Personal and Professional Stress: Strategies for Healthcare/Criminal Justice Professionals 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 exercise.Develop a written plan focused on work-life balance.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.
64 Managing Professional/Personal Stress Attend to your health: physical, emotional, psychological, and spiritualTry to eat healthyExerciseTake mini-vacationsPractice receiving from othersSpend time with important people in your lifeIdentify comforting/relaxing activitiesTake time to eat lunch and chat with co-workersIn each realm of one’s life—personal, professional, and organizational, there are strategies to decrease the stress.