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
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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
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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
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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
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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.
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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)
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SAMHSA Trauma Measures
60.55%
FY 2013: TRAC Crosstabulation/Frequency Report- Trauma Measures
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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
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Severity of Victimization by Age
SAMHSA 2011 GAIN Summary Analytic Data Set (n=29,501)
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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)
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Count of Major Clinical Problems* at Intake by Severity of Victimization
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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.
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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
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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.
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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)
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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
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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
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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.
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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)
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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
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SAMHSA’s Comprehensive Public Health
Approach to Trauma
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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
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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.
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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.
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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
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Recovery Principles
• Person-Driven
• Many Pathways
• Holistic
• Peer Support
• Relational
• Culture
• Addresses Trauma
• Strengths/
Responsibility
• Respect
• Hope
Practices
Supports
Services
Measures
Impacts
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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)
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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)
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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)
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Person
Served
Trauma Sensitive
Trauma Assessment
and TX
Trauma Informed System of
Care
Non-
Coercive
Non-
Controlling
Partnerships Collaboration
Resiliency
Hope Healing
Recovery
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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.
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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.
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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
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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
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mailto:[email protected]