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Trauma-Informed Practices
for Treating Co-Occurring Disorders
Plenary Panel
Norma Finkelstein, PhD
Institute for Health and Recovery
Roger Fallot, PhD
Community Connections
Lisa Russell, PhD
ETR Associates
Vivian B. Brown, PhD
PROTOTYPES
Gloria Gonzales
Family Ties
Overview on
Trauma-Informed Practices
Norma Finkelstein, PhD
Institute for Health and Recovery
Institute for Health and Recovery
I Drank to Their Diseases
They pretended that there was nothing
wrong,
Their lies stole my trust.
The said that they were ―normal.‖
I felt insane.
They said, ―We love you,‖
I was alone.
I used alcohol to kill the pain.
It made me a liar.
I drank to feel ―normal,‖
I became insane.
I cried, ―Please love me!‖
I was still alone. –Katherine, age 40
(Source: Evans and Sullivan, Treating Addicted Survivors of Trauma, 1995, p. 1)
Institute for Health and Recovery
Trauma Definition
• Extreme stress that overwhelms a person‘s
ability to cope
• The subjective experience of a threat to life,
bodily integrity or sanity
• A normal response to an abnormal event that
results in a disruption of equilibrium
Institute for Health and Recovery
TRAUMATIC EVENTS ARE EXTRAORDINARY,
not because they occur rarely, but rather because they
overwhelm the ordinary human adaptations to life.
Unlike commonplace misfortunes, traumatic events
generally involve threats to life or bodily integrity, or a
close personal encounter with violence or death. They
confront human beings with the extremities of
helplessness and terror, and evoke the responses of
catastrophe. The common denominator of trauma is a
feeling of intense fear, helplessness, loss of control, and
threat of annihilation. (Judith Herman, MD, Trauma and Recovery, 1992)
Institute for Health and Recovery
‘Going Out of My Mind’
―That‘s a victim thing; you ask yourself, ‗Am I
just crazy? Did I make all this up?‘ Somehow it
might be easier to accept that you‘re crazy and
you made it all up than to admit that it happened
and how awful it was.‖
Teri Hatcher, star of TV show Desperate Housewives
and survivor of child sexual abuse by her uncle.
(Source: Janet Yassen, VOV Program, Cambridge Hospital, 2006)
Institute for Health and Recovery
Traumatic Events
• Physical Assault • Witnessing
• Sexual Abuse including abuse/violence
sex work • Living in dangerous
• Emotional/ environment
Psychological Abuse
• Experienced as an
• Domestic Violence adult or child
• War/Genocide • Occurred over time or
• Accidents one incident or time
• Natural or Man-Made limited
Disaster
Institute for Health and Recovery
Interpersonal Violence
Interpersonal Violence – physical/sexual abuse
is not like natural disasters, car accidents, etc.
• Human-fostered violence against another human
being
• Causes extreme disconnection from other human
beings
Institute for Health and Recovery
Why Trauma Matters
• A significant proportion of men and women entering
services for substance use disorders have histories of
trauma (Brems, 2004; Clark, 2001; Farley, 2004; Medrano, 1999; Moncrieff, 1996; Rice,
2001).
• Women in community samples report a lifetime
history of physical & sexual abuse ranging from 36
to 51%, while women with substance abuse problems
report a lifetime history ranging from 55 to 99%
(Najavits et al., 1997).
Institute for Health and Recovery
Women in Methadone Treatment
• 75% report lifetime history of physical and/or
sexual abuse
• 33% report abuse in past year
• 50% report abuse as children
• 33% report witnessing abuse of mother
(El-Bassel et al., 2004)
• Women who were both physically and
sexually abused in childhood were six times
more likely to abuse alcohol then non abused
women.
(Bensley, Eenwyk, and Simmons, 2000)
Institute for Health and Recovery
Co-occurrence of Substance Abuse
& Domestic Violence
• Research Institute on Addictions (1997)
80% of women with substance use disorders
had been the victim of domestic violence
• Brookhoff et al. (1997)
42% of victims of domestic violence
contacting the police had used alcohol or
other drugs on the day of the assault
Institute for Health and Recovery
Special Issues for Victims of Violence
Who Have Co-Occuring Disorders
The presence of both alcohol and drug use & domestic
violence increases the severity of injuries & lethality rates
(Mackey, 1992)
Perpetrators may pose risk to partners by:
• Introducing partner to drugs
• Forcing or coercing partner use
• Isolating partner from help
• Coercing partner to engage in illegal acts
• Using withholding drugs as a threat
• Using legal history as a threat
• Blaming abuse on partner use
Institute for Health and Recovery
History of Abuse & Mental Illness
Muesser et al., 1998
• 90% of public mental health clients have histories
of trauma
• most with multiple instances
Kessler et al, 1995
• 34-53% report childhood physical or sexual abuse
• 43-81% report some type of victimization
Institute for Health and Recovery
Domestic Violence
& Mental Health Problems
On average, over half of women seen in a range of
mental health settings are either currently
experiencing or have experienced abuse by an
intimate partner.
Institute for Health and Recovery
Prostitution &Trauma
• 99% report at least one traumatic event
• 93% report multiple traumas
• 53% report 6 or more traumatic events
• 75% report child sexual abuse
• 26% report child sexual abuse before age 6
• 81 % raped as adults
• 81% physically assaulted as adults
(Roxburgh, Degenhardt, & Copeland [2006])
Institute for Health and Recovery
Adverse Childhood Experiences
ACE Study
• Kaiser Permanente (Felitti) & CDC (Anda)
• Large-scale epidemiological study of influence
of stressful/traumatic childhood experiences
• Interviewed over 17, 000 people
• Compares adverse childhood experiences
against adult health status
Institute for Health and Recovery
ACE Study
• Scoring system used – one point for each category
of Adverse Childhood Experiences (ACE) before
18
• ACEs not only common, but effects were
cumulative
• Compared to persons with ACE score of 0, those
with ACE score of 4 or more were 2x more likely
to be smokers, 12x more likely to have attempted
suicide, 2x more likely to be alcoholic and 10x
more likely to have injected street drugs
Institute for Health and Recovery
Adverse Childhood Experiences
• Recurrent and severe physical abuse
• Recurrent and severe emotional abuse
• Sexual abuse
• Growing up in household with:
◦ Alcohol or drug user
◦ Member being imprisoned
◦ Mentally ill, chronically depressed, or
institutionalized member
◦ Mother being treated violently
◦ Both biological parents absent
◦ Emotional or physical abuse (Fellitti, 1998)
Institute for Health and Recovery
ACE Study
Controlling for other adverse childhood experiences
• Women with a history of childhood sexual abuse were
60% more likely to have alcohol problems and 70%
more likely to have used illegal drugs.
• Men with a history of childhood sexual abuse were
30% more likely to have alcohol problems and 60%
more likely to have used illegal drugs.
(Dube et al. (2005)
Institute for Health and Recovery
Messina and Grella (2006)
Number of childhood traumatic events associated
with:
• Prostitution
• Eating Disorders
• Mental Health disorders
• STIs
• Alcohol problems
• Early onset of criminal behavior
Institute for Health and Recovery
Impacts of Trauma
• Physiological – Changes in neurobiology and
physical health
• Cognitive – Flashbacks, dissociation
• Feelings – Feeling numb or overhwhelmed
• Beliefs – About self, other people, the world
• Skill Deficits – Self-protection, self-soothing
• Mental Health – PTSD, Substance Abuse
• Relational Disconnection
Institute for Health and Recovery
Pathways of Co-Occurrence
Trauma
Sequelae Self-
Medication
Mental Health
Problems
(Begin Anywhere)
Victimization Addiction
Lack of
Self-Care
Institute for Health and Recovery
What Makes Impact More Severe?
Trauma Characteristics
• Interpersonal violence
• Perpetrator is known/trusted
• Recurrent
• Degree of exposure
• Response of social environment
Institute for Health and Recovery
What Makes Impact More Severe?
Person Characteristics
• Age
• Prior coping skills
• Prior trauma history
• Chronic stressors
• Current stressors
Institute for Health and Recovery
The impact of violence/trauma on both men and
women is inadequately understood and addressed by
service providers.
Less than half of the women with interpersonal
trauma and co-morbidity will receive treatment that
addresses their trauma history and co-occurring
conditions. (Timko & Moos, 2002)
Institute for Health and Recovery
―I am an incest survivor and never dealt with it. Left
treatment, did drugs. The most important thing is to
integrate [services]. I‘m a slicer and before no place
would take me and if [I] say I‘ve been sexually
abused they boot you…I thought, here we go again.
Substance abuse identified and you‘re welcome…
need to work all 3 areas…others throw you out
because they are afraid.‖
(WELL Project, 2005)
Institute for Health and Recovery
Treatment Programs Often Fail to
Adequately Deal with Trauma.
Why?
• Lack of research/knowledge dissemination; training
• Trauma not seen as central/critical to recovery
• ―Uncovering‖ trauma would ―destabilize‖ symptoms
– need to stabilize mental health/ substance abuse –
Opening a ―Pandora‘s Box‖
• A belief that trauma work requires more
sophisticated clinical skills
Institute for Health and Recovery
Failure to understand
and address trauma can lead to:
1. Failure to engage in treatment services (Farley, 2004)
2. Increase in symptoms (eating disorders, self-
harm)
3. Increase in management problems
4. Retraumatization (Harris and Fallot, 2001)
5. Increase in relapse
6. Withdrawal from service relationship
7. Poor treatment outcomes (Easton et al 2000; Ouimette et al 1999)
Institute for Health and Recovery
Quote
―It was not until I became a part of the Women, Co-
Occurring Disorders & Violence Study that I became trauma
informed. I remember realizing one day, what perfect sense
this all makes. I was able to finally fit the pieces of the puzzle
together. Being a survivor was the reason I drank & used
drugs. Post Traumatic Stress Disorder had set in, & the
drinking and using suppressed my true feelings. I am among
one of the lucky few. So many of us have not solved the
puzzle – survivors, & providers.
One of the most important things I have learned is how to
keep myself safe. The word Safety never came up in
treatment. I now realize how much jeopardy I put myself in
when I was using substances, not caring what time of the
night it was, not caring that the guy just came into the room
waving a gun, just give me another hit. We continue to put
ourselves in situations that can retraumatize us on a daily
basis. Learning how important safety is to my recovery
process has changed my outlook.‖
Institute for Health and Recovery
Trauma-Informed Services:
Changes in Understanding
and Changes in Practice
Roger D. Fallot, Ph.D.
Community Connections
Conference on Co-Occurring Disorders
Long Beach, California
February 8, 2008
What are Trauma-Informed
Services?
Trauma-informed vs. trauma-specific
Characteristics of trauma-informed services
Incorporate knowledge about trauma—
prevalence, impact, and recovery—in all
aspects of service delivery
Hospitable and engaging for survivors
Minimize revictimization
Facilitate recovery and empowerment
Why Trauma-Informed Services?
Trauma is pervasive
Trauma‘s impact is broad and diverse
Trauma‘s impact is deep and life-shaping
Trauma, especially interpersonal violence, is often
self-perpetuating
Trauma is insidious and differentially affects the
more vulnerable
Trauma affects how people approach services
The service system has often been retraumatizing
A Repetitive Cycle of Risk
Incarceration Homelessness
Violence and
Trauma
Substance Mental Health
Abuse Problems
Comparing Traditional and
Trauma-Informed Paradigms
Understanding of Trauma
Understanding of the Consumer/Survivor
Understanding of Services
Understanding of the Service Relationship
A Culture Shift: The Core
Principles of a Trauma-Informed
System of Care
Safety: Ensuring physical and emotional safety
Trustworthiness: Maximizing trustworthiness,
making tasks clear, and maintaining appropriate
boundaries
Choice: Prioritizing consumer choice and control
Collaboration: Maximizing collaboration and
sharing of power with consumers
Empowerment: Prioritizing consumer
empowerment and skill-building
A Culture Shift: Scope of Change
in a Distressed System
Involves all aspects of program activities, setting,
and atmosphere (more than implementing new
services)
Involves all groups: administrators, supervisors,
line staff, consumers, families (more than direct
service providers)
Involves making change into a new routine, a new
way of thinking and acting (more than new
information)
Protocol for Developing a
Trauma-Informed Service System
Services-level changes
Service procedures and settings
Formal service policies
Trauma screening, assessment, and
service planning
Systems-level/administrative changes
Administrative support for program-wide
trauma-informed services
Trauma training and education
Human resources practices
Trauma-Informed Services:
Qualitative Pilot Outcomes
Consumers report greater safety, trust, and
engagement in services; more collaboration with
providers; emphasis on empowerment, recovery,
and healing
Providers report greater collaboration with
consumers; enhanced skills and sense of efficacy;
more support from agency
Administrators report more collaboration within
and outside agency; enhanced staff morale; fewer
negative events and more effective services
Conclusion
What we know about trauma, its impact, and the
process of recovery calls for trauma-informed
service approaches
A trauma-informed approach involves
fundamental shifts in thinking and practice at all
programmatic levels
Trauma-informed services offer the possibility of
enhanced collaboration for all participants in the
human service system
Trauma-Specific Group
Services
Lisa Russell, Ph.D.
ETR Associates
lisar@etr.org
Traumatic-Specific Interventions
Services designed specifically to address
violence, trauma, and related symptoms
and reactions.
Increase skills and strategies that allow
survivors to manage their trauma
symptoms and reactions and eventually to
reduce or eliminate debilitating symptoms
and prevent further traumatization and
violence.
Trauma-Specific Curricula Used in
Substance Abuse Treatment Settings
Maxine Harris—Trauma Recovery &
Empowerment (TREM)
Lisa Najavits—Seeking Safety
Dusty Miller—Addiction & Trauma Recovery
Integration Model (ATRIUM)
Clark & Fearday—TRIAD
Stephanie Covington—Helping Women Recover &
Beyond Trauma
Julian Ford—Trauma Adaptive Recovery Group
Education & Therapy for Persons in Recovery from
Addiction (TARGET-AR)
Features in Common
Stages of trauma recovery
Cognitive behavioral
Coping skills
Group orientation, adaptable for individual
sessions
Can be co-facilitated by a professional and
a peer
Stages of Trauma Recovery:
Treatment Aims
Stage One: ESTABLISHING SAFETY
Securing safety
Stabilizing symptoms
Fostering self-care
Stage Two: REMEMBRANCE & MOURNING
Reconstructing the trauma
Transforming traumatic memory
Stage Three: RECONNECTION
Reconciliation with self
Reconnection with others
Resolving the trauma (Herman, Trauma and Recovery)
Stage One: Establishing Safety
Focusupon establishing both
physical & psychological safety
Increasing
understanding of links
between trauma & substance abuse
Teaching coping skills
(Herman, Trauma and Recovery)
Seeking Safety
Najavits, L.M. (2002). Seeking Safety: A treatment manual for
PTSD and substance abuse. New York: Guilford Press.
• Integrates safety and recovery
• Stresses accessing other community supports
• 25 topics, including Safety, When substances control you,
Grounding
• Session format:
◦ Check in
◦ Quotation
◦ Relating topic to women’s lives
◦ Closing
• 80 safe coping skills
ATRIUM:
Addiction and Trauma Recovery Integrated Model
Miller, D. & Guidry, L. (2001). Addictions and Trauma
Recovery: Healing the body, mind, and spirit. New
York: WW. Norton & Co.
• Addresses mental, physical & spiritual health
• Creating sacred connections to the world beyond the
self
• 12 sessions, including self-harm, relationship
changes, spiritual disconnections
TRIAD
Clark, C. & Fearday, F. (Eds.) (2003). Triad women’s
project: Group facilitator’s manual. Tampa, FL: Louis
de la Parte Florida Mental Health Institute,
University of South Florida.
• Promotes survival, recovery & empowerment
• 16 sessions, divided into 4 phases
◦ Mindfulness
◦ Interpersonal effectiveness skills
◦ Emotional regulation
◦ Distress tolerance
• Has been modified for use in jails
TREM
Trauma Recovery and Empowerment
Harris, M. & The Community Connections Trauma Work
Group (1998). Trauma Recovery and Empowerment: A
clinician’s guide for working with women in groups. NY:
Free Press.
• Current problematic behaviors and symptoms may
have originated as legitimate and courageous
attempts to cope with or defend against trauma
• 33 topics, divided into four categories:
◦ Empowerment (11 sessions)
◦ Trauma Recovery (10 sessions)
◦ Advanced Trauma Recovery Issues (9 sessions)
◦ Closing Rituals (3 sessions)
Helping Women Recover
Covington, S.S. (1999). Helping Women Recover: A
program for treating addiction. San Francisco:
Jossey-Bass.
• Integrates expressive arts
• Accompanying journal
• 17 sessions, divided into four modules:
◦ Self
◦ Relationships
◦ Sexuality
◦ Spirituality
TARGET-AR
Trauma Adaptive Recovery Group Education and
Therapy for Persons in Addiction Recovery
Ford, J.D., Mahoney, K., Russo, E., Kasimer, N., & MacDonald, M.
(2003). Trauma Adaptive Recovery Group Education and
Therapy (TARGET): Revised composite 9 session leader and
participant guide. Farmington, CT: University of Connecticut
Health Center.
• Cognitive-behavioral
• Present-focused
• Systematic skills training
• Designed to be brief treatment
Considerations for Choosing a
Curriculum
Evidence of effectiveness
Fit with client characteristics
Program values and treatment philosophy
Curriculum length and format
Group facilitator’s expertise
Adaptations for specific populations
Cost, training, setting
Integrating the Curriculum into
Substance Abuse Treatment
Pilot-testing the curriculum
Adapting, if necessary, based on pilot results
(Trying evidence-based adaptations first.)
Training for staff and supervisors
Ongoing supervision and support for the new
practice
Monitoring of fidelity
Outcomes from the Women
with Co-Occurring Disorders
and Violence/Trauma Study
CENTERS FOR INNOVATION IN
HEALTH, MENTAL HEALTH AND
SOCIAL SERVICES
Vivian B. Brown, Ph.D.
SAMHSA’s Women with
Co-Occurring Disorders and
Violence Study
Boston Consortium of
Services for Families in
Recovery
Women Embracing Life &
Living (W.E.L.L.)
Franklin County
Women’s Research
Project
Allies New Directions
for Families D.C. Trauma Portal
PROTOTYPES Collaboration Project
Study
Triad Women’s
Project
The 9 National Program Sites
Sample Sizes Across Program Sites by Condition (N=2,729)
Program / Site Intervention Group Comparison Group
PROTOTYPES
187 215
Los Angeles, CA
Allies
169 266
Stockton, CA
Arapahoe House—New
Directions for Families 57 108
Metropolitan Denver, CO
D.C. Trauma Collaboration
150 97
Washington, D.C.
Triad Women’s Project
179 123
Avon Park, FL
Boston Consortium of
Services for Families in Recovery 181 161
Boston, MA
The W.E.L.L. Project
218 110
Cambridge, MA
Franklin County Women’s
Research Project 105 120
Greenfield, MA
Portal Project
169 114
New York, NY
Total 1415 1314
Baseline Demographic Characteristics by Program Site: Hispanic Ethnicity
Triad Women’s Project
Collaboration Study
The W.E.L.L. Project
Boston Consortium
Franklin Co. Women’s
PROTOTYPES SCC
New Directions for
Research Project
Portal Project
of Services
DC Trauma
Families
Allies
Total
Variable (n =402)
(n =435) (n =165) (n =247) (n =302) (n =342) (n =328) (n =225) (n =283) (n=2729)
Hispanic Ethnicity (%)* 30.6 17.5 27.3 3.2 6.0 34.2 6.7 5.3 25.4 18.1
Race**
41.3 56.3 52.1 13.4 81.5 37.4 78.4 85.3 7.1 50.3
% White/Caucasian
Race**
22.9 16.6 18.2 79.4 13.2 27.8 6.1 3.1 66.8 27.2
% African-American
Race**
24.4 17.9 9.1 2.0 2.0 29.8 5.8 3.1 23.7 14.5
% Other Race
Race**
11.4 7.6 4.8 4.0 1.0 2.6 8.2 4.9 2.1 5.6
%Multi-racial***
Race**
0.0 1.6 15.8 1.2 2.3 2.3 1.5 3.6 0.4 2.4
% None-specified
* Hispanic ethnicity was measured independent of race; ** Not all percentages total to 100%, as excluded from the totals were
subjects for whom data were missing; *** Category includes subjects who identified two or more races
Participants in the Study
• 2,729 women were enrolled in the study
• All are18 or older with histories of mental health
and substance abuse services use and histories
of physical or sexual abuse
• Average age (both groups) is about 26. Age
ranges from 18 to 76
• 54% were Caucasian, 18% Hispanic/Latina, 29%
African American
• 87% were mothers
• 50% had completed high school
Trauma Experiences Profile
Ever Experienced Number Percent
Sent to Jail or Juvenile detention 1,918 70%
Been homeless 1,969 72%
A serious physical or mental illness 1,666 61%
Separated from Children against your will 1,653 61%
Someone close to you other than your child died 2,349 86%
Witness physical violence between family 2,054 75%
members
Physically abused 2,323 85%
Stalked 1,954 72%
Sex because you felt forced 1,983 73%
When first
Age of First Onset
experienced Trauma
0-5 6-10 11-13 14-17 18+
years years years years years
Witness physical
violence between family 42% 43% 11% 5%
members (n=2,054)
Emotionally abused or
32% 33% 13% 10% 13%
neglected (n=2,300)
Physically neglected
31% 36% 13% 8% 12%
(n=887)
Physically abused
18% 24% 11% 16% 31%
(n=2,323)
Primary Outcomes & Measures
Outcomes Measures
Substance Abuse: Addiction Severity Index
– Alcohol Composite (ASI-A)
– Drug Abuse Composite (ASI-D)
Mental Health: Brief Symptom Inventory
– Global Severity Index (GSI)
Trauma: Post Traumatic Diagnostic Scale
– Post Traumatic Symptom Scale
(PSS)
The 6-Month Outcome Components
• Intent-to-treat design
• 2,006 women (1,023 in intervention condition,
983 in comparison condition) were interviewed 6
months after initial enrollment re: outcomes plus
services received and other elements
• Four outcome measures: mental health
symptoms, alcohol use, other drug use, and
trauma-related symptoms
• Women in both intervention and comparison
conditions had decreased symptoms in all four
areas at 6 months
Differences between Intervention and
Comparison Conditions
• On two of four measures (post-traumatic
symptoms and drug use severity), women in the
intervention programs showed significantly
greater improvement than those in usual care
• On mental health status, differences almost
reach significance
• Effect sizes are small, but present
Morrissey, J.P. et al. (2005) Journal of Substance Abuse Treatment
6-Month Data on All Sites
• On drug use problem severity (ASI-D), 49% of the
intervention women and 36% of the comparison
women reported no drug use or drug-related
problems at 6 months
• On alcohol use problem severity (ASI-A), 52% of
intervention and 40% of comparison women
reported no use or related problems at 6 months
The 12-Month Outcome Components
• 2,026 women were interviewed 12 months after
initial enrollment re: outcomes plus services
received and other elements
• Four outcome measures: mental health
symptoms, alcohol use, other drug use, and
trauma-related symptoms
• Women in both intervention and comparison
conditions had decreased symptoms in all four
areas at 12 months
Morrissey, J.P. et al. (2005) Psychiatric Services
Differences between Intervention and
Comparison Conditions
• The 12-month effect sizes for mental health and
post traumatic symptoms show statistically
significant improvements for women in the
intervention condition relative to those in the
comparison condition
• The two substance use severity outcomes show
no additional improvement over the
corresponding values at 6 months
Morrissey, J.P. et al. (2005) Psychiatric Services
Program-Level Differences
• There is considerable variation across sites
• Sites were compared on eight program
characteristics
• Integrated counseling was positively related
to three of the four outcomes measured
across sites
Program Differences (continued)
• Integrated counseling defined as receiving all
three types of services in individual and/or
group counseling reported in three-month
interview
• Number of core services provided were not
associated with improved outcomes, unless
integrated counseling was present
Costs
• Controlling for baseline use, there are no
significant differences in total costs between
participants in the intervention condition and
those in the usual care comparison
• This is true from a governmental or Medicaid
reimbursement perspective
Some Key Learnings
• Providing complex sets of integrated services
is feasible, including attention to trauma in
systemic ways
• Collaborations between those with lived
experience and researchers increases the
quality of the research (and probably the
services)
Learnings (continued)
• Women with these complicated sets of issues
can reduce their problems
• Integrated counseling of mental health,
substance abuse, and violence issues in a
trauma-informed context appears to be more
effective and no more costly than services as
usual
