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Trauma-Informed Treatment:
Best Practices
James A. Peck, Psy.D.
Los Angeles County Annual Drug Court Conference
May 15, 2009
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
What are Trauma-Informed
Services?
• 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 re-victimization
– Facilitate recovery and empowerment
Comparing Traditional and
Trauma-Informed Paradigms
• Understanding of Trauma
• Understanding of the Consumer/Survivor
• Understanding of Services
• Understanding of the Service Relationship
Trauma-Informed
Human Services Paradigm
• Understanding of Trauma
– Traumatic events are not rare; experiences of life
disruption are pervasive and common
– The impact of trauma is seen in multiple, apparently
unrelated life domains
– Repeated trauma is viewed as a core life event around
which subsequent development organizes
– Trauma begins a complex pattern of actions and
reactions which have a continuing impact over the course
of one’s life
Trauma-Informed
Human Services Paradigm
• Understanding of the Consumer/Survivor
– An 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 solutions
– A contextual, relational view of both problems and
solutions
– Appropriate and collaborative responsibility allocation
Trauma-Informed
Human Services Paradigm
• Understanding of Services
– Primary goals are empowerment and recovery
– Survivors are survivors; their strengths need to be
recognized
– Service priorities are prevention driven
– Service time limits are determined by survivor self-
assessment and recovery/healing needs
– Risk to the consumer is considered along with risk to the
system and the provider
Trauma-Informed
Human Services Paradigm
• Understanding of the Service Relationship
– A collaborative relationship between the consumer and
the provider of her or his choice
– Both the consumer and the provider are assumed to
have valid and valuable knowledge bases
– The consumer is an active planner and participant in
services
– The consumer’s safety must be guaranteed and trust
must be developed over time
A Culture Shift: Core Principles of a
Trauma-Informed System
• 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
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.
Screening & Assessment
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.
What is the Difference between…
Screening Assessment
Screening/Diagnosis Issues
• Identification of PTSD or sub-threshold
PTSD symptoms is complicated by the fact
that these symptoms mimic symptoms of
anxiety and depression
• Many individuals with PTSD also abuse
alcohol and drugs
• If trauma screening isn’t conducted, these
individuals are usually treated as people with
just depression, or just anxiety, or just AOD
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 others
– Response to event included intense fear,
helplessness, or horror
– Combat-related PTSD vs. non-combat related
Screening/Diagnosis Issues
PTSD Diagnostic Criteria
Three categories of symptoms:
1. Re-experiencing; 2. Avoidance; 3. Arousal
1.Re-experiencing:
– Recurrent re-experiencing of trauma, i.e.
flashbacks, nightmares, intrusive thoughts or
images
– Intense psychological and/or physiological
reactions to external or internal cues that
represent some aspect of the traumatic event(s)
Screening/Diagnosis Issues
PTSD Diagnostic Criteria
2. Avoidance Symptoms
– Persistent avoidance of stimuli associated with
the trauma, i.e.
• Thoughts, feelings, conversations
• Activities, people, places
• Impaired memory of aspects of trauma
• Reduced interest or participation in usual activities
• Feeling detached/estranged from others
• Restricted range of affect (i.e. unable to feel
loving/loved)
• Sense of shortened lifespan
Screening/Diagnosis Issues
PTSD Diagnostic Criteria
3. Persistent symptoms of increased arousal
– Difficulty falling asleep or staying asleep
– Frequent irritability or angry outbursts
– Impaired concentration/focus
– Hypervigilance
– Exaggerated startle response
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.
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:
– adolescents
– women with children
– adults
– transition age youth with trauma histories
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.
The COJAC Screening Committee
• Screening Committee therefore decided to
design a California screening tool that would:
• Identify potential co-occurring disorders
• Identify potential trauma histories
• Be short enough to not burden clients/staff
• Be 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.
The COJAC Screener
• COJAC Screener currently being implemented
in mental health departments in a number of
California counties including LA
• CA Alcohol and Drug Programs (ADP) is
simultaneously implementing a two-year pilot
test of the Screener
• Goal is to increase capacity to detect
consumers/clients with potential mental health,
substance use, or trauma-related problems
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.
Trauma Assessment
• Not 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.
Importance of Trauma Assessment
• Trauma assessment typically involves
conducting a thorough trauma history
– Identify all forms of traumatic events experienced
directly or witnessed by the consumer/client, to
inform the choice of intervention
• Supplement trauma history with trauma-
specific standardized clinical measures to
assist in identifying the type and severity of
symptoms the individual is experiencing
Interventions
Recommendations for Integrated Treatment
For Trauma and Substance Abuse
• Cross training in mental health and substance abuse
• Utilize screening and assessment tools that identify needs in
both areas
• Provide more intense treatment options to address the
magnitude of difficulties often experienced by this population
• Emphasize management and reduction of both substance
use and PTSD symptoms early in the recovery process
• Be aware that reducing substance use may initially increase
PTSD symptoms
• Provide relapse prevention efforts, targeting both substance
and trauma-related cues, early in treatment
Sources: Back et al., 2000; Giaconia, et al., 2003; Ouimette & Brown, 2003
Common Elements of Evidence-Based
Trauma and Substance Abuse Treatments
• Starting treatment
– Psychoeducation
– Strategies to promote client engagement
• Cognitive behavioral approaches
– Skill building to improve ability to cope with distress
– Skill building to improve ability to cope with cravings
• Family interventions (adolescent clients)
– Improve parental monitoring and limit setting
– Improve communication
A Cognitive-Behavioral Model of the Relapse Process
CLIENT
Confronts a high-risk
situation
Response does not use adequate coping
Chooses and makes use of
appropriate coping Experiences decrease in self-efficacy, with
response a resulting sense of helplessness or
passivity and decreased self control
Has expectation that a drink would help
the situation (positive outcome
Experiences a sense of expectancies)
mastery and an ability to
cope with the situation
These perceptions and expectancies lead
to initial use of alcohol
Results in “abstinence violation effect”
These perceptions decrease
the likelihood of relapse
Feels guilt and loss of control
These feelings increase probability
of relapse
Source: Adapted from Alan & Kadden, 1995
Core Components of Trauma-Informed
Evidence-Based Treatment
Trauma-informed approaches incorporate
some or all of the following elements:
– Building a strong therapeutic relationship
– Psychoeducation about normal responses to
trauma
– Family support or conjoint therapy
– Emotional expression and regulation skills
– Anxiety management and relaxation skills
– Cognitive processing or reframing
Core Treatment Components
Additional elements of trauma-informed
treatment:
– Construction of a coherent trauma narrative
– Strategies that allow exposure to traumatic
memories and feelings in tolerable doses so
that they can be mastered and integrated into
the consumer/client’s experience
– Personal safety training and other important
empowerment activities
– Resilience and closure
Core Treatment Components
Cognitive
• Traumatized individuals often show negative patterns of
thinking as a result of their traumatic experiences
– Distrust of others or expectations that they might be
harmed by others
– Overestimation of and preoccupation with danger
– Low self-esteem and self-blame (feeling responsible
for the trauma or what happened as a result)
– Helplessness and hopelessness about the future
– Shame and/or stigma
– Survivor guilt
Core Treatment Components
Cognitive
• Polarized thinking—framing things in black/white,
good/bad terms, either they achieve perfection or
they have failed
• Control 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 them
• Blaming—holding other people responsible for
your pain or blaming yourself for every problem
(externalizing or internalizing to the extreme)
Core Treatment Components
• Cognitive processing/reframing/restructuring
can help consumers/clients identify these
faulty patterns of thinking and practice using
healthier cognitive coping strategies
Core Treatment Components
Cognitive Processing
• Learn about thoughts, feelings, and behavior
– Distinguish between accurate and inaccurate
cognitions, or helpful and unhelpful cognitions
– Understand relationship between feelings, thoughts,
and behavior
• Learn how to identify and correct unhelpful thoughts
– Identify: Identifying the thought related to the emotion
– Challenge: Evaluating the thought based on the
evidence and logic
– Replace: Choosing alternative, more accurate,
adaptive or helpful thoughts. Changing the emotion or
the behavior by changing thoughts
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 trauma
• Generating a trauma narrative helps a consumer/client to:
– Control intrusive and upsetting trauma-related imagery
– Reduce avoidance of trauma-related cues
– Identify unhelpful cognitions about traumatic events
– Recognize and prepare for reminders of trauma
Core Treatment Components
Motivational Interviewing
• Motivational Interviewing strategies
– Taking an empathic, non-judgmental stance and
listening reflectively
– Developing discrepancy between the client’s
goals and their current behaviors
– Rolling with the client’s resistance and avoiding
argumentation
– Supporting/building self-efficacy
Source: Miller & Rollnick, 2002
Stages of Change
Source: Prochaska & DiClemente, 1982
Motivational Interviewing
Decisional Balance Exercise
Good things about no change Not-so-good things about no change
(continuing to use) (continuing to use)
I don’t have to deal with my problems. I feel guilty or ashamed.
I feel more confident. I don’t like the way I look and feel after use.
I have something to do when I am bored. It is a source of conflict between me and my family.
It helps me avoid thinking about (the trauma). It is a source of conflict between me and my friends.
I have more fun at parties. I will have money problems.
It helps me calm down and relax. I will continue to feel anxious and depressed.
I will harm my health.
Not-so-good things about changing Good things about changing
(reducing or stopping use) (reducing or stopping use)
I will feel more depressed and/or anxious. I will feel more in control over my life.
I won’t have anything to do when I’m bored. I will gain more self-esteem.
I won’t have any way to relax. It will improve my relationship with my family.
I will be more anxious. I will have more money.
I won’t be able to interact with people. I will have fewer problems at work and/or school.
I don’t know if I can make change stick. It will help make my counseling/therapy more effective.
Seeking Safety: An
Intervention for PTSD and
Substance Abuse
Seeking Safety
Developed by:
Lisa M. Najavits, PhD
VA Boston Health Care System
150 South Huntington, 1168-3
Belmont, MA 02130
E-Mail: Lnajavits@hms.harvard.edu or
lisa.najavits@va.gov
www.seekingsafety.org
Source: Najavits, L.M., 2002
Seeking Safety
• Evidence-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 Abuse
Source: Najavits, L.M., 2002
Seeking Safety
Treatment Topics
• Introduction to Treatment and Case Management
• Safety
• PTSD: Taking Back Your Power
• Detaching from Emotional Pain (Grounding)
• When Substances Control You
• Asking for Help
• Taking Good Care of Yourself
• Compassion
• Red and Green Flags
Seeking Safety
Treatment Topics
• Honesty
• Recovery Thinking
• Integrating the Split Self
• Commitment
• Creating Meaning
• Community Resources
• Setting Boundaries in Relationships
• Discovery
Seeking Safety
Treatment Topics
• Getting Others to Support Your Recovery
• Coping with Triggers
• Respecting Your Time
• Healthy Relationships
• Self-Nurturing
• Healing From Anger
• Life Choices Game (review)
• Termination
Adapting Seeking Safety to
Different Contexts
12 Sessions (original CTN Study) 5 Sessions:
• Introduction to Treatment
• Safety
• Safety
• PTSD: Taking Back Your Power
• PTSD: Taking Back Your Power
• Detaching from Emotional Pain • When Substances Control You
(Grounding) • Detaching from Emotional Pain
• When Substances Control You (Grounding)
• Taking Good Care of Yourself • Asking for Help
• Compassion
• Red and Green Flags
• Honesty
• Integrating the Split Self
• Creating Meaning
• Setting Boundaries in Relationships
• Healing from Anger
Seeking Safety
5-Session Module
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 SA
– Empower the patient to regain control
– Help the patient to identify cues (who, what, when) that are safe
– Teach coping skills that may never have been learned in
childhood
– Assess the impact of SA and develop a plan for harm
reduction/abstinence
– Provide psychoeducation about SA and PTSD
Seeking Safety
5-Session Module
Session 1: SAFETY
DO:
• Be active and directive
• Give the patient control
• Seek to understand the patient’s self-destructive behaviors
as ―symbolic or literal reenactment of the initial abuse.‖
DO NOT:
• Do not offer dynamic interpretations
• Do not confront defenses
• Do not focus on therapist-patient relationship
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 PTSD
• Explore the relationship between PTSD and SA
• Help clients to take back their power by viewing PTSD and
SA with compassion
• Help clients understand the long-term impact of severe
trauma
Intervention includes handouts for all of the above topics
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 disorder
• Raise patient’s awareness of how substance abuse prevents
healing from PTSD
• Identify 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 substances
• Help patients recognize that it is normal to have mixed feelings
about giving up substances, as long as their actions remain safe
• Discuss the role of self-help groups and encourage patients to
attend
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 pain
• Conduct 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
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 help
• Rehearse/roleplay how to ask for help
• Explore clients’ experiences of asking for help, i.e.
were people willing to help, were they rejected, etc
A Trauma-Informed Approach
Includes a Trauma-Informed Team
• A trauma-informed team integrates mental
health, substance abuse, and trauma work
• A trauma-informed team working with
adolescents integrates youth interventions with
parent/family interventions
• A trauma-informed team coordinates efforts
with the multiple systems affecting the
consumer/client
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 coverage
• It 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
Managing Professional and
Personal Stress When
Working with Trauma Victims
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.
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).
Impact of Working with
Victims of Trauma
• Trauma experienced while working in
healthcare/criminal justice roles has been described
as:
– Compassion fatigue
– Countertransference
– Secondary traumatic stress (STS)
– Vicarious traumatization
• Unlike 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.
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 tears
– Feelings of ―burnout‖
– Feelings of despair and hopelessness
– Reduced productivity
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.
Managing Professional/Personal Stress
• Attend to your health: physical, emotional,
psychological, and spiritual
• Try to eat healthy
• Exercise
• Take mini-vacations
• Practice receiving from others
• Spend time with important people in your life
• Identify comforting/relaxing activities
• Take time to eat lunch and chat with co-
workers
Resources
http://www.seekingsafety.org/
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