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Trauma Matters - October 2007

The e-Newsletter from CMHS' National Center for Trauma-Informed Care

A Look at Domestic Violence Trauma Interventions

As we observe National Domestic Violence Awareness Month, NCTIC is pleased to draw your attention to some of the trauma-based service models for domestic violence victims (including child trauma survivors). Following are just a few of the empirically-supported treatment approaches that are available.

Addictions and Trauma Recovery Integration Model (ATRIUM)

ATRIUM is a 12-session recovery model designed for groups as well as for individuals and their therapists and counselors. The acronym, ATRIUM, is meant to suggest that the recovery groups are a starting point for healing and recovery. This model has been used in local prisons, jail diversion projects, AIDS programs, and drop-in centers for survivors. ATRIUM is a model intended to bring together peer support, psycho-education, interpersonal skills training, meditation, creative expression, spirituality, and community action to support survivors in healing form trauma.

Click here for more information.

Domestic Violence: A 10-Session Group Treatment Intervention

This 10-session group intervention is intended to help women who have experienced domestic violence. Intervention is written as a leader’s manual, with a rationale, goals, questions to prompt discussion, and experiential exercises for each topic. Topics include the relational context of domestic violence; the cycle of violence; power and control; multi-generational violence; the impact of domestic violence on children; anger; assertiveness; and communication skills.

Click here for more information.

Risking Connection®: A Training Curriculum for Working with Survivors of Childhood Abuse

Risking Connection is intended to be a trauma-informed model aimed at mental health, public health, and substance abuse staff at various levels of education and training. There are several audience-specific adaptations of the model, including clergy, domestic violence advocates, and agencies serving children. The program emphasizes concepts of empowerment, connection, and collaboration.

Click here for more information.

Sanctuary Model®

The goal of the Sanctuary Model is to help children who have experienced the damaging effects of interpersonal violence, abuse, and trauma. The model is intended for use by residential treatment settings for children, public schools, domestic violence shelters, homeless shelters, group homes, outpatient and community-based settings, juvenile justice programs, substance abuse programs, parenting support programs, acute care settings, and other programs aimed at assisting children.

Click here for more information.

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Trauma, Addiction, Mental Health, and Recovery (TAMAR)

Developed as part of the first phase of SAMHSA’s Women, Co-Occurring Disorders and Violence Study, TAMAR Trauma Treatment Group Model is a structured, manualized 15-week intervention combining psycho-educational approaches with expressive therapies. It is designed for women and men with histories of trauma in correctional systems. Groups are run inside detention centers, in state psychiatric hospitals, and in the community.

For more information, contact Marian Bland, LCSW-C, at 410-724-3242 or blandm@dhmh.state.md.us

Click here for more information on these and other trauma-specific interventions.

Trauma-Informed Systems of Care: An Update

Note: This guest article was written by Roger D. Fallot, Ph.D., and Maxine Harris, Ph.D., who co-edited the referenced book, Using Trauma Theory to Design Service Systems.

In considering ways to respond helpfully to those affected by traumatic experiences, a basic distinction has been made between trauma-specific and trauma-informed services. Trauma-specific services are those whose primary task is to address the impact of trauma and to facilitate trauma recovery. Such services may include individual and group interventions designed to ameliorate posttraumatic stress disorder symptoms—exposure therapy, stress inoculation training, and cognitive reprocessing therapy, among others. By contrast, trauma-informed systems and services are those that have thoroughly incorporated an understanding of trauma, including its consequences and the conditions that enhance healing, in all aspects of service delivery. Any human service program, regardless of its primary task, can become trauma-informed by making specific modifications in both administrative- and service-level practice to be responsive to the needs and strengths of people with personal experience of trauma.

In Using Trauma Theory to Design Service Systems (Harris, M. and Fallot, R.D. (Eds.). (2001). New Directions for Mental Health Services Series. San Francisco: Jossey-Bass.), we outlined the basic changes in understanding—the paradigm shift—involved in a trauma-informed framework and then described the application of this model to a number of different kinds of services. Becoming trauma-informed means changing the ways we think—about trauma itself, about the survivor, about services, and about the services relationship—as a prelude to changing the ways we act in structuring and offering services. It means moving trauma from the periphery to the center of our understanding. Rather than asking, “What is your problem?” trauma-informed providers may ask, implicitly or explicitly, “What has happened to you?” and, “How have you tried to deal with it?” Rather than adopting a stance of, “Here is what I can do to help you,” a trauma-informed approach asks, “How can you and I work together to meet your goals for healing and recovery?” In every aspect of the program’s functioning, there is enhanced awareness of the ways in which trauma may have affected people coming for services. There is a corresponding shift in attitude, practice, and setting to welcome, engage, and sustain helpful relationships with consumer-survivors.

Since 2001, we have had the opportunity to consult with numerous States and individual programs that have expressed interest in adopting a more trauma-informed approach in their settings and activities. Several lessons and new materials have emerged from these consultations and discussions. First, we have developed written guidelines for an agency or program to review the extent to which it is currently operating in a trauma-informed way and to make plans for prioritizing and initiating appropriate changes. This Trauma-Informed Self-Assessment and Planning Protocol draws on several domains at both the services level and the administrative level. The review of day-to-day service procedures and settings provides a starting point. In this process, agencies review the extent to which their day-to-day service procedures and settings are welcoming and hospitable for trauma survivors and the extent to which they minimize the possibility of retraumatization. Program administrators, staff, and consumers consider each step of a hypothetical prospective service recipient’s experience with the program, from initial to final meeting. They ask a variety of questions relevant for their program. What is the usual first point of contact? By telephone or in person? Who is likely to greet the individual? In what way? With what information? How engaging and nonthreatening are these initial contacts likely to be, especially for people with histories of abuse and related interpersonal concerns? Are the physical settings responsive to the needs of trauma survivors? Is there adequate space in the waiting area? Are there private areas for confidential conversations? Questions like this address the full range of service relationships over the course of a person’s involvement with the program.

From a large number of conversations with program staff and consumers discussing these questions, we have distilled five core principles to guide the assessment and planning process: Safety, trustworthiness, choice, collaboration, and empowerment. The broad assessment questions are straightforward. To what extent do current service delivery practices and settings do the following:

• Ensure the physical and emotional safety of consumers and staff? (safety);

• Make the tasks involved in service delivery clear? Ensure consistency in practice? Maintain boundaries, especially interpersonal boundaries, that are appropriate for the program? (trustworthiness);

• Prioritize consumer experiences of choice and control? (choice);

• Maximize collaboration and the sharing of power with consumers? (collaboration); and

• Prioritize consumer empowerment? Recognize consumer strengths? Build skills? (empowerment).

As programs move into the planning phase, they discuss and plan specific changes that can maximize these five characteristics of a trauma-informed program.

In addition to this review of routine activities and settings, assessment and planning involve two other domains at the service level. Formal, usually written, policies are examined to ensure, among other indicators, that confidentiality policies are clear and implemented consistently; that policies avoid involuntary or coercive practices; that the program prioritizes consumer preferences in responding to crises; and that a clearly written statement of consumer rights and grievance procedures is routinely accessible. The final service domain addresses trauma screening, assessment, and service planning. Here the program review focuses on universal trauma screening, more detailed trauma assessment as appropriate, and referral and followup procedures that ensure access to affordable and effective trauma-specific services.

The self-assessment then turns to administrative-level domains. Gauging administrative support for program-wide, trauma-informed services is essential. Some possible indicators that programs consider include the following: Formal policy or mission statements that highlight the importance of trauma; forming a trauma workgroup to take a leadership role in trauma-related service development; making resources (time, money, staff) available in support of trauma-informed recommendations; and active participation by senior administrators in the review and planning process. Trauma training and education is the second domain. Programs assess the extent to which all staff have received basic education in trauma, its effect on people’s lives, and some of the ways in which trauma-related dynamics may be evident in the work setting. In addition, the extent to which direct service staff has received trauma training related to their area of specialization is considered. Finally, programs examine their human resource practices. They assess the extent to which knowledge of trauma is considered in the hiring, orientation, and performance review processes.

This comprehensive assessment and planning process ends with a structured exercise to help programs set their own priorities for making trauma-informed changes. Considering such factors as feasibility, impact, and available resources, programs make a sequenced work plan for implementing their planned modifications. To aid programs in monitoring their progress, we have developed a Trauma-Informed Self-Assessment Checklist as a companion document. This checklist includes a five-point scale for each of the above domains, with higher ratings indicating more fully developed trauma-informed practice.

Based on our work with a variety of programs and jurisdictions, we have learned certain lessons about the most effective ways to implement a trauma-informed change initiative. Because these initiatives are designed to facilitate a changed culture and changed system, they go well beyond simply adding a new service and beyond the involvement of direct service staff alone. For trauma-informed changes to take root and become part of an agency culture, participants from all stakeholder groups need to be involved: Upper-level administrators (e.g., executive directors and clinical directors), supervisors or other middle managers, direct service staff, support staff, and consumers. Those programs that are most successful in developing significant and lasting trauma-informed approaches have engaged frequently underrepresented groups in all aspects of planning, implementing, and monitoring the change process.

A corollary of this observation is that considerable attention must be paid in the preplanning phase of instituting a trauma-informed initiative. For example, if an administrative authority (at either the program or larger systems level) decides to implement such a change process, it is important to consider ways to maximize buy in from the constituencies involved. Administrative decisionmakers need to model the kind of collaboration that a trauma-informed approach values. This may mean taking the time to provide information, to anticipate obstacles, to offer needed resources and incentives, and to develop solutions to potential problems. It may mean starting the initiative with a highly motivated part of the agency, or pilot project, that will then disseminate its learning to the larger system. It may mean timing or pacing the initiative to fit with other contextual factors, including programs’ financial stability and other concurrent administrative or service system changes that can potentially interfere with a new initiative.

Qualitative findings from our consultations have been promising. In programs that have implemented this process, each of the major constituency groups—administrators, direct service staff, and consumers—have reported positive responses to trauma-informed changes in the system of care. Administrators note greater collaboration, both within and outside the agency; enhanced staff morale; fewer negative incidents; and more effective service implementation. Providers report more collaboration with consumers, an enhanced sense of their own efficacy, and greater support from the larger agency. Consumers report a stronger sense of safety, trust, and engagement in services; more collaboration with service providers; and a special appreciation of the emphasis on empowerment, recovery, and healing. One consumer stated that she had previously felt it necessary to leave part of herself outside the agency door, but the trauma-informed initiative had made it possible for her to “bring her whole self” to the program. Such whole-person engagement with the full experiences of trauma survivors is a powerful expression of a trauma-informed culture.

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Child Sexual Abuse and Trauma-Informed Care

by Pamela Pine, Ph.D., Founder and Executive Director
Stop the Silence: Stop Child Sexual Abuse, Inc.

Child abuse and neglect—including childhood sexual abuse (CSA)—is among the most pervasive, devastating and cyclical of all violent traumas. 

Research shows us that women are perhaps as likely to experience CSA as they are sexual assault or stalking, and approximately 15 percent of men are survivors of CSA.  However, there remains a general lack of awareness of and no comprehensive or integrated strategy to address the national (and international) problem of CSA-related trauma and its vast public health and social impacts.

CSA constitutes a broad range of behaviors occurring along a continuum (from voyeurism to rape), usually over an extended period of time. It is occurring in pandemic proportions and causes grave physical and psychological trauma and social havoc.

Among the adverse effects of CSA on children and adolescents are decreased school performance, delinquency, depression, anxiety, substance abuse, antisocial behavior, incarceration, sexual promiscuity, teen pregnancy and HIV.  Approximately 60 percent of teens who become pregnant were sexually abused as children, and approximately 95 percent of teen prostitutes were sexually abused.

Decades of research documents that adults who were sexually victimized as children have a higher likelihood of being negatively impacted in their adulthood by numerous types of psychological and physiological ailments and sociological pathologies, including post traumatic stress disorder, self-destructive behavior, or violent behavior. CSA also is precursor to and a part of the commercial sexual exploitation and trafficking of children. 

As with other types of violent crime, most CSA is never reported, and CSA is likely even more underreported due to extreme fear and shame. In addition, report data is highly "filtered"— select victims disclose the abuse or the abuse is found out by an adult; reported incidents then may change the actual circumstances of the reporting; and authorities then often minimize or dismiss the abuse.

Only one in 10 children in the U.S. tells, and 42 percent of women and 33 percent of men never disclose the experience to anyone. In the United States, CSA affects between 15 percent and 33 percent of females and between 13 and 16 percent of males. 

A national, comprehensive and collaborative approach is required to prevent CSA and to ensure that CSA survivors get the trauma-informed care they desperately need.  Also required are:

• more research to obtain a better understanding of the scale and impact of the problem;

• advocacy to foster policy reform;

• training so that adults are able to keep children safe;

• pubic education to combat the deeply entrenched social stigmas associated with CSA; and

• policy change to ensure that an understanding of CSA and trauma-informed care are integrated in to policies and procedures at the many places where they are applicable (if not central). 

Toward that end, Stop the Silence: Stop Child Sexual Abuse, Inc. has a number of ongoing and planned activities, including training for service providers and a planned training for judges on CSA-related trauma; the fifth annual International Race to Stop the Silence in April 2008; and a Congressional briefing on CSA, also planned for 2008

Stop the Silence: Stop Child Sexual Abuse, Inc. (Stop the Silence) is a non-profit organization whose mission is to expose and stop CSA and to help survivors heal worldwide. Its overarching goals are to: 1) help stop CSA and related forms of violence; 2) promote healing of survivors through comprehensive programming; and 3) celebrate the lives of those healed. Stop the Silence also aims to address relationships between CSA and the broader issues of overall family and community violence.

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CMHS’ National GAINS Center Continues Under “Transformation” Program

SAMHSA’s Center for Mental Health Services (CMHS) has renewed funding for five more years of its National GAINS Center’s efforts to promote a closer partnership of the mental health and criminal justice systems.

The work will be implemented through a Transformation Center that also includes a major initiative to provide technical assistance and support to the nine states funded under the CMHS Mental Health Transformation State Incentive Grant.

The Transformation Center will facilitate an ongoing leadership forum, a bi-annual conference and a criminal justice-focused trauma services program for jail and community-based systems serving returning combat veterans with post-traumatic stress disorder. In addition, the GAINS Center will continue to facilitate peer support trauma intervention models for times of disaster, including peer training approaches for use at the state and community level.

Click here for more information.

SAMHSA Awards Jail Diversion Grants

SAMHSA recently awarded two grants totaling more than $2 million over three years to county agencies in New York and Georgia. The grants will be used to divert people with mental illness away from the criminal justice system and into community-based mental health and substance abuse treatment services.

The Monroe County Office of Mental Health in Rochester, New York, will receive $1.1 million while almost $1 million will go to the DeKalb County Diversion Treatment Court in DeKalb County, Georgia.

“All too often individuals with mental illness, especially those who have a co-occurring substance use disorder, are incarcerated instead of receiving treatment for their disorder,” said SAMHSA Administrator Terry Cline, Ph.D. “By diverting non-violent adult offenders with mental illnesses from jail to community-based mental health services, individuals and the criminal justice system in these counties will benefit.”

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