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ANOTHER Trendy Initiative?!? -Integrating Trauma-Informed and Co-Occurring Capable Care. Cary Hopkins Eyles, MA, CAP Samantha A. Farro, PhD Colleen Clark, PhD. Annual Conference August 25, 2011 Orlando, Florida. Agenda. The Centrality of Trauma What is Trauma-Informed Care?

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Another trendy initiative integrating trauma informed and co occurring capable care

ANOTHER Trendy Initiative?!? -Integrating Trauma-Informed and Co-Occurring Capable Care

Cary Hopkins Eyles, MA, CAPSamantha A. Farro, PhDColleen Clark, PhD

Annual Conference

August 25, 2011

Orlando, Florida

Agenda and

  • The Centrality of Trauma

  • What is Trauma-Informed Care?

  • Assessing Readiness for Trauma-Informed Care

  • Integrating Care for Co-occurring Disorders and Trauma Issues

  • Making it all Work for the Client

Introduction and

  • Clients seeking substance abuse and mental health treatment often have history of trauma.

  • History of trauma complicates treatment.

  • Integrated care is more cost effective and demonstrates more positive outcomes of treatment

Another trendy initiative integrating trauma informed and co occurring capable care

ACE Score vs. Adult Alcoholism and

Family Care Version: Understanding Trauma & Trauma-Informed Care

Integration and

How mental health,

substance abuse, violence

work together

Another trendy initiative integrating trauma informed and co occurring capable care

Trauma and

Substance Abuse

Trauma and substance abuse
Trauma and Substance Abuse and

  • Following traumatic event – substance abuse as “self-medication” “self-soothing”

  • Substance abuse leading to high risk situations or poor judgment increasing chances of victimization

Another trendy initiative integrating trauma informed and co occurring capable care

Trauma and

Mental illness, Emotional disorders

Trauma and mental illness
Trauma and Mental Illness and

  • Violence and abuse, especially over a long term, abuse by multiple perpetrators and/or extremely violence abuse is associated with the development of many disorders.

  • Some responses to abuse – SIV, flashbacks, result in involuntary hospitalization, seclusion , restraints and possible retraumatization

  • People with mental illnesses are more likely to be victims of violence

Another trendy initiative integrating trauma informed and co occurring capable care

Substance abuse and

Mental illness, Emotional disorders

Problem and

  • Integrated treatment is complex to assess and difficult to implement.

  • Current empirical approaches require a great deal of time and resources

Potential solution
Potential Solution and

Consumer Perspective

Staff Perspective


Assesses staff perspective about residential treatment’s level of trauma informed care on six dimensions


Semi-structured interviews of staff are qualitatively coded using an anchored rating scale


Agency’s staff leaders in residential treatment


Examines prevalence of childhood trauma and perceptions of service integration and choice at DACCO’s residential treatment


Survey data is statistically analyzed to examine mean differences, correlations, and frequencies.


Female and male clients in residential treatment

Current approach
Current Approach and

  • Adverse Childhood Experiences Scale

  • Consumer Perceptions of Care Scale

  • Community Readiness Model Interviews

Current approach1
Current Approach and

  • Adverse Childhood Experiences

    • Measures the extent of exposure from the study’s sample to different types of childhood trauma.

Current approach2
Current Approach and

  • Consumer Perceptions of Care

    • Measures client’s perceptions of and satisfaction with services for substance abuse, mental health, and trauma related disorders.

Current approach3
Current Approach and

  • Community Readiness Model

    • Guide for assessing readiness and capacity to successfully develop and implement a program on a community/organizational level

    • Theoretically based on stages of change

Stages of change brief overview
Stages of Change: Brief Overview and

  • Developed by Prochaska and DiClemente

  • Change is a process and each person progresses at their own rate through this process

  • Decisions must come ultimately from inside, an internal locus of control, as long-term stable change cannot be externally imposed

  • The stages describe an individual's attitude toward behavior change

    • Precontemplation

    • Contemplation

    • Preparation

    • Action

    • Maintenance

    • Relapse

Another trendy initiative integrating trauma informed and co occurring capable care

Stages of Change and

  • Assess where the person or system is in the change process to determine the appropriate intervention

  • Once you assess where you are in the process then you can what steps you need to take next to get to your goal

  • This research will help us determine our readiness as a division and then each of us will need to personally decide how ready we are to focus on trauma with our population

Crm results
CRM Results and

  • Community Efforts

    • 7 Stabilization

  • Community Knowledge of the Efforts

    • 6 Initiation

  • Leadership

    • 6 Initiation

  • Community Climate

    • 7 Stabilization

  • Community Knowledge About the Issue

    • 5 Preparation

  • Resources for Efforts

    • 5 Preparation

  • Crm results1
    CRM Results and

    • Community Efforts and Community Climate

    • Level 7 - Stabilization

      • One or two efforts are running, supported by administrators/community decision-makers

      • Programs and activities are viewed as stable

      • Staff are trained and experienced

      • No in-depth evaluation of effectiveness as of yet

      • Climate supports activities

    Crm results2
    CRM Results and

    • Level 7 – Stabilization Goal and Strategies

      • Goal: Stabilize efforts or establish programs

        • Plan events to maintain support for TIC efforts

        • Introduce evaluation results through multiple media sources

        • Review efforts/activity progress on a quarterly basis

        • Maintain business and outside organizational support for the effort/activity

        • Increase and further develop media exposure to reach community, use evaluation data

    Crm results3
    CRM Results and

    • Community Knowledge of the Efforts and Leadership

    • Level 6 – Initiation

      • Information is available to justify the efforts

      • Activity and action is underway but still viewed as a new effort

      • Staff are being trained

      • Great enthusiasm in leaders, as limitations and issues have yet to be met

      • Improved attitude in community members is reflected by continued modest support

    Crm results4
    CRM Results and

    • Level 6 – Initiation Goal and Strategies

      • Goal: Provide Community Specific Information

        • If local data sources are non-existent or unreliable, plan how to begin accurate local data collection

        • Inform other community providers and leaders through multidisciplinary meetings, administrative meetings, in-service trainings, etc. and talk about the progress of your efforts

        • Network with existing resources to enhance your efforts

        • Sponsor or co-sponsor larger community events

        • Plan publicity efforts associated with start up of activity, program, or efforts

        • Begin discussion about basic evaluation efforts

    Crm results5
    CRM Results and

    • Community Knowledge About the Issue and Resources for Efforts

    • Level 5 – Preparation

      • Planning is going on and focuses on details

      • General information about problem and pros and cons of efforts

      • Leadership is active and energetic

      • Resources (people, money, time, etc) are actively being sought

      • Community climate offers modest support

    Crm results6
    CRM Results and

    • Level 5 – Preparation Goal and Strategies

      • Goal: Gather pertinent information

        • Organize and present local statistics, local efforts, and survey information to the community through agency newsletters, emails, etc. (Compile the facts: locals statistics, local stories, emotional cost, consequences to the division, future impact, financial costs, etc)

        • Begin searching for potential funding for resources through state federal and foundation sources

        • Network within your agency to foster support for initiatives

    Some history
    Some History and

    • Co-occurring initiative has been strong for 10 years at DACCO

    • Have made significant changes in terms of having services available to clients on-site, assessing for comorbidity, making clients’ mental health concerns part of the treatment planning and clinical chart, etc

    • Realization that trauma is at the root of many of the clients’ disorders (both SA and MH)

    Cod and tic principles

    COD and TIC principles and

    Integrating Care

    Outline and

    • Co-Occurring Disorders

      • Definition

      • CCISC (Minkoff & Cline) Model

    • Trauma-Informed Care

      • Components of Trauma Informed Care

      • System changes

    • Fully Integration Care

      • Combining Mental Health, Substance Abuse, and Trauma Treatment

    Co occurring disorders
    Co-Occurring Disorders and

    • People who are diagnosed with both mental health and substance abuse disorders and are, therefore, living with symptoms of both.

      • Often struggle to cope with past trauma, medical problems, social concerns (i.e., involvement in the child welfare system), criminal justice/legal problems.

    Comprehensive continuous integrated system of care model ccisc
    Comprehensive, Continuous, Integrated System of Care Model and (CCISC)

    • Designed to improve access and implementation of treatment for clients in a holistic manner

    Ccisc principles
    CCISC principles and

    • Welcoming

    • Accessible

    • Integrated

    • Continuous

    • Comprehensive

    • Consumer / Family Oriented

    Ccisc principles1
    CCISC Principles and

    • Dual diagnosis is an expectation, not an exception

    • Empathic, hopeful, integrated treatment relationships are one of the most important contributors to treatment success in any setting; provision of continuous integrated treatment relationships is an evidence based best practice for individuals with the most severe combinations of psychiatric and substance difficulties

    Ccisc principles2
    CCISC Principles and

    • All COD clients are not the same (quadrant model)

    • Case management and care must be balanced with empathic detachment, expectation, contracting, consequences, and contingent learning for each client, and in each service setting

    Ccisc principles con t
    CCISC Principles, con’t and

    • When psychiatric and substance disorders coexist, both disorders should be considered primary, and integrated dual (or multiple) primary diagnosis-specific treatment is recommended.

    • “Disease and recovery model” (Minkoff)

    • No single correct intervention for persons with COD (quadrants, diagnoses, level of functioning, stage of change, etc)…

    • Clinical outcomes for persons with COD must also be individualized, based on similar parameters for individualizing treatment interventions

    CCISC and

    • Change to occur throughout the system of care

    • Tries to use the existing resources or the most efficient use of existing resources

    • Use of evidence-based practices and consensus-based best practices

    • Integrated treatment

    CCISC and

    • Co-morbidity

    • Integrated treatment

    • Acknowledgement that readiness varies (which fits best with what modalities?)

    • Continuous relationships with providers

    • Both dx are primary

    • Chronic, relapsing illnesses

    Service provider recommendations
    Service Provider Recommendations and

    • Create a Committee or sub-committee in your organization to discuss issues of co-occurring disorders

    • Leadership and Change Agents need to prioritize

    • Review the following areas:

      • Admission

        • Are you currently excluding clients who have substance abuse (if a MH agency) or mental health (if a SA agency)

        • Do you have standard methods of screening for both disorders?

      • Records

        • Are both diagnoses documented?

        • Do staff include treatment plan objectives for both?

    Service provider recommendations1
    Service Provider Recommendations and

    • Treatment Quality Enhancements

      • Manualized groups discuss the integration of SA and MH.

      • Use of the stages of change in a systematic way.

      • Program employs drug testing procedures, routinely or as indicated

      • Program participants have access to self-help groups onsite or are regularly transported to groups that specifically address COD (e.g., Dual Recovery / Double Trouble)

    Service provider recommendations2
    Service Provider Recommendations and

    • Staff Structure

      • Program staff includes persons onsite that have expertise / professional backgrounds in mental health and substance use disorders

      • Human resource policies and written training expectations focus on the acquisition of skills related to the treatment of persons with co-occurring disorders

    • Program Administration

      • Program Mission Statement specifically welcomes persons with active co-occurring disorders

      • MIS / data entry systems are employed that identify and track services delivered to persons with COD

    Trauma informed care1
    Trauma-Informed Care and

    For an organization to be trauma-informed, “all staff…from the receptionist to the direct care workers to the board of directors, must understand how violence impacts the lives of people being served, so that every interaction is consistent with the recovery process and reduces the possibility of re-traumatization (Elliot, 2005, pg 462).”

    Trauma informed care2
    Trauma-Informed Care and

    It is when every part of a human service program’s organization, management, and service delivery system is assessed and potentially modified to include an understanding of how trauma affects the life of an individual seeking services.

    Trauma-informed organizations, programs, and services are based on an understanding of the vulnerabilities or triggers of trauma survivors that traditional service delivery approaches may exacerbate, so that these services and programs can be more supportive to help engage the client.

    Trauma informed care3
    Trauma Informed Care and

    • Client Focused:

      • Client Safety

      • Trustworthiness

      • Client Choice

      • Collaboration

      • Client Empowerment

    Relationships heal
    Relationships Heal….. and

    Family Care Version: Understanding Trauma & Trauma-Informed Care


    Healing happens in relationships when
    Healing Happens in Relationships when….. and

    Safety is ensured

    Connection happens

    Empathy is present

    Attunement occurs

    New skills are taught & practiced

    There is focus on the positive

    The helpers remain calm, committed, and are also cared for

    Family Care Version: Understanding Trauma & Trauma-Informed Care


    Healing happens in environments where
    Healing Happens in Environments where…… and

    Physical & psychological safety is ensured

    Trustworthiness is present

    There is choice rather than compliance

    There is collaboration rather than control

    There is empowerment rather than coercion

    There is transparency rather than secrecy

    There is resiliency rather than despair

    Family Care Version: Understanding Trauma & Trauma-Informed Care


    Trauma informed care in all settings
    Trauma-Informed Care in all Settings and

    Maximizes survivor’s sense of physical and psychological safety

    Avoids re-traumatization of the survivor through recognition of triggers

    Helps survivor to reduce overwhelming emotion

    Family Care Version: Understanding Trauma & Trauma-Informed Care


    Ten principles
    Ten Principles and

    Trauma-informed services

    • recognize the impact of violence and victimization on development and coping strategies.

    • identify recovery from trauma as a primary goal.

    • employ an empowerment model.

    • strive to maximize women’s/men’s choices and control over her/his recovery.

    • are based in a relational collaboration.

      Note: taken from Elliot et al., 2005

    Ten principles1
    Ten Principles and

    Trauma-informed services

    • create an atmosphere that is respectful of survivors’ need for safety, respect, and acceptance.

    • emphasize women’s strengths, highlighting adaptations over symptoms, resilience over pathology.

    • minimize the possibilities of retraumatization.

    • strive to be culturally competent and to understand each women in the context of her life experiences and cultural background.

    • solicit consumer input and involve consumers in designing and evaluating services.

      Note: taken from Elliot et al., 2005

    Tenants and

    • Supports Clients In:

      • Relationship Building

      • Skills Training

      • Personal Safety

    Tenants of tic
    Tenants of TIC and

    • Central tenants: relationship building, skill training, and safety.

    • Relationship Building. Trauma informed care treats clients in a way that is understanding of their traumatic experiences rather than focusing on their current “inappropriate” behavior. It is a philosophy that involves asking “What happened to you?” versus “What’s wrong with you?” or “Why do you continue to behave this way?”

    • By respecting the effects traumatic experiences have, rather than focusing on behavior modification, organizations develop strong relationships with clients.

    Tenants of tic1
    Tenants of TIC and

    • Skill Training. Skill building, which leads to increased self-worth, is another important aspect of trauma-informed care. It is important to teach skills, as well as provide them with a safe environment to practice these newly acquired skills. Because skill development equips clients with new options when making decisions in the future, this will hopefully lead them to experience less trauma in the future.

    • Safety. Safety is a huge component of trauma informed care. Clients must feel safe in their treatment and/or residential program. Otherwise, they will not trust and respect staff enough to talk about and discuss “What happened to you?”

    • Safety includes consistency, respect, environment, and trust. It is essential that staff are trained in and understand safety concepts as they relate to trauma informed care.

    Components of a trauma informed treatment program
    Components of a Trauma-Informed Treatment Program and

    • A program that provides Trauma Informed Treatment is made up of the following components, or parts:

    • Treatment and care providers who understand the dynamics of trauma and violence.

    • Staff training about trauma and violence issues, and how to provide treatment and care to individuals who have experienced trauma or violence.

    • Treatment and care providers understand and recognize that the use of seclusion and restraint and the forcing of intramuscular shot medications is re-traumatizing.

    Components of a trauma informed treatment program1
    Components of a Trauma- Informed Treatment Program and

    • Assessment of an individual's experiences with trauma and violence.

    • Treatment planning that facilitates consumer choice, control, and participation in: treatment, program/policy development, and evaluation.

    • An environment that is physically and practically designed to avoid re-traumatization.

    • An environment that is safe and nurturing.

    • An environment that is empowering.

    • An environment that is culturally competent.

    What are trauma specific interventions
    What are Trauma-Specific Interventions? and

    • Trauma-specific interventions are designed specifically to address the consequences of trauma in the individual and to facilitate healing. Treatment programs generally recognize the following:

    • The survivor's need to be respected, informed, connected, and hopeful regarding their own recovery

    • The interrelation between trauma and symptoms of trauma (e.g., substance abuse, eating disorders, depression, and anxiety)

    • The need to work in a collaborative way with survivors, family and friends of the survivor, and other human services agencies in a manner that will empower survivors and consumers

    What are trauma specific interventions1
    What are Trauma-Specific Interventions? and

    • Behavioral Health treatment providers must understand the dynamics and impact of trauma on people's lives.

    • Individuals who have experienced trauma in their lives must be involved in the design, delivery and evaluation of treatment services.

    • Providers must be culturally sensitive while incorporating evidence based, best practice, Trauma Informed Treatment models in their programs.

    What are trauma specific interventions2
    What are Trauma-Specific Interventions? and

    • Trauma-specific interventions are designed specifically to address the consequences of trauma in the individual and to facilitate healing. Treatment programs generally recognize the following:

    • The survivor's need to be respected, informed, connected, and hopeful regarding their own recovery

    • The interrelation between trauma and symptoms of trauma (e.g., substance abuse, eating disorders, depression, and anxiety)

    • The need to work in a collaborative way with survivors, family and friends of the survivor, and other human services agencies in a manner that will empower survivors and consumers

    Service provider recommendation
    Service Provider Recommendation and

    • Develop a trauma team, including trauma survivors, in your facility.

    • Implement evidence based Trauma-Informed Treatment models.

    • Develop a facility culture that is trauma sensitive.

    • Review policies and procedures from a trauma awareness perspective.

    • Assess current treatment environments to eliminate possible re-traumatization.

    Service provider recommendation1
    Service Provider Recommendation and

    • Provide on-going staff training on trauma and its impact on children.

    • Conduct thorough trauma assessments on admission.

    • Include children in all aspects of planning and evaluation.

    • Collaborate with other providers by combining their training money for county or regional training consultants.

    • Provide culturally competent services for persons of all races, colors, religions, sexes, sexual orientations, national origins, disabilities and ages.

    Culture shift
    Culture Shift and

    • Have a welcome statement and/or agency mission that welcomes people with co-occurring disorders and trauma.

    • Ensure that even non-clinical staff have knowledge that the people walk through the door are likely to have experienced trauma and be dealing with complicated issues and multiple disorders so we need to be compassionate and patient.

    • Review policies and add language about trauma and COD.

    • Provide trainings in COD and TIC. On-site talent, free local trainings, webinars. Does not have to be expensive.

    • Put on the agenda at committee meetings in agency.

    Practical examples
    Practical examples and

    • When doing bio-psychosocial assessments, ask about childhood/family history. Don’t be afraid to ask about physical, sexual, or psychological abuse – both past and present – in a direct but caring way.

    • Provide group interventions that allow clients to share and hear others’ stories. Seeking Safety is a good example that can be run by a direct care staff and is a safe environment for clients.

    • Ask what the client needs and hopes to achieve in treatment.

    • Ask about prior treatment (mental health, suicidal ideation).

    Don t get overwhelmed
    Don’t get overwhelmed! and

    • Start with baby steps and measurable, achievable goals

    • Change one policy this quarter, add one thing to a form, provide one training

    Discussion question
    Discussion Question and

    • What do you see that you need to do to make your system Co-Occurring Capable?

    • What do you need to do to make your system Trauma-Informed?

    • What would be similar?

    • Different?

    Some references resources
    Some References & Resources and


    • Kenneth Minkoff, M.D. & Christie Cline, M.D.


    • Becoming Dual Diagnosis Capable: An Overview (2007) Holly Hills, PhD

    • SAMHSA:

    • Trauma Informed Treatment in Behavioral Health Settings:

    For more information cary hopkins eyles dacco 813 621 8781 x225 caryh@dacco org

    For more information: and Cary Hopkins Eyles, DACCO813-621-8781