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  1. TRAUMA INFORMED TREATMENT FOR CO-OCCURRING DISORDERS Ruth Karnes, MSW, CADC Alexandria Markel, MS, CRC Dona Howell, MS, CRADC Char Rosa Mark Hagene

  2. SESSION 8-A • This presentation will provide clinicians/supervisors/practitioners with information regarding the utilization of trauma informed treatment for dually diagnosed clients

  3. EBPs Evidence Based Practices • SAMHSA's National Center for Trauma-Informed Care (NCTIC) is a technical assistance center dedicated to building awareness of trauma-informed care and promoting the implementation of trauma-informed practices in programs and services.

  4. NCTIC • The National Center for Trauma-Informed Care (NCTIC) was created in 2005 to offer technical assistance to stimulate and support interest in and implementation of trauma-informed care in publicly-funded systems and programs.

  5. NCTIC • With a better collective understanding of trauma, more consumers and survivors will find their path to healing and wellness. • With a greater public commitment to trauma-informed programs and systems for survivors, we lessen and prevent a wide range of health, behavioral health, and social problems for generations to come. • For more information about training and technical assistance, please contact NCTIC at or by calling 866-254-4819

  6. DEFINITION • Trauma-informed care • an approach to engaging people with histories of trauma • helps client recognize the presence of trauma symptoms • acknowledges the role that trauma has played in clients’ lives.

  7. FACILITATING ENVIRONMENTS • NCTIC facilitates the adoption of trauma-informed environments in the delivery of a broad range of services including • mental health • substance use • housing • vocational or employment support • domestic violence and victim assistance • and peer support. • In all of these environments, NCTIC seeks to change the paradigm from one that asks, "What's wrong with you?" to one that asks, "What has happened?”

  8. SEEKING SERVICES • Many individuals seeking public behavioral health services and other public services, such as homeless and domestic violence services, have histories of trauma-inducing experiences. • These experiences often lead to co-occurring disorders such as • mental health disorders • chronic health conditions • substance abuse • eating disorders • HIV/AIDS • contact with the criminal justice system

  9. TRAUMA EXPERIENCES CAN BE • dehumanizing, • shocking or terrifying, • singular or multiple compounding events over time • often include betrayal of a trusted person or institution • loss of safety • intergenerational trauma • Induced powerlessness, fear, hopelessness, and constant state of alertness • can result from experiences of violence • including physical, sexual, emotional, and institutional abuse or neglect

  10. TRAUMA IMPACTS • one's spirituality • relationships with self, others, communities and environment • often results in recurring feelings of shame, guilt, rage, isolation, and disconnection. • Healing is possible.

  11. POPULATION/PREVALENCE • Although exact prevalence estimates vary, there is a consensus in the field that most consumers of mental health services are trauma survivors and that their trauma experiences help shape their responses to outreach and services.

  12. APPLICATIONS • What are Trauma-Specific Interventions? • Trauma-specific interventions are designed specifically to address the consequences of trauma in the individual and to facilitate healing.

  13. APPLICATIONS • 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

  14. TRAUMA FOCUSED COPING • Trauma Focused Coping (TFC) • A school-based group intervention for children and adolescents in grades 4-12 who have been exposed to a traumatic stressor (disaster, violence, murder, suicide, fire, accident) • Targets posttraumatic stress disorder (PTSD) symptoms and other trauma-related symptoms, including depression, anxiety, anger, and external locus of control

  15. EVIDENCE BASED PRACTICE/TRAUMA INFORMED TREATMENT TOOL • Addiction 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 addressing and healing form trauma. • Dusty Miller, author and creator of ATRIUM, is available for training, consultation, workshops, and keynote presentations. She works with groups that address issues of self-sabotage, traumatic stress, trauma re-enactment, substance abuse, self-injury, eating disorders, anxiety, body-based distress, relational challenges, and spiritual struggles.

  16. EVIDENCE BASED PRACTICE FOR TRAUMA INFORMED PROGRAMMING • Risking Connection® • 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. • Risking Connection emphasizes concepts of empowerment, connection, and collaboration. The model addresses issues like understanding how trauma hurts, using the relationship and connection as a treatment tool, keeping a trauma framework when responding to crises such as self-injury and suicidal depression, working with dissociation and self-awareness, and transforming vicarious traumatization. • The Sidran Institute provides educational materials, training, and implementation support.

  17. EBP-TRAUMA INFORMED PROGRAMMING • Seeking Safety • Seeking Safety is designed to be a therapy for trauma, post-traumatic stress disorder (PTSD), and substance abuse. The developer feels that this model works for individuals or with groups, with men, women or with mixed-gender groups, and can be used in a variety of settings (e.g. outpatient, inpatient, residential). • The developer indicates that the key principles of Seeking Safety are safety as the overarching goal, integrated treatment, a focus on ideals to counteract the loss of ideals in both PTSD and substance abuse, knowledge of four content areas (cognitive, behavioral, interpersonal, and case management), and attention to clinician processes. • Seeking Safety provides on-site training sessions and telephone consultation

  18. EBPS • Trauma, Addiction, Mental Health, and Recovery • Developed as part of the first phase of the SAMHSA 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. • The Trauma Addictions Mental Health and Recovery Treatment Manual provides basic education on trauma, its developmental effects on symptoms and current functioning, symptom appraisal and management, the impact of early chaotic relationships on healthcare needs, the development of coping skills, preventive education concerning pregnancy and sexually transmitted diseases, sexuality, and help in dealing with role loss and parenting issues.

  19. EBPS • Trauma Affect Regulation: Guide for Education and Therapy (TARGET) • TARGET is a model designed for use by organizations and professionals with a broad range of experience with and understanding of trauma. The developer feels that TARGET works with all disciplines and can be used in all levels of care for adults and children. • The developer indicates that TARGET is an educational and therapeutic approach for the prevention and treatment of complex Post Traumatic Stress Disorder (PTSD). The developer feels that this model provides practical skills that can be used by trauma survivors and family members to de-escalate and regulate extreme emotions, manage intrusive trauma memories experienced in daily life, and restore the capacity for information processing and memory. • The University of Connecticut’s Research and Development Corporation is creating a behavioral health service company to provide training and consultation in the TARGET model which will include training, long-term small group consultation, quality assurance, and program evaluation.

  20. EBPS • Trauma Recovery and Empowerment Model (TREM and M-TREM) • The Trauma Recovery and Empowerment Model is intended for trauma survivors, particularly those with exposure to physical or sexual violence. This model is gender-specific: TREM for women and M-TREM for men. This model has been implemented in mental health, substance abuse, co-occurring disorders, and criminal justice settings. The developer feels this model is appropriate for a full range of disciplines. • Community Connections provides manuals, training, and ongoing consultation in TREM and M-TREM

  21. SELF HELP INFORMATION • If you feel the cause of your symptoms is related to trauma in your life, you will want to be careful about your treatment and in making decisions about other areas of your life. • Have hope. • It is important that you know that you can and will feel better. In the past you may have thought you would never feel better—that the horrible symptoms you experience would go on for the rest of your life. • Many people who have experienced the same symptoms that you are experiencing are now feeling much better. • They have gone on to make their lives the way they want them to be and to do the things they want to do

  22. SELF HELP INFORMATION • Wherever you go for help, the program or treatment should include the following: • Empowerment–You must be in charge of your healing in every way to counteract the effects of the trauma where all control was taken away from you. • Validation–You need others to listen to you, to validate the importance of what happened to you, to bear witness, and to understand the role of this trauma in your life. • Connection–Trauma makes you feel very alone. As part of your healing, you need to reconnect with others. • This connection may be part of your treatment.

  23. SELF HELP INFORMATION • Talk to one or more people about what happened to you. Telling others about the trauma is an important part of healing the effects of trauma. • Make sure the person or people you decide to tell are safe people, people who would not hurt you, and who understand that what happened to you is serious. They should know, or you could tell them, that describing what happened to you over and over is an important part of the healing process. • Don’t tell a person who responds with statements that invalidate your experience, like “That wasn’t so bad.” “You should just forget about it,” “Forgive and forget,” or “You think that’s bad, let me tell you what happened to me.” They don’t understand. • In connecting with others, avoid spending all your time talking about your traumatic experiences. Spend time listening to others and sharing positive life experiences, like going to movies or watching a ball game together. • You will know when you have described your trauma enough, because you won’t feel like doing it anymore

  24. SELF HELP INFORMATION • Take personal responsibility. When you have been traumatized, you lose control of your life. You may feel as though you still don’t have any control over your life. • You begin to take back that control by being in charge of every aspect of your life. Set small daily goals to accomplish. • Others, including your spouse, family members, friends, and health care professionals will try to tell you what to do. Before you do what they suggest, think about it carefully. Do you feel that it is the best thing for you to do right now? You can follow others advice, but be aware that you are choosing to do so. • Being traumatized is not an acceptable excuse for behavior that hurts you or hurts others.

  25. SELF HELP • Develop a close relationship with another person. • You may not feel close to or trust anyone. This may be a result of your traumatic experiences. • Part of healing means trusting people again. Think about the person in your life that you like best. Invite them to do something fun with you. If that feels good, make a plan to do something else together at another time—maybe the following week. Keep doing this until you feel close to this person. • Then, without giving up on that person, start developing a close relationship with another person. Keep doing this until you have close relationships with at least five people. • Support groups and peer support centers are good places to meet people.

  26. IN CONCLUSION • Trauma informed care is an Evidence Based Practice • Developed initially as a gender specific application, it is now widely recognized as a useful tool for both male and female populations