Trauma Informed Treatment in Behavioral Health Settings

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Introduction

The intent of this publication is to advocate for the implementation of Trauma Informed Treatment for Ohio's children who are victims of violence and have been traumatized.

Over the past decade, the national mental health community has focused increased attention on the long term effects of violence and trauma on children and adults. To explore this issue, in the early 1990's, the Substance Abuse Mental Health Services Administration (SAMHSA) brought together individuals who had experienced trauma in their lives, and policymakers, researchers, clinicians and providers.

These individuals shared the vision that behavioral health services must be trauma informed, which means services must be designed to acknowledge the impact of violence and trauma on people's lives and the importance of addressing trauma in treatment.

SAMHSA funded research designed to evaluate the effectiveness of treatment models for people who have experienced trauma. The research identified these trauma treatment principles:

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.

Based on its research and findings, SAMHSA challenged policymakers to create a Blueprint for Change in their state or community to improve behavioral health services to those who have experienced violence or trauma.

This booklet is Ohio's suggested Blueprint for Change.

What is Trauma?

Many Ohioans' lives have been devastated by these traumatizing experiences:

community & school violence
refugee & war zone trauma
domestic violence
serious accidents
natural disasters
physical abuse
abandonment
sexual abuse
verbal abuse
terrorism
neglect
torture

Every 9-1/2 minutes, an Ohio child is abused or neglected. (In 2000, there were 54,084 substantiated or indicated cases of abuse and neglect in Ohio.)

Trauma is an emotional shock that creates significant and lasting damage to a person's mental, physical and emotional growth.

"Trauma is interpersonal violence, over the life span, including sexual abuse, physical abuse, severe neglect, loss, and/or the witnessing of violence." — National Association of State Mental Health Program Directors

"When trauma occurs early in life, children do not develop the capacity to regulate their experience…to calm themselves down when they're upset, to soothe themselves, to interact in appropriate ways with other people, to learn from their behavior." — Margaret Blaustein, Presenter, The Traumatized Child, A Video Series on Traumatized Children. Cavalcade Productions, Inc. Nevada City, California. 2004

The Connection Between Trauma and Behavioral Health

Many people who have experienced trauma in their lives may look to the behavioral health system for help. Studies over the past decade show that between 34% and 53% of people with a severe mental disability report childhood physical or sexual abuse.

The behavioral health system must be sufficiently aware of the existence of trauma, and its effect, in the lives of the children it serves by providing trauma informed treatment. A study published in the Journal of Traumatic Stress (Switzer, et.al., 1999) found that 94% of clients in an urban mental health setting had a history of trauma and 42% had PTSD.

The Center for Victims of Violence and Crime (2005) report that children with any kind of disability are more than twice as likely as children without a disability to be abused and almost twice as likely to be sexually abused.

Sullivan, Vernon, and Scanlan (1987), reported:

50% of girls who are Deaf have been sexually abused as compared to 25% of hearing girls.
54% of boys who are Deaf have been sexually abused as compared to 10% of boys who hear.

The following is a quote by Pat Risser, a 48-year-old consumer advocate, reflecting on his history of abuse and the effects of over 20 hospitalizations. (Psychiatric Survivor Oral Histories: Implications for Contemporary Mental Health Policy, by Oryx Cohen, Capstone Report. Center for Public Policy and Administration, University of Massachusetts, Amherst. 2001)

"The overwhelming feeling while being raped or battered as a child was one of helplessness. I went to the mental health system for help with my emotional distress and they responded by hospitalizing me and retriggering the trauma of helplessness. I fought the restraints and seclusion because it only served to retraumatize me with the same helpless feelings of immobility that was present when I was being raped by my step-father. The mental health system didn't understand and they continued to try and treat me with painful drugs and other things that didn't help."

Effects of Trauma

The Adverse Childhood Experiences Study (ACE study), a decade-long and ongoing collaboration between Kaiser Permanente's Department of Preventive Medicine in San Diego, California, and the Centers for Disease Control and Prevention, addressed how childhood experiences affect adult health. The study found that harsh experiences such as physical and sexual abuse, neglect, or exposure to domestic violence during childhood result in health problems in adulthood. The study revealed "a powerful relationship between our emotional experiences as children and our physical and mental health as adults …" The researchers documented "the conversion of traumatic emotional experiences in childhood into organic disease later in life."

"Persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, greater than or equal to 50 sexual intercourse partners, and sexually transmitted disease; and a 1.4- to 1.6-fold increase in physical inactivity and severe obesity.

The number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life."

"Having three or four adverse childhood experiences would increase your risk of being an alcoholic six- seven- or eight-fold. It would increase your risk of attempting suicide up to twenty- or thirty-fold."

(Vincent Felitti, M.D., Adverse Childhood Experiences Study, www.acestudy.org)

The impact of violence and trauma varies — some victims may emerge from the experience relatively unscathed — others suffer long term devastating emotional and medical effects.

Facility administrators reported that 70% -90% of children in Ohio's residential treatment facilities are victims of violence. (Closer Look: Our Kids. Ohio Legal Rights Service, 2000)

"Victims of abuse are holistically impacted by their experiences." (Ruta Mazelis, Editor. The Cutting Edge, Page 1, Vol 8, Issue 3. Fall 1997)

Victims of trauma or violence may receive treatment for:

Post Traumatic Stress Disorder
Substance abuse (SA) or dependence
Anxiety/panic disorder
Eating disorders
Borderline Personality Disorder (BPD)
Disassociative Identity Disorder (DID)
Depression
Medical illness and somatization disorders
Bipolar Disorder
Self inflicted violence
Behavioral problems
Anger management

Statistics:

Approximately 30% of those who have spent time in war zones experience PTSD. (NIMH)
66% of those in SA treatment report childhood abuse or neglect.
90% of alcoholic women were sexually abused or suffered violence at the hand of a parent.
90% of those diagnosed with BPD or DID were victims of violence.
80% of those in psychiatric hospitals experienced physical or sexual abuse as children.
Boys who experience or witness violence are 1000 times more likely to commit violence than those who do not.

(Anne Jennings. What Can Happen to Abused Children When They Grow Up - If No One Notices, Listens, or Helps? January 2001)

Research indicates that children and adolescents from minority backgrounds are at increased risk for trauma exposure and development of Posttraumatic Stress Disorder (PTSD). For example, African American, American Indian, and Latin American children are over-represented in reported cases of child maltreatment, and in foster care. (Department of Health and Human Services, Administration for Children and Families 2002).

Traditional "Placement Steps" for Traumatized Children

Children who have been traumatized may move from one step, or placement, to another. A child may go to any or all of these placements, once, or more than once, and in no particular order.

foster home
group home
inpatient psychiatric unit
residential treatment facility
detention center
Department of Youth Services (DYS) facility

Trauma Informed Treatment

Evidence based Trauma Informed Treatment models address the needs of children who have been traumatized. Trauma Informed Treatment is based on two major concepts:

Concept One - Trauma Informed Service Systems: A behavioral health system that acknowledges and understands the effects of trauma and values consumer participation.
Concept Two - Trauma Specific Treatment Services: Evidenced based and best practice treatment models that have been proven to facilitate recovery from trauma.

Concept One - Trauma Informed Service Systems

Definition: Trauma Informed Service Systems take into account knowledge about trauma — its impact, interpersonal dynamic, and paths to recovery — and incorporate this knowledge into all aspects of service delivery.

Trauma Informed Service Systems:

Integrate an understanding of trauma, substance abuse and mental illness throughout the program.
Review service policies and procedures to ensure prevention of retraumatization.
Involve consumers in designing/evaluating services.
See trauma as a defining and organizing experience that can shape survivors' sense of self and others.
Create a collaborative relationship between providers and consumers, and place priority on consumer safety, choice and control.
Focus on empowerment and emphasize strengths.

(Brown & Gonzales, Presenters, Dare to Act Conference, December 2004)

"Traumatized people are frequently misdiagnosed and mistreated in the mental health system … Because of the number and complexity of their symptoms, their treatment is often fragmented and incomplete." (Debra Wells, Disturbing the Sound of Silence. September 2004)

Concept Two: Trauma Specific Treatment Services

Definition: Trauma Specific Treatment Services address directly the impact of trauma on an individual's life and facilitate trauma recovery.

Trauma Specific Treatment Services include:

grounding techniques which help trauma survivors manage dissociative symptoms.
desensitization therapies which help to render painful images more tolerable.
and behavioral therapies which teach skills for the modulation of powerful emotions.

(Harris & Fallot, Using Trauma Theory to Design Service Systems. New Directions for Mental Health Services. 2001)

Children who are victims of violence and trauma deserve Trauma Specific Treatment Services delivered in a Trauma Informed Service System.

Components of a Trauma Informed Treatment Program

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 retraumatizing.
Assessment of an individual's experiences with trauma and violence prior to admission to the program.
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 retraumatization.
An environment that is safe and nurturing.
An environment that is empowering.
An environment that is culturally competent.

Trauma Specific Treatment Services can and should be provided in all treatment environments.

"It took 10 years, many admissions, a lot of different medication, ECTs. No one was able to draw out any abuse issues until my very last admission and I talked with a psychologist who asked me, 'have you been abused?'" — Debra Wells, Disturbing the Sound of Silence. September 2004

LRS Blueprint for Change Recommendations

The recommendations on the following pages are Ohio's Blueprint for Change. By acting on these recommendations, Ohio can begin to build a statewide Trauma Informed Treatment system for our children.

Change must be implemented on three levels to be effective and comprehensive — the individual advocacy level, the service provider level, and the state policymaking level.

"It needs to be widely recognized that individuals who experienced trauma in their lives, and who have learned the skills necessary to manage their lives and their emotions, can be tremendous resources to others who are experiencing the consequences of trauma." — Andrea Blanch, Developing Trauma-Informed Behavioral Health Systems. 2003

Individual Advocacy Recommendations (Level I)

Advocate at local and state levels for Ohio to develop Trauma Informed Service Systems.
Participate in conferences, task forces, trainings, advisory boards, and provide testimonies to promote a Trauma Informed Service System in Ohio.
Network with other trauma survivors to increase your power and voice.

Service Provider Recommendation (Level II)

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 retraumatization.
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 Ohioans of all races, colors, religions, sexes, sexual orientations, national origins, disabilities and ages.

State Policymaking Recommendations (Level III)

LRS supports the Transformation State Incentive Grant Childhood Trauma Task Force in its efforts to develop a foundation for a Trauma Initiative in Ohio that:

Creates a standing, statewide Trauma Task Force that includes, as members, individuals with lived experience and their family members, and provides support to enable them to attend meetings.
Develops a written policy statement about a Trauma Informed Service System.
Reviews and makes changes to the current treatment system including rules, policies, programs, and funding to promote a Trauma Informed Treatment Service System.
Develops recommendations for a Trauma Informed Service System.
Establishes a clearly identified, point-of-responsibility Trauma Office within the Ohio Department of Mental Health, led by a Director to coordinate statewide activities.
Coordinate cross systems Trauma Informed Treatment Services at the state level with the Ohio Departments of: Drug Addiction and Alcohol Services, Job and Family Services, Youth Services, DD, and Health.
Develops timelines for implementing Trauma Informed Treatment Service Systems in Ohio.
Requires providers to provide Trauma Informed Services.
Involves Ohio trauma based programs.
Provides culturally competent services for Ohioans of all races, colors, religions, sexes, sexual orientations, national origins, disabilities and ages.

"The National Trauma Consortium (NTC) acknowledges that not all survivors of trauma receive diagnostic labels, abuse substances, or seek out substance abuse, mental health and/or trauma treatment. In dedication to the idea of inclusivity and integration, the NTC has decided to adopt the language of 'persons with lived experience of trauma' to replace the acronym C/S/R (Consumer/Survivor/Recovery)." — National Trauma Consortium

Summary

This Closer Look publication highlighted the following:

Many children in Ohio are victims of violence and trauma.
The effects of violence and trauma on children are pervasive, devastating and long lasting.
The majority of children receiving behavioral health treatment or involved with the juvenile justice system have been traumatized.
Children can be re-traumatized by current treatment settings.
Evidence based trauma treatment models are available that address the needs of children who have been traumatized by providing:(1) Trauma Informed Service Systems and (2) Trauma Specific Treatment Services.
Trauma Informed Treatment must be provided for children by the behavioral health system.

Now is the time to promote statewide behavioral health systems change to assure all traumatized children receive Trauma Informed Treatment.

A Journey in Trauma: The Story of Juna

Thousands of Ohio's children experience trauma or violence. This trauma or violence is just the beginning of a stressful journey that often takes them into and through the social services system.

This is the story of Juna, a child who represents these thousands of children. It is the story of Juna's journey into and through the social services system to her recovery.

While Juna is fictional, her journey is typical. Juna's story will show why Ohio's systems must be changed to encourage and support children's resiliency and recovery through Trauma Informed Treatment.

Both of Juna's parents survived abusive childhoods. They became alcoholics as adults. They married and had Juna and her two sisters.

Throughout her childhood, Juna frequently witnessed domestic violence during her parents' alcoholic binges. It was not uncommon for the neighbors to call the police. There was a well documented history of domestic violence in the marriage.

Around the age of four, Juna's father began to sexually molest her. When Juna resisted, her father beat her. Within two years, Juna's maternal grandfather also began to sexually abuse her during his weekend visits.

Juna's mother was aware of the abuse but did not take any steps to protect her.

When Juna was in first grade, her teacher noted that Juna had "problems with attention, anger management, poor social skills" and that "she appeared very sad."

When she was in fourth grade, Juna was socially withdrawn and had no friends. She missed 40 days of school. When she was in school, Juna was frequently sent to the principal's office because she was "acting out" and was "disruptive in class".

As Juna reached puberty, she was less isolated, but began to use alcohol and drugs.

When Juna was 13, the physical education teacher at her school sent her to the school nurse after noticing bruises on Juna's back and legs. The nurse notified the local Public Children Services Agency (PCSA). PCSA suspected abuse, removed Juna from her family home and placed her in foster care.

During the PCSA investigation, Juna would not admit that she was sexually abused. PCSA substantiated physical abuse, and she remained in foster care.

While Juna was in foster care, she continued to use alcohol and drugs, run away, and began to cut and burn her upper legs and stomach.

Due to these behaviors, Juna's placement at the first foster home and two subsequent foster placements failed. At her fourth foster home, Juna hit the foster mother who filed assault charges against her.

At court, the Juvenile Judge ordered Juna to go to a residential treatment facility. The facility psychiatrist diagnosed Post Traumatic Stress Disorder and Borderline Personality Disorder.

During the time she was in the residential treatment facility, staff frequently physically restrained her because of her aggression.

At the facility, Juna's behavior deteriorated and she attempted suicide. After that, Juna was taken to a private psychiatric unit for treatment.

Juna stayed in the private psychiatric unit for a week. She was returned to the same residential treatment facility, and she attempted suicide again.

Following a restraint episode, staff filed menacing charges against Juna, and she was transferred to a detention facility.

Juna's guardian ad litem, in consultation with her county case worker and her court appointed attorney, reviewed Juna's social and treatment history. They noted that Juna had not received treatment at any facility that specifically addressed her trauma issues. They were able to convince the judge to offer Juna two options: go to juvenile detention or accept placement in a residential facility that provided trauma informed treatment.

At age 16, Juna's journey to recovery begins.

She entered a program that provided Trauma Specific Treatment Services. At admission, a program counselor who was trained in conducting trauma assessments, did a trauma assessment of Juna. Then, a team which included Juna as the key member, developed a treatment plan for her. Juna's treatment plan addressed her trauma, substance abuse, and mental health issues.

The team not only involved Juna in the development of her treatment plan, but also asked for her input on all aspects of the planning, programming, and evaluation of her treatment services.

As Juna reflected back on her experiences, she acknowledged that this placement was "much different than all the other placements I've ever been in. Over time, I began to feel safer and I felt that staff respected me."

There could be two endings to Juna's journey.

Ending Number 1: With Trauma Informed Supports

After Juna received residential trauma informed treatment, she returned to her foster home until her 18th birthday. During this time, Juna received transitional programming which focused on housing, employment, education, ongoing trauma informed treatment, care and crisis intervention services from the local mental health center.

Juna became involved with a peer support group in her community, which further supported her recovery.

Juna's experience with trauma informed treatment supported and guided her road to recovery.

Ending Number 2: Without Trauma Informed Supports

After Juna received residential trauma informed treatment, she returned to her foster home until her 18th birthday where she did not receive transitional services.

When she turned 18, she was out of foster care and homeless. She looked for a therapist but none of them accepted Medicaid. Juna refused to go to the local mental health center because they did not have a staff member with trauma expertise.

Juna continued to abuse alcohol and drugs and engage in self-inflicted violence and was frequently admitted to the crisis shelter.

Juna was homeless, unemployed and pregnant.

At age 20, she committed suicide.

Trauma Resources

Evidence Based Programs and Trauma Specific Treatment Models

Cognitive Behavioral Therapy
www.nacbt.org

short-term psychotherapy
based on an educational model

Trauma Adaptive Recovery Group Education and Therapy (TARGET), Julian Ford, Ph.D.
www.nctsnet.org/nccts/asset.do?id=726

a strength based model
participants learn self regulatory states
participants learn skills to control PTSD symptoms

Seeking Safety, Lisa Najavits, Ph.D
www.seekingsafety.org

focus on learning coping skills
used with people who have substance abuse issues
addresses skill areas around boundaries, grounding and self care

Trauma Recovery and Empowerment Model (TREM) Community Connections, Washington DC
www.communityconnectionsdc.org/trauma/trem.htm

focuses on skill building around trauma, responses and support
uses culturally related exercises
uses gender specific approaches

Risking Connections, Sidran Foundation, Karen Saakvitne, Ph.D
www.sidran.org

developed between Maine and New York
focuses on building hope and connection

Sanctuary Model, Sandra Bloom, M.D.
www.sanctuaryweb.com

inpatient
democrat, non violent community
appropriate for children or adults
skill building around safety and affect

Websites

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A publication of the Legal Rights Service (LRS)
January 2007

The information provided in any LRS publication is not a substitute for legal advice. You should consult with a lawyer concerning your rights in a specific case. Contact your local bar association or visit the Ohio State Bar Association Web site to find a lawyer in your area.

Legal Rights Service prepared this publication, in part, with funding from the Protection and Advocacy for Individuals with Mental Illness (PAIMI) Act of 1986, administered by the Center for Mental Health Services, US Department of Health and Human Services.

This booklet is protected by copyright under United States law and by international copyright laws and treaty provisions. You may copy and distribute the work provided that you use the work for personal, noncommercial use; do not add the work to a collection or use it with any other text, photographs, artwork, etc; do not modify or alter the work in any way or delete or modify any copyright; and do not publish or post all or any part of the work on any Internet site or in or on any other media without obtaining the prior written consent of Ohio Legal Rights Service.

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