Acknowledgments

This publication was produced under contract numbers 270-99-7072, 270-04-7049, and 27009-0307 by the Knowledge Application Program (KAP), a Joint Venture of The CDM Group,Inc., and JBS International, Inc., for the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). AndreaKopstein, Ph.D., M.P.H., Karl D. White, Ed.D., and Christina Currier served as the Contracting Officer’s Representatives.

Disclaimer

The views, opinions, and content expressed herein are the views of the consensus panel members and do not necessarily reflect the official position of SAMHSA or HHS. No official support ofor endorsement by SAMHSA or HHS for these opinions or for the instruments or resources described are intended or should be inferred. The guidelines presented should not be considered substitutes for individualized client care and treatment decisions.

Public Domain Notice

All materials appearing in this volume except those taken directly from copyrighted sources arein the public domain and may be reproduced or copied without permission from SAMHSA orthe authors. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, HHS.

Electronic Access and Copies of Publication

This publication may be ordered or downloaded from SAMHSA’s Publications Ordering Webpage at http://store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-7264727) (English and Español).

Recommended Citation

Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS PublicationNo. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

Originating Office

Quality Improvement and Workforce Development Branch, Division of Services Improvement,Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857.

HHS Publication No. (SMA) 14-4816 First Printed 2014

Consensus Panel

Note: Each panelist’s information reflects his or her affiliation at the time of the Consensus Panel meeting and may not reflect that person’s most current affiliation.

Chair

Linda B. Cottler, Ph.D., M.P.H.

Professor of Epidemiology in Psychiatry

Department of Psychiatry

Washington University–St. Louis

St. Louis, MO

Workgroup Leaders

Stephanie S. Covington, Ph.D., LCSW,MFCC

Co-Director

Center for Gender and Justice

Institute for Relational Development

La Jolla, CA

Margaret Cramer, Ph.D.

Clinical Psychologist/Clinical Instructor

Harvard Medical School

Boston, MA

Anne M. Herron, M.S.

Director

Treatment Programming

New York State Office of Alcoholism and Substance Abuse Services

Albany, NY

Denise Hien, Ph.D.

Research Scholar

Social Intervention Group

School of Social Work

Columbia University

New York, NY

Dee S. Owens, M.P.A.

Director

Alcohol-Drug Information

Indiana University

Bloomington, IN

Panelists

Charlotte Chapman, M.S., LPC, CAC

Training Director

Division of Addiction Psychiatry

Mid-Atlantic Addiction Technology Transfer Center

Virginia Commonwealth University

Richmond, VA

Scott F. Coffey, Ph.D.

Associate Professor

Department of Psychiatry and Human Behavior

University of Mississippi Medical Center

Jackson, MS

Renee M. Cunningham-Williams, M.S.W.,M.P.E., Ph.D.

Research Assistant/Professor of Social Work

Department of Psychiatry

Washington University

St. Louis, MO

Chad D. Emrick, Ph.D.

Administrative Director

Substance Abuse Treatment Program

Denver VA Medical Center (116A1)

Denver, CO

Charles R. Figley, Ph.D.

Professor

Director of the Traumatology Institute

Florida State University

Tallahassee, FL

Larry M. Gentilello, M.D., FACS

Professor and Chairman

Division of Burn, Trauma, and Critical Care

University of Texas Southwestern Medical School

Dallas, TX

Robert Grant, Ph.D.

Trauma Consultant

Oakland, CA

Anthony (Tony) Taiwai Ng, M.D.

Disaster Psychiatrist

Washington, DC

Pallavi Nishith, Ph.D.

Associate Research Professor

Center for Trauma

Department of Psychology

University of Missouri–St. Louis

St. Louis, MO

Joseph B. Stone, Ph.D., CACIII, ICADC

Program Manager and Clinical Supervisor

Confederated Tribes of Grand Ronde Behavioral Health Program

Grand Ronde, OR

Michael Villanueva, Ph.D.

Research Professor

Center on Alcoholism, Substance Abuse, and Addiction

Albuquerque, NM

KAP Expert Panel and Federal Government Participants

Barry S. Brown, Ph.D.

Adjunct Professor

University of North Carolina–Wilmington

Carolina Beach, NC

Jacqueline Butler, M.S.W., LISW, LPCC,CCDC III, CJS

Professor of Clinical Psychiatry

College of Medicine

University of Cincinnati

Cincinnati, OH

Deion Cash

Executive Director

Community Treatment and Correction Center, Inc.

Canton, OH

Debra A. Claymore, M.Ed.Adm.

Owner/Chief Executive Officer

WC Consulting, LLC

Loveland, CO

Carlo C. DiClemente, Ph.D.

Chair

Department of Psychology

University of Maryland–Baltimore County

Baltimore, MD

Catherine E. Dube, Ed.D.

Independent Consultant

Brown University

Providence, RI

Jerry P. Flanzer, D.S.W., LCSW, CAC

Chief, Services

Division of Clinical and Services Research

National Institute on Drug Abuse

Bethesda, MD

Michael Galer, D.B.A.

Independent Consultant

Westminster, MA

Renata J. Henry, M.Ed.

Director

Division of Alcoholism, Drug Abuse and Mental Health

Delaware Department of Health and Social Services

New Castle, DE

Joel Hochberg, M.A.

President

Asher & Partners

Los Angeles, CA

Jack Hollis, Ph.D.

Associate Director, Center for Health Research

Kaiser Permanente

Portland, OR

Mary Beth Johnson, M.S.W.

Director

Addiction Technology Transfer Center

University of Missouri–Kansas City

Kansas City, MO

Eduardo Lopez

Executive Producer

EVS Communications

Washington, DC

Holly A. Massett, Ph.D.

Academy for Educational Development

Washington, DC

Diane Miller

Chief

Scientific Communications Branch

National Institute on Alcohol Abuse and Alcoholism

Bethesda, MD

Harry B. Montoya, M.A.

President/Chief Executive Officer

Hands Across Cultures

Española, NM

Richard K. Ries, M.D.

Director/Professor

Outpatient Mental Health Services

Dual Disorder Programs

Seattle, WA

Gloria M. Rodriguez, D.S.W.

Research Scientist

Division of Addiction Services

New Jersey Department of Health and Senior Services

Trenton, NJ

Everett Rogers, Ph.D.

Center for Communications Programs

Johns Hopkins University

Baltimore, MD

Jean R. Slutsky, P.A., M.S.P.H.

Senior Health Policy Analyst

Agency for Healthcare Research & Quality

Rockville, MD

Nedra Klein Weinreich, M.S.

President

Weinreich Communications

Canoga Park, CA

Clarissa Wittenberg

Director

Office of Communications and Public Liaison

National Institute of Mental Health

Bethesda, MD

Consulting Members of the KAP Expert Panel

Paul Purnell, M.A

Social Solutions, LLC

Potomac, MD

Scott Ratzan, M.D., M.P.A., M.A.

Academy for Educational Development

Washington, DC

Thomas W. Valente, Ph.D.

Director

Master of Public Health Program

Department of Preventive Medicine

School of Medicine

University of Southern California

Los Angeles, CA

Patricia A. Wright, Ed.D.

Independent Consultant

Baltimore, MD

What Is a TIP?

Treatment Improvement Protocols (TIPs) are developed by the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services (HHS). Each TIP involves the development of topic-specific best practice guidelines for the prevention and treatment of substance use and mental disorders. TIPs draw on the experience and knowledge of clinical, research, and administrative experts of various forms of treatment and prevention. TIPs are distributed to facilities and individuals across the country. Published TIPs can be accessed via the Internet at http://store.samhsa.gov.

Although each consensus-based TIP strives to include an evidence base for the practices it recommends, SAMHSA recognizes that behavioral health is continually evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey “front-line” information quickly but responsibly. If research supports a particular approach, citations are provided.

Foreword

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities.

The Treatment Improvement Protocol (TIP) series fulfills SAMHSA’s mission to improve prevention and treatment of substance use and mental disorders by providing best practices guidance to clinicians, program administrators, and payers. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program administrators, and patient advocates debates and discusses their particular area of expertise until they reach a consensus on best practices. This panel’s work is then reviewed and critiqued by field reviewers.

The talent, dedication, and hard work that TIP panelists and reviewers bring to this highly participatory process have helped bridge the gap between the promise of research and the needs of practicing clinicians and administrators to serve, in the most scientifically sound and effective ways, people in need of behavioral health services. We are grateful to all who have joined with us to contribute to advances in the behavioral health field.

Pamela S. Hyde, J.D.

Administrator

Substance Abuse and Mental Health Services Administration

H. Westley Clark, M.D., J.D.,M.P.H., CAS, FASAM

Director

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services Administration

Frances M. Harding

Director

Center for Substance Abuse Prevention

Substance Abuse and Mental Health Services Administration

Paolo del Vecchio, M.S.W.

Director

Center for Mental Health Services

Substance Abuse and Mental Health Services Administration

How This TIP Is Organized

This Treatment Improvement Protocol (TIP) is divided into three parts:

• Part 1: A Practical Guide for the Provision of Behavioral Health Services
• Part 2: An Implementation Guide for Behavioral Health Program Administrators
• Part 3: A Review of the Literature

Part 1 is for behavioral health service providers and consists of six chapters. Recurring themes include the variety of ways that substance abuse, mental health, and trauma interact; the importance of context and culture in a person’s response to trauma; trauma-informed screening and assessment tools, techniques, strategies, and approaches that help behavioral health professionals assist clients in recovery from mental and substance use disorders who have also been affected by acute or chronic traumas; and the significance of adhering to a strengths-based perspective that acknowledges the resilience within individual clients, providers, and communities.

Chapter 1 lays the groundwork and rationale for the implementation and provision of trauma-informed services. It provides an overview of specific trauma-informed intervention and treatment principles that guide clinicians, other behavioral health workers, and administrators in becoming trauma informed and in creating a trauma-informed organization and workforce.Chapter 2 provides an overview of traumatic experiences. It covers types of trauma; distinguishes among traumas that affect individuals, groups, and communities; describes trauma characteristics;and addresses the socioecological and cultural factors that influence the impact of trauma. Chapter 3 broadly focuses on understanding the impact of trauma, trauma-related stress reactions and associated symptoms, and common mental health and substance use disorders associated with trauma. Chapter 4 provides an introduction to screening and assessment as they relate to trauma and is devoted to screening and assessment processes and tools that are useful in evaluating trauma exposure, its effects, and client intervention and treatment needs. Chapter 5 covers clinical issues that counselors and other behavioral health professionals may need to know and address when treating clients who have histories of trauma. Chapter 6 presents information on specific treatment models for trauma, distinguishing integrated models (which address substance use disorders, mental disorders, and trauma simultaneously) from those that treat trauma alone.

Advice to Counselors and/or Administrators boxes in Part 1 provide practical information for providers. Case illustrations, exhibits, and text boxes further illustrate information in the text by offering practical examples.

Part 2 provides an overview of programmatic and administrative practices that will help behavioral health program administrators increase the capacity of their organizations to deliver trauma-informed services. Chapter 1 examines the essential ingredients, challenges, and processes in creating and implementing trauma-informed services within an organization. Chapter 2 focuses on key development activities that support staff members, including trauma-informed training and supervision, ethics, and boundaries pertinent to responding to traumatic stress,secondary trauma, and counselor self-care.

Advice to Administrators and/or Supervisors boxes in Part 2 highlight more detailed information that supports the organizational implementation of trauma-informed care (TIC). In addition,case illustrations, organizational activities, and text boxes reinforce the material presented within this section.

Part 3 is a literature review on TIC and behavioral health services and is intended for use by clinical supervisors, interested providers, and administrators. Part 3 has three sections: an analysis of the literature, links to select abstracts of the references most central to the topic, and a general bibliography of the available literature. To facilitate ongoing updates (performed periodically for up to 3 years from first publication), the literature review is only available online at the Substance Abuse and Mental Health Services Administration (SAMHSA) Publications Ordering Webpage (http://store.samhsa.gov).

Terminology

Behavioral health: Throughout the TIP, the term “behavioral health” is used. Behavioral health refers to a state of mental/emotional being and/or choices and actions that affect wellness. Behavioral health problems include substance abuse or misuse, alcohol and drug addiction, serious psychological distress, suicide, and mental and substance use disorders. This includes a range of problems from unhealthy stress to diagnosable and treatable diseases like serious mental illness and substance use disorders, which are often chronic in nature but from which people can and do recover. The term is also used in this TIP to describe the service systems encompassing the promotion of emotional health, the prevention of mental and substance use disorders, substance use and related problems, treatments and services for mental and substance use disorders, and recovery support. Because behavioral health conditions, taken together, are the leading causes of disability burden in North America, efforts to improve their prevention and treatment will benefit society as a whole. Efforts to reduce the impact of mental and substance use disorders on America’s communities, such as those described in this TIP, will help achieve nationwide improvements in health.

Client/consumer: In this TIP, the term “client” means anyone who seeks or receives mental health or substance abuse services. The term “consumer” stands in place of “client” in content areas that address consumer participation and determination. It is not the intent of this document to ignore the relevance and historical origin of the term “consumer” among individuals who have received, been subject to, or are seeking mental health services. Instead, we choose the word“client,” given that this terminology is also commonly used in substance abuse treatment services.Note: This TIP also uses the term “participant(s)” instead of “client(s)” for individuals, families, or communities seeking or receiving prevention services.

Complex trauma: This manual adopts the National Child Traumatic Stress Network (NCTSN) definition of complex trauma. The term refers to the pervasive impact, including developmental consequences, of exposure to multiple or prolonged traumatic events. According to the NCTSNWeb site (http://www.nctsn.org/trauma-types), complex trauma typically involves exposure to sequential or simultaneous occurrences of maltreatment, “including psychological maltreatment,neglect, physical and sexual abuse, and domestic violence…. Exposure to these initial traumatic experiences—and the resulting emotional dysregulation and the loss of safety, direction, and the ability to detect or respond to danger cues—often sets off a chain of events leading to subsequent or repeated trauma exposure in adolescence and adulthood” (NCTSN, 2013).

Co-occurring disorders: When an individual has one or more mental disorders as well as one or more substance use disorders (including substance abuse), the term “co-occurring” applies.Although people may have a number of health conditions that co-occur, including physical problems, the term “co-occurring disorders,” in this TIP, refers to substance use and mental disorders.

Cultural responsiveness and cultural competence: This TIP uses these terms interchangeably,with “responsiveness” applied to services and systems and “competence” applied to people, to refer to “a set of behaviors, attitudes, and policies that…enable a system, agency, or group of professionals to work effectively in cross-cultural situations” (Cross, Bazron, Dennis, & Isaacs, 1989, p.13). Culturally responsive behavioral health services and culturally competent providers “honor and respect the beliefs, languages, interpersonal styles, and behaviors of individuals and families receiving services…. [C]ultural competence is a dynamic, ongoing developmental process that requires a long-term commitment and is achieved over time” (U.S. Department of Health and Human Services, 2003, p. 12).

Evidence-based practices: There are many different uses of the term “evidence-based practices.”One of the most widely accepted is that of Chambless and Hollon (1998), who say that for a treatment to be considered evidence based, it must show evidence of positive outcomes based on peer-reviewed randomized controlled trials or other equivalent strong methodology. A treatment is labeled “strong” if criteria are met for what Chambless and Hollon term “well-established”treatments. To attain this level, rigorous treatment outcome studies conducted by independent investigators (not just the treatment developer) are necessary. Research support is labeled “modest” when treatments attain criteria for what Chambless and Hollon call “probably efficacious treatments.”To meet this standard, one well-designed study or two or more adequately designed studies must support a treatment’s efficacy. In addition, it is possible to meet the “strong” and“modest” thresholds through a series of carefully controlled single-case studies. An evidence-based practice derived from sound, science-based theories incorporates detailed and empirically supported procedures and implementation guidelines, including parameters of applications (such as for populations), inclusionary and exclusionary criteria for participation, and target interventions.

Promising practices: Even though current clinical wisdom, theories, and professional and expert consensus may support certain practices, these practices may lack support from studies that are scientifically rigorous in research design and statistical analysis; available studies may be limited in number or sample size, or they may not be applicable to the current setting or population. This TIP refers to such practices as “promising.”

Recovery: This term denotes a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. Major dimensions that support a life in recovery, as defined by SAMHSA, include:

• Health: overcoming or managing one’s disease(s) as well as living in a physically and emotionally healthy way.
• Home: a stable and safe place to live.
• Purpose: meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income, and resources to participate in society.
• Community: relationships and social networks that provide support, friendship, love, and hope.

Resilience: This term refers to the ability to bounce back or rise above adversity as an individual,family, community, or provider. Well beyond individual characteristics of hardiness, resilience includes the process of using available resources to negotiate hardship and/or the consequences of adverse events. This TIP applies the term “resilience” and its processes to individuals across the life span.

Retraumatization: In its more literal translation, “retraumatization” means the occurrence of traumatic stress reactions and symptoms after exposure to multiple events (Duckworth &Follette, 2011). This is a significant issue for trauma survivors, both because they are at increased risk for higher rates of retraumatization, and because people who are traumatized multiple times often have more serious and chronic trauma-related symptoms than those with single traumas. In this manual, the term not only refers to the effect of being exposed to multiple events, but also implies the process of reexperiencing traumatic stress as a result of a current situation that mirrors or replicates in some way the prior traumatic experiences (e.g., specific smells or other sensory input; interactions with others; responses to one’s surroundings or interpersonal context, such as feeling emotionally or physically trapped).

Secondary trauma: Literature often uses the terms “secondary trauma,”“compassion fatigue,”and “vicarious traumatization” interchangeably. Although compassion fatigue and secondary trauma refer to similar physical, psychological, and cognitive changes and symptoms that behavioral health workers may encounter when they work specifically with clients who have histories of trauma, vicarious trauma usually refers more explicitly to specific cognitive changes, such as in worldview and sense of self (Newell & MacNeil, 2010). This publication uses “secondary trauma”to describe trauma-related stress reactions and symptoms resulting from exposure to another individual’s traumatic experiences, rather than from exposure directly to a traumatic event. Secondary trauma can occur among behavioral health service providers across all behavioral health settings and among all professionals who provide services to those who have experienced trauma(e.g., healthcare providers, peer counselors, first responders, clergy, intake workers).

Substance abuse: Throughout the TIP, the term “substance abuse” has been used to refer to both substance abuse and substance dependence. This term was chosen partly because behavioral health professionals commonly use the term substance abuse to describe any excessive use of addictive substances. In this TIP, the term refers to the use of alcohol as well as other substances ofabuse. Readers should attend to the context in which the term occurs to determine what possible range of meanings it covers; in most cases, it will refer to all varieties of substance-related disorders as found in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American Psychiatric Association, 2013a).

Trauma: In this text, the term “trauma” refers to experiences that cause intense physical and psychological stress reactions. It can refer to “a single event, multiple events, or a set of circumstances that is experienced by an individual as physically and emotionally harmful or threatening and that has lasting adverse effects on the individual’s physical, social, emotional, or spiritual wellbeing” (SAMHSA, 2012, p. 2). Although many individuals report a single specific traumatic event, others, especially those seeking mental health or substance abuse services, have been exposed to multiple or chronic traumatic events. See the “What Is Trauma” section in Part 1, Chapter 1, for a more in depth definition and discussion of trauma.

Trauma-informed: A trauma-informed approach to the delivery of behavioral health services includes an understanding of trauma and an awareness of the impact it can have across settings,services, and populations. It involves viewing trauma through an ecological and cultural lens and recognizing that context plays a significant role in how individuals perceive and process traumatic events, whether acute or chronic. In May 2012, SAMHSA convened a group of national experts who identified three key elements of a trauma-informed approach: “(1) realizing the prevalence of trauma; (2) recognizing how trauma affects all individuals involved with the program, organization, or system, including its own workforce; and (3) responding by putting this knowledge into practice” (SAMHSA, 2012, p 4).

Trauma-informed care: TIC is a strengths-based service delivery approach “that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment” (Hopper, Bassuk, & Olivet, 2010, p.82). It also involves vigilance in anticipating and avoiding institutional processes and individual practices that are likely to retraumatize individuals who already have histories of trauma, and it upholds the importance of consumer participation in the development, delivery, and evaluation of services.

Trauma-specific treatment services: These services are evidence-based and promising practices that facilitate recovery from trauma. The term “trauma-specific services” refers to prevention,intervention, or treatment services that address traumatic stress as well as any co-occurring disorders (including substance use and mental disorders) that developed during or after trauma.

Trauma survivor: This phrase can refer to anyone who has experienced trauma or has had a traumatic stress reaction. Knowing that the use of language and words can set the tone for recovery or contribute to further retraumatization, it is the intent of this manual to put forth a message of hope by avoiding the term “victim” and instead using the term “survivor” when appropriate.