Trauma frequently accompanies the lives of people who seek substance abuse treatment. Therefore, this series of the Addiction Messenger provides information focusing on the role that trauma may play. In Part 2 of this series, the focus was on potential trauma screening and assessment instruments for agencies moving toward a trauma informed services model. Additionally, effective interventions for clients with trauma histories were also highlighted in Part 2 (N-SSATS, September 30, 2010, Harris & Fallot, 2001). Whether you are a researcher, a student, or an addiction professional you may be interested in understanding the most effective techniques to use with a client to disclose a trauma history. As an addiction counselor, you may have weighed your options for effective treatment planning and possibly contemplated providing services that were trauma-informed. Therefore, this final issue of the series will explore the personal experiences, comments and suggestions from agencies that have integrated and systematically employed trauma-informed services and concepts into their approach to client care. How did the agency begin adopting trauma-informed services? What were the benefits they discovered through incorporating trauma-informed services? What were the barriers to providing these services? The following paragraphs include summarized interviews from three different treatment agencies (Willamette Family Services in Eugene, OR, YKHC Behavioral Health Division in Bethel, AK, and Tanana Chiefs Conference in Fairbanks, AK) that are currently providing trauma-informed services.
The first interview is with Lucy Zammarelli, Program Supervisor at LaneCare in Eugene, OR (former Program Director at Willamette Family Services (WF) in Eugene, OR). Ms Zammarelli provides a helpful overview of one agency's accomplishments in the provision of trauma-informed services. When asked about using trauma informed services at WF she notes that "Willamette Family Services (WF) has integrated trauma treatment into a broad array of services, particularly in addressing child trauma with the women and families in residential treatment. The Seeking Safety model and elements of the Sanctuary Model are used successfully in WF women's program in group formats. Through the addition of mental health services at the agency for both outpatient and residential clients, trauma is sensitively included as a part of individual sessions. Trauma Focused Cognitive Behavioral Therapy (TF-CBT) is a general practice that works well at WF." She explains that "in 2005 WF received a SAMHSA grant to become a member of the National Child Traumatic Stress Network (NCTSN). This grant was for the adolescent program, and included on-going staff training collaboratives, access to an on-line TF-CBT training course, supervision models for efficacy, and numerous other helpful resources. However, maintaining the practices was challenging, especially after the grant ended in 2009. Challenges continue as staff turnover and program changes impact services." Ms. Zammarelli notes that the TF-CBT web training is based at the Medical University of South Carolina, and is free and available for all master's level clinicians at www.tfcbt.musc.edu."
When specifically asked about barriers to establishing trauma informed services, Ms. Zammarelli replied: "There were many challenges to establishing trauma-informed services at WF, but the need to incorporate these services is great. Trauma is a common foundational issue for substance users. The eclectic models of counseling that are widely used in the addiction field tend to make change difficult at the service provision level, even when the program administration has implemented new models. We found that therapist attitudes ranged from positive to guarded, so engagement at the therapist level was the focus of our initial goals. The greatest help in surmounting barriers could be found in the very positive client responses to the services at WF. Clearly, few people want to focus on their traumatic memories, but focusing on coping skills as a prerequisite to further treatment was very successful. The TF-CBT model helped to move this process along. At the organizational level, financial resources often impact service change as well, but because of the NCTSN grant, this barrier was removed for WF."
She notes that "financial resources and administrative commitment are very important to create change". In addition, she reflects that "counselor flexibility and openness to new treatment models is key. State support and adoption of the Trauma Policy by Addictions and Mental Health Division in Oregon was also helpful. Change in the field is always a constant as well. In the future, the integration of behavioral health and primary care will continue to help focus attention on trauma for some populations, particularly women and children."
When invited to share her thoughts on the benefits of using trauma informed services she replied, "Psychological trauma is a wound to the psyche - it may scab over, but it leaves a scar and often festers in the hidden recesses of a client's mind. For behavioral change, trauma should be addressed or it may sabotage the new behavioral changes the client is focusing on. Particularly with substance abusers, trauma histories that haven't been addressed can negatively impact their quality of life and new relationships. For those with co-occurring disorders, trauma may be a block to effective and lasting treatment progress. Ms. Zammarelli concluded the interview by stating that "trauma can't be ignored and how it manifests can be changed through the healing work of counselors and therapists."
The next interview focuses on trauma-informed services and historical trauma issues. Both Michael G Bricker, Education & Training Director, YKHC Behavioral Health Division in Bethel, AK and Bruce Johnson, Clinical Team leader at Peninsula Community Health Services in Soldatna, AK (former Clinical Coordinator at YKHC's Crisis Respite Center) were interviewed with regard to their experiences in providing trauma-informed services in rural Alaska.
Mr. Bricker and Mr. Johnson summarized their thoughts on the initial barriers they encountered in establishing trauma informed services as: "The clinical administration, at that time, was not overly responsive to the concept of incorporating trauma-informed services and they expressed concern about overwhelming the staff with new duties. The staff at CRC loved learning about the ACEs study and thought it was very important. In addition, they felt using the questionnaire was beneficial and very healing. Most of our staff had experienced trauma in their lives. They had been on their own healing journey for many years and this just let them know that what they knew from their own experience was indeed true. Another barrier was encountered with clinicians who didn't want to change how they are doing therapy or they didn't want to take the time to read the research and understand how important trauma-informed therapy could be."
The lessons they learned included "how common ACEs are among our general population." They reported that in their agency "the average number of ACEs was 5, indicative of a severe trauma load. Over half reported emotional and physical and sexual abuse; ¾ reported growing up in an alcoholic home. A number of clients recorded 8 or more out of 10 ACEs questionnaire. The larger community sample that we did was found to be somewhat lower, but still averaged 3+ ACEs. We agree that the most valuable use of the ACEs Survey was to open a conversation with the client and begin to work through their residual responses to trauma."
When asked to reflect on historical trauma for Native American/Alaskan Native populations they explained: "Historical trauma is not 'historical' in bush Alaska. The economic hardships, loss (theft) of aboriginal hunting & fishing rights, erosion of the subsistence lifestyle and traditional gender roles, generations of sexual abuse compounded by alcoholism and suicides make the "historical" an every-day challenge. Often people have not been able to process one trauma before another is added to their load. When clients gain insight into why they are doing harmful things to themselves it helps them in turning their lives around. I don't think any miracles have occurred, but people have realized that there is a reason for the things they do. They understand that they, too, can start on their healing journey and that others have been there before them and they can change their lives."
They illustrated the benefits of providing trauma-informed services with the following story of a 35 year old female. "When she came to CRC she reported that she could stay sober for months and then she would resume drinking. She was suicidal because her substance use was harming her marriage and her role as a mother. Although, after being screened using the ACE study, she reported she finally got it. She returned home and now reports that she has been sober for over one year, has a job and that her marriage is stable. She is on her healing journey. Although there may be some more rough spots, she is getting stronger every day."
Mr. Bricker and Mr. Johnson said that they have "spread the word to several clinicians who agree that using trauma-informed screening instruments is a good opportunity to initiate talking with clients about their trauma histories." They concluded the interview by noting that "most of our clients welcome the opportunity to bring their childhood trauma out into the open and talk about it."
The third, and final, interview is with Shannon Sommers, Behavioral Health Acting Director, Tanana Chiefs Conference, Fairbanks, AK. Ms. Sommers describes her agency's use of trauma informed services as "beginning when a new client is screened into the various programs we offer. They are given choices as to how long, and what kind of therapy they will accept, and what issues to address. We offer early intervention and prevention therapies as well as longer styles of therapy. Empowering the consumer and building on their strengths is seen as a major component, as is their cultural ties. The therapist and consumer work together as equals in developing a treatment plan, if it is determined that one is needed. The goal is to increase the consumer's skills to allow them to manage their symptoms and reactions on their own."
When reflecting on the difficulties and lessons learned in providing trauma informed services Ms. Sommers said "As with any change, there has been some staff resistance; but as more information is given, the resistance has changed to a sense of acceptance. The primary barrier was the attitude that therapists should make the decisions for their client, both in treatment planning and length of treatment. The lesson learned is that you never know where the resistance will come from. Some people have a harder time giving up the power."
Additionally, she expressed that the benefits of incorporating trauma-informed services can be seen in "giving the consumer the ability to choose, and be supported in that choice. As a result clients feel that they doing something for themselves, and are also receiving professional support for their decisions. The client is able to show that they know themselves better than the staff does and that their input is invaluable." Ms. Sommers ended by stating that "the client is the expert, the therapist can make suggestions, but the client has the ability to pick and choose what is right for them. With this type of approach clients are more likely to stay in treatment longer, and have better outcomes. "
The need for utilizing trauma-informed services is an ever increasing concern. Substance Abuse and Mental Health Services Administration (SAMHSA) has recently released Leading Change: A Plan for SAMHSA's Roles and Actions 2011-2014 which details eight Strategic Initiatives that provide a framework to support the vision and mission of SAMHSA. Specifically, Strategic Initiative #2 focuses on Trauma and Justice. The goals of Strategic Initiative # 2 are:
If you would like more information on each of these goals this publication may be downloaded or ordered at store.samhsa.gov.
Another resource, The National Center for Trauma-Informed Care (NCTIC) provides training that facilitates implementation of trauma-informed services in mental health and substance abuse treatment agencies. Moreover, they are able to provide technical assistance and consultation to support agencies that are committed to implementing trauma-informed approaches to services. The technical assistance they provide may help agencies take the necessary steps as they move toward establishing trauma-informed services. They can contribute technical assistance in the areas listed below:
For more information on The National Center for Trauma-Informed Care you can email them at NCTIC@NASMHPD.org, phone them directly at 866-254-4819, our review their website at http://www.samhsa.gov/nctic/training.asp
Mary Anne Bryan, MS, LPC is the Program Manager for the Northwest Frontier ATTC and the Editor of the Addiction Messenger Monthly Articles. She is preparing this series of articles on Trauma Informed Services for the Addiction Messenger.
The Addiction Messenger's monthly article is a publication from Northwest Frontier ATTC that communicates tips and information on best practices in a brief format.
Northwest Frontier Addiction Technology Transfer Center
A project of OHSU Department of Public Health & Preventive Medicine
Mary Anne Bryan, MS, LPC