by A Jennings · Cited by 174 — Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services 11 study focusing on the children in these families was also

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Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services 2004 Prepared by: Ann Jennings, Ph.D. Prepared for: National Technical Assistance Center for State Mental Health Planning (NTAC), National Association of State Mental Health Program Directors (NASMHPD) Under contract with the Center for Mental Health Services (DMHS), Substance abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS) This report was produced by the National Association of State Mental Health Program Directors (NASMHPD) and the National Technical Assistance Center for State Mental Health Planning (NTAC) and is supported under a Contract between the Division of State and Community Systems Development, Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services Administration (SAMHSA), and the National Association of State Mental Health Program Directors. Its content is solely the responsibility of the author(s) and does not necessarily represent the position of SAMHSA or its centers.

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Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services 2 Table of Contents Acknowledgments3 Introduction.5 Who Are the Models Designed For?.5 What Kinds of Trauma are Experienced by Persons Who Develop Serious and Persistent Mental Illness and Addiction?..6 What Percentages of Mental Health Clients Have Histories of Trauma?..6 Evolution of Trauma-Informed and Trauma-Specific Services in State Mental Health Systems.8 Factors Contributing to the Growth of Awareness and Activity in State Mental Health Service Systems9 Trauma-Informed and Trauma-Specific Models..15 Definitions of fiTrauma-Informedfl and fiTrauma-Specificfl..15 Models for Developing Trauma-Informed Service Systems and Organizations..17 Individual Trauma-Informed Service Models22 Trauma-Specific Service Models for Adults:.24 Manualized Adaptations to Trauma-Specific Service Models for Adults40 Trauma-Specific Models for Parenting.42 Trauma-Specific Service Models for Children..47 Trauma-Specific Peer Support and Self Help Models54 Recommendations for Moving Forward59 Appendix: Criteria for Building a Trauma-Informed Mental Health Service System65 References.70

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Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services 3 Acknowledgments The National Technical Assistance Center for State Mental Health Planning (NTAC) and the National Association of State Mental Health Program Directors (NASMHPD) gratefully acknowledge the many individuals and organizations that contributed to the development of this report. In particular, we would like to thank Charles Curie, M.A., A.C.S.W., Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), and A. Kathryn Power, M.Ed., Gail P. Hutchings, M.P.A., Joyce T. Berry, Ph.D., J.D., and Susan E. Salasin of the Center for Mental Health Services (CMHS) within SAMHSA for their time and effort and for continuing to demonstrate their commitment to this issue. Among the many individuals who contributed resources and time to this report, we would like to especially thank those dedicated and talented people who created the trauma-informed and trauma-specific service models and treatment approaches presently in use within state mental health and substance abuse service systems. They patiently and carefully reviewed and revised our descriptions of their models, clarifying those aspects of each model with relevance to state mental health and substance abuse settings, indicating the status of research and evaluative findings and identifying the specific women, men and children and parents for whom each individual approach was designed. The names of and contact information for each of these individuals is included after the description of each model. Their commitment and continuing work in the field of trauma, especially with regard to the creation and research of models which are applicable to public mental health and substance abuse settings and address the complex deeply rooted kinds of childhood abuse trauma experienced by so many recipients of public mental health and addition services, has been essential to moving the field forward towards achieving the vision of recovery and transformation portrayed in the Presidents New Freedom Commission on Mental Health Final Report. We also want to recognize and express our appreciation to the National Trauma Consortium, its Executive Director Andrea Blanch, Ph.D. its nine founding board members: Vivian Brown, Ph.D., Jennie Heckman, Ph.D., Nancy Van DeMark, Ph.D., Roger Fallot, Ph.D., Colleen Clark, Ph.D., Norma Finkelstein, Ph.D., Hortensia Amaro, Ph.D., Rene Andersen, and Sharon Cadiz, Ed.D. for their contributions not only in creating some of the exemplary models described in this report, but for their patience with and responsiveness to our continual requests for more information . Chan Noether, Ph.D. of Policy Research Associates was particularly helpful in defining findings of the Women, Co-occurring Disorders and Violence Study. More than 30 state mental health service systems and organizations, including numerous administrators, clinicians, advocates and consumers, contributed information on where, how and with whom the models described in this report are being used. Their activities to address the needs of persons with histories of trauma and mental health problems and the specific ways and settings in which they are utilizing the models described in this report are described state by state in the NASMHPD Blueprint for Action: Building

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Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services 4 Trauma-Informed Mental Health Service Systems. Their participation in the State Public Systems Coalition On Trauma (SPSCOT Πa network of state system administrators, providers, researchers and C/S/Rs who share ideas, resources and support the development of trauma-informed systems of care through the SPSCOT Listserve) and their responsiveness to our many phone calls and emails, made it possible for us to identify trauma treatment and support models in use in public sector settings. The varied perspectives of members of The Women, Co-Occurring Disorders Violence Study: Research into Practice in State Mental Health Systems Advisory Workgroup were particularly helpful in the preparation of this report. Members include: Kevin Huckshorn, R.N., M.S.N., I.C.A.D.C. (Director, NASMHPD/NTAC), Andrea Blanch, Ph.D. (Director NTC), Chan Noether, M.A. (PRA), Oscar Morgan,( Chief Operating Officer, NMHA: National Mental Health Association), Steven Karp, D.O. (Medical Director), Michele Dodge (Office on Violence Against Women, DOJ), Ruta Mazelis (Cutting Edge), Vicki Cousins (OCA of SC), Suzanne Clifford (Director, Division of MH and Addiction, IN), and Carol Shapiro (Executive Director, Family Justice, Inc). Finally, acknowledgments and thanks go to NTAC staff members who helped produce, publish and disseminate this report, including Robert Hennessy, editor and publications coordinator; Ieshia Haynie, program associate. -Kevin Ann Huckshorn, R.N., M.S.N., I.C.A.D.C., Director NASMHPD Office of Technical Assistance

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Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services 5 Introduction This report identifies criteria for building a trauma-informed mental health service system, summarizes the evolution of trauma-informed and trauma-specific services in state mental health systems, and describes a range of trauma-based service models and approaches implemented by increasing numbers of state systems and localities across the country. A summary of current state activities meeting 16 Criteria for Building a Trauma-Informed Mental Health System (see Appendix) is contained in the document Trauma Informed Mental Health Service Systems: Blueprint for Action (Jennings, in press). This technical report is focused on the trauma service models which were reported by states and organizations to meet the Blueprint™s Criteria 15, Trauma-informed services and service systems, and Criteria 16, Trauma-specific services, including evidence-based and emerging best practice treatment models. Who Are the Models Designed For? All of the models described in this document are designed for persons receiving public mental health and/or substance abuse services who have been traumatized by interpersonal violence and abuse during their childhood and/or adolescence. Many of the models were designed specifically to address the kinds of complex traumatic stress issues and problems common in the lives of individuals seen in public service sector settings today. These individuals often have severe and persistent mental health and/or substance abuse problems and are frequently the highest users of the system™s most costly inpatient, crisis, and residential services. They may carry any psychiatric diagnosis, and frequently do carry varied diagnoses over time such as Posttraumatic Stress Disorder (PTSD), borderline personality disorder, schizophrenia, depression and other affective disorders, anxiety disorder, eating disorder, psychotic, dissociative disorder, addictive, somatoform, and sexual impairmentŠall diagnoses which have been related to past trauma (Ford et al., 2004; Read et al., 2001; Felitti et al., 1998; Mueser et al., 2002). Many of the individuals described above have developed extreme coping strategies to manage the impacts of overwhelming traumatic stress, including suicidality, substance abuse and addictions, self-harming behaviors such as cutting and burning, dissociation, and re-enactments such as abusive relationships (Saakvitne et al., 2000). Although the trauma they experienced in their formative years as children may be core to their illness and central to their healing, it has seldom been asked about or viewed as an issue central to treatment in the public mental health settings. For the most part these individuals have never received screening, assessment or treatment for trauma. (Mueser et al., 1998; Frueh et al., 2002)

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Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services 6 What Kinds of Trauma are Experienced by Persons Who Develop Serious and Persistent Mental Illness and Addiction? The kinds of trauma experienced by persons who are recipients of public mental health services are usually not associated with fisingle blowfl traumatic events (Terr, 1991) such as natural disasters, accidents, terrorist acts, or crimes occurring in adulthood such as rape and domestic violence (Giller, 1999). Rather, the traumatic experiences of persons with the most serious mental health problems are interpersonal in nature, intentional, prolonged and repeated, occur in childhood and adolescence, and may extend over years of a person™s life. They include sexual abuse or incest, physical abuse, severe neglect, and serious emotional and psychological abuse. They may also include the witnessing of violence, repeated abandonments, and sudden and traumatic losses. As adults, these individuals often experience trauma and re-victimization through domestic violence, sexual assaults, gang and drug related violence, homelessness, and poverty (Saakvitne, 2000). They are traumatized further by coercive interventions (Cusack et al., in press; Frueh et al., 2000) and at times sexual and physical abuse in inpatient or institutional settings, jails, and prisons. They frequently have serious and disabling health problems (Felitti et al., 1998). As parents, individuals with mental illness may participate in or witness the intergenerational effects of violence and abuse, and women in particular are vulnerable to revictimization, ongoing exploitation and abuse (Frueh et al., 2000; Rosenberg et al., 2001; Russell, 1986; Browne, 1992). What Percentages of Mental Health Clients Have Histories of Trauma? Individuals with histories of violence, abuse, and neglect from childhood onward make up the majority of clients served by public mental health and substance abuse service systems. 90% of public mental health clients have been exposed to (and most have actually experienced multiple experiences of trauma (Goodman, Rosenburg et al., 1997; Mueser et al., 1998) 75% of women and men in substance abuse treatment report abuse and trauma histories (SAMHSA/CSAT, 2000) 97% of homeless women with mental illness experienced severe physical and/or sexual abuse, 87% experienced this abuse both as children and as adults (Goodman, Dutton et al., 1997)

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Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services 8 Evolution of Trauma-Informed and Trauma-Specific Services in State Mental Health Systems As awareness of the prevalence and impacts of trauma increases, the individuals for whom the trauma-informed and trauma-specific services described in this report were designed are increasingly viewed not as a subgroup or an anomalous or special population of clients, but as encompassing nearly all persons served by public mental health and substance abuse service systems. This increasing awareness is reflected in the rising number of states taking significant steps toward integrating knowledge about trauma into existing services and developing and/or implementing new fitrauma-specificfl services. In 2001, about 12 states formed an informal network (State Public Systems Coalition On Trauma [SPSCOT]) to share ideas and support the development of trauma-informed systems of care. State mental health policymakers including Commissioners and senior staff, trauma experts, advocates, and mental health consumers with histories of sexual and physical abuse trauma (Consumer/Survivor/Recovering persons [C/S/Rs]) formed a listserve as a vehicle for on-going communication. A list of criteria for building trauma-informed mental health service systems was compiled, and a report entitled Trauma Services Implementation Toolkit for State Mental Health Agencies was prepared, listing trauma-related activities initiated and resources created by 15 state public service systems. This report, published as an appendix to The Damaging Consequences of Violence and Trauma: Facts, Discussion Points, and Recommendations for the Behavioral Health System (Jennings, 2004), was 28 pages in length. In 2004, an update of the original Trauma Services Implementation Toolkit, entitled Trauma-Informed Service Systems: Blueprint for Action, has increased in size from 21 to over 130 pages, reflecting a dramatic increase both in the number of states now reporting trauma-related activities (from 15 to 31) and the multiplicity of strategies and programs they have adopted, initiated, or in some way support. Trauma-related activities reported by states fall within 3 areas: 1) administrative policies or guidelines regarding the service system; 2) administrative policies and guidelines regarding services; and 3) trauma services. They meet one or more of the following sixteen Criteria for Building a Trauma-Informed Mental Health Service System (see Appendix for criteria descriptions). Many of the criteria are related to recommendations made in the President™s New Freedom Commission on Mental Health™s Achieving the Promise: Transforming Mental Health Care in America. 1. A designated trauma function and focus in the state mental health department 2. State trauma policy or position paper

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Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services 9 3. Workforce orientation, training, support, competencies and job standards related to trauma 4. Linkages with higher education to promote education of professionals in trauma 5. Consumer/Trauma Survivor/Recovering person (C/S/R) involvement and trauma-informed rights 6. Trauma policies and services that respect culture, race, ethnicity, gender, age, sexual orientation, disability, and socio-economic status 7. Systems integration/coordination among systems of care serving persons with trauma histories and including life-span perspective 8. Trauma-informed disaster planning and terrorism response 9. Financing criteria and mechanisms to pay for best practice trauma treatment models and services 10. Clinical practice guidelines for working with people with trauma histories 11. Procedures to avoid retraumatization and reduce impacts of trauma 12. Rules, regulations, and standards to support access to evidence-based and emerging best practices in trauma treatment 13. Research, needs assessments, surveys, data to explore prevalence and impacts of trauma, assess status of services, and support more rapid implementation of evidence-based and emerging best practice trauma treatment models 14. Trauma screening and assessment 15. Trauma-informed services and service systems 16. Trauma-specific services, including evidence-based and emerging best practice treatment models Factors Contributing to the Growth of Awareness and Activity in State Mental Health Service Systems A number of factors are shaping and influencing increased awareness of trauma as a key public health and policy issue while promoting growth in trauma related activities within state mental health systems and localities. It has become evident to a critical mass of mental health leaders in decision making positions that:

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Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services 10 a majority of persons served in public mental health and substance abuse systems have experienced repeated trauma since childhood; they have been severely impacted by this trauma; ignoring and neglecting to address trauma has huge implications for use of services and costs incurred; evidence exists for effectiveness of trauma-based integrated treatment approaches and emerging best practice models designed for (and providing renewed hope of) recovery to clients with complex, severe, and persistent mental health and addition problems; and these trauma-informed and trauma-specific models are applicable and replicable within public service sector settings. With increased awareness and commitment to a trauma paradigm on the part of policy makers, the kind of change and transformation of the existing mental health system called for by the President™s New Freedom Commission on Mental Health report will follow. The following factors provide both impetus and support for changes leading to a large-scale transformation of mental health service systems and their core services to a trauma-informed paradigm. Leadership of the Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA has designated trauma a cross-cutting issue in its formal matrix of SAMHSA Priorities: Programs & Principles and has consistently supported local, state, and national level initiatives addressing trauma in the lives of both adults and children with mental health and substance abuse problems. In the 1990s, SAMHSA™s Center for Mental Health Services (CMHS) developed a specific agenda on women™s issues and gender-specific treatment, and in 1994 held a landmark conference, Dare To Vision. The conference brought together over 350 consumers, practitioners, and policy makers and created a national momentum on trauma and violence. This momentum led to the creation of a series of national fitechnical expert groupsfl on trauma and stimulated the development and testing of innovative approaches. In the 2000s, SAMHSA™s Center for Substance Abuse Treatment (CSAT) published the first Treatment Improvement Protocol (TIP) on Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues. Several major studies and initiatives focused on trauma have also been initiated by SAMHSA/CMHS including the Women, Co-Occurring Disorders and Violence Study and the National Child Traumatic Stress Network. The Women, Co-Occurring Disorders and Violence Study (WCDVS). This landmark five-year multi-site study, launched by SAMHSA in 1998, was the first federal effort to address the significant lack of appropriate services for women with co-occurring substance abuse and mental health disorders who experienced trauma, and their children. During the first two years of the program, 14 organizations located in ten states developed and documented integrated service models and agreed upon site-specific and cross-site research protocols. A separate

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Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services 11 study focusing on the children in these families was also developed. In the second phase of the study, nine study sites developed and tested manualized trauma-specific service intervention models integrating trauma, mental health, and substance abuse issues. Preliminary cross-site findings indicated significantly positive outcomes for the women and their children who received these integrated services. Further, the study indicated that interventions are cost effective. This study has impacted on service delivery, both within the states where study sites were located and nationally, by contributing a group of emerging best practice models which are applicable to public sector service settings and relevant and appropriate to clients served by public mental health service systems. The models are increasingly being adopted by state systems and adaptations of some models have made them appropriate for other genders and a variety of ethnic groups (www.nationaltraumaconsortium.org). Leadership of the National Association of State Mental Health Program Directors (NASMHPD). NASMHPD, along with its National Technical Assistance Center for State Mental Health Planning (NTAC), has utilized its established reputation and considerable networking capacity with federal and other national agencies, state mental health authorities (SMHAs), researchers, service providers, and mental health service consumers across the country to promote the development, dissemination, and implementation of new scientific knowledge and to bring emerging best practices in the field of trauma to state mental health systems. In 1998, the NASMHPD membership of state mental health Commissioners unanimously passed a Position Statement on Services and Supports to Trauma Survivors (NASMHPD, 1998). In 1998, NASMHPD held the first national trauma experts meeting, created an annotated bibliography on trauma and mental health, and declared NASMHPD to have a strategic role in keeping trauma at the forefront of a national mental health agenda. Plenary panels and other major presentations on trauma have been held at biannual NASMHPD Commissioners meetings. From 2002 to 2004, additional expert meetings were hosted by NASMHPD, a major initiative was undertaken by NASMHPD/NTAC to reduce seclusion and restraint practices and the retraumatization of such practices (see below), and a technical assistance project was produced to bring emerging best practice models to NASMHPD Division directors, the NASMHPD Research Institute, Inc., and SMHAs across the country. NASMHPD/NTAC produced several documents including, Developing Trauma-Informed Behavioral Health Systems (Blanch, 2003), The Damaging Consequences of Violence and Trauma: Facts, Discussion Points, and Recommendations for the Behavioral Health System (Jennings, 2004), Trauma Informed Mental Health Service Systems: Blueprint for Action (Jennings, in press), and this document. The National Trauma Consortium (NTC). Dedicated to improving the lives of trauma survivors and their families, the NTC was founded in 2003 by a group of individuals who had played key roles in the SAMHSA WCDVS study. NTC has three primary goals: to strengthen the interaction of research and practice; to increase the impact of our growing knowledge about trauma through activities in

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