Trauma Informed Services
Part 2 - Assessment and Interventions
There is a critical need to address trauma as part of substance abuse treatment. Part 1, in this Addiction Messenger series on Trauma Informed Services, focused on the importance of developing trauma-informed services that recognize the importance of creating agencies that support and accommodate the vulnerabilities of those who have suffered from major adverse events. The information and research on the importance of addressing client trauma histories in all aspects of treatment agency services is increasing.
Screening clients for trauma and using appropriate trauma specific interventions is also crucial in providing trauma informed services (N-SSATS, September 30, 2010, Harris & Fallot, 2001). As noted earlier in this AM series, people seeking substance abuse treatment may not initially present themselves as requesting assistance with issues related to trauma. Appropriate screening and assessment can improve the probability that a client's history is identified and addressed. When clients with trauma histories are not recognized and accommodated it can hamper their engagement in treatment, lead to early dropout, and may make relapse more likely (Brown, 2000).
Trauma-informed screening refers to a brief, focused inquiry to determine whether an individual has experienced specific traumatic events. Trauma assessment is a more in-depth exploration of the nature and severity of the traumatic events, the consequence of those events, and the client's current trauma-related issues. Harris & Fallot suggest universal screening of clients is important because of the high prevalence and under recognition of trauma (2001). Discovering adverse childhood experiences through the screening and assessment process is important because they have a strong positive correlation to your client's health status. These adverse experiences include: emotional, physical, and sexual abuse, emotional/physical neglect, household substance abuse, household mental illness, incarcerated household member, mother treated violently, and parental separation or divorce. Clients reporting a high number of these experiences in the assessment process may be at an increased risk for health problems such as alcoholism, smoking, depression, liver disease, pulmonary disease, risk for intimate family violence, and suicide attempts (Felitti et al, 1998).
Universal trauma screening can communicate to new clients that your treatment agency is aware of and responsive to the role of trauma in their lives. Asking all clients about trauma, as part of the initial intake or assessment process can assist in:
- Determining appropriate follow-up and referral
- Understanding any imminent danger requiring urgent response
- Identifying the need for trauma-specific services
- Communicating to the client that the agency believes abuse and violence are significant events
- Demonstrating that the agency staff recognizes and is opens to hearing about past trauma
- Facilitating later disclosure if the client initially decides not to talk about traumatic experiences
It's important to directly explain to the client the reasons for the screen (e.g. informing the client that some people who come for services have been physically or sexually abused at some time in their lives). The client can also be offered the option of not answering the questions, delaying the screening interview to a later time, or be given the choice to complete a self-administered trauma questionnaire instead. Overall, it's important to educate the client about the impact unresolved trauma and emotional issues may have on their recovery and health (Felitti et al, 1998). In general, this approach will place a priority on the client's preferences, control of the interview pace, and content of any trauma history discussions. Usually, screenings are limited to several questions regarding any client experiences with natural disasters, accidents, deaths, or other traumatic events. In particular, questions should be clear and explicit when exploring any physical (e.g. ask about being beaten, kicked, punched, or choked) and sexual abuse (e.g. ask about being inappropriately or forcibly touched sexually). It may be beneficial to screen early in the intake process, although some clients may not be comfortable disclosing such information readily and further assessment can be included later in the treatment process. If the client has an initial negative screen for a trauma history a counselor may decide to repeat questions later to offer the client another opportunity to share any experiences. When a solid environment of safety and trust is established the client may be more willing to disclose.
Trauma Screening Instruments
Trauma screening, assessment and counseling is delicate work and if done incorrectly may cause retraumatization. The following are a few examples of normed and validated tools your agency may want to explore that are widely accepted in screening for trauma related issues. Each provides a brief description of the instrument and a website for exploring more detailed information regarding the instrument such as the counselor qualifications desired for administration.
Trauma Screening Questionnaire (TSQ)
A 10-item self-report measure designed to screen for posttraumatic stress disorder (PTSD). Each item is derived from the DSM-IV criteria and describes either a re-experiencing symptom or an arousal symptom of PTSD.
Impact of Events Scale (IES-R)
The IES-R is a 22-item self-report measure that assesses subjective distress caused by traumatic events related to symptoms of avoidance, intrusion and hyperarousal.
PTSD Checklist- Civilian and Military
The PTSD Checklist is a 17-item self-report measure that assesses for symptoms of re-experiencing, avoidance, dissociation and hyperarousal. It takes approximately 5-10 minutes to complete a PCL.
There are three versions of the PCL:
The PCL-M (military) asks about symptoms in response to "stressful military experiences." It is often used with active service members and Veterans.
The PCL-C (civilian) asks about symptoms in relation to "stressful experiences." The PCL-C is useful because it can be used with any population.
The PCL-S (specific) asks about symptoms in relation to an identified "stressful experience." The PCL-S is useful because the symptoms endorsed are clearly linked to a specified event.
Child/Adolescent/Parent Trauma Measures
Website provides an overview of several measurement instruments for this particular population. It summarizes selected instruments and provides further contact information.
Impact of Events Scale 8-Item Child/Adolescent Scale (IES-8)
The IES-8 has probably been the most widely used measure of post-traumatic stress, with a focus on the classic avoidance and intrusion symptoms.
Life Stressor Checklist – Revised (LSC-R)
The Life Stressor Checklist-Revised is a self-report measure that assesses traumatic or stressful life events. The questionnaire includes 30 life events and follows a yes/no format.
Post-traumatic Stress Diagnostic Scale (PDS)
The PDS is a 49-item self-report measures the severity of PTSD symptoms related to a single identified traumatic event.
Trauma Assessment for Adults (TAA)
This 17-item self-report instrument examines different types of stressful life events. It assesses 14 life events such as combat exposure, physical or sexual assault, serious car accidents, and others stressful events.
Traumatic Events Screening Inventory (TESI-C)
The TESI is a 15-item interview assesses a child's experience of a variety of traumatic events including current and previous injuries, hospitalizations, domestic violence, community violence, disasters, accidents, physical abuse, and sexual abuse.
Brief Trauma History Questionnaire (THQ)
The THQ is a 24-item self report measure that examines experiences with traumatic events such as crime, general disaster, and sexual and physical assault. For each event endorsed, respondents are asked to provide the frequency of the event as well as their age at the time of the event.
Trauma Symptom Inventory (TSI)
The TSI is a 100-item self-report measure of posttraumatic stress and uses 10 clinical scales to assess domains related to trauma: Anxious Arousal, Depression, Anger/Irritability, Intrusive Experiences, Defensive Avoidance, Dissociation, Sexual Concerns, Dysfunctional Sexual Behavior, Impaired Self-reference, and Tension Reduction Behavior. A computer scoring program is available.
Clinician-Administered PTSD Scale (CAPS)
The CAPS is the gold standard in PTSD assessment. It is a 30-item structured interview that is used to make a current (past month) or lifetime diagnosis of PTSD. The questions target the impact on social and occupational functioning. The full interview takes 45-60 minutes to administer, but it is not necessary to administer all parts.
PTSD Symptom Scale - Interview (PSS-I)
This is a 17-item semi-structured interview that assesses the presence and severity of DSM-IV PTSD related to a single identified traumatic event. The PSS-I takes 20 minutes to administer and focuses on any trauma effects experienced in the "past two weeks".
Trauma Symptom Checklist - 40 (TSC-40)
The TSC-40 is a 40-item self-report measure of distress in adults arising from childhood or adult traumatic experiences. It uses a 4-point frequency rating scale with 6 subscales: Anxiety, Depression, Dissociation, Sexual Abuse Trauma Index, Sexual Problems, and Sleep Disturbances.
Trauma Specific Interventions
Addressing trauma in substance abuse treatment involves both "trauma-informed" and "trauma-specific" approaches. Trauma-informed systems and services take into account knowledge about trauma and its impact. Whereas the primary goals of trauma-specific services are to directly address the symptoms and consequences of the adverse events and traumatic experiences the client survived to facilitate recovery and healing (SAMHSA, 2011)
The following paragraphs highlight some well-known trauma-specific interventions that are based on psychosocial educational empowerment principles (SAMHSA, 2011) (Morrissey, 2005). Each description provides a website for more detailed information and exploration.
1. Addiction and Trauma Recovery Integration Model (ATRIUM)
This model is organized into 12 sessions which include a didactic component, a process section, an experiential component and a homework assignment. The ATRIUM protocol is organized into sections representing a graded exposure to the painful layering of the participant's traumatic experiences. It includes information on anxiety, sexuality, self-harm, depression, anger, physical health problems, sleep difficulties and spiritual disconnection.
The four basic principles of recovery in the ATRIUM model are:
- recognizing and reinforcing resilience
- achieving abstinence from addiction
- recognizing and healing the wounds of non-protection
- creating a sacred connection to the world coupled with a sense of social purpose.
2. Essence of Being Real
The Essence of Being Real model is a peer-to-peer structure intended to address the effects of trauma. This model is particularly helpful for survivor groups (including abuse, disaster, crime, shelter populations, and others), first responders, and frontline service providers and agency staff. It is geared to promoting relationships rather than focusing on the "bad things that happened." http://www.sidran.org
3. Risking Connection
Risking Connection is a trauma-informed model used in mental health, public health, and substance abuse settings. There are audience-specific adaptations of the model for clergy, domestic violence advocates, and agencies serving children. Risking Connection emphasizes empowerment, connection, and collaboration. The model addresses issues such as how trauma hurts, using relationships and connections as treatment tools, keeping a trauma framework when responding to crises (e.g. self-injury and suicidal thoughts), working with dissociation and self-awareness, and transforming vicarious traumatization.
4. Sanctuary Model
The goal of the Sanctuary Model is to help children who have experienced interpersonal violence, abuse, and trauma. The model is intended for use in residential treatment settings for children, public schools, domestic violence shelters, homeless shelters, group homes, outpatient and community-based settings, juvenile justice programs, substance abuse programs, parenting support programs, and other programs that provide assistance to children. This model helps organizations create collaborative and healing environments that improve efficacy in the treatment of traumatized individuals.
5. Seeking Safety
Seeking Safety is designed to be a therapy for trauma, post-traumatic stress disorder, and substance abuse. This model is used with individuals, groups, both men and women, and mixed-gender groups. It can be used in a variety of settings (e.g. outpatient, inpatient, residential). Seeking Safety consists of 25 topics: Introduction/Case Management, Safety, PTSD: Taking Back Your Power, When Substances Control You, Honesty, Asking for Help, Setting Boundaries in Relationships, Getting Others to Support Your Recovery, Healthy Relationships, Community Resources, Compassion, , Creating Meaning, Discovery, Integrating the Split Self, Recovery Thinking, Taking Good Care of Yourself, Commitment, Respecting Your Time, Coping with Triggers, Self-Nurturing, Red and Green Flags, Detaching from Emotional Pain (Grounding). Life Choices, and Termination.
6. Trauma, Addiction, Mental Health, and Recovery (TAMAR)
This intervention was developed as part of the SAMHSA Women, Co-Occurring Disorders and Violence Study. The TAMAR model is a manualized 15-week intervention that combines psycho-educational approaches with expressive therapies. It is designed for women and men in correctional systems. It provides basic education on trauma, developmental effects and current functioning, symptom management, coping skills, preventive education concerning pregnancy and sexually transmitted diseases, sexuality, and the impact of parental role loss and parenting issues.
(For more information contact: Marian Bland, LCSW-C, Maryland Mental Hygiene Administration, p: 410-724-3242, email@example.com)
7. Trauma Affect Regulation: Guide for Education and Therapy (TARGET)
TARGET is a model designed for use by organizations in all levels of care for adults and children. It is an educational and therapeutic approach for the prevention and treatment of complex Post Traumatic Stress Disorder. This model focuses on practical skills for trauma survivors and family members to help de-escalate and regulate extreme emotions, and to manage intrusive trauma memories. http://www.ptsdfreedom.org
8. Trauma Recovery and Empowerment Model (TREM and M-TREM)
The Trauma Recovery and Empowerment Model is intended for trauma survivors exposed to physical and/or sexual violence. This model is gender-specific: TREM for women and M-TREM for men. It can be implemented in mental health, substance abuse, co-occurring disorders, and criminal justice settings.
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
3181 Sam Jackson Park Rd. CB669
Portland, OR 97239
Phone: (503) 494-9611
FAX: (503) 494-0183
A project of OHSU Department of Public Health & Preventive Medicine
Mary Anne Bryan, MS, LPC
Program Manager, Editor
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