Abstract Content moderation generally refers to the practice of monitoring user generated content

and applying a set of rules defining what is acceptable. As a result, Content Moderators (CMs) are
responsible for reviewing and removing harmful online material, which has the potential to cause
psychological harm. However, little is known about the perceived impacts of the job. Semi-
structured interviews were conducted with 11 commercial CMs who were exposed to child sexual
abuse material (CSAM) as part of their job. Interviews were analysed using framework analysis to
investigate any psychological impacts. Results demonstrated that CMs manifested with a range of
symptoms consistent with experiencing repeated trauma. This included experiencing intrusive
thoughts of CSAM, triggered by situations with similar contexts to those encountered at work,
avoidance of children and negative cognitive and emotional effects such as cynicism, anxiety and
detachment. These symptoms fit into a framework of post traumatic and secondary traumatic stress
and suggest CMs wellbeing and exposure to stressful stimuli may be comparable to professionals
working in the emergency services or caring professions, such as social workers. These personnel are
at heightened risk of various problems including compassion fatigue, vicarious trauma and burnout.
Companies which employ moderators should learn from these comparable professions and provide
psychoeducation and trauma-informed care to CMs which have been demonstrated to help mitigate
these challenges. Keywords: child sexual abuse material; content moderation; trauma; posttraumatic
stress disorder; work stress Editorial Record First submission received: November 27, 2022 Revisions
received: March 29, 2023 July 14, 2023 Accepted for publication: August 7, 2023 Editor in charge:
Lenka Dedkova Introduction Social media and the internet have become ubiquitous. It is estimated
that nearly three billion people use Facebook each day (Facebook, 2022b), while Instagram has 2
billion active users (Statista, 2022). However, with the freedom to share information comes the
ability to upload and distribute more troubling content. In the second quarter of 2022 alone,
Facebook actioned 20.4 million pieces of child sexual exploitation (Facebook, 2022a). The increasing
amount of user generated uploaded content means that companies need to hire more and more
content moderators (CMs), these are the individuals who evaluate and remove material that is
flagged by users as harmful or in violation of platform policy. There is a wealth of evidence that
exposure to other people’s trauma at work affects wellbeing and mental health (e.g., Léonard et al.,
2020; Ralph, 2020) and research focusing on CMs suggest they suffer from impacts similar to those
found in other professionals (Steiger et al., 2021). However, despite a growing number of businesses
employing moderators ([Link], 2022), research attempting to evaluate the impact on CMs has
largely focused on volunteer moderators (Cook et al., 2022; Schöpke-Gonzalez et al., 2022). It is
likely that volunteer and commercial CMs have distinct working conditions, likely leading to
experiencing the role differently, in that it may be associated with different expectations, training,
and levels of support (Burns et al., 2008). The present study was designed to qualitatively explore
any psychological impacts in commercial CMs. This was to illustrate the potential difficulties
experienced within their roles, while also providing information for more effective work practice in
this field. The use of in-depth semi-structured interviews allows participants to express themselves
freely and articulate a diversity of experiences. The results can be used to inform organisations
about how the work may affect employees and therefore what types of support should be put in
place. Indeed, without a sound understanding of any specific psychological effects on CMs, attempts
to ameliorate or counter any impacts could be misguided or even harmful (Wessely et al., 2000). This
would impede efficiencies within the role and could adversely affect staff retention and recruitment.
In the remainder of this introduction, a review of the different work environments populated by CMs
and how the work CMs undertake might give rise to psychological difficulties is considered. The
Work of a Content Moderator CMs enforce the online rules which tell users how to behave and what
content is acceptable on a particular internet site (Gerrard, 2022). Some sites use a “community
reliant approach” where communities define their own standards that are then put into effect by
volunteer moderators, whilst other sites use an industrial approach, where workers are employed to
enforce a set of standardised rules (Caplan, 2018). As such, the ways in which CMs are employed
vary. Whilst some are volunteers, paid moderators can range from in-house workers employed
directly by the company needing moderation; to boutique firms specialising in content moderation
for other companies; to outsourced third party vendors and microlabour platforms (Roberts, 2019).
This means CMs can experience a range of working conditions where some have less workplace
protection as technically, they are not employees - thus the company requiring moderation work has
a level of “plausible deniability” to the harm faced by these CMs (Barrett, 2020; Roberts, 2019).
Nevertheless, CMs play a critical role in protecting firms’ reputations, ensuring online platforms do
not become unusable, hostile spaces that are unprofitable for these business (Drootin, 2021).
Furthermore, they shape what is seen online as they make hundreds of daily decisions, and for some
this can be with limited oversight (Parks, 2019). In 2014 Chen estimated there were over 100,000
paid CMs worldwide. It is likely that in the intervening years this number has increased. In 2021
Messenger and Simmons reported Facebook and Instagram had expanded their moderation
workforce to 15,000 people, and companies continue to hire more with a proliferation of businesses
that specialise in brand protection and moderation ([Link], 2022). These figures do not include the
numerous unpaid CMs used by sites like Reddit (Witynski, 2022). As part of their role, material
deemed offensive or harmful is sorted into queues and sent to CMs for review where they must
make decisions about suitability in line with the set of policies they are currently enforcing (Ahmad &
Krzywdzinski, 2022). CMs can be required to view depictions of child sexual abuse and violence, as
well as less graphic but no less noxious content that displays cruelty, humiliation and discrimination.
Thus, moderators engage in emotional labour as they are expected to regulate their own emotions
when exposed to this material, as well as during interactions with users as they work to represent
the platform (Steiger et al., 2021). The content they view can range from text, to still photos to
explicit video and the amount of time spent viewing material varies; it can however be substantial in
terms of hours every working day (Dwoskin, 2019). In addition, CMs have to maintain high accuracy
levels and throughput quotas to meet acceptable job performance standards, which contribute to
stress above that which might be experienced through viewing the content alone (Dwoskin et al.,
2019; Wohn, 2019). Dwoskin et al. (2019) described how moderators had their performance
regularly audited and were expected to maintain an accuracy score of over 95 percent when
identifying and correctly removing harmful content in accordance with company standards. There is
a body of evidence highlighting the consequences of chronic job-related stress or exposure to
difficult or traumatic content at work being serious and long-lasting (Vasconcelos et al., 2021).
Research with front-line professionals such as first responders has revealed that exposure to other
people’s traumatic experiences can lead to post-traumatic stress disorder (PTSD), a disorder that can
develop after exposure to actual or threatened death, serious injury, or sexual violence either
directly, through experiencing or witnessing the event, or experiencing repeated or extreme
exposure to aversive details of the traumatic event(s). It is marked by intrusion, avoidance, negative
symptoms and hyperarousal (American Psychiatric Association, 2013). Professionals in caring
professions such as social workers and therapists who are exposed to second-hand accounts of
trauma can develop syndromes such as secondary traumatic stress (STS), vicarious trauma (VT) and
burnout (Craig & Sprang, 2010; Greinacher et al., 2019; Lee et al., 2018). These have been referred
to as the “cost of caring” and relate to the stress reaction experienced by someone in response to
another’s distress (Figley, 1995). STS has similar symptoms to PTSD such as intrusive thoughts,
hyperarousal and hypervigilance, as does VT, although it is also associated with a transformation of
self-image and worldview (Foley & Massey, 2021; Krause, 2009). Burnout is characterised by
emotional exhaustion, cynicism and reduced feelings of accomplishment (Brady, 2017; O’Malley et
al., 2019). This is also true for professions not traditionally considered front-line staff. For example,
journalists exposed to traumatic events while working with difficult content such as child abuse,
child cruelty, war and aviation accidents, report higher levels of PTSD and the internalization of guilty
cognitions (Browne et al., 2012). Drone pilots involved in military operations have reported higher
levels of burnout, and an increased likelihood of developing anxiety, depression and PTSD (Asaro,
2013). Judges and lawyers report sleep disturbances, feeling isolated, concentration problems and
interpersonal issues (Jaffe et al., 2003; Léonard et al., 2020). Lastly, police officers who specialise in
internet child exploitation and are repeatedly exposed to images and videos of child abuse as part of
their investigations show raised rates of STS, mental health difficulties and absenteeism (Bourke &
Craun, 2014; Ralph, 2020). Furthermore, disorders such as PTSD, STS and burnout are often
comorbid with other mental health problems such as depression and anxiety and in some cases their
onsets are linked (e.g., Hakanen et al., 2008; Schindel-Allon et al., 2010). Anecdotal accounts from
investigative journalists suggest the work of CMs places them at risk for a range of
psychopathological difficulties. CMs report anxiety, depression, nightmares, fatigue and panic
attacks, with their relationships and physical health also affected (Newton, 2019, 2020b). Both
Microsoft and Facebook have been sued for substantial sums by CMs who developed PTSD on the
job and held the companies responsible (Ghoshal, 2017; Newton, 2020a). Similarly, academic
research highlights high stress levels and fatigue (Cook et al., 2022) and symptoms of insomnia,
anxiety, low mood and experiencing intrusive images (Benjelloun & Otheman, 2020) and work by
Roberts (2019) found that although CMs would report not being negatively impacted by the work
they would demonstrate via anecdotes that the work was affecting them and their relationships.
More broadly, moderators have reported feeling burnout and emotionally exhausted (Dosono &
Semaan, 2019; Riedl et al., 2020; Schöpke-Gonzalez et al., 2022), apathy (Lo, 2018) and
underappreciated (Wohn, 2019), as well as being harassed by users or feeling guilty for enforcing
rules or taking actions they do not necessarily agree with (Dosono & Semaan, 2019; Wohn, 2019).
Moral injury occurs when someone acts, fails to prevent or bears witness to acts that transgress
their moral beliefs (Litz et al., 2009) and therefore for some, the work of CMs could manifest as
moral injury. Indeed, a mismatch between the community and moderator’s values is associated with
quitting in volunteer moderators (Schöpke-Gonzalez et al., 2022). Nevertheless, some individuals
inevitably are more susceptible to trauma than others and there is individual variability to the
degree of negative impact as a result of the role (Powell et al., 2015). People exposed to trauma can
experience post-traumatic growth, whereby their coping leads to a greater sense of purpose and life
meaning (Steiger, 2020). A survey of internet child exploitation police officers found they had higher
wellbeing than a normative adult sample (Tomyn et al., 2015), and similarly, a study of volunteer
moderators found low levels of STS (Schöpke-Gonzalez et al., 2022). Organisational support can also
raise feelings of compassion satisfaction where the focus rests on the benefits rather than costs of
the job, and positive feelings are experienced when helping someone who has been traumatised
(Brady, 2017; Hunsaker et al., 2015). This can act as a buffer against compassion fatigue, STS and
burnout (Brady, 2017; Conrad & Kellar-Guenther, 2006). Thus, the role of CM may produce
significant stress for some, but not all. The evidence suggests that content moderation is associated
with a variety of negative impacts, although it is possible for some individuals the work will be
associated with positive effects. To date, there have been few academic studies that explore what
impacts the demands of the job might engender and many that have been conducted have focused
on the experience of volunteer CMs (e.g., Dosono & Semaan, 2019; Lo, 2018; Wohn, 2019).
However, volunteer moderators may experience different types of psychological distress due to their
distinct motivational factors and the range of activities they engage in which commercial CMs do not
(Matias, 2019). The current study aims to qualitatively explore the impact of the job on commercial
CMs, with the objective of using these results to highlight areas where problems may arise.
Specifically, the study set out to investigate a) what, if any, behavioural changes moderators may
experience due to their job and b) how, if at all, the work affects their relationships with others. The
findings can act as a first step to guide larger scale studies on the impacts. Methods Participants
Eleven CMs with experience of moderating CSAM were recruited. Initial recruitment was through
online advertising on social media platforms and utilising existing networks, with further recruitment
relying on a snowball technique where interviewees provided the research team’s details to
potential participants. Participation was voluntary and CMs were not remunerated for their time.
Moderators who wanted to participate were given an information sheet which explained the study
and outlined that they had to have experience of moderating CSAM. All participants were given the
opportunity to ask questions before, during and after involvement. There was no minimum
requirement with regards to how much exposure a participant had as the study was interested in
exploring various CM experiences. All participants spoke English but for the majority it was not their
native language. Specific employment-related details such as the participant’s employer or specific
sites they may have moderated were not requested, however at the beginning of each interview
participants were asked to outline what their job entailed and confirm they were exposed to CSAM
as part of their work. All participants worked full-time as CMs either for commercial companies or
CSAM specific hotlines. The sample included six females and five males, from eight countries: the
Netherlands, UK, Ireland, Germany, Brazil, Colombia, Malaysia and India. Procedure All participants
took part in an online interview, and could participate with their camera on or off. Interviews were
administered by two of the research team and were conducted from April to June 2022. They ranged
in duration from 47 to 78 minutes, with average interview time of an hour. The interviews all
followed a similar structure with participants asked about their role, how the material affected
them, how they coped, other occupational stressors, how the job was perceived by others and the
impact of COVID on their working conditions. This paper focuses on data relating to impacts of the
work. Interviewers asked open-ended questions and follow up probes were used as needed to elicit
further information and clarify answers. Informed consent was recorded verbally before the
interview commenced. Ethical approval was granted for the study by the university’s psychology
research ethics committee (ref: 20888). The interviewers did not specifically ask about non-
disclosure agreements (NDAs; contracts CMs may be required to sign that prohibit them from talking
about their work) but anonymity and confidentiality were guaranteed through the use of participant
codes, and participants personal details were not stored. All data was secured on password
protected drives in line with Data Protection and UK GDPR regulations and the interview recordings
were deleted after transcription. Data Analysis All interviews were audio-recorded, transcribed
verbatim and anonymised through removal of identifiable information. A Framework approach was
used to analyse the data (Gale et al., 2013). This enables in-depth exploration of the data whilst
making the process of data analysis transparent and is particularly suited to the analysis of cross-
sectional descriptive data (Ritchie & Lewis, 2003). It involved six stages, Familiarisation: the
transcripts are read repeatedly to enable familiarisation with the data and identify key themes.
Coding: descriptive or conceptual labels are systematically applied to interesting or notable excepts
of raw data. The coding framework is then discussed and agreed by the research team. Developing
an analytical framework: codes are grouped into categories representing interrelated ideas or
concepts. Applying the analytical framework: the codes and categories are applied across all the
transcripts. Entering the data into the framework matrix: a spreadsheet is used to generate a matrix.
In the matrix, each column represents a key category and each row represents an individual
participant. The summarised data from each transcript are entered into the matrix so each cell
represents a category by participant. Interpreting the data: the final analytic stage involves working
through the data in the matrix, drawing out the range of experiences and views expressed during the
interviews, identifying
similarities and differences across participants, and interrogating the data to seek to explain
emergent patterns and findings. Results The CMs reported a number of different impacts across a
variety of domains, particularly emotional and cognitive. They also discussed factors that
exacerbated work stress aside from the content. The identified themes and subthemes are
presented in Table 1. Table 1. Themes Identified Through Framework Analysis. Superordinate
Themes Sub-Themes Impact Awareness Barriers to talking about impacts, Harmful Content
Detachment Desensitisation, Keeping a distance from victims, Suitability, View of Self, Sensitivity to
Some Material Negative Cognitive Changes Thoughts of CSAM, Hypervigilance Regarding Children,
Incompatible with Family Life, World is Darker Place, Cynical Views of People Emotional Toll Anger,
Anxiety, Mental Health, Fatigue, Sleep Disturbance, Self-Care, Effects Relationships Stressful Work
Environment Respect, Ill-Equipped, Quotas Impact Awareness Regardless of if CMs felt they were
personally affected by the work, there was an awareness amongst all the moderators that the
content they were being exposed to was harmful and had the potential to affect them longterm. “I
think the turnover’s always higher in the more problematic content. We didn’t see that much
turnover in terms of bullying or election misinformation or adult nudity because those policies are,
that kind of content doesn’t really traumatise you as much as the other ones.” (CM8) Nevertheless,
some CMs did assert they were unaffected by the job. However, further probing always elicited
either current or past examples of difficulties. The reluctance to talk about impacts was notable and
possibly reflects attitudes towards the work, such as not wanting to talk about the difficulties,
because they agreed to take on the job and accepted that exposure to content was part of their
profession. Additionally, many effects may come on gradually and may be hard for CMs to recognise,
quantify and put into words. CMs are aware that something has changed and can talk about being
affected in general, but find it difficult to identify specifics. “It has an effect on you detrimentally
when you’re on your own. It affects your imagination in ways that you can’t quantify, but it still
affects you.” (CM3) Therefore, although all CMs gave examples of how they had been negatively
affected by their role, the level of distress caused and insight about effects varied. A couple reported
they could not identify any impacts within themselves and viewing traumatic content was “just their
job” but noticed impacts in others, or gave examples of impacts that occurred in the past, possibly
reflecting that any effects or symptoms associated with the work change over time for some CMs.
Detachment Associated with change in effects over time was the ability of CMs to detach from the
material. It seemed after the initial shock of viewing content, a common way to cope with the
feelings evoked was to shut down emotionally. This ability seemed to develop over the first few
months in the job and enabled CMs to look at content without experiencing any adverse reactions.
“They kind of get used to see those tickets and to see that kind of content and it’s like they
transform into robots and suppressing their emotions and stuff like that.” (CM7) In particular, CMs
tried to keep an emotional distance from the victims. This both involved remaining analytical, but
also a conscious effort not to think about the children as people or think about what had happened
to those victims both before and after that particular piece of content was created. “I’m just trying
to keep my mind to analysing the material, and it’s been working so far... It helps me because then I
don’t remind myself that it’s actual people and actual stuff that happened. It helps me to just think
about it as something like a TV series that they’re analysing or whatever”. (CM1) However, others
struggled with maintaining that boundary and could not remain detached from the victims. This
resulted in them subjecting themselves to the content more than they had to as a result. “That child,
when on his own, showed his trauma and as a reviewer I kind of think this is my responsibility to
make sure that, even if I do it years after the event happened, it’s my responsibility to make sure
that the child in some way wasn’t on his own going through this trauma.” (CM9) At the extreme end
the emotional blunting could turn into desensitisation, where CMs became anesthetised to what
they were witnessing. Although perhaps an adaptive response overall, it made a couple of CMs
question themselves and if their ability to do the work meant there was something wrong with
them. However, it may be that those who were unable to turn off their emotional response in this
way did not last long in the job. “If you see a child being sexually abused how do you look at this in a
numb way or can you ever look at it? It leads to a lot of burnout. A lot of people in the child sexual
exploitation or terrorism spheres particularly have a quick turnaround in terms of the work that they
do because it’s traumatic for them. It’s not something that people want to view.” (CM8)
Desensitisation did not occur across all content. Some CMs had personal sensitivities and reported
certain types of content continued to be upsetting, even after they had adjusted to what they were
being exposed to overall. This could be both in terms what was in the content but also across
different types of content, e.g., text rather than images was more disturbing for some. “My trigger is
bestiality. I cannot work on the bestiality content, but I had to do it at some point, and it was really
tough for me because I have my dog.” (CM5) Negative Cognitive Changes CMs experienced intrusive
thoughts and discussed how images of CSAM remained in their minds after initial exposure. The
intrusive thoughts were generally associated with feelings of psychological distress or unease. “So
that was quite disturbing for that moment. Yes, I did take about two or three days off from work
after that... I was not physically ill. It just was immediate that I couldn’t take off my head from that.”
(CM6) CMs reported that intrusive thoughts were particularly prevalent during, and indeed triggered
by, sexual relations with their partners. This often resulted in them having to stop and/or
deliberately distract themselves from thoughts of CSAM. This could leave them questioning their
sexuality and reduced feelings of intimacy within the relationship. “Same with my own sexuality,
sometimes I say to my boyfriend, just let me have a minute for myself and then I’ll try to bring my
thoughts to nice thoughts and then it’s okay, but that wasn’t there before. That’s new since I started
the job.” (CM2) The presence of children also appeared to trigger thoughts of CSAM and worry
about child welfare. In a couple of cases this even led to CMs trying to avoid children, especially
situations where a child might become upset as this was particularly distressing and triggered or
intensified intrusive thoughts of CSAM. CMs who had children particularly struggled with the content
and it was reported that staff often left the job when they were either planning on or having children
of their own, demonstrating a recognition that having children would impact their ability to do the
work. CMs in general demonstrated heightened concerns about child safety and feeling more
protective of children. “When my aunt had her child… I tried to explain to her what’s happening,
what’s actually happening… and that you need to be more attentive as a parent when you’re leaving
your child even to a simple game. It’s not just a game anymore.” (CM7) More general changes in
cognition were also evident, with the exposure to disturbing content leading to the development of
a more negative world view. CMs talked about having lived in a bubble or having been sheltered but
that their job had revealed another darker side of the world. This was also associated with the
development of a cynical view of people and their behaviour. This general distrust of others
experienced by CMs could result indifficulties with interpersonal relationships. In particular, a couple
of female CMs expressed concerns about men in general as they developed suspicions of their
possible involvement in perpetrating or watching CSAM. As a result, some described experiencing a
more general loss of hope and fewer positive emotions. “But sometimes I feel like my joy has been
taken away from life. It’s not in a very serious way but, I don’t know, I just see the world a little bit
less colourful. Yes, it’s a bit difficult to explain, but I guess I know now how dark the world can be.”
(CM1) Emotional Toll The work also took an emotional toll on CMs. Many talked about feelings of
anger or frustration and this was discussed generally in the context of the content, feeling anger
when they thought about what they had seen or the people that were involved. However, a couple
were more explicit in saying their anger was more generalised than that. CMs also spoke about
physical affects experienced at work, with one even describing having panic attacks. The descriptions
offered varied but all were indicative of experiencing a “fight or flight” response to the content.
“Sometimes I feel not exactly nervous but like my body is very awake but not in the sense of not
being tired, more like being a little, maybe shaking a little but not shaking on the inside. More like
nervous but without a reason when I see very much content or content that is very disturbing.”
(CM2) In general though, CMs did not articulate the exact emotional affects. They tended to talk in
generalities about mental health issues, getting “sick” due to the content and experiencing
emotional stress. This suggested the job might be associated with a general malaise rather than
specific problems. “He just said, ‘I knew that there would be some really gross content, but I really
didn’t expect this.’ Honestly, I didn’t have really words to tell him. I mean, literally, I just go and tell
him that that’s the part of work that you’re feeling.” (CM6) They also discussed feeling fatigue at
work and being drained or exhausted by the work. This might be a slightly different way of
expressing the malady experienced by workers in this role. This weariness could be linked to the
emotional effects of being exposed to content, or a business need in meeting quotas. “When I
started here, I actually was off sick for 60 per cent, because I had no energy and I wasn‘t feeling
good. I couldn‘t even stay awake when I was here.” (CM1) CMs reported sleep disturbances, such as
nightmares, which often were connected to the violence they had witnessed during work. There was
also difficulty falling or staying asleep, which may have contributed to day time tiredness. This was
due to replaying images as they were trying to get to sleep or waking up for fear of being asleep. “I
started to have sleeping problems, I don’t know it was really irrational, everything comes to me and I
had problems sleeping, I was afraid to sleep for a week. I wanted to sleep, but I didn’t sleep well,
that week I would sleep 2 or 3 hours. I would wake up and be like no no, I wasn’t sleeping, no I have
to be awake.” (CM4) CMs also mentioned that self-care suffered as a result of the work. This was
attributed to stress, whether caused by the content itself or having to hit specific targets and quotas,
individuals developed ways to comfort themselves at work. “I know of many people who say that
they do eat a lot of chocolate while working. Chocolate is one; coffee is another… Thirdly, smokers
who smoke, they tend to take a lot more smoking breaks… One is to help them cope with what they
see. Secondly, the stress of meeting their daily numbers.” (CM6) CMs felt unable to talk to friends
and family about their work. They felt that others did not want to know or that they would be
traumatised if they did know. However, for some this was associated with a feeling of disconnection
because not only were they shielding others from what they had seen, but also they were hiding the
affects the job could have on them. For some this contributed to a sense of isolation. “For my
grandparents, I’m a researcher. That’s all that they know about me, they don’t know more. My
parents know that I’m working on CSAM but I don’t tell them anything else. Same thing for my
partner, but because of this, when you’re having a bad day, when you have your emotions all over
the place, you still have to pretend that you’re okay, that everything is fine.” (CM9) Stressful Work
Environment The emotional toll involved in the work could be exacerbated or alleviated by the
response of management, and this seemed to hinge on whether managers respected the role that
CMs played within the company. This was often more likely if leaders had direct experience of the
work and could empathise with what CMs experienced, both in terms of content but also the targets
that CMs had to hit. “I got affected by the management when they started pressuring you. Lots of
things, and you didn’t even realise that how much we are affected by the content as well. It’s really
disturbing content what we’re working in, specifically in a minor content, but still, the managers
didn’t care about that. They were like, ‘Now, oh, your performance this way. We need to extend
something, or…’” (CM5) Quotas were also mentioned by many of the CMs as something which
added to a feeling of pressure or stress on top of what they were witnessing. This was both the
levels of accuracy that had to be maintained and throughput. This too, was often linked to the
approach of management with a feeling that their focus was on reaching the quotas with no
appreciation of the wider context of the job. “’You’re not getting your quota.’ Bring you into the
office, ‘[CM’s name] you need to improve on this, this, and this,’ and it’s like, ‘Woah, hold on a
second, you should watch this stuff.’ There’s a bit of a divorce going on there, a disconnect.” (CM3)
Lastly, CMs felt that the tools they had to work with often were not designed with content
moderation and their role in mind. This added to the frustration and stress associated with their job
because they felt it prevented them from being able to do it effectively. Discussion Exposure to other
people’s trauma at work can be detrimental to employees (Greinacher et al., 2019; Lee et al., 2018)
and to the efficient fulfilment of their work. Existing literature suggests that this is also the case for
CMs (Cook et al., 2022; Schöpke-Gonzalez et al., 2022). Research to date examining the
psychological effects of this work is sparse and tends to focus on the experience of volunteer
moderators who may have a different set of motivations and job-related tasks (Matias, 2019). The
present study adds to this literature by qualitatively exploring the psychological effects of content
moderation in commercial CMs. The results show both negative cognitive and emotional changes
take place and that these are associated with behavioural changes such as avoidance and
hypervigilance. Overall, the effects are consistent with commercial CMs experiencing a trauma
response in relation to their work, and provides evidence demonstrating why organisations
employing CMs need to provide traumainformed care for their employees. Similar to previous
research, although CMs knew the content was difficult and that people struggled, there was a
reluctance to talk openly about the personal impacts of the job (Roberts, 2019). There are several
possible reasons for this, such as: a lack of awareness around how they are being impacted or the
inability to put the impacts into words. Syndromes such as VT and burnout are cumulative and
gradual, this can make it difficult for individuals to recognise any changes within themselves or
others (Krause, 2009; Ledingham et al., 2019). Alternatively, CMs may not want to admit to impacts
either because they agreed to the job or because as Roberts (2019) argued, adverse effects may
suggest they are unable to perform the job adequately. Equally, the participants all worked full-time
as content moderators and therefore some may have signed NDAs, which can be associated with a
fear of speaking out about the job (Schiffer, 2021). Nevertheless, some CMs did appear to be coping
well. Again, there are several possible reasons for this: some CMs reported they were more sensitive
to particular types of content. It could be that certain people, for example those who do not interact
with children in their daily lives, are more resilient to working with CSAM material. Similarly, people
who stay in in this profession for a long time, may be the ones who are affected less, cope relatively
well and experience little in the way of impairment, or even undergo a period of post-traumatic
growth. There appeared to be an initial period at the beginning of the job whereby people either
tended to adjust to the role or leave. Therefore, CM resilience may be dependent on the content
they are exposed to, or may change overimilarities and differences across participants, and
interrogating the data to seek to explain emergent patterns and findings. Results The CMs reported a
number of different impacts across a variety of domains, particularly emotional and cognitive. They
also discussed factors that exacerbated work stress aside from the content. The identified themes
and sub themes are presented in Table 1. Table 1. Themes Identified Through Framework Analysis.
Superordinate Themes Sub-Themes Impact Awareness Detachment Negative Cognitive Changes
Emotional Toll Stressful Work Environment Barriers to talking about impacts, Harmful Content
Desensitisation, Keeping a distance from victims, Suitability, View of Self, Sensitivity to Some
Material Thoughts of CSAM, Hypervigilance Regarding Children, Incompatible with Family Life, World
is Darker Place, Cynical Views of People Anger, Anxiety, Mental Health, Fatigue, Sleep Disturbance,
Self-Care, Effects Relationships Respect, Ill-Equipped, Quotas Impact Awareness Regardless of if CMs
felt they were personally affected by the work, there was an awareness amongst all the moderators
that the content they were being exposed to was harmful and had the potential to affect them long
term. “I think the turnover’s always higher in the more problematic content. We didn’t see that
much turnover in terms of bullying or election misinformation or adult nudity because those policies
are, that kind of content doesn’t really traumatise you as much as the other ones.” (CM8)
Nevertheless, some CMs did assert they were unaffected by the job. However, further probing
always elicited either current or past examples of difficulties. The reluctance to talk about impacts
was notable and possibly reflects attitudes towards the work, such as not wanting to talk about the
difficulties, because they agreed to take on the job and accepted that exposure to content was part
of their profession. Additionally, many effects may come on gradually and may be hard for CMs to
recognise, quantify and put into words. CMs are aware that something has changed and can talk
about being affected in general, but find it difficult to identify specifics. “It has an effect on you
detrimentally when you’re on your own. It affects your imagination in ways that you can’t quantify,
but it still affects you.” (CM3) Therefore, although all CMs gave examples of how they had been
negatively affected by their role, the level of distress caused and insight about effects varied. A
couple reported they could not identify any impacts within themselves and viewing traumatic
content was “just their job” but noticed impacts in others, or gave examples of impacts that
occurred in the past, possibly reflecting that any effects or symptoms associated with the work
change over time for some CMs. Detachment Associated with change in effects over time was the
ability of CMs to detach from the material. It seemed after the initial shock of viewing content, a
common way to cope with the feelings evoked was to shut down emotionally. This ability seemed to
develop over the first few months in the job and enabled CMs to look at content without
experiencing any adverse reactions. “They kind of get used to see those tickets and to see that kind
of content and it’s like they transform into robots and suppressing their emotions and stuff like
that.” (CM7) In particular, CMs tried to keep an emotional distance from the victims. This both
involved remaining analytical, but also a conscious effort not to think about the children as people or
think about what had happened to those victims both before and after that particular piece of
content was created. “I’m just trying to keep my mind to analysing the material, and it’s been
working so far... It helps me because then I don’t remind myself that it’s actual people and actual
stuff that happened. It helps me to just think about it as something like a TV series that they’re
analysing or whatever”. (CM1) However, others struggled with maintaining that boundary and could
not remain detached from the victims. This resulted in them subjecting themselves to the content
more than they had to as a result. “That child, when on his own, showed his trauma and as a
reviewer I kind of think this is my responsibility to make sure that, even if I do it years after the event
happened, it’s my responsibility to make sure that the child in some way wasn’t on his own going
through this trauma.” (CM9) At the extreme end the emotional blunting could turn into
desensitisation, where CMs became anesthetised to what they were witnessing. Although perhaps
an adaptive response overall, it made a couple of CMs question themselves and if their ability to do
the work meant there was something wrong with them. However, it may be that those who were
unable to turn off their emotional response in this way did not last long in the job. “If you see a child
being sexually abused how do you look at this in a numb way or can you ever look at it? It leads to a
lot of burnout. A lot of people in the child sexual exploitation or terrorism spheres particularly have a
quick turnaround in terms of the work that they do because it’s traumatic for them. It’s not
something that people want to view.” (CM8) Desensitisation did not occur across all content. Some
CMs had personal sensitivities and reported certain types of content continued to be upsetting, even
after they had adjusted to what they were being exposed to overall. This could be both in terms
what was in the content but also across different types of content, e.g., text rather than images was
more disturbing for some. “My trigger is bestiality. I cannot work on the bestiality content, but I had
to do it at some point, and it was really tough for me because I have my dog.” (CM5) Negative
Cognitive Changes CMs experienced intrusive thoughts and discussed how images of CSAM
remained in their minds after initial exposure. The intrusive thoughts were generally associated with
feelings of psychological distress or unease. “So that was quite disturbing for that moment. Yes, I did
take about two or three days off from work after that... I was not physically ill. It just was immediate
that I couldn’t take off my head from that.” (CM6) CMs reported that intrusive thoughts were
particularly prevalent during, and indeed triggered by, sexual relations with their partners. This often
resulted in them having to stop and/or deliberately distract themselves from thoughts of CSAM. This
could leave them questioning their sexuality and reduced feelings of intimacy within the
relationship. “Same with my own sexuality, sometimes I say to my boyfriend, just let me have a
minute for myself and then I’ll try to bring my thoughts to nice thoughts and then it’s okay, but that
wasn’t there before. That’s new since I started the job.” (CM2) The presence of children also
appeared to trigger thoughts of CSAM and worry about child welfare. In a couple of cases this even
led to CMs trying to avoid children, especially situations where a child might become upset as this
was particularly distressing and triggered or intensified intrusive thoughts of CSAM. CMs who had
children particularly struggled with the content and it was reported that staff often left the job when
they were either planning on or having children of their own, demonstrating a recognition that
having children would impact their ability to do the work. CMs in general demonstrated heightened
concerns about child safety and feeling more protective of children. “When my aunt had her child… I
tried to explain to her what’s happening, what’s actually happening… and that you need to be more
attentive as a parent when you’re leaving your child even to a simple game. It’s not just a game
anymore.” (CM7) More general changes in cognition were also evident, with the exposure to
disturbing content leading to the development of a more negative world view. CMs talked about
having lived in a bubble or having been sheltered but that their job had revealed another darker side
of the world. This was also associated with the development of a cynical view of people and their
behaviour. This general distrust of others experienced by CMs could result in difficulties with
interpersonal relationships. In particular, a couple of female CMs expressed concerns about men in
general as they developed suspicions of their possible involvement in perpetrating or watching
CSAM. As a result, some described experiencing a more general loss of hope and fewer positive
emotions. “But sometimes I feel like my joy has been taken away from life. It’s not in a very serious
way but, I don’t know, I just see the world a little bit less colourful. Yes, it’s a bit difficult to explain,
but I guess I know now how dark the world can be.” (CM1) Emotional Toll The work also took an
emotional toll on CMs. Many talked about feelings of anger or frustration and this was discussed
generally in the context of the content, feeling anger when they thought about what they had seen
or the people that were involved. However, a couple were more explicit in saying their anger was
more generalised than that. CMs also spoke about physical affects experienced at work, with one
even describing having panic attacks. The descriptions offered varied but all were indicative of
experiencing a “fight or flight” response to the content. “Sometimes I feel not exactly nervous but
like my body is very awake but not in the sense of not being tired, more like being a little, maybe
shaking a little but not shaking on the inside. More like nervous but without a reason when I see very
much content or content that is very disturbing.” (CM2) In general though, CMs did not articulate
the exact emotional affects. They tended to talk in generalities about mental health issues, getting
“sick” due to the content and experiencing emotional stress. This suggested the job might be
associated with a general malaise rather than specific problems. “He just said, ‘I knew that there
would be some really gross content, but I really didn’t expect this.’ Honestly, I didn’t have really
words to tell him. I mean, literally, I just go and tell him that that’s the part of work that you’re
feeling.” (CM6) They also discussed feeling fatigue at work and being drained or exhausted by the
work. This might be a slightly different way of expressing the malady experienced by workers in this
role. This weariness could be linked to the emotional effects of being exposed to content, or a
business need in meeting quotas. “When I started here, I actually was off sick for 60 per cent,
because I had no energy and I wasn‘t feeling good. I couldn‘t even stay awake when I was here.”
(CM1) CMs reported sleep disturbances, such as nightmares, which often were connected to the
violence they had witnessed during work. There was also difficulty falling or staying asleep, which
may have contributed to day time tiredness. This was due to replaying images as they were trying to
get to sleep or waking up for fear of being asleep. “I started to have sleeping problems, I don’t know
it was really irrational, everything comes to me and I had problems sleeping, I was afraid to sleep for
a week. I wanted to sleep, but I didn’t sleep well, that week I would sleep 2 or 3 hours. I would wake
up and be like no no, I wasn’t sleeping, no I have to be awake.” (CM4) CMs also mentioned that self-
care suffered as a result of the work. This was attributed to stress, whether caused by the content
itself or having to hit specific targets and quotas, individuals developed ways to comfort themselves
at work. “I know of many people who say that they do eat a lot of chocolate while working.
Chocolate is one; coffee is another… Thirdly, smokers who smoke, they tend to take a lot more
smoking breaks… One is to help them cope with what they see. Secondly, the stress of meeting their
daily numbers.” (CM6) CMs felt unable to talk to friends and family about their work. They felt that
others did not want to know or that they would be traumatised if they did know. However, for some
this was associated with a feeling of disconnection because not only were they shielding others from
what they had seen, but also they were hiding the affects the job could have on them. For some this
contributed to a sense of isolation. “For my grandparents, I’m a researcher. That’s all that they know
about me, they don’t know more. My parents know that I’m working on CSAM but I don’t tell them
anything else. Same thing for my partner, but because of this, when you’re having a bad day, when
you have your emotions all over the place, you still have to pretend that you’re okay, that everything
is fine.” (CM9) Stressful Work Environment The emotional toll involved in the work could be
exacerbated or alleviated by the response of management, and this seemed to hinge on whether
managers respected the role that CMs played within the company. This was often more likely if
leaders had direct experience of the work and could empathise with what CMs experienced, both in
terms of content but also the targets that CMs had to hit. “I got affected by the management when
they started pressuring you. Lots of things, and you didn’t even realise that how much we are
affected by the content as well. It’s really disturbing content what we’re working in, specifically in a
minor content, but still, the managers didn’t care about that. They were like, ‘Now, oh, your
performance this way. We need to extend something, or…’” (CM5) Quotas were also mentioned by
many of the CMs as something which added to a feeling of pressure or stress on top of what they
were witnessing. This was both the levels of accuracy that had to be maintained and throughput.
This too, was often linked to the approach of management with a feeling that their focus was on
reaching the quotas with no appreciation of the wider context of the job. “’You’re not getting your
quota.’ Bring you into the office, ‘[CM’s name] you need to improve on this, this, and this,’ and it’s
like, ‘Woah, hold on a second, you should watch this stuff.’ There’s a bit of a divorce going on there,
a disconnect.” (CM3) Lastly, CMs felt that the tools they had to work with often were not designed
with content moderation and their role in mind. This added to the frustration and stress associated
with their job because they felt it prevented them from being able to do it effectively. Discussion
Exposure to other people’s trauma at work can be detrimental to employees (Greinacher et al.,
2019; Lee et al., 2018) and to the efficient fulfilment of their work. Existing literature suggests that
this is also the case for CMs (Cook et al., 2022; Schöpke-Gonzalez et al., 2022). Research to date
examining the psychological effects of this work is sparse and tends to focus on the experience of
volunteer moderators who may have a different set of motivations and job-related tasks (Matias,
2019). The present study adds to this literature by qualitatively exploring the psychological effects of
content moderation in commercial CMs. The results show both negative cognitive and emotional
changes take place and that these are associated with behavioural changes such as avoidance and
hypervigilance. Overall, the effects are consistent with commercial CMs experiencing a trauma
response in relation to their work, and provides evidence demonstrating why organisations
employing CMs need to provide trauma informed care for their employees. Similar to previous
research, although CMs knew the content was difficult and that people struggled, there was a
reluctance to talk openly about the personal impacts of the job (Roberts, 2019). There are several
possible reasons for this, such as: a lack of awareness around how they are being impacted or the
inability to put the impacts into words. Syndromes such as VT and burnout are cumulative and
gradual, this can make it difficult for individuals to recognise any changes within themselves or
others (Krause, 2009; Ledingham et al., 2019). Alternatively, CMs may not want to admit to impacts
either because they agreed to the job or because as Roberts (2019) argued, adverse effects may
suggest they are unable to perform the job adequately. Equally, the participants all worked full-time
as content moderators and therefore some may have signed NDAs, which can be associated with a
fear of speaking out about the job (Schiffer, 2021). Nevertheless, some CMs did appear to be coping
well. Again, there are several possible reasons for this: some CMs reported they were more sensitive
to particular types of content. It could be that certain people, for example those who do not interact
with children in their daily lives, are more resilient to working with CSAM material. Similarly, people
who stay in in this profession for a long time, may be the ones who are affected less, cope relatively
well and experience little in the way of impairment, or even undergo a period of post-traumatic
growth. There appeared to be an initial period at the beginning of the job whereby people either
tended to adjust to the role or leave. Therefore, CM resilience may be dependent on the content
they are exposed to, or may change over time. However, the adjustment seemed to be associated
with the ability to suppress emotions, which may have longer-term consequences for social and
mental wellbeing (Chervonsky & Hunt, 2017; Hu et al., 2014). Future research should investigate
what predicts resiliency in CMs, but also the potential long-term effects both in terms of ongoing
resiliency and any possible deleterious consequences of this. Many of the impacts described by CMs
are in line with the symptoms described by volunteer moderators (Dosono & Semaan, 2019;
Schöpke-Gonzalez et al., 2022). The symptoms are also reminiscent of those occurring after repeated
or extreme exposure to aversive details of trauma as described by PTSD or STS, and the majority of
themes could be grouped in this way (see Table 2). When CMs gave examples of how they were
affected, they talked about intrusive thoughts and images of CSAM including that these were
triggered by children and their own sexual activity. Additionally, some described avoiding children
and there were a number of negative cognitive and emotional affects, including hypervigilance
around children, anger and increased distrust of others. There were also symptoms of hyperarousal,
presenting as sleep disturbance and bodily sensations of anxiety. However, the interviewers asked
open ended questions regarding possible impacts. Specific questions that could be used to assess or
diagnose different disorders were not utilised. More research is needed to investigate whether CMs
reach the threshold for any potential diagnoses, to what extent symptoms reflect one or many
different potential syndromes such as burnout, PTSD or VT and to estimate their potential
prevalence in this population. Nevertheless, this study suggests the psychological impacts
experienced by commercial CMs are comparable to those experienced by professionals such as first
responders and police tasked with analysing child exploitation material (Greinacher et al., 2019;
Bourke & Craun, 2014). In these professions, these risks are more widely recognised, for the most
part, contributing to support being implemented and facilitating more understanding from managers
and the community (Burns et al., 2008; Krause, 2009). In contrast, despite their centrality to the
business model of many online platforms (Barrett, 2020) moderators remain an undervalued, often
hidden profession (Gillespie, 2018), frequently located in the global south and commonly not
afforded the same benefits and provisions as offered to other professionals (Roberts, 2019; Jereza,
2021). However, the increasing amount of literature demonstrating the potential negative
consequences of this work (e.g., Benjelloun & Otheman, 2020; Roberts, 2019) illustrates that
companies need to take more responsibility for the welfare of these employees and volunteers and
provide better protection against the possible deleterious psychological effects. Understanding the
effects this work has on CMs from a psychological perspective allows the symptoms to be positioned
in a framework that can draw on the large psychological literature around trauma and its sequalae.
It can link the experiences and emotional responses direct from the voices of CMs to clinical practice
and empirically ground potential recommendations. This includes creating interventions based on
“what works” and for whom, as well as better designing systems to protect CMs. Many organisations
provide technological solutions such as blurring to minimise the impact (Das et al., 2020). However,
these are not necessarily considered useful by moderators (Spence et al., 2023) and a lack of support
has been associated with quitting in volunteer moderators (Schöpke-Gonzalez et al., 2022).
Nevertheless, there are potentially processes which could be put in place to alleviate emotional
distress, for instance playing Tetris after trauma exposure has shown some early promise in reducing
the occurrence of intrusive memories (Iyadurai et al., 2018). Regardless, these results suggest that
companies should provide trauma-informed care at work, which is guided by the principles of safety,
trustworthiness, peer support collaboration and mutuality, empowerment, and cultural, historical
and gender issues (Substance Abuse and Mental Health Services Administration, 2014) and is shown
to reduce STS and burnout amongst staff (Handran, 2015; Schepers & Young, 2022). Table 2. Themes
Rearranged Into PTSD Symptom Domains. PTSD Domain Sub-Themes Intrusion Avoidance Negative
Symptoms Hyperarousal Thoughts of CSAM Incompatible with Family Life Cynical Views of People,
World is Darker Place, Mental Health, Desensitisation, Anger, Fatigue, Self-Care, Effects
Relationships, View of Self Hypervigilance Regarding Children, Sleep Disturbance, Anxiety Although
trauma responses such as intrusive thoughts might be disturbing, what may be more insidious is the
slow change in perceptions of the world and those in our communities, which could be more
pervasive and affect all spheres of the CMs life. Research with volunteer moderators found they
experience cognitive changes like increased apathy and guilt (Dosono & Semaan, 2019; Lo, 2018). In
this study, commercial CMs described having a darker, more cynical view of the world and other
people, and these views may not change once they leave their job (O’Malley et al., 2019). Although
the specific ages of the CMs were unknown, they tended to be young and, generally, most CMs are
younger than thirty (Mukhopadhyay, 2020). Although the evidence is inconsistent, younger age has
been associated with greater distress after experiencing trauma and more symptoms (Acierno et al.,
2006; Adams & Boscarino, 2006), as well as higher levels of burnout (Brady, 2017). This may be
because when compared to older workers, they lack a wide array of life experiences to draw on,
making them less equipped to deal with stressful situations (Lerias & Byrne, 2003). Older workers
are also more likely to use positive emotion regulation strategies and possess higher emotional
competencies to stave off negative consequences (Steiger, 2020). Therefore because of their age,
CMs may be a group that are particularly vulnerable to repeatedly working with traumatic material.
There is currently limited research that investigates the psychological impacts of the role. However,
there is some evidence that suggests the harmful impacts of moderation are not necessarily
restricted to those viewing overtly disturbing material such as CSAM. In work by Jereza (2022, p. 12)
a moderator commented “working with hate speech so much is it would get into my head. Like these
images and words would flash across my brain like with no warning, and I didn’t want them there. It
was—it was awful. I was like, I would kind of torturing myself, um, and so I do think, you know, it can
get into your head easier than you would think perhaps? Or when I was out and bout like if I ever
saw a white guy with a tattoo, I would immediately start scanning his body for hate symbols. And
every white guy has a tattoo in [City] . . . I was like hating myself for it. They’re not supposed to be
there. I’m not this person” (emphasis added). This suggests that intrusive thoughts and
hypervigilance may also be associated with working with hate speech. This content is the most
prevalent type that CMs have to analyse on social media platforms (Facebook, 2022a; Twitter, 2021)
therefore, research into the effects of working with this content specifically is needed. In particular,
if it is associated with VT, where the world views of moderators may be changed, possibly even in
agreement with what they being exposed to. Indeed, it is possible that many of the same impacts
might be present across different content types but the substance of the impacts could vary in line
with the material the CM is exposed to. Limitations The current study was a cross-sectional
qualitative design therefore was not able to capture changes over time. Additionally, time in post
was not reported, therefore it cannot be ascertained if certain impacts were more likely to be
described by those earlier or later in their career as a CM. Similarly, to encourage participation CMs
were not asked about details of their role such as if they were employed directly by the company or
were outsourced labour, although all participants were in paid positions and were able to conduct
an interview in English. There are numerous volunteer CMs used by sites like Reddit (Caplan, 2018)
and moderation is a global phenomenon. Thus, this study was unable to fully capture the full range
of different work environments CMs will be exposed to, not only in terms of support provided but
also working conditions, which are likely impact CM resilience (Burns et al., 2008; Substance Abuse
and Mental Health Services Administration, 2014). However, this study opens up future avenues for
research, including larger scale studies that can quantify potential impacts and explore potential
factors that increase CM resilience. Conclusions Many of the CMs described a range of symptoms
that were associated with experiencing trauma at work, including intrusive thoughts, avoidance and
hypervigilance around children. This suggests it is crucial for companies to provide psychoeducation,
intervention and trauma informed care. Of particular concern were the cognitive biases that
highlighted a cynical and suspicious framework as these may be harder for CMs to recognise and be
resistant to change, even after leaving the role. Larger scale quantitative and longitudinal research
are both needed to quantify the possible effects and their long-term consequences.

The Useof Social Media in Children and Adolescents: Scoping Review on the Potential Risks Elena
Bozzola 1,2,* , Giulia Spina 1,2 Antonio Di Mauro 2 , Rino Agostiniani 2,3, Sarah Barni 1,2, Rocco
Russo 2, Elena Scarpato 2,4, , Antonella Vita Di Stefano 2, Cinthia Caruso 2, Giovanni Corsello 2,5 and
Annamaria Staiano 2,4 1 2 3 4 5 * Citation: Bozzola, E.; Spina, G.; Agostiniani, R.; Barni, S.; Russo, R.;
Scarpato, E.; Di Mauro, A.; Di Stefano, A.V.; Caruso, C.; Corsello, G.; et al. The Use of Social Media in
Children and Adolescents: Scoping Review on the Potential Risks. Int. J. Environ. Res. Public Health
2022, 19, 9960. [Link] ijerph19169960 Pediatric Unit, IRCCS Bambino Gesù
Children Hospital, 00100 Rome, Italy The Italian Pediatric Society, 00100 Rome, Italy Department of
Pediatrics, San Jacopo Hospital, 51100 Pistoia, Italy Department of Translational Medical Sciences-
Section of Pediatric, University Federico II, 80100 Naples, Italy Department of Health Promotion,
Mother and Child Care, Internal Medicine and Medical Specialties “G. D’Alessandro”, University of
Palermo, 90100 Palermo, Italy Correspondence: [Link]@[Link] Abstract: In recent years,
social media has become part of our lives, even among children. From the beginning of COVID-19
pandemic period, media device and Internet access rapidly increased. Adolescents connected
Internet alone, consulting social media, mostly Instagram, TikTok, and YouTube. During “lockdown”,
the Internet usage allowed communication with peers and the continuity activities such as school
teaching. However, we have to keep in mind that media usage may be related to some adverse
consequences especially in the most vulnerable people, such as the young. Aim of the review is to
focus on risks correlated to social media use by children and adolescents, identifying spies of rising
problems and engaging in preventive recommendations. The scoping review was performed
according to PRISMA guidelines, searching on PubMed the terms “social media” or “social network”,
“health”, and “pediatrics”. Excluding articles not pertinent, we found 68 reports. Out of them, 19
were dealing with depression, 15 with diet, and 15 with psychological problems, which appeared to
be the most reported risk of social media use. Other identified associated problems were sleep,
addiction, anxiety, sex related issues, behavioral problems, bodyimage, physical activity, online
grooming, sight, headache, and dental caries. Public and medical awareness must rise over this topic
and new prevention measures must be found, starting with health Academic Editors: Ansgar Thiel,
Carey Mather and Paul B. Tchounwou Received: 25 July 2022 Accepted: 10 August 2022 Published:
12 August 2022 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published
maps and institutional affil iations. Copyright: © 2022 by the authors. Licensee MDPI, Basel,
Switzerland. This article is an open access article distributed under the terms and conditions of the
Creative Commons Attribution (CC BY) license (https:// [Link]/licenses/by/ 4.0/).
practitioners, caregivers, and websites/application developers. Pediatricians should be aware of the
risks associated to a problematic social media use for the young’s health and identify sentinel signs
in children as well as prevent negative outcomes in accordance with the family. Keywords: social
media; adolescents; children; social network; health; COVID-19 1. Introduction Media device use is
increasing year by year in Italy as well as in many other countries. An ISTAT report referred that in
2019, 85.8% of Italian adolescents aged 11–17 years regularly used smartphones, and over 72%
accessed Internet via smartphones [1]. Almost 95% of Italian families with a child had a broadband
internet connection [2]. Internet connection was mostly used to communicate with friends and to
use social networks [1]. In 2020, COVID-19 pandemic represented one of the greatest disruptions for
everybody’s everyday life, in Italy as well as all around the world. From the beginning of the
pandemic period, media device and Internet access rapidly increased. In line, a 2021 CENSIS report
revealed an even progressive increment of smartphone use by adolescents, which reached 95% [3].
In particular, the majority of adolescents (59%) admitted they use smartphone even more frequently
than in the past with a daily use of more than 3 h in 46% of cases. Adolescents connected Internet
alone (59%), consulting social media, mostly Instagram Int. J. Environ. Res. Public Health 2022, 19,
9960. [Link] [Link] Int. J. Environ.
Res. Public Health 2022, 19, 9960 2 of 33 (72%), TikTok (62%), and YouTube (58%) [4]. In this context,
social interaction over the Internet or simply social network consulting may play an important part in
the lives of many young people, influencing them and their relationship with self-esteem and well
being [5]. Not being guided and monitored in Internet fruition, the young may be exposed to several
risks, including cyberbullying which affects 7% of children aged 11–13 years and 5.2% of 14–17 years
old adolescents or stalking which affects more than 600 minors in Italy. Onsocial media, the young
are more vulnerable and may display risk behavior, including pertaining substance abuse, sexual
behaviors, or violence [6]. On the other hand, media and social networks are, actually, present in
almost any house and are considered a great resource for anybody, including children and
adolescents. Especially during “lockdown”, the Internet usage allowed communication with peers
and the continuity activities such as school teaching. Social media services enable various form of
communication verbally or visually by internet-based networking, bringing people together,
facilitating instant connection and interaction, such as a like or a comment on something [7]. There
was also a “school” use of smartphones and social media during lockdown which represented a tool
of information and education [8]. In line, websites and applications that enable users to create and
share content or to participate in social networking may be currently use as a definition of a social
media. Facebook launched in 2004 and Twitter in 2006 were the first social media introduced,
rapidly followed by many others [9]. Actually, Facebook with 2.9 billion monthly active users,
YouTube with 2 billion, Instagram with 1.5 billion, and TikTok with 1 billion are the most accessed
social media in the world [10]. As social media are spreading in every day’s life, regulatory models
are required to address a broad range of challenges social media pose to the community, including
privacy and protection of sensitive data. Mediausageis related to some adverse consequences
especially in the most vulnerable people. The health emergency had a strong impact on the mental
and psychological health of adolescents causing changing in their routine and daily activities. Forced
isolation increased anxiety and stress especially in the most fragile individuals, such as children and
adolescents, leading to a change in habitual lifestyles. The greatest risk was that of taking refuge in
excessive use of smartphones, electronic devices, and social networks, running into a “digital
overdose” [11]. Arecent survey conducted by the Italian Society of Pediatrics in collaboration with
State Police and [Link] investigated the relationship with media devices in times of pandemic,
investigating the habits of adolescents on the use of media and social net works, underlined that
15% of them declared they “cannot stay without” their own media device [1]. The aim of the review
is to focus on risks correlated to social media use by the young, identifying spies of rising problems,
and engaging in preventive recommendations. 2. Materials and Methods This scoping review has
been conducted by The Italian Pediatric Society Scientific Communication Group in order to provide
an overview of a complex research area. The aim is reviewing international literature disguising
about social media and their effect on the pediatric age, including minors less than 18 years, to
underline possible risks found so far, identifying the signs of a dangerous use, and to eventually give
new recommendation based on these findings. Wedefinearisk as the possibility of something
unfavorable happens, as an effect or an implication of social media usage and which may potentially
affect human health. This scoping review has been performed according to the PRISMA Extension
guidelines for Scoping Reviews [12]. An electronic search was undertaken on PubMed database on
23 January 2022. To avoid missing results that may be of note for our revision study, constructing
our search in PubMed, weused all of the important concepts from our basic clinical question,
avoiding unnecessary filters. Int. J. Environ. Res. Public Health 2022, 19, 9960 3 of 33 So, the search
terms “social media”, “health”, and “pediatrics” in text or title/abstract were used, with the time
span set as “all years”. The search on the selected database has produced n 651 among articles and
reviews. Another research was made using “social network”, “health” and “pediatrics” as search
terms in text or title/abstract, with the time span always set as “all years”. It resulted in 354
articles/reviews. The two research were downloaded from PubMed and then uploaded to the web
application “Rayyan” [13], a website used to screen and analyze articles, specific for writing reviews.
Additional articles for potential inclusion were identified in a second stage by hand searching the
reference lists in relevant articles. Studies were considered eligible for this scoping review if they
met the following inclusion criteria: Full-length articles or reviews.-------- Pertaining to children and
adolescents up to 18 years old. Negative impact on a pediatric population using social media. Social
media meant as forms of electronic communication. The exclusion criteria were: Reports not in
English. Duplications. Not pertinent field of investigation (e.g., use of the social media to promote
healthcare, benefits of social media, social media used to debate on health-related issues, and social
network meant as real social interactions). The population analyzed was adult (>18 years). The
population had previous pathologies. To reduce errors and bias, two researchers independently, two
researchers conducted the screening process to identify articles that met all inclusion criteria. Using
the web application “Rayyan”[13], duplicates wereremoved, thentitlesandabstractswereanalyzed to
exclude distinctly irrelevant articles. Finally, the eligibility of the articles was confirmed by evaluating
the full text. Disagreements regarding inclusion/exclusion were settled by discussion between the
researchers. Relevant articles were selected on the web application “Rayyan” and grouped together
based on the issue they were dealing with. Afterwards, data were compiled in a Microsoft Excel
spreadsheet to calculate frequencies and percentages of the problems related to social media use,
found in the research. 3. Results All the 1005 documents have been reviewed for relevance and
eligibility. AsshownintheFigure1, through the help of the web application “Rayyan” [13] we re
movedbefore screening 9 duplicates, 25 foreign language works, and 49 publications dated before
2004. We excluded paper published before 2004, the year of Facebook foundation, because before
that year “social networks” was a term used to mean “social interactions in real life”, as they were
not pertinent to our research. According to PRISMA guidelines [12], of the 922 works identified, all
abstracts were analyzed, and832recordswereexcluded.
Around66%oftheexcludedrecordsweredealing with other topics (e.g., vaccines, promoting health by
social media, social networks meant as real social interactions, and social lockdown during SARS-
CoV-2 period), a percentage of 28% of the records corresponded to a wrong population: mostly
parents, pregnant women, young adults, or children with pathologies (e.g., ADHD). About 6% of the
excluded studies used social media tools to recruit people in their studies or to deliver
questionnaires. In conclusion, 90 were the records to be analyzed reading their full-length articles.
The whole article of four of them has not been found (“reports not retrieved”), arriving at 86 reports
assessed for eligibility. Figure 1 presents the flow chart of the selection process, adapted from
PRISMA guideline [14] dies. Of the 86 reports attained, we read the whole length articles and then
excluded 20 studies. Of these twenty, 6 were excluded because not leading to any conclusion; 13
were dealing with wrong topics, such as: doctors’ social media knowledge; social lock down during
the pandemic; social media marketing; underage and privacy; survey on how social Of these twenty,
6 were excluded because not leading to any conclusion; 13 were dealing with wrong topics, such as:
doctors’ social media knowledge; social lock down during the pandemic; social media marketing;
underage and privacy; survey on how social media is perceived by adolescents; time consumed on
social media; predictor factors of problematic social media use. Finally, one was not included
because it focused on parents and families. media is perceived by adolescents; time consumed on
social media; predictor factors of problematic social media use. Finally, one was not included
because it focused on parents and families. Searching through the cited studies in the included
reports, two reviews which were not initially included in the research were added.
With68includedreports analyzed, there were 15 reviews; of these two were systematic reviews, one
validation study, and one editorial. Cross-sectional studies and longitudinal studies have been
considered, eight and nine, respectively. Manyarticles reported more than one issue correlated to
social media use. The most frequent problems involved mental health, followed by diet and weight
problems. Table 1 Int. [Link].PublicHealth2022,19,9960 5of33
showstheproblematictopicsfoundtoberelatedtosocialmediauseinchildrenand
adolescentsandtheirprevalence,expressedaspercentage,overthe68reportsanalyzed.

[Link]
foundinthisscopingreview.Depressionwasarguedin19reports,beingthemaintopicfound(27.9%
ofthewholestudy).Dietassociatedproblemswerediscussedin15reports,cyberbullyingin15,
psychologicalproblemsin14,sleeprelatedproblemsin13,addictionin10,anxietyin10,sexrelated
problemsin9,behavioralproblemsin7,bodyimagesdistortionin6,reducedphysicalactivityand
relatedproblemshasbeenreportedin5reports,onlinegroomingin3reports,sightproblemsin3,
alsoheadachein3,anddentalcariesintotalof2articles. Issue n % Depression 19 27.9% Diet 15 22.1%
Cyberbullying 15 22.1% PsychologicalProblems 14 20.6% Sleep 13 19.1% Addiction 10 14.7% Anxiety
10 14.7% SexRelated 9 13.2% BehavioralProblems 7 10.3% BodyImage 6 8.8% PhysicalActivity 5 7.4%
OnlineGrooming 3 4.4% Sight 3 4.4% Headache 3 4.4% DentalCaries 2 2.9%
Themostfrequentproblemsfoundarerelatedtomentalhealth:depression,anxiety, andaddiction.
Otherproblemsarerelatedtosleep,dietandnutrition,cyberbullying,psychologi
calaspects,behavioralproblems, sex,bodyimageperception,physicalactivity,online
grooming,sight,headache,anddentalcaries. [Link] [Link]
Weidentified19publicationsreportingarelationshipbetweensocialmediauseand depression[15–
33].[Link]
them,fourinvestigatedtheimpactofCOVID19pandemiconbothsocialmediauseand depression(Table2).
[Link]. Domains Reference TypeofPublication Highlighted Depression
Addiction Anxiety [Link]. [15] Clinicalstudy Socialmediaincreasedusecorrelatesto
EmergencyDepartmentvisitsformentalillness, includingdepression,addiction,andanxiety. Depression
Anxiety [Link]. [16] Clinicalstudy Socialmediausecorrelateswithdepressive
symptoms,anxiety,[Link] activitynegativelycorrelateswithdepression. Depression
Psychologicalproblems Addiction Anxiety Bodyimage [Link]. [17] Review
Highlevelsofscreentimeandsocialmediause correlatestodepression,anxiety,and
misperceptionofbodyimage,addiction,and mentalhealthoutcomes. Int. J. Environ. Res. Public Health
2022, 19, 9960 6 of 33 Table 2. Cont. Domains Reference Type of Publication Highlighted Depression
Sleep Anxiety Hoge E. et al. [18] Review The more time adolescents spend on smartphone, the
higher levels of depression, insomnia, and anxiety are found one year later. Depression Hoare E. et
al. [19] Clinical study Adolescents suffering for depression and mental health impairment in
adolescence reported a greater use of social media. Depression HaL. et al. [20] Clinical study Swedish
adolescents who spent more than 2 h on social media had higher odds of feeling depressed.
Depression Diet Cyberbullying Sleep Sex related problems Online grooming Risks of media device
use include obesity, sleep, attention, and learning impairment, Chassiakos Y.L.R. et al. [21] Review
illicit substance use, high-risk sexual behaviors, depression, cyberbullying, and compromised privacy
and confidentiality. Depression Cyberbullying Sleep Anxiety Sex related problems Behavioral
problems Sight Maurer B.T. et al. [22] Review Anincrease in digital and social media use relates to
physical and mental status impairment in children, including depression, anxiety, cyberbullying,
sleep disturbance, behavioral problems, sexting, and myopia. Depression Psychological problems
Anxiety Keles B. et al. [23] Review Time spent on social media, repetitive activities, addictive, or
problematic use associated with depression, anxiety, and psychological impairment. Nevertheless, it
is not possible to establish whether a causative effect exists. Depression Addiction Khalil S.A. et al.
[24] Clinical Study Apercentage of 65.6% of Egyptians adolescents are having internet addiction,
especially Facebook addiction (92.8%) and gaming (61.3%). Those affected by Facebook addiction
are at risk of dysthymia. Depression Cyberbullying Body image Richards D. et al. [25] Review Social
media overuse impacts on mental health, self-esteem, and wellbeing. Depression Cyberbullying
Sleep Sex related problems Hadjipanayis A. et al. [26] Review Social media use facilitates
socialization, communication, learning skills, and may positively affect education. Potential risks
include cyberbullying, Facebook depression, sleep disturbances, and sexting. Depression
Cyberbullying [Link]. [27] Review Cyberbullying and depression correlate with a regular and
constant social media use. Depression Cyberbullying Carpenter L.M. et al. [28] Review Internet,
mobile devices, and social networking sites link to mental health impairment and cyberbullying.
Depression Cyberbullying Aboujaoude E. et al. [29] Review Internet penetrance and connectivity are
strictly related to cyberbullying and altered mental status. Depression Listernick Z.I. et al. [30]
Review Depressive symptoms increased during COVID-19 pandemic era. Risk factors include social
isolation, family stress, and social media overuse. Int. J. Environ. Res. Public Health 2022, 19, 9960 7
of 33 Table 2. Cont. Domains Reference Type of Publication Highlighted The degree of social media
usage in children Depression Sleep Anxiety correlates with depression, anxiety, and perceived
Armitage R.C. et al. [31] Letter to editor stress level. Bedtime access to and use of mobile devices is
significantly associated with inadequate sleep in terms of quality and quantity. Depression Anxiety
Manyfactors including isolation, excessive social Caffo E. et al. [32] Review media use, and parental
stress worsened mental status health during COVID-19 era. Depression Psychological problems
Anxiety Chen I.H. et al. [33] Review During school closure in COVID-19 pandemic smartphone and
social media use increased. An increase of 15–30 min daily negatively influenced mental health
status in children. 4.1.1. Before COVID-19 Pandemic Investigating the impact of social media on
adolescents’ wellbeing is a priority due to a progressive increase in mental health problems or
addiction and access to Emergency Department [15]. As Chiu and Rutter stated, there is a positive
relationship between internalizing symptoms, such as depression and anxiety, and social media use
[15,16]. Depression is connected to a rapidly increased of digital communication and virtual spaces,
which substitute face-to-face contact by excessive smartphone use and online chatting. The more
time adolescents spend on social device the higher levels of depression are found out. In this sense,
social media are representing a risk factor for depression in the young. Depression, anxiety, and
behavioral disorders are among the leading causes of illness and disability among adolescents [15–
22]. Key findings which correlate to depression regarding social media exposure are repeated
activities such as checking messages, investment, and addition [23]. The findings were similar all
over the world. For example, in Sweden, spending more than 2 h on social media was associated
with higher odds of feeling [20]. In Egypt, as well, students who have problematic Inter net use, have
higher psychiatric comorbidities, such as depression, anxiety, and suicidal tendency [24]. Social
media addiction and more precisely Facebook addiction was linked not only to depression but
eventodysthymia, sothattheexpression “Facebookdepression”wascoined to identify a relationship
between depression and social networking activity [15,25,26]. Individuals suffering from Facebook
depression may be at an increased risk of social isolation and may be more vulnerable to drugs or
behavioral problems [26]. Internet penetrance and connectivity are also connected to cyberbullying
which can lead to depression and suicidality [27–29]. Onthe other side, physical activity may
decrease depression and anxiety, potentially protecting the young against the harmful effect of
social media abuse [16]. At last, even if a positive correlation between internalizing symptoms and
media use device is noted, Hoge states that there is also evidence that social media communication
mayimprove moodandpromote health strategies in some occasions [18]. Finally, even if evidence
revealed that social media use is linked to poor mental health, the relationship between social media
and depression in adolescents is still to be completely understood. It is still unclear whether social
media use leads to more depression or if these depressive symptoms cause individuals to seek out
more social media, which could feed into a vicious cycle [16]. Keles’s conclusion as well suggest
defining the relationship between internalizing symptoms and social media use as an association and
not a causative effect [23]. Int. J. Environ. Res. Public Health 2022, 19, 9960 8 of 33 4.1.2. After
COVID 19 Pandemic During COVID-19 pandemic, the state of emergency and social isolation
determined an increase in time on screen not only as a source of online education, but to
continuously access social media. According to recent data, a percentage of 48% of adolescents
spent a mean of 5hperdayonsocial media and 12% spent more than 10 h. Moreover, with that
increase in virtual time depression arose [30]. The degree of social media usage in children is a
significant predictor of depression, which increases with each additional hour of social media use
[31]. During the pandemic, depressive symptoms may have been reactive to the context of being
afraid of the virus and necessitating social isolation [32]. However, in this peculiar period,
schoolchildren who increased time spent on either smartphones, social media, or gaming had
significantly elevated psychological distress, such as depressive symptoms, than those with
decreased time spent on these internet related activities [33]. 4.2. Social Media and Diet Out of the
reports, 15 dealt with the association of social media use and diet [21,34–47].
Theproblemswererelatedtojunkfoodmarketing(9reports)[34–41]obesity(4 reports) [21,41–43],
unhealthy eating behaviors (3 reports) [44–46], and alcohol marketing (2 reports) [21,47]. In Table 3
the retrieved articles dealing with social media and diet, and their major findings are presented
(Table 3). Table 3. Social media and diet. Domains Reference Type of Publication Highlighted
Depression Diet Cyberbullying Sleep Sex related problems Online grooming Chassiakos Y.L.R. et al.
[21] Review Risks of media device use include obesity, sleep, attention, and learning impairment,
illicit substance use, high-risk sexual behaviors, depression, cyberbullying, and compromised privacy
and confidentiality. Diet Théodore F.L. et al. [34] Clinical Study Digital Marketing represents a major
threat for children and adolescents in Mexico, because of its persuasive techniques. Diet Dental
Caries Radesky J. et al. [35] Clinical Study Exposure to advertising is associated with unhealthy
behaviors. Children are uniquely vulnerable to the persuasive effects of advertising because of
immature critical thinking skills and impulse inhibition. Ads also promote intake of foods that
contribute to dental caries. Unhealthy food is advertised intensively on Diet Folkvord F. et al. [36]
Review several media platforms that are increasingly used by children. This contributes to the
obesity epidemic. Exposure to the marketing of unhealthy products, on social media is associated
with a Diet Sacks G. et al. [37] Clinical Study higher risk of related unhealthy behaviors. Analysis of
the advertising policies of the 16 largest social media platforms proved them ineffective in protecting
children and adolescents from exposure to the digital marketing of unhealthy food. Int. J. Environ.
Res. Public Health 2022, 19, 9960 9 of 33 Table 3. Cont. Domains Reference Type of Publication
HDomains Reference Type of Publication Highlighted Diet Tan L. et al. [38] Clinical Study Unhealthy
food marketing to children is a key risk factor for childhood obesity. Analysis of ads encountered in
YouTube videos targeted at children revealed that food and beverage ads appeared most frequently
with more than half of these promoting noncore or unhealthy foods. Diet Murphy G. et al. [39]
Clinical Study Adolescents respond more positively to unhealthy food advertising compared to
healthy food or non-food advertising. Diet Lutfeali S. et al. [40] Clinical Study Heavy social media
users (>3 h/day) were 6.366 times more willing to comment on ads compared to light users (p <
0.001). Diet Khan [Link] al. [41] Clinical Study The food industry has intensified online advertising
focused on children during COVID-19 pandemic, helping the widespread of weight gain. Diet
Khajeheian D. et al. [42] Clinical Study Students, in primary school and high school, who spend more
time using social media, exhibit a greater increase in BMI. Diet Sleep Mazur A. et al. [43] Clinical
Study Obesity correlated to junk food advertisement and a more sedentary lifestyle promoted by
social media use. Poor or deregulated sleep affects the regulation of energy balance representing a
risk factor for childhood obesity. Raising in the presence of pro-eating disorder Diet Custers K. et al.
[44] Review content on websites and social media, which correlates of eating disturbances. Diet
Cyberbullying Psychological problems Body image Physical activity Borzekowski D.L.G. et al. [45]
Review Constant media access and exposure to unhealthy and risky media messages may increase
the interactions, facilitating cyberbullying and exacerbating body image apprehension promoting
poor nutrition, psychological problems, and leading to a more sedentary lifestyle. Diet Body image
Greater use the internet sources for MoormanE.L. et al. [46] Clinical Study nutritional information is
related to greater disordered eating. Diet Sleep Online grooming Purves R.I. et al. [47] Clinical Study
Alcohol brands on social media portray drinking identities, appealing for young adolescent and with
the potential risk to peer group acceptance. 4.2.1. Before COVID-19 Pandemic Junk Food Marketing
Reports found that children are exposed to the marketing of unhealthy foods on social media and to
their persuasive techniques. Digital marketing represents a major threat for children and adolescents
in Mexico, because of its persuasive techniques. Cola and soft drinks, sweetened juices and in
general the so-called junk food have high followers on Facebook and Twitter. [34]. This may cause an
increase in children’s immediate consump tion of the promoted product, unhealthy behaviors and
may led to obesity, as confirmed by several studies [34–36]. Reports agree on the youth major
vulnerability to unhealthy food Int. J. Environ. Res. Public Health 2022, 19, 9960 10 of 33
advertisement, including digital marketing, sponsored content, influencers, and persuasive design
[34–36]. This contributes to the obesity epidemic [36]. Major social media platforms do not have
comprehensive policies in place to restrict the marketing of unhealthy foods on their platforms
[36,37]. Therefore, exposure to the marketing of unhealthy products, on social media may be
considered a risk factor for related unhealthy behaviors. Analysis of the advertising policies of the 16
largest social media platforms proved them ineffective in protecting children and adolescents from
exposure to the digital market ing of unhealthy food [37]. Among social media, YouTube is
particularly worrying considering the affinity of the young toward the platform. Unhealthy food
advertisements predominate in YouTube content aimed towardschildren. In fact, analysis of
advertisements encountered in YouTube videos targeted at children revealed that food and
beverage ads appeared most frequently, with more than half of these promoting unhealthy foods
[38]. As confirmed by an Irish study, adolescents are very attracted to junk food adver tisements and
are likely to share comments on their network: generalized linear mixed models showed that
advertisements for unhealthy food evoked significantly more positive responses, compared to non-
food and healthy food. Of all the advertising, they see in social media, they view unhealthy food
advertising posts for longer [39]. This confirms the vulnerability of children towards ad and digital
marketing. Moreover, it has been demonstrated that adolescent heavy social media users (>3 h/day)
are more willing to engage with food ads compared to light social media users, and are more willing
to “like” Instagram food ads featuring many “likes” versus few “likes”, demonstrating the power of
social norms in shaping behaviors. Adolescents interact with brands in ways that mimic interactions
with friends on social media, which is concerning when brands promote unhealthy product. [40].
There is a need of more strict policies to limit digital marketing, which is becoming more and more
intense, especially towards children and adolescents. 4.2.2. After COVID-19 Pandemic During the
COVID-19 pandemic, this phenomenon even increased. In fact, the combi nation of staying at home,
online education and social media usage have all caused screen time to surge and the food industry
has been quick to identify this change in their target audience and has intensified online advertising
and focused on children. The COVID-19 experience led to an increase in risk and severity of
inappropriate behavioral eating habits, affecting the health and weight [41]. 4.2.3. Before COVID-19
Pandemic Obesity Social media is the first independent risk factor for obesity in primary school
children and the second for high school students. In both primary school and high school models,
children’s social media use has the highest impact on child’s BMI [42]. In addition, heavy media use
during preschool years is associated with small but significant increases in BMI, especially if used 2 h
of media per day [21]. 4.2.4. After COVID-19 Pandemic Obesity and social media correlated through
junk food advertisements [41,43]. During COVID 19 pandemic poor quality food, energy-dense, and
nutrient-poor products con sumption increased, leading to the risk of overweight and obesity. The
phenomenon has been called “Covibesity” [41]. 4.3. Unhealthy Eating Behavior Some social media
contents promote pro-anorexia messages [44–46]. These messages are no longer limited to websites
that can be easily monitored, but instead have been Int. J. Environ. Res. Public Health 2022, 19, 9960
11 of 33 transferred to constantly changing media such as Snapchat, Twitter, Facebook, Pinterest,
and Tumblr. Consequently, pro-eating disorder content has become more easily accessible by the
users. Pro-anorexia website use is correlated with a higher drive for thinness, lower evaluations of
their appearance, and higher levels of perfectionism, and all correlates with eating disturbances
[44,46]. In detail, there is a real bombardment of unhealthy messages on media promoting low-
nutrition aliments and sugar-sweetened drinks [45]. It is likely that the suboptimal quality of online
information on social media platform contributes to the development of unhealthy eating attitudes
and behaviors in young ado lescent internet users seeking nutritional information. They look for
nutritional information on internet sources such as commercial websites or social media in order to
lose weight. In this occasion, they may be exposed to higher risk of eating disorders due to the high
quantity of misinformation. Moreover, they may find dangerous methods to rapidly lose weight with
possible harm for their health [46]. Literature agrees on the risk of time spent on social media as well
as on the poor quality and reliability of weight loss information on media [44–46]. 4.4. Alcohol
Marketing Adolescents identify drinking brands to peculiar images of ideal adults. Brands know well
this underlying psychological mechanism and promote that identity adolescents seek, with specific
advertisement on social media [47]. Studies have shown that exposure to alcohol in TV or movies is
associated with initiation of this behavior. The major alcohol brands have a strong advertising
presence on social media, including Facebook, Twitter, and YouTube. Several studies underlined
risky health behaviors, such as illegal alcohol use or overuse. Evidence suggests that peer viewers of
this content are likely to consider these behaviors as normative and desirable. Therefore, targeted
advertising via social media has a significant effect on adolescent behavior [21]. 4.5. Social Media
and Cyberbullying Weidentified 15 publications reporting a relationship between social media use
and cyberbullying [21,22,25–29,45,48–54]. Table 4 summarized the main finding regarding each
article (Table 4). Table 4. Social media and cyberbullying. Domains Reference Type of Publication
Highlighted Depression Diet Cyberbullying Sleep Sex related problems Online grooming Chassiakos
Y.L.R. et al. [21] Review Risks of media device use include obesity, sleep, attention, and learning
impairment, illicit substance use, high-risk sexual behaviors, depression, cyberbullying, and
compromised privacy and confidentiality. Depression Cyberbullying Sleep Anxiety Sex related
problems Behavioral problems Sight Maurer B.T. et al. [22]. Review Anincrease in digital and social
media use relates to physical and mental status impairment in children, including depression,
anxiety, cyberbullying, sleep disturbance, behavioral problems, sexting, and myopia. Depression
Cyberbullying Body image Richards D. et al. [25] Review Social media overuse impacts on mental
health, self-esteem, and wellbeing. Int. J. Environ. Res. Public Health 2022, 19, 9960 12 of 33 Table 4.
Cont. Domains Reference Type of Publication Highlighted Depression Cyberbullying Sleep Sex related
problems Hadjipanayis A. et al. [26] Review Social media use facilitates socialization, communication,
learning skills, and may positively affect education. Potential risks include cyberbullying, Facebook
depression, sleep disturbances, and sexting. Depression Cyberbullying [Link]. [27] Review
Cyberbullying and depression correlate with a regular and constant social media use. Depression
Cyberbullying Carpenter L.M. et al. [28] Review Internet, mobile devices, and social networking sites
link to mental health impairment and cyberbullying. Depression Cyberbullying Internet penetrance
and connectivity are Aboujaoude E. et al. [29] Review strictly related to cyberbullying and altered
mental status. Diet Cyberbullying Psychological problems Body image Physical activity Borzekowski
D.L.G. et al. [45] Review Constant media access and exposure to unhealthy and risky media
messages may increase the interactions, facilitating cyberbullying and exacerbating body image
apprehension promoting poor nutrition, psychological problems, and leading to a more sedentary
lifestyle. Cyberbullying Wise J. et al. [48] Letter to Editor Potential negative effects of social media
include damage to sleep patterns, cyberbullying, and online grooming. Cyberbullying Psychological
problems Sleep Addiction Behavioral problems Physical activity Sight Bozzola E. et al. [49] Review
Cyberbullying, sleep impairment, psychological problems, addiction, musculoskeletal disorders, and
eye problems are among the risks of media device use in adolescence. Cyberbullying Sex related
problems Body image Shah J. et al. [50] Review Increased social media usage correlates with
decreased self-esteem and body satisfaction, increment of cyberbullying, and exposure to
pornographic material and risky sexual behaviors. Cyberbullying Addiction Sex related problems
O’Keeffe G.S. et al. [51] Editorial Risks of social media overuse include sexting, cyberbullying, privacy
issues, and Internet addiction, all of which may present with vague health symptoms. Cyberbullying
Psychological problems Addiction Nagata J.M. et al. [52] Editorial More than 7% of adolescents have
problematic media use and addiction to social media. Problematic media use is associated with
cyberbullying, poor outcomes in life satisfaction, and mental health. The risk of cyber-victimization is
higher in Cyberbullying Marengo N. et al. [53] Clinical study case of problematic social media use and
in female gender. Cyberbullying Uludasdemir D. et al. [54] Clinical study Having daily access to the
Internet and the sharing of gender on social media increased the likelihood of cyber victimization.
Int. J. Environ. Res. Public Health 2022, 19, 9960 13 of 33 Cyberbullying may be defined as
anybehavior performed through electronic or digital
mediabyindividualsorgroupsthatrepeatedlycommunicatehostileoraggressivemessages intended to
inflict harm or discomfort on others. Compared to bullying, cyberbullying may be even more
dangerous as victims can be reached anytime and in any place. Moreover, anonymity amplifies
aggression as the perpetrator feels out of reach. Moreover, the ability to hide behind fake names
provides bullies the opportunity to communicate in content and language they would not use in
front of people [26,48,49]. As
confirmedbyShahetal.,theanonymityofcyberbullyingincreasestheriskforinappropriate behaviors
among adolescents [50]. In literature, cyberbullying has been identified in phone calls, text
messages, pic tures/video clips, emails, and messaging apps. This is a great public health concern: in
Italy, 2015 ISTAT data showed that 19.8% of 11–17 years old internet users report being cyberbullied
[49]. This phenomenon is increasing. In fact, the number of adolescents being cyberbullied at least
once in their life increased from 20.8% in 2010 to 33.8% in 2016 [50]. Victims of bullies exhibit
increased depressive symptoms, anxiety, internalizing be haviors, externalizing behaviors, and
greater academic distractions [21,22,25,27–29,51]. Cyberbullying has been associated with higher
risks of depression, paranoia, anxiety, and suicide than the traditional form of bullying [21,22].
According to a metanalysis of 34 studies, traditional bullying increased suicide ideation by a factor of
2.16, whereas cyberbullying increased it by a factor of 3.12 [39]. In adolescence, social media intense
or problematic use and frequent online contact with strangers are all independently associated with
cyberbullying [45,52,53]. In this contest, social media represent a risk factor for cyberbullying and for
inappropriate behavior related to it. In fact, problematic social media use is an important driver of
cyberbullying victimization and perpetration, especially among girls [50,53]. The highest percentage
is observed in adolescents, aged 13 to 15 years as suggested by literature reviews and, in particular,
by Marengo and Uludasdemir [53,54]. However, Marengo also suggests that in presence of social
support, the phenomenon is attenuated [53]. Moreover, having daily access to the Internet and the
sharing of gender on social media increased the likelihood of cyber victimization among adolescents
aged 12–17 years. Those whouse Tumblr and Snapchat were found to become victims even more
frequently [54]. 4.6. Psychological Problems and Social Media Weidentified 14 publications reporting
a relationship between social media use and psychological problems [17,23,33,45,49,52,55–62].
Table 5 summarized the main finding regarding each article (Table 5). Table 5. Social media and
psychological problems. Domains Reference Type of Article Highlighted Depression Psychological
problems Addiction Anxiety Body image Mougharbel F. et al. [17] Review High levels of screen time
and social media use correlates to depression, anxiety, misperception of body image, and mental
health outcomes. Depression Psychological problems Anxiety Keles B. et al. [23] Review Time spent
on social media, repetitive activities, addictive, or problematic use associated with depression,
anxiety, and psychological impairment. Nevertheless, it is not possible to establish whether a
causative effect exists. Int. J. Environ. Res. Public Health 2022, 19, 9960 14 of 33 Table 5. Cont.
Domains Reference Type of Article Highlighted Depression Psychological problems Anxiety Chen I.H.
et al. [33] Review During school closure in COVID-19 pandemic smartphone and social media use
increased. Anincrease of 15–30 min daily negatively affected mental health status in children. Diet
Cyberbullying Psychological problems Body image Physical activity Borzekowski D.L.G. et al. [45]
Review Constant media access and exposure to unhealthy and risky media messages may increase
the interactions, facilitating cyberbullying and exacerbating body image apprehension promoting
poor nutrition, psychological problems, and leading to a more sedentary lifestyle. Cyberbullying
Psychological problems Sleep Addiction Behavioral problems Physical activity Sight Bozzola E. et al.
[49] Review Cyberbullying, sleep impairment, psychological problems, addiction, musculoskeletal
disorders, and eye problems are among the risks of media device use in adolescence. More than 7%
of adolescents have problematic Cyberbullying Psychological problems Addiction Nagata J.M. et al.
[52] Editorial media use and addiction to social media. Problematic media use is associated with
cyberbullying, poor outcomes in life satisfaction, and mental health. Psychological problems Favotto
L. et al. [55] Clinical study Children with low family communication have high levels of media use and
loneliness. Psychological problems Boer M. et al. [56] Clinical study Data among 154,981 adolescents
of the world, described that problematic media use is associated with lower well-being.
Psychological problems Sleep Physical activity Buda G. et al. [57] Clinical study Problematic social
media use correlates with about two times higher odds for worse sleep quality and lower life
satisfaction, and it is related to lower levels of vigorous physical activity in girls. Psychological
problems McDoolE. et al. [58] Clinical study Among6300 English students, internet use is negatively
associated with feel about appearance, especially in girls. Psychological problems Twigg L. et al. [59]
Clinical study Higher levels of social media use are associated with lower happiness, especially in
girls. Problematic social media use such as substance Psychological problems Walsh S.D. et al. [60]
Clinical study use, bullying, and low social support, have been identified as clusters of risk for
children mental health. Psychological problems Sleep Sümen A. et al. [61] Clinical study Social media
addiction in school students is related with lower communication among families, loneliness,
emotional problems, attention deficit, peer problems, and it decreases students’ sleep efficiency.
Psychological problems Headache Marino C. et al. [62] Clinical study Adolescent problematic
Internet users have higher levels of somatic symptoms such as headaches and psychological
consequences of social media use such as loss of control and relational problems with family and
friends. Int. J. Environ. Res. Public Health 2022, 19, 9960 15 of 33 4.6.1. Before COVID-19 Pandemic
Ahigh use of screen device has been correlated to a low psychological well-being among children
and adolescents, especially among females [17]. For examples, in Canadians adolescents, the
prevalence of loneliness was higher for daily computer-mediated communication users than non-
daily users [55]. As well as for cyberbullying, adolescents may benefit from social support, family
communication, and interaction to ameliorate feelings of loneliness [53,55]. Boer et al. confirmed
that intense user reported more frequent psychological complaints than non-intense user as well as
less family and friend support [56]. In line with this finding, in Lithuania a problematic social media
use has been associated with two times higher odds for lower life satisfaction [57]. Moreover, an
intense social media use correlated to either low school well-being and reduced social well-being
(decreased family and friends support and relations) [56]. Arelationship between poor life
satisfaction, problematic social media use, and lack of social support was found not only in
adolescents, but also in children [52,57–60]. Social media use is also correlated with conduct and
emotional problems, attention deficit, peer problems, school impairments, and psychological
distress [23,45,61,62]. Social networks and media device use correlate to low academic outcomes,
reduced concentration, and procrastination. In fact, problematic smartphone use correlates to a
surface approach to learning rather than to a deep approach, leading to reduced creativity,
organization skills, own thinking, and comprehension of information [49]. 4.6.2. After COVID-19
Pandemic During this COVID-19 pandemic, primary school children reported significantly higher
psychological distress than the period prior to the COVID-19 outbreak. Studies showed that
schoolchildren who increased time spent on either smartphones, social media, or gaming had
significantly elevated psychological distress than those with decreased time spent on these internet-
related activities [33]. 4.7. Social Media and Sleep Extended use of digital media screen time
correlates with sleep impairment [18,21,22, 26,31,43,47,49,57,61,63–65]. Table 6 summarizes the
evidence in literature (Table 6). Expo sure to screen-based devices, online social networking sites,
and video-sharing platforms is significantly associated with sleep-onset difficulties in adolescents
[18,49]. Findings from a meta-analysis of 20 cross-sectional studies show 53% higher odds of poor
sleep quality among adolescents with consistent bedtime media use [63]. Moreover, the use of
computers and smartphones among adolescents is associated with daytime sleepiness and fatigue,
shorter sleep duration, later bedtime, and unfavorable changes in sleep habits over time [22].
Smartphones may be easily carried around and even taken to bed. Several sleep disorders correlate
to both overall and night phone use among adolescents. It has been demonstrated that social media
addiction in school students decreases students’ sleep efficiency [61]. Use of cellphones, particularly
for nighttime texting, and consulting social media were associated with insufficient sleep [63]. A 5 or
more hours daily of media devices use has been related to a higher risk of sleep problems when
compared to a 1 h use daily [49]. This finding is confirmed by Buda who correlates problematic social
media with about two times higher odds for a bad sleep quality [57]. Varghese as well associated
social media use with sleep difficulties. Furthermore, YouTube user had two-times higher odds for
sleep-onset difficulties [63]. In addition, it seems that girls suffer more than boys from these sleep
problems [57]. Sleeping problems, especially sleep duration, have been then associated with time
spent on screen, problematic behaviors, and higher internalizing and externalizing symp toms [64].
Int. J. Environ. Res. Public Health 2022, 19, 9960 16 of 33 Table 6. Social media and sleep. Domains
Reference Type of Article Highlighted Depression Sleep Anxiety The more time adolescents spend on
smartphone, the Hoge E. et al. [18] Review higher levels of depression, insomnia, and anxiety are
found one year later. Depression Diet Cyberbullying Sleep Sex related problems Online grooming
Chassiakos Y.L.R. et al. [21] Review Risks of media device use include obesity, sleep, attention, and
learning impairment, illicit substance use, high-risk sexual behaviors, depression, cyberbullying, and
compromised privacy and confidentiality. Depression Cyberbullying Sleep Anxiety Sex related
problems Behavioral problems Sight Maurer B.T. et al. [22]. Review Anincrease in digital and social
media use relates to physical and mental status impairment in children, including depression,
anxiety, cyberbullying, sleep disturbance, behavioral problems, sexting, and myopia. Depression
Cyberbullying Sleep Sex related problems Hadjipanayis A. et al. [26] Review Social media use
facilitates socialization, communication, learning skills, and may positively influence education.
Potential risks include cyberbullying, Facebook depression, sleep disturbances, and sexting. The
degree of social media usage in children correlates Depression Sleep Anxiety Armitage R.C. et al. [31]
Letter with depression, anxiety, and perceived stress level. Bedtime access to and use of mobile
devices is significantly associated with inadequate sleep in terms of quality and quantity. Obesity
correlated to junk food advertisement and a Diet Sleep more sedentary lifestyle promoted by social
media use. Mazur A. et al. [43] Clinical study Poor or deregulated sleep affects the regulation of
energy balance representing a risk factor for childhood obesity. Diet Sleep Online grooming Purves
R.I. et al. [47] Letter Potential negative effects of social media include damage to sleep patterns,
cyberbullying, and online grooming. Cyberbullying Psychological problems Sleep Addiction
Behavioral problems Physical activity Sight Bozzola E. et al. [49] Review Cyberbullying, sleep
impairment, psychological problems, addiction, musculoskeletal disorders, and eye problems are
among the risks of media device use in adolescence. Psychological problems Sleep Physical activity
Buda G. et al. [57] Clinical study Problematic social media use correlates with about two times higher
odds for worse sleep quality and lower life satisfaction, and it is related to lower levels of vigorous
physical activity in girls. Social media addiction in school students is related Psychological problems
Sleep Sümen A. et al. [61] Clinical study with lower communication among families, loneliness,
emotional problems, attention deficit, peer problems, and it decreases students’ sleep efficiency.
Sleep Varghese N.E. et al. [63] Clinical study Exposure to media device and social media is
significantly associated with adolescent sleep-onset difficulties. Int. J. Environ. Res. Public Health
2022, 19, 9960 17 of 33 Table 6. Cont. Domains Reference Type of Article Highlighted Sleep
Behavioral problems Guerrero M.D. et al. [64] Clinical study Time spent on screen has been
associated to sleeping problems, especially sleep duration, and with problematic behaviors, higher
internalizing, and externalizing symptoms. Sleep Lund L. et al. [65] Review Relationship between
social media use, late sleep onset, sleep quality, and duration. Even among children, there is a
problem with extended use of social media sites, which result in sleep deprivation due to delayed
bedtimes and reduced total sleep duration and quality of rest [31,65]. The report by Hadjipanayis as
well confirms that sleeping disturbances may be associated with the disruption of circadian rhythms
due to the blue light emission from the electronic screen-based media devices [26]. Negative
outcomes including poor school performance, childhood overweight and obesity, and emotional
issues have all been associated with sleep deprivation [21,26,43,47]. Inadequate sleep quality or
quantity associated to social media use represents a risk factor for metabolic conditions such as for
diabetes, cardiovascular disease and for mental problem, such as depression or substance abuse
[49]. 4.8. Social Media and Addiction Ten reports found correlations between social media use and
risk of different types of addictions: with internet [17,24,49,51,52,66], with substance abuse [15,67],
with alcohol addiction and gaming [67], with gambling [68], and with tobacco use [69]. In Table 7,
the major findings of the related reports are presented (Table 7). Table 7. Social media and
addiction. Domains Reference Type of Article Highlighted Depression Addiction Anxiety Chiu M. et al.
[15] Clinical Study Social media increased use correlates to Emergency Department visits for mental
illness, including depression, addiction, and anxiety. Depression Psychological problems Addiction
Anxiety Body image High levels of screen time and social media use Mougharbel F. et al. [17] Review
correlates to depression, anxiety, and misperception of body image, addiction, and mental health
outcomes. Depression Addiction Khalil S.A. et al. [24]. Clinical Study Apercentage of 65.6% of
Egyptians adolescents are having internet addiction, especially Facebook addiction (92.8%) and
gaming (61.3%). Those affected by Facebook addiction are at risk of dysthymia. Cyberbullying
Psychological problems Sleep Addiction Behavioral problems Physical activity Sight Bozzola E. et al.
[49] Review Cyberbullying, sleep impairment, psychological problems, addiction, musculoskeletal
disorders, and eye problems are among the risks of media device use in adolescence. Cyberbullying
Addiction Sex related problems O’Keeffe G.S. et al. [51] Editorial Risks of social media overuse
include sexting, cyberbullying, privacy issues, and Internet addiction, all of which may present with
vague health symptoms. Int. J. Environ. Res. Public Health 2022, 19, 9960 18 of 33 Table 7. Cont.
Domains Reference Type of Article Highlighted Cyberbullying Psychological problems Addiction
Nagata J.M. et al. [52] Editorial More than 7% of adolescents have problematic media use and
addiction to social media. Problematic media use is associated with cyberbullying, poor outcomes in
life satisfaction, and mental health. The Digital Addiction Scale for Children was validated on 822
participants, to assess the behavior of Addiction Hawi N.S. et al. [66] Clinical Study children 9 to 12
years old in association with video gaming, social media, and texting. Females are more susceptible
to social media addiction. Addiction Turhan P. et al. [67] Clinical Study Amongagroupof93adolescents
with substance abuse, social media addiction and gaming disorders have been documented more
than control group. Addiction [Link] al. [68] Review Gambling and gaming addiction are
emerging problems in children and adolescents. Children are exposed to gambling adverts using
media device and television. Moreover, social media sometimes promotes gambling. Addiction
Unger J.B. et al. [69] Clinical Study Tobacco use in adolescents correlates to tobacco content on
social media. In particular, adolescents with more tobacco tweets were more likely to use cigarettes.
Advertising messages about tobacco shared trough social media have been connected to tobacco
use in adolescents. Investigating the impact of social media on adolescents’ wellbeing is a priority
due to a progressive increase in mental health problems and access to Emergency Department [15].
Chiu reported that mental health or addiction related emergency department access in creased by
almost 90% in ten years mainly among adolescents aged 14–21 years. The increment well correlates
to an increase availability of social media [15]. High screen use associated with internet addiction is
also confirmed by O’Keeffe who states that technology is influencing children’s lives from a very
young age [51]. More than 7% of youth have problematic social media use, indicated by symptoms
of addiction to social media [52]. Warning signs of internet addiction can be skipping activities,
meals, and homework for social media; weight loss or gain; a reduction in school grades [41]. In
detail: concern, loss of controlling tolerance, withdrawal, instability and impulsiveness, mood
modification, lies, and loss of interest have been identified as risk fac tors for smartphone addiction.
Females have almost three times more risk for smartphone addiction than males and it may be
related to a stronger desire for social relationships [66]. Main problems correlated to addiction are
low self-esteem, stress, anxiety, depression, insecurity, solitude, and poor scholastic outcomes.
Smartphone addiction correlates to both fear of missing out (FOMO) and boredom. FOMO is the
apprehension of losing experiences and the consequent wish to remain constantly connected with
others, continu ously checking social applications. Boredom is defined as an unpleasant emotional
state, related to lack of psychological involvement and interest associated with dissatisfaction, to
cope with boredom adolescents may seek additional stimulation and compulsively use smartphones
[49]. As well as O’Keeffe, Hawi found out that children are starting to use digital devices at a very
young age, and so should be screened for the risk of digital addiction. New scales of early
identifications have been developed such as the Digital Addiction Scale for Children, validated to
assess the behavior of children 9 to 12 years old in association with digital devices usage. Out of the
sample size, 12.4% were identified as at risk of addiction and Int. J. Environ. Res. Public Health 2022,
19, 9960 19 of 33 most of them (62.4%) were male. Nevertheless, results demonstrated that
weekday device use among females causes more conflicts [66]. Different grading scales can test
addictions. A study assessed 700 adolescents aged from 14 to 18years and found out that 65.6%
were having internet addiction, 61.3% were gaming addicts, and 92.8% Facebook addicts. Internet
addict students had statistically significant higher age, higher socioeconomic scale score, male
gender, and lower last year grades in comparison to non-addicts. Depression, dysthymia, suicide,
social anxiety, and phobias were common comorbidities in addicted adolescents [24]. In
undergraduate students, disordered online social networking use is associated with higher levels of
alcohol craving and in pupils aged from 11 to 13, it is associated with a higher likelihood of being
substance users [67]. In addition, excessive video gaming is associated with increased substance use
[15,67]. One report showed greater risk for children and adolescents to develop gambling problems.
In fact, the prevalence of adolescent gambling has increased in recent years. Across Europe, self-
reported rates of adolescent gambling in 2019 ranged from 36% in Italy to 78% in Iceland.
Adolescent problem gambling prevalence ranges from 1.6 to 5.6%. Not only adolescents but also
children are widely exposed to gambling advertisements on television and via social media.
Inrecentyears, there hasbeenanexpansioninsportsbetting online, and this has been heavily promoted
by advertising and marketing attractive to adolescents. Gambling is also promoted to children via
social media: children are sharing and re-tweeting messages from gambling companies, they are
active in conversations around gambling, and regularly consume and share visual gambling adverts.
Lastly, there is also a strong relationship between gaming and gambling: in video games, children
pretend to gamble and some video games would ask real money to play [68]. Finally, there might be
a relationship between youth using tobacco and tobacco social media posts. It is not clear if the
relationship can be cause-effect or only a correlation. Adolescents who participate in conversations
about tobacco in social media by posting positive messages about tobacco are more likely to be past-
month tobacco users. Posting even only one positive tobacco-related tweet was associated with
greater odds of using cigarettes, e-cigarettes, or any tobacco product, compared to those who did
not post positive messages about tobacco [69]. Finally, social media has been associated to social
media use and may represent a risk factor for the young as it interferes with dailies activities leading
to unhealthy habits. The easy access to social media by smartphone undoubtedly facilitates
addiction. 4.9. Social Media and Anxiety Weidentified 10 publications reporting a relationship
between social media use and anxiety. Out of them, three investigated the impact of COVID 19
pandemic on social media use and anxiety [15–18,22,23,31–33,70]. Table 8 summarized the main
findings (Table 8). Table 8. Social media and anxiety. Domains Reference Type of Publication
Highlighted Depression Addiction Anxiety Chiu M. et al. [15] Clinical Study Social media increased
use correlates to Emergency Department visits for mental illness, including depression, addiction,
and anxiety. Depression Anxiety Rutter L.A. et al. [16] Clinical Study Social media use correlates with
depressive symptoms, anxiety, and loneliness. Physical activity negatively correlates with
depression. Depression Psychological problems Addiction Anxiety Body image Mougharbel F. et al.
[17] Review High levels of screen time and social media use correlates to depression, anxiety, and
misperception of body image, addiction, and mental health outcomes. Int. J. Environ. Res. Public
Health 2022, 19, 9960 20 of 33 Table 8. Cont. Domains Reference Type of Publication Highlighted
Depression Sleep Anxiety Hoge E. et al. [18] Review The more time adolescents spend on
smartphone, the higher levels of depression, insomnia, and anxiety are found one year later.
Depression Cyberbullying Sleep Anxiety Sex related problems Behavioral problems Sight Maurer B.T.
et al. [22] Review Anincrease in digital and social media use relates to physical and mental status
impairment in children, including depression, anxiety, cyberbullying, sleep disturbance, behavioral
problems, sexting, and myopia. Depression Psychological problems Anxiety Time spent on social
media, repetitive activities, addictive or problematic use associated with Keles B. et al. [23] Review
depression, anxiety, and psychological impairment. Nevertheless, it is not possible to establish
whether a causative effect exists. Depression Sleep Anxiety Armitage R.C. et al. [31] Letter The
degree of social media usage in children correlates with depression, anxiety, and perceived stress
level. Bedtime access to and use of mobile devices is significantly associated with inadequate sleep
in terms of quality and quantity. Depression Anxiety Caffo E. et al. [32] Review Manyfactors including
isolation, excessive social media use and parental stress worsened mental status health during
COVID-19 era. Depression Psychological problems Anxiety Chen I.H. et al. [33] Review During school
closure in COVID-19 pandemic smartphone and social media use increased. An increase of 15–30
min daily negatively influenced mental health status in children. Anxiety Muzaffar N. et al. [70]
Clinical Study Increased anxiety correlates with increased Facebook use and repetitive behavior on
social media among adolescents. 4.9.1. Before COVID-19 Pandemic Evidence agrees that the degree
of social media usage in children is a significant predictor of anxiety and perceived stress levels and
that it increases with each additional hour of social media use [17,23,31]. Anxiety may represent a
risk factor for children and adolescents’ health as it influences the way they see their body, the way
they feel, and it mayimpact on social acceptance and relations with peers. The excessive use of at
least one type of screen, including television, computer, social media, and video gaming, has been
connected with anxiety symptoms in the pediatric age [22,23,31]. Furthermore, in Rutter’s study a
significant association between depression and anxiety with social media use has been detached
[16]. Nevertheless, it is still unclear if social media use provoke anxiety or if anxiety is the cause of
excessive use of social media [16]. Emergency department visits for mental health, including anxiety
problems, has arisen since 2009, likely linked to the increased use and the harmful effect of social
media [15]. On the contrary, physical activity may protect the young against the harmful effect of
social media, preventing depression and anxiety [16]. In a scientific report, Muzaffar confirmed that
an association between anxiety and social media is of note. In detail, increased adolescent
generalized anxiety symptoms were associated with increased Facebook use and repetitive
Facebook habits. Anxious adolescents may not be able to control their discomfort to the point that
they need to regularly go back to check their previous posting on Facebook [70]. Int. J. Environ. Res.
Public Health 2022, 19, 9960 21 of 33 The constant connection to social networks through digital
devices, on its side, po tentially contributes to feelings of anxiety. Adolescents and children suffering
from social anxiety may prefer to interact with texting, instant messaging, and emailing than over
face to-face interactions. However, the behavior may increase risk in individuals vulnerable to social
anxiety disorder because substituting digital media for interpersonal communication to avoid feared
situations may be reinforced over time, making the person even more avoidant and worsening the
symptoms and severity of social anxiety disorder [18]. However, in some studies, not just
overexposure but also underexposure to social media was associated with adolescent anxiety,
depression, and suicidal ideation [22]. 4.9.2. After COVID-19 Pandemic Screen time and social media
use have increased during the pandemic. Social media has been helpful during lockdown to keep
social relationships and not to discontinuate school activities. However, an excessive Internet use
may negatively affect children and adolescents’ well being. So, during social lockdown, an elevated
psychological distress and anxious symptoms have been described in schoolchildren who increased
time spent on screen [32,33]. Children who increased by 15 or 30 min daily the time spent on
internet presented a high level of psychological distress. 4.10. Social Media and Sex Related
Problems Studies have found social media use related to sexual problematic behaviors such as early
sexual activity, exposure to pornography, and sexting. [21,22,26,50,51,71–74]. Table 9 summarizes
the results (Table 9). Table 9. Social media and sex related problems. Domains Reference Type of
Publication Highlighted Depression Diet Cyberbullying Sleep Sex related problems Online grooming
Chassiakos Y.L.R. et al. [21] Review Risks of media device use include obesity, sleep, attention, and
learning impairment, illicit substance use, high-risk sexual behaviors, depression, cyberbullying, and
compromised privacy and confidentiality. Depression Cyberbullying Sleep Anxiety Sex related
problems Behavioral problems Sight Maurer B.T. et al. [22]. Review Anincrease in digital and social
media use relates to physical and mental status impairment in children, including depression,
anxiety, cyberbullying, sleep disturbance, behavioral problems, sexting, and myopia. Depression
Cyberbullying Sleep Sex related problems Hadjipanayis A. et al. [26] Review Social media use
facilitates socialization, communication, learning skills, and may positively affect education. Potential
risks include cyberbullying, Facebook depression, sleep disturbances, and sexting. Cyberbullying Sex
related problems Body image Shah J. et al. [50] Review Increased social media usage correlates with
decreased self-esteem and body satisfaction, increment of cyberbullying, exposure to pornographic
material, and risky sexual behaviors. Cyberbullying Addiction Sex related problems O’Keeffe G.S. et
al. [51] Editorial Risks of social media overuse include sexting, cyberbullying, privacy issues, and
Internet addiction, all of which may present with vague health symptoms. Int. J. Environ. Res. Public
Health 2022, 19, 9960 22 of 33 Table 9. Cont. Domains Reference Type of Publication Highlighted Sex
related problems Gazendam N. et al. [71] Clinical Study Sexual activity has been described in a
sample of 7882 Canadian students. An increase of sexual activity has been observed in both girls and
boys using media. A great social media use has been connected to the strongest association with
early sexual activity for girls (RR = 1.42, 95% CI: 1.01–1.47). Social media use has been described as a
risk factor Sex related problems Wana [Link] al. [72] Clinical Study for sexual behavior. About 7% of
adolescents use media to watch pornographic content. Sex related problems Body image Physical
activity Sight Headache Addictive, smart phone activities of youth is Solecki S. et al. [73] Clinical
Study directly affecting their perception of the body, also causing physical problems, eye diseases,
headache, and exposure to unwanted sexual material online. Sex related problems Collins R.L. et al.
[74] Clinical Study Traditional media and social media use among adolescents are related to sexual
activities and behavior. Video games contain sexual contents. Newtechnologies facilitate
pornography access among young. The prevalence of sex related problems cannot be accurately
recorded as for a wide range of definition and sampling methods and the comparison among reports
is difficult. Especially for girls, higher social media use, associated with lower family affluence and
poorer body image, are key to early sexual activity [71]. Social media use was found to be
significantly associated with risky sexual behav ior among pre-college students in Ethiopia. Facebook,
Instagram, YouTube, and other platforms have been identified as a factor that alters adolescent’s
perception and influ ences them to engage in risky sexual behavior. Those who view sexually
suggestive Facebook photos have a higher chance of having unprotected sexual intercourse and sex
with strangers [72]. Moreover, youth can be exposed to unwanted sexual material online, including
un wanted nude pictures or sexually explicit videos through means such as pop-up windows or spam
e-mails [73]. Children exposed to inappropriate sexual content are prone to high-risk behaviors in
subsequent sexual encounters. [22] Sexting activities may also affect emotional and social wellbeing
of adolescents; it is correlated to depression and risky health behaviors, such as substance use,
alcohol consumption, and suicide [26,50]. The odds of risky sexual behavior were 1.23 higher in
social media user than in other students [72]. Furthermore, on the internet, pornography is readily
accessible by media device, so that Wana found out that 7% of students use social media for
pornography. In most cases, adolescents admit they intentionally viewed materials [74].
Pornographic media depict a fantasy world in which unrealistic encounters result in immediate
sexual gratification, and intimate relationships are nonexistent. Repeated exposure of the
adolescent brain to the world of online pornography can make it difficult for adolescents to develop
mature healthy sexual relationships [22]. Internet pornography usage has been documented in
adolescents before the age of 18. Online pornography is often the first source of sex education for
many adolescents, and ex posure to violent pornography increases the odds of sexually aggressive
behavior [50]. Peer advice as well as substance abuse are significant predictor for risky sexual
behavior [72]. Finally, among adolescents 10–19 years of age, the rate of sexting ranges from 5 to
22% [50,72,74]. Int. J. Environ. Res. Public Health 2022, 19, 9960 23 of 33 Sexting is the use of media
to send nude or sexualized contents such as texts, photos, or videos. An extensive sharing of these
contents through technology has been connected with a negative impact on the emotional and
social wellbeing of adolescents involved. An earlier sexual debut such as the use of drugs and
promiscuity have been all associated to the excessive use of sexting. It can also cause spreading of
sexual content material without consent, to a third party as a method of bullying or revenge
[21,26,51,74]. 4.11. Social Media and Behavioral Problems Out of the reports, seven explored the
influence of social media and behavioral prob lems [22,49,64,75–78]. Table 10 outlines the
highlighted findings (Table 10). Behavioral outcomes usually cover five areas, including
hyperactivity/inattention, emotional symp toms, conduct problems, peer relationship, and pro-social
behavior. Table 10. Social media and behavioral problems. Domains Reference Type of Publication
Highlighted Depression Cyberbullying Sleep Anxiety Sex related problems Behavioral problems
Maurer B.T. et al. [22]. Review Anincrease in digital and social media use relates to physical and
mental status impairment in children, including depression, anxiety, cyberbullying, sleep
disturbance, behavioral problems, sexting, and myopia. Cyberbullying Psychological problems Sleep
Addiction Behavioral problems Physical activity Sight Bozzola E. et al. [49] Review Cyberbullying,
sleep impairment, psychological problems, addiction, musculoskeletal disorders, and eye problems
are among the risks of media device use in adolescence. Sleep Behavioral problems Guerrero M.D. et
al. [64] Clinical Study Time spent on screen has been associated to sleeping problems, especially
sleep duration, and with problematic behaviors, higher internalizing, and externalizing symptoms.
Behavioral problems McNameeP. et al. [75]. Clinical Study Excessive time of media use has a strong
association with emotional distress and worse behavioral outcomes. Association between hours of
media use and Behavioral problems Okada S. et al. [76]. Clinical Study behavioral problems has been
documented among children aged 9–10 years old, in Japan. Regression analysis predicted a strong
positive Behavioral problems Tahir A. et al. [77]. Clinical Study association of exposure to violent
social/electronic media content with level of aggression of adolescents ( = 0.43). Behavioral
problems Deslandes S.F. et al. [78]. Clinical Study Online challenges are a powerful communicative
resource but can involve potential self-inflicted injuries to participants, with risks ranging from minor
to lethal. For children aged 10–15 years old, limited time on social media has no effect on most
emotional and behavioral outcomes (and can even positively impact social relationships), while
there are strong negative associations between very long hours on social media and increased
emotional distress and worse behavioral outcomes, which continue for several years [75]. In
accordance to McNamee, the study by Okada conducted in Japan [76] among children aged 9–10
years old highlighted that mobile devices usage time of less than 1 h wasaprotective factor for
behavior problems in boys. Instead, the usage time of 1 h or more Int. J. Environ. Res. Public Health
2022, 19, 9960 24 of 33 was a risk factor in girls. Among girls, a dose–response positive association
was found between duration of mobile devices usage and total difficulty score. A U-shaped
association was found between duration of mobile devices usage and behavioral problems in boys:
moderate use of mobile devices might be a tool for relaxation or alleviating distress through
interactions with peers. However, in the subscale analysis, boys who use two or more hours of
mobile devices showed higher risk of emotional problems and peer problems [76]. Moreover, the
social media violent content exposure may be a risk factor for violent and aggressive behaviors. In
this context, levels of aggression are directly proportional to exposure of types of violent media
content. Electronic and social media showing contents with fights, stealing, dead bodies, and
people’s belongings being destroyed influence young viewers, as per observational-learning theory,
making them believe that reacting aggressively in response to perception of any offense is
acceptable [77]. In line with Tahir’s report, Maurer underlined a significant association between
expo sure to media violence and aggressive behavior, aggressive thoughts, angry feelings, and
physiologic arousal. Media exposure is also negatively related to personal adjustment and school
performance and positively related to risk-taking behaviors [22]. Another study confirmed that
longer the time spent on screens, higher the risk for behavioral problems among children 9–10 years
old, and depending on the content type visualization, the risk for an aggressive and rule-breaking
behavior. This association was mediated by sleep duration: longer sleep duration was associated
with fewer problem behaviors [64]. Challenges and risk-taking attitudes are frequent in child and
youth culture. However, online challenges take on new meanings when mediated by digital
sociability; they appear as a powerful communicative resource to reaffirm belonging, recognition,
and audience adherence. They are a media strategy adopted by youth in the construction of an
internet mediated identity in which risk and violence are crucial devices in building a self-image
capable of maintaining an audience. Nevertheless, they can involve potential self-inflicted injuries to
participants, with risks ranging from minor to even lethal [78]. Finally, an emerging problem is the
social phenomenon called Shakaiteki Hikikomori (social withdrawal). Most of them are males and
they usually experience a social reclusion range from 1 to 4 years. They refuse to communicate even
with their own family and spend even more than 12 h a day in front of a screen [49]. 4.12. Social
Media and Body Image Onsocial media platforms such as Facebook, Snapchat, and Instagram, body
image has become an important topic [17,25,45,46,50,73]. Table 11 summarized the evidence.
(Table 11). People post their most flattering photos and view those of others, creating an online
environment that could be damaging to body image acceptance. Spending time on social media puts
adolescents under a higher risk of comparing themselves to models that are more attractive. As a
result, these unfavorable social comparisons of physical appearance may exacerbate body image
apprehension [17,45]. Moreover, beauty trends are constantly reinforced through social media
networks and image-editing tools are often used to alter images to fit beauty standards. Teenagers
who, perhaps, are not aware of these digital changing made in commercial photos may become
insecure of their image. This may reduce self-esteem and body satisfaction, mainly amongadolescent
girls, developing body image concerns, engaging in weight-modification behavior, and potentially
developing eating disorders. Nowadays, adolescents, and, in particular, girls, need to fit “social
media” standard for photo posting; they use to modify photos with specific programs in order to
respect society beauty standard. In fact, 28% of girls aged 8–18 years admit to editing their photos to
make themselves look more attractive prior to posting online [50]. Int. J. Environ. Res. Public Health
2022, 19, 9960 25 of 33 Table 11. Social media and body image. Domains Reference Type of
Publication Highlighted Depression Psychological problems Addiction Anxiety Body image
Mougharbel F. et al. [17] Review High levels of screen time and social media use correlates to
depression, anxiety, and misperception of body image, addiction, and mental health outcomes.
Depression Cyberbullying Body image Richards D. et al. [25] Review Social media overuse impacts on
mental health, self-esteem, and wellbeing. Diet Cyberbullying Psychological problems Body image
Physical activity Borzekowski D.L.G. et al. [45] Review Constant media access and exposure to
unhealthy and risky media messages may increase the interactions, facilitating cyberbullying and
exacerbating body image apprehension promoting poor nutrition, psychological problems, and
leading to a more sedentary lifestyle. Diet Body image MoormanE.L. et al. [46] Clinical Study Greater
use the internet sources for nutritional information is related to greater disordered eating.
Cyberbullying Sex related problems Body image Shah J. et al. [50] Review Increased social media
usage correlates with decreased self-esteem and body satisfaction, increment of cyberbullying,
exposure to pornographic material, and risky sexual behaviors. Sex related problems Body image
Physical activity Sight Headache Solecki S. et al. [73] Review Addictive, smart phone activities of
youth is directly affecting their perception of the body, also causing physical problems, eye diseases,
headache, and exposure to unwanted sexual material online. In addition to social media causing
body image problems, adolescents with body image misperception may look on the internet for
advice on how to lose weight quickly. However, the suboptimal quality of online information
contributes to the development of unhealthy eating attitudes and behaviors in young adolescents. It
may be that the content of these sites promotes eating disorders by providing unhealthy weight loss
advice [46]. Furthermore, the desire of perfection and selfie mania with repeated selfie can cause
depression and self-harm. This is a typical symptom of body dysmorphic disorder [73]. Finally, this
association between the use of social media, self-esteem and body image can beacorrelation
andnotacause-effect relation: girls with lower self-esteem and sensitive to body image complains
may use social media more frequently than girls with a higher level of self-esteem. For example,
users can make a “selective self-presentation” where they show themselves only in a positive way on
their social media profiles [25]. 4.13. Social Media and Physical Activity Evidence supports a
correlation between social media and physical activity [45,49,57,73,79]. Excessive use of
smartphones and other digital devices can also cause physical problems, such as a more sedentary
lifestyle [45], which is positively associated with childhood obesity. In addition, non-physiological
postures assumed while using smartphones may lead to cervical rigidity and muscle pain resulting in
neck strain or “Tech Neck”. Moreover, “texting thumb” is a form of tendinitis that comes from
overusing the thumb from excessive texting, video gaming, and web browsing using a smartphone
[49,73]. AnAustralian study found that non-organized physical activity declines between 11 and 13
years, especially in children with a large increase in activities of texting, emailing, social media, and
other internet use [79]. Int. J. Environ. Res. Public Health 2022, 19, 9960 26 of 33 Another study
showed that problematic social media use is related to lower levels of vigorous physical activity,
especially in girls [57]. In Table 12 are listed the reports related to this topic and their major content
(Table 12). Table 12. Social media and physical activity. Domains Reference Type of Publication
Highlighted Diet Cyberbullying Psychological problems Body image Physical activity Borzekowski
D.L.G. et al. [45] Review Constant media access and exposure to unhealthy and risky media
messages may increase the interactions, facilitating cyberbullying, and exacerbating body image
apprehension promoting poor nutrition, psychological problems, and leading to a more sedentary
lifestyle. Cyberbullying Psychological problems Sleep Addiction Behavioral problems Physical activity
Sight Bozzola E. et al. [49] Review Cyberbullying, sleep impairment, psychological problems,
addiction, musculoskeletal disorders, and eye problems are among the risks of media device use in
adolescence. Psychological problems Sleep Physical activity Buda G. et al. [57] Clinical Study
Problematic social media use correlates with about two times higher odds for worse sleep quality
and lower life satisfaction, and it is related to lower levels of vigorous physical activity in girls. Sex
related problems Body image Physical activity Sight Headache Solecki S. et al. [73] Review Addictive,
smart phone activities of youth is directly influencing their perception of the body, also causing
physical problems, eye diseases, headache, and exposure to unwanted sexual material online.
Physical activity KempB.J. et al. [79] Clinical Study Australian children between 11 y and 13 y
whohadalarger increase in social media use had lower participation in overall physical activity. 4.14.
Online Grooming Online grooming may be defined as a situation in which an adult builds a
relationship with a minor finalized to a sexual abuse using social media. [47,80]. The risk of
developing post-traumatic stress disorder in the victims is of note and may affect mental and well-
being of children and adolescents [80]. Children are more vulnerable online as they often escape
their parents’ control and maybemorewilling to share information or pictures about themselves than
in real life. Online grooming, differently to offline sexual abuse, is simpler to perpetrate, due to
internet’s technology and accessibility. Furthermore, often the perpetrator misrepresents himself as
another child or teenager, in order to establish a trusting relationship [21]. Teenage girls appear to
be more at risk, even if the proportion of male victims is considerable too. In general, minors with
problematic internet use are at greater risk of being groomed. Sexual solicitation has been found to
be more common in children spending longer time on internet on weekdays, being involved in
sexting, having strangers in social net works friends list, playing online games, and chats. The risk is
high even for adolescents whose curiosity and unconsciousness set them at risk of being deceived
[80]. Table 13 presents the reports related to this topic and their major content (Table 13). Int. J.
Environ. Res. Public Health 2022, 19, 9960 27 of 33 Table 13. Social media and online grooming.
Domains Reference Type of Publication Highlighted Depression Diet Cyberbullying Sleep Sex related
problems Online grooming Chassiakos Y.L.R. et al. [21] Review Risks of media device use include
obesity, sleep, attention, and learning impairment, illicit substance use, high-risk sexual behaviors,
depression, cyberbullying, and compromised privacy and confidentiality. Diet Sleep Online grooming
Purves R.I. et al. [47] Letter Potential negative effects of social media include damage to sleep
patterns, cyberbullying, and online grooming. Online grooming Forni G. et al. [80] Review This review
describes the online grooming phenomenon, victim and perpetrators characteristics, and the
importance to implement attention on this problem with preventive measures. 4.15. Social Media
and Sight Studies have investigated the risk of social media on sight, in terms of visual im balance
[22,49,73]. Evidence underlines that children can develop ocular disorders from excessive screen
time, including myopia, eye fatigue, dryness, blurry vision, irritation, burning sensation, conjunctival
injection, ocular redness, dry eye disease, decreased visual acuity, strain, fatigue acute acquired
concomitant esotropia, and macular degeneration. During smartphone use, there is a reduction of
the blink rate to 5–6/min that promotes tear evaporation and accommodation, leading to dry eye
disease [49,73]. In addition, excessive screen time and less time spent outdoors may lead to early
development of myopia, particularly with smartphone and tablet use [22]. Table 14 presents the
reports related to this topic and their major content (Table 14). Table 14. Social media and sight.
Domains Reference Type of Publication Highlighted Depression Cyberbullying Sleep Anxiety Sex
related problems Behavioral problems Sight Maurer B.T. et al. [22]. Review Anincrease in digital and
social media use relates to physical and mental status impairment in children, including depression,
anxiety, cyberbullying, sleep disturbance, behavioral problems, sexting, and myopia. Cyberbullying
Psychological problems Sleep Addiction Behavioral problems Physical activity Sight Cyberbullying,
sleep impairment, psychological Bozzola E. et al. [49] Review problems, addiction, musculoskeletal
disorders, and eye problems are among the risks of media device use in adolescence. Sex related
problems Body image Physical activity Sight Headache Addictive, smart phone activities of youth is
directly Solecki S. et al. [73] Review influencing their perception of the body, also causing physical
problems, eye diseases, headache, and exposure to unwanted sexual material online. 4.16. Social
Media and Headache There are increased complaints of headaches related to staring at a screen for
too long [62,73,81]. Reports dealing with social media and headache are listed in Table 15 (Table 15).
Int. J. Environ. Res. Public Health 2022, 19, 9960 28 of 33 Table 15. Social Media and headache.
Domains Reference Type of Publication Highlighted Psychological problems Headache Marino C. et
al. [62] Clinical Study Adolescent problematic Internet users have higher levels of somatic symptoms
such as headaches and psychological consequences of social media use such as loss of control and
relational problems with family and friends. Sex related problems Body image Physical activity Sight
Headache Solecki S. et al. [73] Review Addictive, smart phone activities of youth is directly
influencing their perception of the body, also causing physical problems, eye diseases, headache,
and exposure to unwanted sexual material online. Headache Çaksen H. et al. [81] Review Abuse of
electronic screens more than 2 h contributes to the chance of reporting headache. Headache is
actually the most common neurologic disorder in the population, children and adolescents included
[81]. It may negatively impact on children and adolescents’ well being, leading to stress, tiredness,
anxiety, and bad mood. Time of usage of media device has been directly connected to headache: in
particular, adolescents using more than 3 h a screen have a significantly higher risk of headache
compared with those using a device for less than 2 h (p < 0.001). Spending even 2–3 h with a
computer significantly increases the chance of suffering a headache in comparison with those using
a computer for less than 2 h (p < 0.01). Excessive use of electronic devices is considered a risk factor,
especially for the development of migraine-type headache (p < 0.05) [81]. According to recent
studies, headache and somatic symptoms have been found mostly in patients with problematic
social media usage, compared with non-problematic peers. There is a consistent association
between the problematic use of social media and adolescent psychosomatic health [62,73]. 4.17.
Social Media and Dental Caries The association between use of internet and social media has been
studied in litera ture [35,82]. Table 16 summarizes the main findings (Table 16). Table 16. Social
media and dental caries. Domains Reference Type of Publication Highlighted Exposure to advertising
is associated with unhealthy Diet Dental Caries behaviors. Children are uniquely vulnerable to the
persuasive Radesky J. et al. [35] Clinical Study effects of advertising because of immature critical
thinking skills and impulse inhibition. Ads also promote intake of foods that contribute to dental
caries. Dental Caries Almoddahi D. [82] Clinical Study Study conducted in England, Wales, and
Northern Ireland. Excessive internet use is associated to dental caries, and this could be mediated by
health behaviors. The association between use of internet social media to obtain oral health
information and dental caries has been highlighted in Almoddahi’s report [82]. In detail, problematic
internet use has been associated with unhealthy lifestyles, poor oral health behaviors, and more oral
symptoms such as toothache, bleeding gums, and poor self-perceived oral health. Caries and junk
food have been both connected to excessive internet use and ads [82]. Therefore, social media may
be a risk factor for caries, poor oral health, and dental outcomes. In line with Almoddahi, Radesky
underlines that advertisements on social media promote intake of foods that contribute to dental
caries, such as fast food and sugar Int. J. Environ. Res. Public Health 2022, 19, 9960 29 of 33
beverages [35]. Nevertheless, evidence suggests that smartphone applications may improve health
and oral health wheninternet-based health interventions are in place. Delivering oral health
information via social media may increase tooth brushing and dental outcome [82]. 5. Limitations
From the literature, it is not possible to decide whether social media use causes internalizing
symptoms and problematic behaviors examined in this manuscript or whether children and
adolescents suffering from depression, anxiety, or other psychological distress are more likely to
spend time on social media. We can just state that there is an association between social media use
and health problems, but that is not necessarily cause-effect. Moreover, the articles included are
different, ranging from reviewers to clinical studies to letters and to editors, so that it may be
difficult to accurately compare them. Third, as specified in the materials and methods, we excluded
reports not in English letter and not published in PubMed. Nevertheless, through our manuscript we
contribute to the existing literature to high lighting the impact of social media use on adolescents,
providing advices to pediatricians in everyday practice. 6. Conclusions Social media is increasingly
being used by children and adolescents, especially during COVID-19 pandemic and the health
emergency. Although social media use demonstrated to be of utility, an excessive or non-correct use
may be a risk factor for mental health, including depression, anxiety, and addiction. Social media use
may also correlate to a non-adequate nutrition with consumption of junk food marketing leading to
weight gain, obesity, dental caries, and unhealthy eating behaviors. Associations have been found
also with increasing physical problems due to sedentary lifestyle, obesity, and non-physiological
postures. On the other hand, social media can cause problems with body image visualization and
acceptance, especially in young adolescent girls with lower self-esteem, who may look for contents
for losing weight rapidly, and this can help the extension of anorexia disorders. Children and
adolescents who use social media for many hours a day, are also at higher risk for behavioral
problems, cyberbullying, online grooming, sleep difficulties, eye problems, (such as myopia, eye
fatigue, dryness, blurry vision, irritation, burning sensation, conjunctival injection, ocular redness,
and dry eye disease), and headache. Moreover, uncontrolled social media use, can lead to sexting,
exposure to pornography, exposed to unwanted sexual material online, and early sexual activity.
Social media users meet more online risks than their peers do, with an increased risk for those who
are more digitally competence. Public and medical awareness must rise over this topic and new
prevention measures must be found, starting with health practitioners, caregivers, and
websites/application developers. Families should be educating on the dangers and concerns of
having children and adolescence online. Prerequisite to inform families how to handle social media is
to educatethoseresponsible for training, including health practitioners. In detail, pediatricians should
be reminded to screen for media exposure (amount and content) during periodic check-up visits.
They need to keep in mind a potential correlation of problematic social media use with depression,
obesity and unhealthy eating behavior, psychological problems, sleep disorder, addiction, anxiety,
sex related problem, behavioral problem, body image, physical inactivity, online grooming, sight
compromising, headache, and dental caries. Pediatricians can also counsel parents to guidechildren
toappropriatecontentbyconsulting ratings, reviews, plot descriptions, and by a previous screening of
the material. They should inform parents about the potential risk of digital commerce to facilitate
junk food, poor nutrition and sweetened aliments, facilitating overweight and obesity. On the
contrary, a healthy diet, adequate physical activity and sleep need to be recommended.
Pediatricians mayalso play a role in preventing cyberbullying by educating both adolescent and
familie

Theories of motivation: A comprehensive analysis of human behavior drivers Din Bandhu a , M.

Murali Mohan Alok Bhadauria a , * b , Noel Anurag Prashanth Nittala , Kuldeep K. Saxena a e c ,
Pravin Jadhav d , Department of Mechanical and Industrial Engineering, Manipal Institute of
Technology Bengaluru, Manipal Academy of Higher Education, Manipal 576104, Karnataka, India b c
d e Department of Mechanical Engineering, G. Pulla Reddy Engineering College (Autonomous),
Kurnool 518007, Andhra Pradesh, India Department of Sciences, Indian Institute of Information
Technology Design and Manufacturing (IIITDM), Kurnool 518008, Andhra Pradesh, India Department
of Economics, Institute of Infrastructure, Technology, Research and Management (IITRAM),
Ahmedabad 380026, Gujarat, India Division of Research and Development, Lovely Professional
University, Phagwara, India ARTICLE INFO ABSTRACT Keywords: Motivation Motivation theories
Intrinsic Extrinsic ARCS Self-determination Goal-orientation This paper explores theories of
motivation, including instinct theory, arousal theory, incentive theory, intrinsic theory, extrinsic
theory, the ARCS model, self-determination theory, expectancy-value theory, and goal- orientation
theory. Each theory is described in detail, along with its key concepts, assumptions, and implica tions
for behavior. Intrinsic theory suggests that individuals are motivated by internal factors like
enjoyment and satisfaction, while extrinsic theory suggests that external factors like rewards and
social pressure drive behavior. Arousal theory says that to feel motivated, people try to keep an
optimal level of activation or excitement. Incentive theory suggests that behavior is driven by the
promise of rewards or the threat of punishment. The ARCS model, designed to motivate learners,
incorporates elements of attention, relevance, confidence, and satisfaction. Self-determination
theory proposes that individuals are motivated by their needs for autonomy, competence, and
relatedness. The expectation-value theory suggests that behavior is influenced by individuals' beliefs
about their ability to succeed and the value they place on the task. The goal-orientation theory
suggests that individuals have different goals for engaging in a behavior. By understanding these
different theories of motivation, educators, coaches, managers, and individuals may analyze what
drives behavior and how to harness it to achieve their goals. In essence, a nuanced comprehension
of these diverse motivation theories equips in dividuals across varied domains with a strategic toolkit
to navigate the complex landscape of human behavior, fostering a more profound understanding of
what propels actions and how to channel these insights toward the attainment of overarching goals.
1. Introduction Human behavior is influenced by a complex interplay of numerous factors. These
include biological determinants, psychological factors, social and cultural elements, economic and
environmental factors, as well as external stressors that play a significant role in shaping how
individuals interact and respond to their environment. This paper fo cuses on understanding
motivation, a psychological factor that impacts human behavior. Motivation represents the yearning
to accomplish a task, paired with the enthusiasm and determination to see it through. It acts as the
driving force that propels an individual to take proactive steps * Corresponding author. E-mail
address: [Link]@[Link] (A. Bhadauria). [Link]
and reach their goals. The term “intrinsic” refers to motivation that originates internally in the form
of a person's interests and goals, while “extrinsic” refers to motivation that is prompted by external
variables like incentives and penalties (Amaro et al., 2021; Harris & McDade, 2018; Sharma & Gupta,
2022). Motivation can be positive, which means it inspires a person to take positive actions and
make positive changes, or negative, which means it leads a person to take negative actions or make
negative changes (Eccles & Wigfield, 2002; Gollwitzer & Oettingen, 2001; Schiefele, 1991). There is
no standard definition for motivation. Nevertheless, it has been defined by several scholars in their
respective perspectives. According to Received 29 August 2023; Received in revised form 30 January
2024; Accepted 5 February 2024 Available online 13 February 2024 0001-6918/© 2024 The Authors.
Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
([Link] nc-nd/4.0/). D. Bandhu et al. Acta Psychologica 244 (2024)
104177 Dwight D. Eisenhower (Low, 2013), “Motivation is the art of getting people to do what you
want them to do because they want to do it”, which explains that motivation may be used as an
agent to getting one's tasks accomplished by encouraging people without them knowing. Zig Ziglar
defined motivation as fuel, necessary to keep the human engine running (Mcalister, 2018), proving
that motivation is essential to keep human life going. John Adir claimed that “Motivation is the
driving force within an individual that impels them to pursue their goals” (Schiefele, 1991) in
contrast to Dwight who said it can be used to get the work accomplished by others. Similarly, Tony
Robbins defined moti vation as the catalyst that sets the engine of success in motion (Robbins,
2011), which again reiterates the fact that motivation is crucial for an individual to succeed in life.
Numerous hypotheses have been put out to try and make sense of what drives humans. Thus, it is
difficult to determine who gave the first definition of motivation in education, as the concept of
motivation has been studied and discussed by educators, psychologists, and philoso phers for
centuries. While every theory provides insight into a certain facet of motivation, they all inevitably
leave out others. Ambiguity arises from the wide variety of ideas because they all share some
common ground but also disagree on key points, and many of them use a jargon that is unique to
them (Cook & Artino, 2016a; Murphy & Alexander, 2000; Petri, 2012). Despite the unsettling nature
of this, it is important to remember that each theory offers a fresh viewpoint that has the po tential
to yield novel insights and different implications for learning and research activities. In the past,
analyses of motivation have either been centered on the theories' practical applications, provided
very cursory overviews, or concentrated on a single theory (Artino, 2012; Kusurkar et al., 2011;
Mann, 1999; Teunissen & Bok, 2013). Further contemplation is needed to enhance this field of study,
and a review that discusses and analyzes numerous theories would inspire a more nuanced
knowledge of moti vational principles. In this regard, this article condenses nine theories on learning
motivation and illustrates key parallels and differences be tween them to set the stage for future
study. The purpose of this article is not to provide a thorough analysis of recent research findings but
rather to make the theoretical underpinnings of motivation comprehensible to learners in any
discipline to acquire knowledge. Therefore, this article gives a synopsis of motivational theories that
influence people's actions in learning environments. However, further readings are suggested for
individuals interested in delving deeper into these theories. Furthermore, any discussion on
motivation is incomplete without mentioning the earliest and most influential theories of motivation
in education developed by Abraham Maslow in the 1940s, who proposed a hierarchy of needs that
outlined the different types of motivation that drive human behavior. According to Maslow, people
are motivated by physiological needs, safety needs, belongingness and love needs, esteem needs,
and self-actualization needs, with each level of needs building upon the previous one. This theory
suggests that human needs are organized into a hierarchy, with the most basic needs at the bottom
and the most complex needs at the top. Maslow believed that humans must satisfy their lower-level
needs before they can move on to satisfying their higher-level needs. Maslow's hierarchy of needs is
a widely recognized and influential theory of human motivation. It is often dis cussed in psychology,
business, and education because it provides a framework for understanding what motivates people.
Maslow's hierar chy of needs provides a model for understanding what drives people to behave in
the way they do. This understanding can be helpful in a va riety of contexts, such as designing
workplaces that are motivating for employees or developing educational programs that are engaging
for learners. Since then, several academicians explored the term motivation and molded its
definition according to their needs and situations (Collins, 2009; Cook & Artino, 2016b; Dinbandhu &
Jadhav, 2020; Schunk & Zimmerman, 2012; Tracy, 2018). In this context, Nicholls et al. (Nicholls et
al., 1989) defined motivation as the processes that arouse, direct, and maintain behavior toward a
specific goal. Weiner (Weiner, 1992) also came up with a definition of motivation as a psy chological
construct that refers to the forces that initiate, energize, direct, and sustain behavior, often toward
some specific goal or reward. Zeidner et al. (Zeidner et al., 2000) defined motivation as an
individual's internal drive or desire to engage in a particular behavior or activity. It is the
psychological process that initiates, guides and maintains goal- oriented actions. Schunk (Schunk,
2004) saw motivation as the pro cess by which goals are activated and sustained, and it involves the
arousal, direction, and persistence of behavior.” Also, Guerin et al. (Guerin et al., 2011) defined
motivation as the psychological process that gives behavior purpose and direction. It is what causes
us to act, whether it is getting a glass of water to reduce thirst or reading a book to gain knowledge.”
From the aforementioned discussion, it is clear that motivation drives learners to engage in learning
and pursue their educational goals. Without motivation, learners may struggle to find the energy
and determination to complete assignments, prepare for exams, and achieve success in their studies
(Haque et al., n.d.; Schürmann et al., 2021; Tohidi & Jabbari, 2012). Motivation can come from a
variety of sources, including personal interests, future career aspirations, and a desire to make a
positive impact on the world. In the academic setting, many challenges and obstacles can hinder
motivation. These may include the demands of coursework, the pressure to succeed, and the fear of
failure. Additionally, learners may face external factors such as financial chal lenges, family
responsibilities, and other personal commitments that can make it difficult to prioritize their
education. A pictorial representation of the motivation to learn is shown in Fig. 1 (Shkoler & Kimura,
2020; Steinmayr et al., 2019; Vo et al., 2022). Fig. 1 depicts the internal and external factors that
drive the moti vation to learn. A healthy balance between both these factors is essential for learning
to take place effectively. Learners need to find ways to stay motivated and inspired in their academic
pursuits. This may involve setting clear and achievable goals, seeking support and guidance from
mentors and peers, and finding ways to stay engaged and interested in the material being studied.
Building a strong support network and developing effective study habits and strategies can also be
instrumental in helping learners maintain their motivation and achieve success in their academic
endeavors. Overall, learners need to find ways to stay motivated and focused in order to reach their
full potential and achieve their goals (Dweck et al., 2014; Pintrich & De Groot, 2003; Sethi & Scales,
2020; Van Vu et al., 2022). From existing literature, it has been observed that motivation is a
psychological drive that energizes and directs behavior toward a goal. It is a complex phenomenon
that is influenced by a variety of factors, including biology, psychology, social and cultural factors,
economics, the environment, and external stressors. In the academic setting, moti vation is essential
for students to succeed. Without motivation, learners may struggle to find the energy and
determination to complete assign ments, prepare for exams, and achieve their educational goals.
This paper reviews nine theories of learning motivation: instinct theory, arousal theory, incentive
theory, intrinsic theory, extrinsic theory, the ARCS model, self-determination theory, expectancy-
value theory, and goal-orientation theory. The focus will be on understanding the key concepts,
assumptions, and implications that these theories might have on human behavior. 2. Learning
motivation theories Motivation is a psychological construct that drives individuals to engage in
certain behaviors or activities. In the context of learning, motivation refers to the factors that drive
an individual to engage in the process of acquiring knowledge and skills (Willy, n.d.; Hilgard, 2004;
Svinicki & Vogler, 2012). Several motivation theories can influence learning. 2 D. Bandhu et al. Acta
Psychologica 244 (2024) 104177 Fig. 1. A social framework of motivation to learn. 3. Instinct theory
of motivation Instinct theory, which has been considered as a root for all motivation theories, was
very popular in the early 20 th century. The term ‘instinct’ th was coined by Charles Darwin and
George Romanes in the late 19 century to explain the behavior of animals. It is a psychological
theory that suggests that certain behaviors are innate or hard-wired into in dividuals and that these
behaviors are triggered by specific stimuli or cues in the environment. The theory suggests that
certain behaviors are not learned through experience but are instead pre-programmed into the
individual's biology. It is important to note that this theory has been falling out of favor lately in
several recent researches, which suggest that most behaviors are the result of a combination of
genetic, environ mental, and cultural influences. Critics of the instinct theory argue that it is difficult
to define an instinct clearly and objectively and that many behaviors that have been labeled as
“instinctive” are the result of com plex interactions between genes and the environment.
Furthermore, many behaviors that appear to be instinctive in one species are not present or are
much less prominent in closely related species, which suggests that they are not solely determined
by genetics (Burnham, 1972; Gillespie, 1971; Harlow, 2004; Loewald, 1972; Loewald, 1978;
Oppenheimer, 1958). Instinct theory suggests that some behaviors are innate and not learned. In the
context of learning, it implies that certain behaviors may be driven by instinctual responses rather
than acquired knowledge or conditioning. 4. Arousal theory of motivation Arousal theory also comes
under the category of prominent theories of motivation. It is a psychological theory introduced by
Robert Yerkes and John Dillingham Dodson in 1908. It suggests that there is an optimal level of
physiological or psychological arousal that is necessary for optimal performance on a given task.
According to this theory, when an individual is too aroused (i.e., over-aroused), performance may
suffer, while when the individual is not aroused enough (i.e., under-aroused), performance may also
suffer. The theory posits that there is an “optimal” level of arousal that is associated with the best
performance. The well known version of this theory is the Yerkes-Dodson law, which states that as
arousal level increases, performance will also increase up to a point, after which it will decrease.
Arousal can be caused by a wide range of factors, including physiological processes such as the
release of hormones, psychological factors such as stress or motivation, and environmental factors
such as noise or temperature. It's important to note that the theory is based on an inverted-U shape
relationship be tween performance and arousal, meaning that there is a point where high arousal
levels lead to diminishing returns and that optimal per formance will be achieved at moderate levels
of arousal. Arousal the ories have been applied in various fields such as sports, education, and
cognitive psychology. It has been used to explain the effects of stress, anxiety, and other emotional
states on human performance (Kerr, 1985; Kerr, 2021; Reisenzein, 1994; Reisenzein, 2017). Arousal
theory posits an optimal level of stimulation for effective learning. In learning an appropriate balance
of excitement and calmness can enhance the ability to acquire and retain information. 5. Incentive
theory of motivation The incentive theory, which was first proposed by a behaviorist, Clark Hull in
1943. Hull proposed that behavior is a function of drive, which is a physiological state that creates a
need, and incentive, which is the positive or negative values of a particular situation. This theory
explains how behavior is influenced by the presence or absence of incentives, or rewards. The theory
suggests that the magnitude and proximity of an incentive can influence behavior by increasing the
perceived value of a particular action or outcome, which in turn increases the motivation to engage
in that behavior. It further proposes that behavior is driven by an organism's attempt to maximize
pleasure and minimize pain. Incentives can be positive or negative, they can be external, such as
money, or internal, such as hunger or thirst. Incentive theory has been used to explain a wide range
of behaviors, such as drug addiction, consumer choice, and work motivation. It has also been used to
explain how re wards and punishments can influence behavior in educational and work settings.
Recent research has suggested that incentives are just one of many factors that can influence
behavior and that the effectiveness of incentives may depend on the specific context and individual
charac teristics. It's worth mentioning that there are some criticisms of the theory, some argue that
the theory oversimplifies the complexity of human motivation and can be reductionist in nature
(Bosha et al., 2017; Ellingsen & Johannesson, 2008; Hattie et al., 2020; Killeen, 1982; Vi & Thuy,
2020). Incentive theory emphasizes the role of rewards and 3 D. Bandhu et al. Acta Psychologica 244
(2024) 104177 motivations in influencing behavior. In learning, it suggests that offering incentives,
such as rewards or positive outcomes, can stimulate engagement and enhance the learning process.
In its most basic form, the concept of motivation may be broken down into three distinct categories:
intrinsic motivation, extrinsic motivation, and amotivation (Gopalan et al., 2017). In addition, there
are a number of additional theories that have the potential to be put into practice, most notably in
the field of education. These theories are the attribution theory (Weiner, 1972), self-determination
theory (Gagn´ e, & E.D.-J. of O. behavior, undefined, 2005), the ARCS model (Keller, 2010), the social
cognitive theory (Bandura, 1991), and the expectancy theory (Wabba & House, 1974). These
educational theories are capable of existing on their own and making a contribution to the result of
the learning process without requiring the support of any other educational theories. These theories
have been explained in the following section: 6. Intrinsic theory of motivation The intrinsic theory of
motivation is a psychological theory that suggests that individuals engage in certain behaviors or
activities because they find them personally interesting or satisfying, rather than because of the
potential external rewards or pressures. Intrinsic moti vation is considered to be self-driven and is
characterized by feelings of enjoyment, interest, and satisfaction in the activity itself (Ryan & Deci,
2020). Edward Deci originally put out the concept of intrinsic motivation in the 1970s. According to
this theory, people's motivation levels are at their highest when they can fulfill their basic
psychological re quirements. According to Deci, human beings have a desire for auton omy,
competence, and relatedness. The need for autonomy relates to the desire to direct one's own life
and make decisions, the need for compe tence to the conviction that one possesses the skills
necessary for suc cess, and the need for relatedness to the satisfaction that comes from having
meaningful relationships with others (Deci, 1972). Deci's theory of intrinsic motivation has been
employed in a variety of fields, including education, sport, and the workplace, and has been used to
explain why individuals engage in activities such as learning, creativity, and volunteering. Research
suggests that activities that meet these three basic needs, tend to be more intrinsically motivating,
than those that do not, and also tend to lead to better performance, satis faction, and well-being
(Deci et al., 2001; E.D.-O. behavior and human performance, undefined, 1976). Intrinsic motivation is
considered to be a more sustainable and long- term form of motivation, as it is driven by personal
interests and values, rather than external rewards. Nonetheless, this doesn't mean that the external
rewards are not important, they can also play a role in the process of motivation, depending on the
context and the individual (Deci & Ryan, 2013; Ryan & Deci, 2020). The intrinsic theory of moti vation
suggests that people are naturally driven to learn when they find the subject matter engaging and
personally meaningful. In learning, this means that educators can enhance motivation by making the
content relevant and tapping into students' inherent curiosity and interest. 7. Extrinsic theory of
motivation Extrinsic theory suggests that individuals engage in certain behaviors or activities because
of the potential external rewards or pressures, rather than because they find them personally
interesting or satisfying. Extrinsic motivation is considered to be externally driven and is char
acterized by the presence of external factors such as grades, money, or praise that serve as
incentives to engage in a behavior or activity. Extrinsic motivation can take many forms, such as
rewards, like receiving a prize for completing a task, or punishment, such as being given a penalty for
not completing a task. The theory suggests that in dividuals engage in activities in order to earn
rewards or avoid pun ishments (Deci et al., 1991; Ryan & Deci, 2000; Ryan & Deci, 2020). Extrinsic
motivation can also be classified as controlled motivation and integrated motivation. Controlled
motivation refers to behavior that is performed because of external rewards or to avoid punishment.
Inte grated motivation refers to behavior that is performed to gain an external reward but also aligns
with an individual's interests and values (Ryan & Deci, 2020). Although the theory of extrinsic
motivation was proposed by several authors, B.F. Skinner in the 1950s was the pioneer who
emphasized that behavior is controlled by its consequences and that we tend to repeat behaviors
that lead to positive outcomes and avoid behaviors that lead to negative outcomes (Jones & Skinner,
1939). Extrinsic motivation has been applied in a wide range of fields, such as education, sports, and
the workplace, and has been used to explain why individuals engage in activities such as studying,
working, and volunteering. Studies suggest that while extrinsic rewards can be effective in increasing
motivation and performance in the short term, they may have negative effects on motivation and
performance in the long term, as they can reduce the sense of autonomy and interest in the activity
(Duggal et al., 2021; Razali et al., 2020; Sun & Hsieh, 2018). Extrinsic motivation theory posits that
external rewards or punishments can drive learning by of fering incentives for desired behaviors. In
education, this implies that students may be motivated to learn when they are offered tangible re
wards or avoid negative consequences, but the challenge lies in main taining long-term engagement
and fostering genuine interest in the subject matter. 8. Intrinsic theory of motivation as contrasting
to extrinsic theory of motivation Intrinsic motivation theory and extrinsic motivation theory
represent two distinct approaches to understanding the driving forces behind human behavior.
Intrinsic motivation centers on the inherent satisfac tion and enjoyment derived from engaging in an
activity for its own sake, without the need for external rewards. This theory posits that in dividuals
are naturally inclined to pursue tasks that align with their interests and values, fostering a genuine
passion for learning. On the other hand, extrinsic motivation theory focuses on external factors, such
as rewards or punishments, as catalysts for behavior. It suggests that individuals are motivated by
external incentives, like grades or mone tary rewards, to achieve desired outcomes. While both
intrinsic and extrinsic motivations play roles in shaping human behavior, the former is often
associated with sustained interest, creativity, and a deeper level of engagement, whereas the latter
may lead to more temporary compliance driven by external factors. Striking a balance between
intrinsic and extrinsic motivators is crucial in cultivating a holistic and enduring approach to
motivation in various contexts, including education. 9. Attribution theory of motivation The
attribution theory of motivation is a psychological discipline that examines the effects of people's
beliefs about the nature of causation on their motivation. Attribution theory suggests that people
tend to attribute the cause of an event to either internal or external factors and that these
attributions can influence their motivation to engage in similar behaviors in the future. To attribute
an event to internal vari ables, like one's own abilities or the amount of work put in, is called an
internal attribution, for example, when someone excels in a sports competition, they may attribute
their success to their own skills, dedi cation, or hard work. Similarly, attributing an event to external
ele ments, like chance or the actions of others, is called an external attribution for example, if a
learner performs poorly on a test, they might attribute it to the difficulty of the questions rather
than their own lack of preparation (Graham, 1991; Graham, 2020; Weiner, 2010). Attribution theory
was developed by Fritz Heider in the 1950s and later expanded upon by Harold Kelley and others
(Muschetto & Siegel, 4 D. Bandhu et al. Acta Psychologica 244 (2024) 104177 2021). It proposes that
people have a fundamental need to understand the causes of events and that they use a variety of
cues to make judg ments about the causes of events. The theory also suggests that these judgments
can influence motivation by affecting an individual's per ceptions of their ability, control, and self-
esteem. For example, if an individual attributes success to their ability, they are more likely to feel
confident in their ability to achieve similar success in the future, and thus more motivated to engage
in similar behaviors. On the other hand, if an individual attributes a failure to external factors, they
may feel less responsible for the outcome, and therefore less motivated to engage in similar
behaviors in the future (Moring, 2022; Spitzberg & Manusov, 2021; Suhartini et al., 2019). Fig. 2.
presents Weiner's point of view concerning the attribution theory. An incident triggers the process
and depending on the outcome, good or negative feelings (pleasure or irritation) may be
experienced immediately. However, the curious “nave scientist” who strives to un cover a causal
interpretation is generally roused by unanticipated, un favorable, or seemingly significant events.
Each person will “hypothesize” a cause based on their unique perspective on the situa tion, which
will vary across 3 dimensions: locus, stability, and control lability. Stability influences one's
confidence in their own future progress. Emotional reactions (which represent perceptual
significance) are affected by locus, controllability, and stability, all of which in turn regulate
subsequent behaviors (Weiner, 1972). Attribution theory has been applied in a wide range of fields,
including education, sport, and the workplace, and has been used to explain how factors such as
feedback, rewards, and attributions can influence motivation. The theory is also closely related to
self-esteem and self-concept and it helps to understand how people evaluate them selves and how
that evaluation affects their motivation (Cook & Artino, 2016a; Motevalli et al., 2020; Price, 2021).
Individual differences significantly impact motivation in terms of attribution, as people may attribute
success or failure to factors like ability, effort, or external cir cumstances based on their unique
personalities, experiences, and be liefs. These varying attributions can shape individuals' motivation
levels and affect their future behaviors and learning outcomes. Attribution theory focuses on how
individuals attribute their successes and failures, impacting their motivation and future learning
behavior. In learning, when learners attribute their successes to their efforts or strategies and view
failures as opportunities for growth, they are more likely to remain motivated and persist in their
educational pursuits (Harvey & Martinko, n.d.; Baumeister et al., 1990; Saleh & Sturm, 2016). 10.
Expectancy theory of motivation According to the expectancy theory of motivation, people are
prompted to act, if they think doing so will bring about positive results. The theory suggests that
expectancy, instrumentality, and valence are the three most important components of expectancy
motivation. The expectancy is that hard work will provide positive results. The idea that 5 Fig. 2.
Weiner's attribution theory (Weiner, 1972). D. Bandhu et al. Acta Psychologica 244 (2024) 104177
one's efforts should be rewarded with the best possible results is known as “instrumentality.” The
term “valence” is used to describe the signif icance of an outcome to a person (Chopra, 2019; Fudge
et al., 1999; Isaac et al., 2013). Expectancy theory was developed by Victor Vroom in the 1960s, and
it suggests that motivation is a function of expectancy, instrumentality, and valence (Parijat & Bagga,
2014). Fig. 3 depicts the framework of this theory. According to this theory, an individual will be
motivated to engage in a behavior if they believe that: i). their effort will lead to high perfor mance
(expectancy), ii). high performance will lead to the desired out comes (instrumentality), and iii). the
desired outcomes are valuable or important to them (valence). The theory also proposes that people
may be motivated to engage in different behaviors depending on the strength of their expectancies,
the perceived instrumentality, and the valence of the outcomes. Expectancy theory has been
employed in a variety of f ields, including education, sport, and the workplace, and has been used to
explain how factors such as goal-setting, feedback, and rewards can influence motivation (Estes &
Polnick, 2012; Geiger & Cooper, 1996). It's important to mention that the Expectancy theory is one
of the most influential theories of motivation in the workplace and it has been widely used in
management, human resources, and organizational behavior. Expectancy theory has been found to
be useful in under standing how people make decisions regarding their efforts and how they
evaluate the outcomes of their efforts (Dejong et al., 2001; Snead & Harrell, 1994). Expectancy
theory in the context of learning posits that learners are motivated when they believe that their
efforts will lead to successful outcomes and that these outcomes are personally valuable. Learners
who expect their hard work will result in positive educational achievements are more likely to
remain engaged and committed to their learning goals. 11. Expectancy-value theory of motivation
The expectancy-value theory is a psychological theory of motivation that advocates that people are
driven to engage in a behavior or activity based on their beliefs about the likelihood (expectancy) of
success and the value (importance or desirability) of the outcome. The expectancy- value theory is
rooted in the idea that individuals make choices based on their perceived ability to successfully
complete a task and the perceived value of the outcome (Shang et al., 2022; Wigfield, 1994). The
theory suggests that motivation is determined by the product of expectancy (E) and value (V), or
motivation = E x V. Expectancy rep resents an individual's belief that they can successfully complete
a task, while value represents the importance or desirability of the outcome. The theory was first
proposed by Martin Fishbein and Icek Ajzen in the 1970s and it has been applied to various fields
such as education, sport, and the workplace (Fishbein & Ajzen, 1973; Fishbein & Ajzen, 2005). Using
a streamlined form of Wigfield and Eccles' theory, Fig. 4 de picts the expectancy-value theory. It does
not cover every element of their theory and muddles several small but possibly significant distinc
tions. Motivational theories, which are driven by social factors that are seen and understood by
cognitive processes in the learner, impact the important notions of task value and anticipation of
success. The expectancy-value theory has been used to explain why individuals choose to engage in
certain behaviors or activities, and how motivation can be increased or decreased by changing the
perceived expectancy and value of the outcome. Research suggests that when individuals perceive
that their chances of success are high and that the outcome is valuable, they will be highly motivated
to engage in the behavior or activity. The expectancy-value theory has been used to design
instruction, to improve motivation and performance. For example, teachers can increase learners'
motivation by making clear the learning objectives, providing appropriate feedback, and fostering a
sense of self-efficacy. It's worth noting that the Expectancy-value theory is not the only theory that
ex plains motivation, and other factors such as emotional states, cognitive processes, and social
context should also be taken into account (Otsuka & Smith, 2005; Rachmatullah et al., 2021; Wigfield
& Cambria, 2010). Expectancy-value theory suggests that learner motivation is influenced by their
expectations of success and the perceived value of a task. In learning, when learners believe they
can succeed and find a subject meaningful or relevant, their motivation is likely to be higher, leading
to increased effort and better performance. The knowledge of the key differences between
expectancy theory and expectancy-value theory is significant. Expectancy theory focuses on the
belief that efforts will lead to performance and performance will result in desired outcomes. In
contrast, expectancy-value theory in corporates not only the expectation of success but also
emphasizes the perceived value or importance of the outcome, suggesting that motiva tion is
influenced by both expectancy and the subjective value attached 6 Fig. 3. Vroom's expectancy theory
(Parijat & Bagga, 2014). D. Bandhu et al. Acta Psychologica 244 (2024) 104177 Fig. 4. Wigfield and
Eccles's theory. to achieving a goal (Estes & Polnick, 2012; Filipova, 2016). 12. ARCS model of
motivation The ARCS Model of Motivation is a framework for designing and evaluating instructional
materials, which stands for Attention, Rele vance, Confidence, and Satisfaction. The model was
developed by John Keller in the 1980s and is based on the idea that motivation is a key factor in
learning and that instructional materials should be designed to meet the motivational needs of
learners (Keller, 1987). The ARCS model consists of four components as shown in Fig. 5 (Park, 2018).
• Attention: The instructional materials must capture the attention of the learners by being
interesting, novel, and relevant to their needs and interests. • Relevance: The materials must be
relevant to the learners' needs, interests, and goals, and must be presented in a way that connects
to the learners' previous knowledge and experiences. • Confidence: The materials must provide the
learners with a sense of confidence and self-efficacy by providing clear instructions, the appropriate
level of difficulty, and feedback. • Satisfaction: The materials must provide the learners with a sense
of satisfaction and achievement by providing opportunities for success, problem-solving, and
creativity. The model is considered as a problem-solving tool that can help educators and designers
to assess the motivational appeal of the mate rials they are using or planning to use and make
improvements if necessary. The ARCS Model is widely used in education, training, and instruc tional
design, and has been used to design instructional materials for a wide range of learners, including
young learners, adults, and special needs populations. The model is considered a useful framework
for designing instruction that is motivating and effective, but it's important to note that it's not the
only tool that can be used to design instruction, and other factors such as cognitive load, and cultural
considerations, should also be taken into account (Keller, 2000; Li & Keller, 2018). In education, the
ARCS Model has been applied by designing engaging lessons that capture learners' Attention, such as
incorporating multimedia or real-world examples. Relevance is achieved by connect ing the material
to learners' interests or future goals, fostering intrinsic motivation. Building confidence involves
providing scaffolding and positive feedback, while satisfaction is addressed by creating meaningful
assessments, ensuring learners feel a sense of accomplishment. In training, ARCS is utilized similarly,
tailoring content to meet the needs and interests of trainees to enhance motivation and learning
outcomes. In instructional design, the model guides the development of courses that are not only
informative but also captivating, ensuring learners are attentive, perceive the material as relevant,
feel confident in their abilities, and ultimately find satisfaction in their learning experience. Critics
argue that the ARCS model oversimplifies motivation by focusing on discrete components and may
not address the complexity of indi vidual motivations (Chang & Chen, 2015; Keller, 2010). 13. Self-
determination theory (SDT) of motivation The self-determination theory (SDT) of motivation is a
psychological theory that explains how human behavior is influenced by the degree to which the
behavior is autonomous or self-determined. The theory pro poses that behavior that is autonomous
or self-determined is more likely to be sustained over time and to lead to greater well-being and
personal growth than behavior that is controlled by external factors or the in dividual's perceived
lack of choice (Ryan, 2009). SDT was developed by Deci and Ryan in the 1980s as an extension of
Deci's earlier work on intrinsic motivation. The simplified version of SDT, consisting of its three major
elements namely intrinsic, extrinsic, and amotivation has been illustrated in Fig. 6. It suggests that
people have three innate psychological needs: au tonomy, competence, and relatedness, that must
be met in order to maintain optimal motivation. According to SDT, the level of autonomy in behavior
is influenced by the degree to which the behavior is in line with an individual's values, goals, and
needs (Gagn´ e, & E.D.-J. of O. behavior, undefined, 2005). The theory distinguishes between
different types of motivation namely autonomous motivation, controlled moti vation, and
amotivation. Autonomous motivation refers to behavior that is in line with an individual's values,
goals, and needs and is perceived as self-determined. Controlled motivation refers to behavior that
is per formed because of external rewards or to avoid punishment. Amotivation refers to the
absence of motivation. It happens when an individual does not have a reason or belief that behavior
or activity will lead to the desired outcome or goal (Deci & Ryan, 2008; Vallerand et al., 2008). 7 D.
Bandhu et al. Acta Psychologica 244 (2024) 104177 Fig. 5. Keller's ARCS model of motivation. Fig. 6.
Deci's self-determination theory. The theory also suggests that when people feel autonomous and
competent in their behavior, they are more likely to experience positive outcomes such as personal
growth, well-being, and optimal perfor mance. SDT has been applied in a wide range of fields,
including edu cation, sport, health, and the workplace, and has been used to explain the effects of
different types of motivation on behavior and well-being. Research suggests that promoting
autonomy-supportive environments and behaviors can lead to better outcomes, such as improved
perfor mance and satisfaction (Sheldon et al., 2014; Teixeira et al., 2012). The traditional debates
between learning theory, with a focus on extrinsic motivation, and SDT, which emphasizes intrinsic
motivation and autonomy, have been central in understanding motivational pro cesses and their
implications for human behavior and achievement. Learning theory, rooted in behaviorism,
highlights the role of external rewards and reinforcements in shaping behavior. It posits that in
dividuals are motivated to engage in activities to obtain desired out comes or avoid punishment. This
perspective emphasizes the importance of extrinsic motivators, such as grades, rewards, and praise,
8 D. Bandhu et al. Acta Psychologica 244 (2024) 104177 in driving behavior and learning. Despite
this, it has been criticized for its limited consideration of internal motivational factors and the
neglect of individuals' innate psychological needs. On the other hand, SDT emphasizes the intrinsic
motivation that arises from individuals' inherent psychological needs for autonomy, competence,
and related ness. According to SDT, individuals are motivated when their activities align with their
values, interests, and sense of personal autonomy. SDT recognizes the importance of internal
motivators, such as enjoyment, curiosity, and self-determined choice, in promoting engagement,
satis faction, and well-being (Deci & Ryan, 2008; Sheldon et al., 2014; Teixeira et al., 2012). In
comparing these two perspectives, it becomes apparent that learning theory focuses primarily on
external factors, while SDT em phasizes the interplay between internal and external motivational fac
tors. While learning theory may be effective in certain contexts, it often overlooks the role of
autonomy and intrinsic motivation, which have been found to be crucial for long-term engagement
and optimal per formance. SDT provides a broader and more comprehensive conceptu alization of
motivation by considering individuals' psychological needs and the quality of motivation. It posits
that intrinsic motivation, which stems from the satisfaction of psychological needs, leads to greater
engagement, creativity, and well-being. In contrast, extrinsic motivation can vary in its degree of
autonomy, ranging from controlled to auton omous forms. SDT highlights the importance of
fostering autonomous forms of extrinsic motivation that align with individuals' values and interests
(Reeve, n.d.; Grolnick & Ryan, 1987; Vansteenkiste et al., 2006). The interplay between learning
theory and SDT has been a subject of empirical investigation. Studies have examined the complex
dynamics and potential integration of these two motivational factors. Research has shown that
external rewards can undermine intrinsic motivation when they are perceived as controlling or used
as a means of exerting control. Regardless, when external rewards are provided in a way that
supports individuals' autonomy and competence, they can enhance intrinsic motivation and foster a
sense of ownership and engagement. Further more, studies have explored how the learning
environment can be structured to support intrinsic motivation and autonomy. For example,
providing meaningful choices, promoting competence-building experi ences, and nurturing
supportive relationships have been found to enhance intrinsic motivation and the quality of
engagement. By bridging the gap between the traditional debates, the literature demonstrates the
relevance and applicability of both learning theory and SDT in real- world contexts. It highlights the
need for a balanced approach that considers both extrinsic and intrinsic motivators and
acknowledges the importance of autonomy, competence, and relatedness in promoting optimal
motivation and well-being (Grolnick & Ryan, 1987; Niemiec & Ryan, 2009; Vansteenkiste et al.,
2006). 14. Social cognitive theory (SCT) of motivation Social cognitive theory (SCT) of motivation is a
psychological theory that suggests that behavior is influenced by the interaction between personal,
behavioral, and environmental factors. SCT theory of moti vation was developed by Albert Bandura
in the 1980s. It is an extension of Bandura's earlier work on social learning theory (SLT), which pro
posed that individuals learn from observing and imitating the behaviors of others. SCT suggests that
motivation is influenced by the interaction between personal, behavioral, and environmental factors
(Bandura, 2005). According to SLT, people learn not only through direct rein forcement but also by
observing the behaviors of others and the conse quences of those behaviors. This observation can
lead to the acquisition of new behaviors, as well as the shaping of existing behaviors. One of the key
concepts in SLT is observational learning, which is the process of learning new behaviors by
observing others. This process involves four main steps: attention, retention, reproduction, and
motivation. Bandura conducted several experiments to demonstrate the power of observational
learning. In one of his most famous experiments, the Bobo doll experiment, Bandura showed that
children were more likely to imitate aggressive behavior after watching an adult model behave
aggressively. Fig. 7 depicts the modified version of Schunk's model of motivated learning. It
incorporates additional concepts from Bandura and other authors. Schunk's model of motivated
learning provides a framework for understanding the factors that influence learners' motivation to
learn. The model incorporates several key concepts from social cognitive theory (SCT), emphasizing
the interplay between personal, behavioral, and environmental factors in shaping motivation. Key
alignments be tween Schunk's Model and SCT include self-efficacy, observational learning, goal-
setting, and self-regulation. SCT expands upon previous theories by integrating cognitive, behavioral,
and social aspects of motivation. Unlike earlier theories that focused primarily on either internal
drives or external rewards, the so cial cognitive theory emphasizes the interaction between
individuals and their environment. One key aspect that sets social cognitive theory apart is its
emphasis on self-efficacy beliefs. Self-efficacy refers to an individual's belief in their ability to
successfully perform a specific task or behavior. This concept allows for a more nuanced
understanding of motivation as it recognizes the influence of one's perceived competence on their
motivation to engage in specific activities. SCT also highlights the role of observational learning,
where individuals acquire new be haviors and motivations by observing others. This expands the
scope of motivational processes beyond individual experiences and includes the influence of social
modeling and vicarious reinforcement (The Social Cognitive Theory, n.d.; Conti & Amabile, 2011;
Stavropoulou et al., 2023; Thomson & Jaque, 2017). According to SCT, motivation is driven by the
individual's goals and expectations and is influenced by the perceived outcomes of the behavior, the
individual's self-efficacy (i.e., the belief in one's ability to perform the behavior), and the individual's
perceived control over the situation. The theory also suggests that people are more likely to engage
in behavior that they perceive as leading to desired outcomes when they: i). have a high level of self-
efficacy, ii). perceive that the behavior is under their control, and iii). perceive that the behavior is
consistent with their goals and values (Bandura, 2002; Stavropoulou et al., 2023; Wood & Bandura,
1989). Each learner enters a learning encounter with a unique sense of confidence based on their
unique blend of prior knowledge, natural abilities, and social reinforcements. A learner can either do
the activity by themself or observe another learner (either an instructor or a peer model) doing the
activity. Cognitive involvement, motivation to learn, emotional reaction, and work evaluation are all
affected by self-efficacy in addition to other personal and environmental aspects during the ac tivity.
Self-efficacy for subsequent tasks is influenced by indicators that learners pick up, both during and
after work. Like this paradigm, Zim merman's self-regulation cycle consists of three stages: pre-task
planning (pre-task), task execution with self-directed effort (during the task), and post-task
evaluation (after the task). The SCT offers several comparative strengths that make it a valuable
framework for understanding motivation, surpassing some of the limi tations of previous theories.
By addressing these strengths, it can be highlighted why social cognitive theory provides a better
explanation of motivation. Schunk's model specifically incorporates concepts from Bandura's work
on SCT as follows (Alahmad, 2020; Toomey & Heo, 2022; Urhahne & Wijnia, 2023; Young et al.,
2014): • Integration of Cognitive and Behavioral Factors: Unlike earlier theories that predominantly
focused on either internal drives or external re wards, SCT integrates both cognitive and behavioral
factors. It rec ognizes that motivation is influenced not only by external stimuli but also by internal
cognitive processes, such as beliefs, expectations, and self-perceptions. This integration allows for a
more compre hensive understanding of motivation. 9 D. Bandhu et al. Acta Psychologica 244 (2024)
104177 Fig. 7. Schunk's model of motivated learning. • Emphasis on Self-Efficacy: One of the key
strengths of SCT is its emphasis on self-efficacy beliefs. Self-efficacy refers to an in dividual's belief in
their ability to successfully perform a specific task or behavior. This concept addresses the question
of “Can I do it?” and plays a crucial role in motivating individuals to engage in activities. Unlike
previous theories that may have overlooked the role of self- beliefs, SCT recognizes the significance
of self-efficacy in shaping motivation. • Observational Learning and Vicarious Reinforcement: SCT
acknowl edges the influence of observational learning and vicarious rein forcement on motivation.
Individuals can acquire new behaviors and motivations by observing others and witnessing the
outcomes of their actions. This expands the scope of motivational processes beyond individual
experiences and highlights the social aspects of motivation. By considering the role of observational
learning, SCT provides a richer understanding of how individuals' motivations are influenced by their
social environment. • Contextual Factors and Reciprocal Determinism: SCT recognizes the
importance of contextual factors and the dynamic interplay between individuals and their
environment. It proposes the concept of reciprocal determinism, suggesting that individuals and
their envi ronment mutually influence each other. This perspective acknowl edges that motivation is
not solely an individual phenomenon but is shaped by social and environmental factors. By
considering the reciprocal relationship between individuals and their context, SCT offers a more
comprehensive explanation of motivation. When comparing SCT to previous theories, its strengths
become apparent. For instance, compared to intrinsic and extrinsic theories that focus primarily on
internal instincts needs, or incentives, SCT provides a more comprehensive understanding by
considering cognitive processes, observational learning, and the influence of the social context. Addi
tionally, SCT's emphasis on self-efficacy distinguishes it from expectancy-value theories that may
have provided a broader, less task- specific view of beliefs about competence. By incorporating
these comparative strengths, it can be demonstrated how SCT offers a more nuanced and
comprehensive explanation of motivation compared to previous theories. The integration of
cognitive and behavioral factors, emphasis on self-efficacy, recognition of observational learning,
and consideration of contextual factors contribute to a more robust under standing of motivation
(Young et al., 2014). SCT has been applied in a wide range of fields, including education, health,
sport, and the workplace. For example, In the classroom, teachers can foster both intrinsic and
extrinsic motivation by providing stimulating learning activities, allowing leaners to pursue their
interests, and offering clear goals and expectations. However, overemphasis on 10 D. Bandhu et al.
Acta Psychologica 244 (2024) 104177 extrinsic rewards can undermine intrinsic motivation, so it's
crucial to f ind a balance between the two. Also, in sports, coaches can enhance athletes' motivation
by fostering self-efficacy through positive rein forcement, providing realistic goals, and breaking
down tasks into achievable steps. By emphasizing self-belief, coaches can empower athletes to
pursue challenging goals and persist in the face of setbacks. It has been used to explain how people
learn from observing and imitating the behaviors of others and how this learning influences their
behavior. It also has been used to explain how people are motivated to engage in behaviors that
they perceive as leading to desired outcomes, and how factors such as self-efficacy, perceived
control, and goal-setting can in f luence motivation (Bandura, 1988; Ilmiani et al., 2021). 15. Goal-
orientation theory of motivation The goal-orientation theory of motivation is a psychological theory
that suggests that individuals differ in their goals or reasons for engaging in a behavior or activity.
The theory proposes that individuals can be classified into different goal orientations, such as a
performance- approach goal orientation, a performance-avoidance goal orientation, a mastery-
approach goal orientation, and a work-avoidance goal orientation. Performance-approach goal
orientation refers to the ten dency to engage in a task to demonstrate one's ability and outperform
others. Performance-avoidance goal orientation refers to the tendency to engage in a task to avoid
failure and negative evaluation by others. Mastery-approach goal orientation refers to the tendency
to engage in a task to improve one's skills, knowledge, and abilities. Work-avoidance goal orientation
refers to the tendency to avoid engaging in a task because it's viewed as unimportant or
uninteresting (Domurath et al., 2020; Lam et al., 2022). The theory was first proposed by Dweck and
Leggett in 1988 and later by Elliot and McGregor in 2001, and it has been applied in various f ields
such as education, sport, and the workplace. The simplified version of Dweck's theory has been
illustrated in Fig. 8. Carol Dweck and Ellen Leggett identified two distinct goal orienta tions:
performance-goal orientation and mastery-goal orientation. Performance-goal orientation is
characterized by a focus on demon strating ability and achieving external validation, often through
com parisons with others. Individuals with a performance-goal orientation are primarily motivated
by the desire to outperform others, avoid negative judgments, and gain social approval. Mastery-
goal orientation, on the other hand, emphasizes learning, self-improvement, and personal growth.
Individuals with a mastery-goal orientation are intrinsically motivated by the desire to enhance their
skills, understand concepts, and overcome challenges. They view setbacks as opportunities for
learning and growth rather than threats to their self-esteem (Reeve, n.d.; Hattie et al., 2020). In
2002, Andrew Elliot and Helen McGregor expanded upon Dweck and Leggett's theory, proposing a
more complex and multifaceted framework for understanding goal orientations. They identified two
dimensions of goal orientation: task-goal orientation and ego-goal orientation. Task-goal orientation
is similar to mastery-goal orienta tion, emphasizing learning, self-improvement, and the
development of competence. Individuals with a task-goal orientation are motivated by the inherent
satisfaction of mastering new skills and solving problems. Ego-goal orientation is similar to
performance-goal orientation, focusing 11 Fig. 8. Dweck's goal-orientation theory. D. Bandhu et al.
Acta Psychologica 244 (2024) 104177 on demonstrating ability and achieving external validation.
However, Elliot and McGregor further differentiated ego-goal orientation into two subtypes. The
first one is performance-approach ego-goal orientation. This subtype is characterized by a focus on
outperforming others and achieving superior performance. Individuals with this orientation are
motivated by the desire to gain recognition, status, and social approval. The second one is
performance-avoidance ego-goal orientation. This subtype is characterized by a fear of failure and a
desire to avoid negative judgments from others. Individuals with this orientation are motivated by
the need to avoid embarrassment, criticism, and damage to their self-esteem (Linnenbrink &
Pintrich, 2002; Wang et al., 2021). While both Dweck and Leggett's and Elliot and McGregor's in
terpretations of goal-orientation theory share the core distinction be tween performance and
mastery goals, they also differ in their complexity and nuance. Both models emphasize the
significant impact of goal orientation on individuals' motivation, persistence, and achievement. Both
models recognize the importance of both perfor mance and mastery goals, acknowledging that
individuals may exhibit both orientations to varying degrees. Elliot and McGregor's model pro vides a
more refined and multifaceted framework, differentiating ego- goal orientation into two subtypes.
Elliot and McGregor's model places greater emphasis on the motivational consequences of goal
orientations, particularly the contrasting effects of task-goal orientation and performance-approach
versus performance-avoidance ego-goal orien tation (Mccollum & Kajs, 2007; Wang et al., 2021). The
goal-orientation theory of motivation has evolved from Dweck and Leggett's original proposition to
Elliot and McGregor's more com plex interpretation. Both models provide valuable insights into how
individuals' goal orientations influence their motivation, persistence, and achievement. Educators,
coaches, and individuals alike can benefit from understanding the dynamics of goal orientations and
fostering a focus on mastery-oriented and task-goal-oriented goals to promote intrinsic motivation,
learning, and personal growth. Research suggests that individuals with a mastery-approach goal
orientation tend to perform better, experience more satisfaction, and have a better well- being than
those with a performance-approach or performance- avoidance goal orientation. The theory has
been used to design in struction, improve motivation, and increase well-being and perfor mance. For
example, teachers can foster a mastery-approach goal orientation by designing tasks that are
challenging but achievable, providing opportunities for personal growth, and giving feedback that
emphasizes learning and progress over performance (Elliot et al., 2011; Urdan & Kaplan, 2020). 16.
Mutual themes Drawing from the preceding discussions, four main themes emerge from these
theories that can be used to better understand the relation ships and differences between them.
Accordingly, a concise overview of each theory is provided in Table 1. • Competence: Perceptions of
one's competence are deeply embedded within the framework of these motivational theories.
Expectancy of success, self-efficacy, confidence, and self-concept are all names for the same set of
ideas that aim to answer the question “Can I do it?” There are, nevertheless, significant differences
between and within theories, as previously discussed. Self-concept and older concepts of
anticipation of success (expectancy-value theory) saw such views in broad strokes (e.g., covering a
large area like ‘athletics’ or ‘clinical medicine,’ or broadening across time or circumstances). On the
other hand, self-efficacy (social-cognitive theory) and subsequent concepts of expectation of success
interpreted similar views in a variety of task- and situation-specific contexts (e.g., “Can I assess the
serious ness of cardiac stenosis?”). • Value: The value of the learning activity, or its expected
outcome, is also typically discussed in these theories. Beliefs like task worth, expected outcome, and
internal vs. external motivation are examples of such concepts. All of these answers deal with the
dilemma of “Do I want to do it?” or “What will occur (positive or negative) if I do it?” Once again,
there are substantial gaps between competing theories. For instance, task value (expectancy-value
theory) emphasizes the perceived significance or utility of successfully completing a task, while
outcome expectancy (social-cognitive theory) emphasizes the likely (anticipated) consequence of
action if maximum commitment is spent. • Attributions: Most theories highlight the role of
attributions in influencing attitudes and behavior. Whether consciously or uncon sciously, learners
often attribute external events or outcomes to in ternal elements that contributed to them. Learners
are more inclined to keep trying after an early setback if they believe the fundamental cause is
malleable and under their control. • Cognitive: Finally, all current motivation theories are ‘cognitive’
in the sense that, contrary to certain older theories, they all assume the participation of non-
observable mental processes. Furthermore, contemporary theories have come to acknowledge that
motivation is seldom an isolated individual phenomenon, but rather the result of intricate
relationships between the individual and their social envi ronment. Even though Bandura called his
theory a “social-cognitive theory of learning,” the other theories, discussed above, also incor porate
both social and cognitive aspects of the learning process. 17. Summary and recommendation This
study has covered a number of motivation theories used in ac ademic learning. Historically, self-
determination theory (SDT) and the ARCS model were broadly applied in the motivation purview for
learning activities. Theoretical frameworks like the social cognitive theory and the expectancy theory
are just starting to be put into practice. The goal throughout was to identify models with the
potential to boost learner engagement in the field of education. Learning is a complex activity that
requires direction if it is to be accomplished effectively. Theories are crucial to the success of
determined endeavors. A diversion from the necessary goal would be disastrous. As a result,
scholars have developed theoretical frameworks to direct these activities. Theoretical frameworks
are useful for organizing and executing educational activ ities, and they also offer pointers for
dealing with real-world difficulties. Similar to other psychological theories, motivation structures
have led to several competing hypotheses that endeavor to describe compa rable behaviors. The
question of whether motivation is a function, a trait, or a condition is itself a matter of debate. This
conflicting yet inter- connected nature of these theories makes it harder to get accurate in formation
while researching a phenomenon academically. Everyone on a phenomenological level knows that
intrinsic motivation is a key factor in learning, but traditional methods of measuring rely on self-
report (which is notoriously incorrect) or on observable changes in behavior (which involves circular
reasoning). This predicament raises a number of intriguing concerns. The first is the contrast
between the ideas of contextual motivation and self-regulation of motivation. The former view,
which is congruent with behavioral psychology, has only lately been considered in the research of
learning goal concepts and their in f luence on academic motivation, holds that motivation is driven
by ecological variables. When a learner engages in self-regulated motiva tion, he or she uses active
regulatory tactics to manage his or her motivation. Different suggestions for research and
improvement of motivation are provided by these two theories. A common theme across
contemporary theories, namely social cognitive theory, is the idea that one's degree of motivation is
contingent on a dynamic exchange between the individual and their surrounding ecosystem. The
connection between intrinsic and extrinsic forces/factors of motivation offers a rich vein of intriguing
unanswered issues. When compared to motivation that comes from inside or is intrinsically valu able
to the endeavor, what is the value of influence that an extrinsic form 12 D. Bandhu et al. Acta
Psychologica 244 (2024) 104177 Table 1 Overview of theories of motivation. Main Idea Key Concepts
Key Differences Extrinsic theory Attribution theory Expectancy theory Intrinsic theory Expectancy-
value theory ARCS model of motivation Self- determination theory (SDT) Social cognitive theory
(SCT) Goal-orientation theory • Individuals are driven by external rewards, such as money, grades, or
recognition, to engage in certain behaviors. • After an incident, learners unconsciously generate
causal explanations (attributions) for the outcomes. • Attributions differ from the viewpoint of locus,
stability, and controllability. These have an impact on feelings, which in turn motivates future
activities. • Learners are motivated when they believe their efforts will lead to desired performance
and outcomes. • Internal factors, such as personal interests, enjoyment, and the inherent
satisfaction derived from engaging in an activity play a significant role in driving human behavior. •
Motivation is influenced by expectations of achievement and perceived worth. The ARCS (Attention,
Relevance, Confidence, and Satisfaction) Model of Motivation focuses on designing instructional
materials and strategies to enhance learner motivation. • SDT encompasses both intrinsic and
extrinsic motivations contextualized by these three factors: • Intrinsic motivation makes people do
things just to satiate their inquisitiveness or urge to get better at something. • Social values are what
drive extrinsic motivation, which is what drives all other actions. Integrating and internalizing one's
values can transform behavior that was once motivated by external factors into a self- determined
act. • Feelings of competence, autonomy, and relatedness are conducive to intrinsic and internalized
motivations. • Personal characteristics, behavioral tendencies, and external context all interact to
influence an individual's ability to learn and perform. • Self-efficacy is the main source of motivation.
• Learners often look at activities with three main objectives in mind: comprehending the content
(the mastery objective), outperforming their peers (the performance approach objective), and
preventing themself from failure (the performance-avoidance objective). • While performance-
based goals are linked to higher grades, mastery goals seem to promote curiosity and in-depth
study. Negative results are more often related to performance- avoidance aims. • The focus is on the
external factors that influence motivation, such as incentives, punishments, and social recognition. It
assumes that people's behavior is primarily driven by external factors rather than internal desires or
interests. • Locus indicates whether an individual's problem has an internal or external source. •
Stability denotes whether the underlying cause is unchanging or subject to change. • Controllability
indicates whether or not the underlying reason is under the control of the person. • The theory
involves three key components: expectancy (the belief that effort will result in performance),
instrumentality (the belief that performance will lead to desired outcomes), and valence (the value
or importance assigned to the desired outcomes). • The theory emphasizes the intrinsic rewards
associated with an activity, such as the sense of accomplishment, enjoyment, or personal growth. •
It suggests that individuals have an innate drive to pursue activities that align with their interests and
provide intrinsic satisfaction. • Success expectation is the confidence that one will achieve their goal
if one puts out the effort. • A person's job value is determined by how much they value or enjoy
performing the activity for themselves. The model emphasizes creating a learning environment that
captures learners' attention, demonstrates the relevance of the material to their goals and interests,
builds their confidence in their ability to succeed, and provides a sense of satisfaction or
accomplishment. • Autonomy is the freedom to make one's own decisions. • Competence describes
a person's apparent skill and success. • Relatedness is a feeling of connection or being associated
with other people with whom you'd like to feel linked. • Self-efficacy is a personal assessment of
one's capacity for learning or performance at a certain level. • Outcome expectation describes the
view that certain outcomes will come from certain acts. • Self-regulation entails a cyclical pattern of
goal pursuit, wherein individuals monitor their progress and adjust their strategies based on self-
assessment. • Focusing on improving one's intelligence or skill is called a “mastery orientation,” and
it stems from a “growth learning mindset” (skills can be shaped and circumstances can be managed).
• Performance orientation emphasizes seeming intelligent rather than stupid; it results from the
learning mentality known as “entity” (ability is f ixed and circumstances are less under one's control).
13 • In contrast to intrinsic theory, which emphasizes internal motivation and personal satisfaction,
extrinsic theory highlights the role of external rewards in shaping behavior. • Attribution theory
distinguishes from expectancy-value theory by the premise that emotional mediation of task value. •
The goal-orientation theory relies heavily on implicit attributions regarding the consistency of one's
abilities. • According to social-cognitive theory, attribu tions play a crucial role in the process of self-
regulation. • Expectancy theory is distinct from other motivation theories in its focus on the
cognitive processes underlying motivation and the belief in the link between effort, performance,
and outcomes. It emphasizes individuals' perceptions of the likelihood and desirability of outcomes.
• The intrinsic theory stands in contrast to the extrinsic theory, as it highlights the role of internal
factors and personal satisfaction rather than external rewards in driving motivation. • Several other
theories also make use of ideas like an expectancy of success and value. The ARCS Model
complements other motivation theories by providing practical guidelines for instructional design and
implementation, taking into account specific motivational factors that can enhance engagement and
learning outcomes. Self-determination theory is distinguished from other theories by its focus on
autonomy, choice, and human relationships. • Though it shares some similarities with other
constructs of expectancy, self-efficacy tends to be more task-, context-, and goal-oriented. •
Contrary to attribution theory, controllability beliefs differ from person to person (i.e., they are not a
constant attribute of the event or learner). D. Bandhu et al. Acta Psychologica 244 (2024) 104177 of
motivation may have? Specifically relevant to teachers who seek to encourage self-directed,
perpetual learning yet struggle to ignite their learners' enthusiasm in the conventional coursework
and frequently turn to grades as a kind of motivation, problems like these demand solutions.
Emotional influences on motivation go beyond this, it is an emerging f ield of study which highlights
the brain's role in determining behavior. This segment began with difficulty, the requirement for a
better accurate indicator of motivation, and a possible answer may lay in the capacity to assess the
brain's responsiveness to transformations in the ecosystem at multiple levels. CRediT authorship
contribution statement Din Bandhu: Writing – review & editing, Writing – original draft,
Visualization, Conceptualization. M. Murali Mohan: Writing – original draft, Visualization. Noel
Anurag Prashanth Nittala: Writing – review & editing, Resources, Methodology. Pravin Jadhav:
Supervision, Re sources, Formal analysis. Alok Bhadauria: Writing – review & editing, Resources,
Funding acquisition. Kuldeep K. Saxena: Visualization, Supervision, Resources. Declaration of
competing interest The authors declare that they have no known competing financial interests or
personal relationships that could have appeared to influence the work reported in this paper.

1 A Sociocultural Perspective IN THIS CHAPTER • Scope of the TIP • Intended Audience • Before You
Begin • Structure of the TIP • What Is Trauma? • Trauma Matters in Behavioral Health Services •
Trauma -Informed Intervention and Treatment Principles • As You Proceed Many individuals who
seek treatment in behavioral health settings have histories of trauma, but they often don’t recognize
the signifi cant effects of trauma in their lives; either they don’t draw connec tions between their
trauma histories and their presenting problems, or they avoid the topic altogether. Likewise,
treatment providers may not ask questions that elicit a client’s history of trauma, may feel
unprepared to address trauma-related issues proactively, or may struggle to address traumatic
stress effectively within the con straints of their treatment program, the program’s clinical orienta
tion, or their agency’s directives. By recognizing that traumatic experiences and their sequelae tie
closely into behavioral health problems, front-line professionals and community-based programs can
begin to build a trauma informed environment across the continuum of care. Key steps include
meeting client needs in a safe, collaborative, and compas sionate manner; preventing treatment
practices that retraumatize people with histories of trauma who are seeking help or receiving
services; building on the strengths and resilience of clients in the context of their environments and
communities; and endorsing trauma-informed principles in agencies through support, consulta tion,
and supervision of staff. This Treatment Improvement Protocol (TIP) begins by introducing the
scope, purpose, and organization of the topic and describing its intended audience. Along with
defining trauma and trauma informed care (TIC), the first chapter discusses the rationale for
addressing trauma in behavioral health services and reviews trauma informed intervention and
treatment [Link] principles serve as the TIP’s conceptual framework. 3 Trauma-Informed
Care in Behavioral Health Services Scope of the TIP Many individuals experience trauma during their
lifetimes. Although many people exposed to trauma demonstrate few or no lingering symptoms,
those individuals who have experi enced repeated, chronic, or multiple traumas are more likely to
exhibit pronounced symp toms and consequences, including substance abuse, mental illness, and
health problems. Subsequently, trauma can significantly affect how an individual engages in major
life areas as well as treatment. This TIP provides evidence-based and best practice information for
behavioral health service providers and administrators who want to work more effectively with
people who have been exposed to acute and chronic traumas and/or are at risk of developing
traumatic stress reactions. Using key trauma-informed principles, this TIP addresses trauma-related
prevention, intervention, and treatment issues and strategies in behavioral health services. The
content is adaptable across behavioral health settings that service individuals, fami lies, and
communities—placing emphasis on the importance of coordinating as well as inte grating services.
Intended Audience This TIP is for behavioral health service pro viders, prevention specialists, and
program administrators—the professionals directly re sponsible for providing care to trauma survi
vors across behavioral health settings, including substance abuse and mental health services. This
TIP also targets primary care professionals, including physicians; teams working with clients and
communities who have experienced trauma; service providers in the criminal justice system; and
researchers with an interest in this topic. Before You Begin This TIP endorses a trauma-informed
model of care; this model emphasizes the need for behavioral health practitioners and organiza tions
to recognize the prevalence and pervasive impact of trauma on the lives of the people they serve
and develop trauma-sensitive or trauma-responsive services. This TIP provides key information to
help behavioral health practitioners and program administrators be come trauma aware and
informed, improve screening and assessment processes, and im plement science-informed
intervention strate gies across settings and modalities in behavioral health services. Whether
provided by an agency or an individual provider, trauma informed services may or may not include
trauma-specific services or trauma specialists (individuals who have advanced training and education
to provide specific treatment inter ventions to address traumatic stress reactions). Nonetheless,TIC
anticipates the role that trauma can play across the continuum of care— establishing integrated
and/or collaborative processes to address the needs of traumatized individuals and communities
proactively. Individuals who have experienced trauma are at an elevated risk for substance use
disorders, including abuse and dependence; mental health problems (e.g., depression and anxiety
symptoms or disorders, impairment in rela tional/social and other major life areas, other distressing
symptoms); and physical disorders and conditions, such as sleep disorders. This TIP focuses on
specific types of prevention (Institute of Medicine et al., 2009): selective prevention, which targets
people who are at risk for developing social, psychological, or other conditions as a result of trauma
or who are at greater risk for experiencing trauma due to behavioral health disorders or conditions;
and indicated prevention, which targets people who display early signs of trauma-related 4 Part 1,
Chapter 1—Trauma-Informed Care: A Sociocultural Perspective symptoms. This TIP identifies
interventions, including trauma-informed and trauma specific strategies, and perceives treatment as
a means of prevention—building on resilience, developing safety and skills to negotiate the impact
of trauma, and addressing mental and substance use disorders to enhance recovery. This TIP’s target
population is adults. Beyond the context of family, this publication does not examine or address
youth and adolescent responses to trauma, youth-tailored trauma informed strategies, or trauma-
specific inter ventions for youth or adolescents, because the developmental and contextual issues of
these populations require specialized interventions. Providers who work with young clients who
have experienced trauma should refer to the resource list in Appendix B. This TIP covers TIC, trauma
characteristics, the impact of traumatic experiences, assessment, and inter ventions for persons who
have had traumatic experiences. Considering the vast knowledge base and specificity of individual,
repeated, and chronic forms of trauma, this TIP does not provide a comprehensive overview of the
unique characteristics of each type of trauma (e.g., sexual abuse, torture, war-related trauma,
murder). Instead, this TIP provides an over view supported by examples. For more infor mation on
several specific types of trauma, please refer to TIP 36, Substance Abuse Treatment for Persons With
Child Abuse and Neglect Issues (Center for Substance Abuse Treatment [CSAT], 2000b), TIP 25,
Substance Abuse Treatment and Domestic Violence (CSAT, 1997b), TIP 51, Substance Abuse
Treatment: Addressing the Specific Needs of Women (CSAT, 2009d), and the planned TIP,
Reintegration-Related Behavioral Health Issues in Veterans and Military Families (Substance Abuse
and Mental Health Services Administration [SAMHSA], planned f). This TIP, Trauma-Informed Care in
Behavioral Health Services, is guided by SAMHSA’s Stra tegic Initiatives described in Leading Change:
A Plan for SAMHSA’s Roles and Actions 2011– 2014 (SAMHSA, 2011b). Specific to Strate gic Initiative
#2, Trauma and Justice, this TIP addresses several goals, objectives, and actions outlined in this
initiative by providing behav ioral health practitioners, supervisors, and ad ministrators with an
introduction to culturally responsive TIC. Specifically, the TIP presents fundamental concepts that
behavioral health service provid ers can use to: • Become trauma aware and knowledgeable about
the impact and consequences of traumatic experiences for individuals, fami lies, and communities. •
Evaluate and initiate use of appropriate trauma-related screening and assessment tools. •
Implement interventions from a collabora tive, strengths-based approach, appreciating the
resilience of trauma survivors. • Learn the core principles and practices that reflect TIC. • Anticipate
the need for specific trauma informed treatment planning strategies that support the individual’s
recovery. • Decrease the inadvertent retraumatization that can occur from implementing standard
organizational policies, procedures, and in terventions with individuals, including cli ents and staff,
who have experienced trauma or are exposed to secondary trauma. • Evaluate and build a trauma-
informed or ganization and workforce. The consensus panelists, as well as other con tributors to this
TIP, have all had experience as substance abuse and mental health counselors, prevention and peer
specialists, supervisors, clinical directors, researchers, or administrators working with individuals,
families, and 5 Trauma-Informed Care in Behavioral Health Services communities who have
experienced trauma. The material presented in this TIP uses the wealth of their experience in
addition to the available published resources and research relevant to this topic. Throughout the
consen sus process, the panel members were mindful of the strengths and resilience inherent in in
dividuals, families, and communities affected by trauma and the challenges providers face in
addressing trauma and implementing TIC. Structure of the TIP Using a TIC framework (Exhibit 1.1-1),
this TIP provides information on key aspects of trauma, including what it is; its consequences;
screening and assessment; effective prevention, intervention, and treatment ap proaches; trauma
recovery; the impact of trauma on service providers; programmatic and administrative practices;
and trauma re sources. Note: To produce a user-friendly but in formed document, the first two parts
of the TIP include minimal citations. If you are in terested in the citations associated with topics
covered in Parts 1 and 2, please consult the review of the literature provided in Part 3 (available
online at [Link] Parts 1 and 2 are easily read and digested on their own, but it is
highly recommended that you read the literature review as well. Exhibit 1.1-1: TIC Framework in
Behavioral Health Services—Sociocultural Perspective 6 See Appendix C to read about the history of
trauma and trauma interventions. Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural
Perspective What Is Trauma? According to SAMHSA’s Trauma and Justice Strategic Initiative,
“trauma results from an event, series of events, or set of circumstances that is experienced by an
individual as physi cally or emotionally harmful or threatening and that has lasting adverse effects on
the in dividual’s functioning and physical, social, emotional, or spiritual well-being” (SAMHSA, 2012,
p. 2). Trauma can affect people of every race, ethnicity, age, sexual ori entation, gender,
psychosocial background, and geographic region. A traumatic experience can be a single event, a
series of events, and/or a chronic condition (e.g., childhood neglect, domestic violence). Traumas
can affect indi viduals, families, groups, communities, specific cultures, and generations. It generally
over whelms an individual’s or community’s re sources to cope, and it often ignites the “fight, flight,
or freeze” reaction at the time of the event(s). It frequently produces a sense of fear, vulnerability,
and helplessness. Often, traumatic events are unex pected. Individuals may experience the traumatic
event directly, witness an event, feel threat ened, or hear about an event that affects someone they
know. Events may be human made, such as a mechanical error that causes a disaster, war, terrorism,
sexual abuse, or vio lence, or they can be the products of nature (e.g., flooding, hurricanes,
tornadoes). Trauma can occur at any age or developmental stage, and often, events that occur
outside expected life stages are perceived as traumatic (e.g., a child dying before a parent, cancer as
a teen, personal illness, job loss before retirement). It is not just the event itself that determines
whether something is traumatic, but also the individual’s experience of the event. Two peo ple may
be exposed to the same event or series of events but experience and interpret these events in vastly
different ways. Various biopsychosocial and cultural factors influence an individual’s immediate
response and long term reactions to trauma. For most, regardless of the severity of the trauma, the
immediate or enduring effects of trauma are met with resili ence—the ability to rise above the
circum stances or to meet the challenges with fortitude. For some people, reactions to a traumatic
event are temporary, whereas others have pro longed reactions that move from acute symp toms to
more severe, prolonged, or enduring mental health consequences (e.g., posttrau matic stress and
other anxiety disorders, sub stance use and mood disorders) and medical problems (e.g., arthritis,
headaches, chronic pain). Others do not meet established criteria for posttraumatic stress or other
mental disor ders but encounter significant trauma-related symptoms or culturally expressed
symptoms of trauma (e.g., somatization, in which psycho logical stress is expressed through physical
concerns). For that reason, even if an individu al does not meet diagnostic criteria for trauma-related
disorders, it is important to recognize that trauma may still affect his or her life in significant ways.
For more infor mation on traumatic events, trauma character istics, traumatic stress reactions, and
factors that heighten or decrease the impact of trau ma, see Part 1, Chapter 2, “Trauma Aware
ness,” and Part 1, Chapter 3, “Understanding the Impact of Trauma.” Trauma Matters in Behavioral
Health Services The past decade has seen an increased focus on the ways in which trauma,
psychological distress, quality of life, health, mental illness, 7 Two Influential Studies That Set the
Stage for the Development of TIC The Adverse Childhood Experiences Study (Centers for Disease
Control and Prevention, 2013) was a large epidemiological study involving more than 17,000
individuals from United States; it analyzed the long-term effects of childhood and adolescent
traumatic experiences on adult health risks, mental health, healthcare costs, and life expectancy.
The Women, Co-Occurring Disorders and Violence Study (SAMHSA, 2007) was a large multisite study
focused on the role of interpersonal and other traumatic stressors among women; the interre
latedness of trauma, violence, and co-occurring substance use and mental disorders; and the
incorpo ration of trauma-informed and trauma-specific principles, models, and services. Trauma-
Informed Care in Behavioral Health Services and substance abuse are linked. With the at tacks of
September 11, 2001, and other acts of terror, the wars in Iraq and Afghanistan, disas trous
hurricanes on the Gulf Coast, and sexual abuse scandals, trauma has moved to the fore front of
national consciousness. Trauma was once considered an abnormal experience. However, the first
National Comorbidity Study established how prevalent traumas were in the lives of the general popu
lation of the United States. In the study, 61 percent of men and 51 percent of women re ported
experiencing at least one trauma in their lifetime, with witnessing a trauma, being involved in a
natural disaster, and/or experi encing a life-threatening accident ranking as the most common
events (Kessler et al., 1999). In Wave 2 of the National Epidemiologic Survey on Alcohol and Related
Conditions, 71.6 percent of the sample reported witnessing trauma, 30.7 percent experienced a
trauma that resulted in injury, and 17.3 percent expe rienced psychological trauma (El-Gabalawy,
2012). For a thorough review of the impact of trauma on quality of life and health and among
individuals with mental and substance use disorders, refer to Part 3 of this TIP, the online literature
review. Rationale for TIC Integrating TIC into behavioral health ser vices provides many benefits not
only for cli ents, but also for their families and communities, for behavioral health service
organizations, and for staff. Trauma-informed services bring to the forefront the belief that trauma
can pervasively affect an individual’s well-being, including physical and mental health. For behavioral
health service providers, trauma-informed practice offers many oppor tunities. It reinforces the
importance of ac quiring trauma-specific knowledge and skills to meet the specific needs of clients;
of recog nizing that individuals may be affected by trauma regardless of its acknowledgment; of
understanding that trauma likely affects many clients who are seeking behavioral health ser vices;
and of acknowledging that organizations and providers can retraumatize clients through standard or
unexamined policies and practices. TIC stresses the importance of addressing the client individually
rather than applying gen eral treatment approaches. TIC provides clients more opportunities to
engage in services that reflect a compassionate perspective of their presenting problems. TIC can
potentially provide a greater sense of safe ty for clients who have histories of trauma and a platform
for preventing more serious conse quences of traumatic stress (Fallot & Harris, 2001). Although
many individuals may not identify the need to connect with their histo ries, trauma-informed
services offer clients a chance to explore the impact of trauma, their strengths and creative
adaptations in manag ing traumatic histories, their resilience, and the relationships among trauma,
substance use, and psychological symptoms. 8 Advice to Counselors: The Importance of TIC The
history of trauma raises various clinical issues. Many counselors do not have extensive training in
treating trauma or offering trauma-informed services and may be uncertain of how to respond to
clients’ trauma-related reactions or symptoms. Some counselors have experienced traumas them
selves that may be triggered by clients’ reports of trauma. Others are interested in helping clients
with trauma but may unwittingly cause harm by moving too deeply or quickly into trauma material
or by discounting or disregarding a client’s report of trauma. Counselors must be aware of trauma
related symptoms and disorders and how they affect clients in behavioral health treatment.
Counselors with primary treatment responsibilities should also have an understanding of how to rec
ognize trauma-related reactions, how to incorporate treatment interventions for trauma-related
symptoms into clients’ treatment plans, how to help clients build a safety net to prevent further
trauma, how to conduct psychoeducational interventions, and when to make treatment referrals for
further evaluations or trauma-specific treatment services. All treatment staff should recognize that
traumatic stress symptoms or trauma-related disorders should not preclude an individual from
mental health or substance abuse treatment and that all co-occurring disorders need to be
addressed on some level in the treatment plan and setting. For example, helping a client in
substance abuse treat ment gain control over trauma-related symptoms can greatly improve the
client’s chances of sub stance abuse recovery and lower the possibility of relapse (Farley, Golding,
Young, Mulligan, & Minkoff, 2004; Ouimette, Ahrens, Moos, & Finney, 1998). In addition, assisting a
client in achieving abstinence builds a platform upon which recovery from traumatic stress can
proceed. Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective Implementing
trauma-informed services can improve screening and assessment processes, treatment planning,
and placement while also decreasing the risk for retraumatization. The implementation may
enhance communication between the client and treatment provider, thus decreasing risks
associated with misun derstanding the client’s reactions and present ing problems or
underestimating the need for appropriate referrals for evaluation or trauma specific treatment.
Organizational investment in developing or improving trauma-informed services may also translate
to cost effective ness, in that services are more appropriately matched to clients from the outset. TIC
is an essential ingredient in organizational risk management; it ensures the implementation of
decisions that will optimize therapeutic out comes and minimize adverse effects on the client and,
ultimately, the organization. A key principle is the engagement of community, clients, and staff.
Clients and staff are more apt to be empowered, invested, and satisfied if they are involved in the
ongoing development and delivery of trauma-informed services. An organization also benefits from
work de velopment practices through planning for, attracting, and retaining a diverse workforce of
individuals who are knowledgeable about trauma and its impact. Developing a trauma informed
organization involves hiring and promotional practices that attract and retain individuals who are
educated and trained in trauma-informed practices on all levels of the organization, including board
as well as peer support appointments. Trauma-informed or ganizations are invested in their staff and
adopt similar trauma-informed principles, including establishing and providing ongoing support to
promote TIC in practice and in addressing secondary trauma and implement ing processes that
reinforce the safety of the staff. Even though investing in a trauma informed workforce does not
necessarily guar antee trauma-informed practices, it is more likely that services will evolve more
profi ciently to meet client, staff, and community needs. 9 Trauma-Informed Care in Behavioral
Health Services Trauma and Substance Use Disorders Many people who have substance use disor
ders have experienced trauma as children or adults (Koenen, Stellman, Sommer, & Stellman, 2008;
Ompad et al., 2005). Sub stance abuse is known to predispose people to higher rates of traumas,
such as dangerous situations and accidents, while under the in fluence (Stewart & Conrod, 2003;
Zinzow, Resnick, Amstadter, McCauley, Ruggiero, & Kilpatrick, 2010) and as a result of the lifestyle
associated with substance abuse (Reynolds et al., 2005). In addition, people who abuse sub stances
and have experienced trauma have worse treatment outcomes than those without histories of
trauma (Driessen et al., 2008; Najavits et al., 2007). Thus, the process of re covery is more difficult,
and the counselor’s role is more challenging, when clients have histories of trauma. A person
presenting with both trauma and substance abuse issues can have a variety of other difficult life
problems that commonly accompany these disorders, such as other psychological symptoms or men
tal disorders, poverty, homelessness, increased risk of HIV and other infections, and lack of social
support (Mills, Teesson, Ross, & Peters, 2006; Najavits, Weiss, & Shaw, 1997). Many individuals who
seek treatment for substance use disorders have histories of one or more traumas. More than half of
women seeking substance abuse treatment report one or more lifetime traumas (Farley, Golding,
Young, Mulligan, & Minkoff, 2004; Najavits et al., 1997), and a significant number of clients in
inpatient treatment also have subclinical traumatic stress symptoms or posttraumatic stress disorder
(PTSD; Falck, Wang, Siegal, & Carlson, 2004; Grant et al., 2004; Reynolds et al., 2005). Trauma and
Mental Disorders People who are receiving treatment for severe mental disorders are more likely to
have histo ries of trauma, including childhood physical and sexual abuse, serious accidents, homeless
ness, involuntary psychiatric hospitalizations, drug overdoses, interpersonal violence, and other
forms of violence. Many clients with severe mental disorders meet criteria for PTSD; others with
serious mental illness who have histories of trauma present with psycho logical symptoms or mental
disorders that are commonly associated with a history of trauma, including anxiety symptoms and
disorders, mood disorders (e.g., major depression, dys thymia, bipolar disorder; Mueser et al., 2004),
impulse control disorders, and substance use disorders (Kessler, Chiu, Demler, & Walters, 2005).
Traumatic stress increases the risk for mental illness, and findings suggest that traumatic stress
increases the symptom severity of men tal illness (Spitzer, Vogel, Barnow, Freyberger & Grabe,
2007). These findings propose that traumatic stress plays a significant role in per petuating and
exacerbating mental illness and suggest that trauma often precedes the devel opment of mental
disorders. As with trauma and substance use disorders, there is a bidirec tional relationship; mental
illness increases the risk of experiencing trauma, and trauma in creases the risk of developing
psychological symptoms and mental disorders. For a more comprehensive review of the interactions
among traumatic stress, mental illness, and substance use disorders, refer to Part 3 of this TIP, the
online literature review. 10 Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective
Trauma-Informed Intervention and Treatment Principles TIC is an intervention and organizational
approach that focuses on how trauma may affect an individual’s life and his or her re sponse to
behavioral health services from pre vention through treatment. There are many definitions of TIC
and various models for incorporating it across organizations, but a “trauma-informed approach
incorporates three key elements: (1) realizing the prevalence of trauma; (2) recognizing how trauma
affects all individuals involved with the program, organi zation, or system, including its own
workforce; and (3) responding by putting this knowledge into practice” (SAMHSA, 2012, p. 4). TIC
begins with the first contact a person has with an agency; it requires all staff members (e.g.,
receptionists, intake personnel, direct care staff, supervisors, administrators, peer supports, board
members) to recognize that the individual’s experience of trauma can greatly influence his or her
receptivity to and engagement with services, interactions with staff and clients, and responsiveness
to pro gram guidelines, practices, and interventions. TIC includes program policies, procedures, and
practices to protect the vulnerabilities of those who have experienced trauma and those who
provide trauma-related services. TIC is created through a supportive environment and by
redesigning organizational practices, with “A program, organization, or system that is trauma -
informed realizes the widespread impact of trauma and under -stands poten tial paths for healing;
recognizes the signs and symptoms of trauma in staff, clients, and others involved with the system;
and responds by fully integrating knowledge about trauma into policies, procedures, practices, and
settings.” (SAMHSA, 2012, p. 4) consumer participation, to prevent practices that could be
retraumatizing (Harris & Fallot, 2001c; Hopper et al., 2010). The ethical prin ciple, “first, do no
harm,” resonates strongly in the application of TIC. TIC involves a commitment to building com
petence among staff and establishing pro grammatic standards and clinical guidelines that support
the delivery of trauma-sensitive services. It encompasses recruiting, hiring, and retaining competent
staff; involving consum ers, trauma survivors, and peer support special ists in the planning,
implementation, and evaluation of trauma-informed services; devel oping collaborations across
service systems to streamline referral processes, thereby securing trauma-specific services when
appropriate; and building a continuity of TIC as consumers move from one system or service to the
next. TIC involves reevaluating each service deliv ery component through a trauma-aware lens. The
principles described in the following sub sections serve as the TIP’s conceptual Advice to Counselors:
Implementing Trauma-Informed Services Recognizing that trauma affects a majority of clients served
within public health systems, the National Center for Trauma-Informed Care (NCTIC) has sought to
establish a comprehensive framework to guide systems of care in the development of trauma-
informed services. If a system or program is to support the needs of trauma survivors, it must take a
systematic approach that offers trauma-specific diagnostic and treatment services, as well as a
trauma-informed environment that is able to sustain such services, while fostering positive
outcomes for the clients it serves. NCTIC also offers technical assistance in the implementation of
trauma-informed services. For specific administrative information on TIC implementation, refer to
Part 2, Chapters 1 and 2, of this TIP. 11 “Trauma -informed care embraces a per spective that
highlights adaptation over symptoms and resilience over pathology.” (Elliot, Bjelajac, Fallot, Markoff,
& Reed, 2005, p. 467) Trauma-Informed Care in Behavioral Health Services framework. These
principles comprise a com pilation of resources, including research, theo retical papers,
commentaries, and lessons learned from treatment facilities. Key elements are outlined for each
principle in providing services to clients affected by trauma and to populations most likely to incur
trauma. Although these principles are useful across all prevention and intervention services, settings,
and populations, they are of the utmost im portance in working with people who have had traumatic
experiences. Promote Trauma Awareness and Understanding Foremost, a behavioral health service
provider must recognize the prevalence of trauma and its possible role in an individual’s emotional,
behavioral, cognitive, spiritual, and/or physical development, presentation, and well-being. Being
vigilant about the prevalence and po tential consequences of traumatic events among clients allows
counselors to tailor their presentation styles, theoretical approaches, and intervention strategies
from the outset to plan for and be responsive to clients’ specific needs. Although not every client has
a history of trauma, those who have substance use and mental disorders are more likely to have
expe rienced trauma. Being trauma aware does not mean that you must assume everyone has a
history of trauma, but rather that you antici pate the possibility from your initial contact and
interactions, intake processes, and screen ing and assessment procedures. Even the most standard
behavioral health practices can retraumatize an individual ex posed to prior traumatic experiences if
the provider implements them without recogniz ing or considering that they may do harm. For
example, a counselor might develop a treat ment plan recommending that a female cli ent—who has
been court mandated to substance abuse treatment and was raped as an adult—attend group
therapy, but without con sidering the implications, for her, of the fact that the only available group
at the facility is all male and has had a low historical rate of female participation. Trauma awareness
is an essential strategy for preventing this type of retraumatization; it reinforces the need for
providers to reevaluate their usual practices. Becoming trauma aware does not stop with the
recognition that trauma can affect clients; instead, it encompasses a broader awareness that
traumatic experiences as well as the im pact of an individual’s trauma can extend to significant
others, family members, first re sponders and other medical professionals, be havioral health
workers, broader social networks, and even entire communities. Fami ly members frequently
experience the trau matic stress reactions of the individual family member who was traumatized
(e.g., angry outbursts, nightmares, avoidant behavior, other symptoms of anxiety, overreactions or
underre actions to stressful events). These repetitive experiences can increase the risk of secondary
trauma and symptoms of mental illness among the family, heighten the risk for externalizing and
internalizing behavior among children (e.g., bullying others, problems in social rela tionships, health-
damaging behaviors), in crease children’s risk for developing posttraumatic stress later in life, and
lead to a greater propensity for traumatic stress reac tions across generations of the family. Hence,
prevention and intervention services can pro vide education and age-appropriate program ming
tailored to develop coping skills and support systems. 12 Part 1, Chapter 1—Trauma-Informed Care:
A Sociocultural Perspective So too, behavioral health service providers can be influenced by
exposure to trauma-related affect and content when working with clients. A trauma-aware
workplace supports supervi sion and program practices that educate all direct service staff members
on secondary trauma, encourages the processing of trauma related content through participation in
peer supported activities and clinical supervision, and provides them with professional develop ment
opportunities to learn about and engage in effective coping strategies that help prevent secondary
trauma or trauma-related symp toms. It is important to generate trauma awareness in agencies
through education across services and among all staff members who have any direct or indirect
contact with clients (including receptionists or intake and admission personnel who engage clients
for the first time within the agency). Agencies can maintain a trauma-aware environment through
ongoing staff training, continued su pervisory and administrative support, collabo rative (i.e.,
involving consumer participation) trauma-responsive program design and im plementation, and
organizational policies and practices that reflect accommodation and flex ibility in attending to the
needs of clients af fected by trauma. Recognize That Trauma-Related Symptoms and Behaviors
Originate From Adapting to Traumatic Experiences A trauma-informed perspective views trauma
related symptoms and behaviors as an individ ual’s best and most resilient attempt to man age, cope
with, and rise above his or her experience of trauma. Some individuals’ means of adapting and
coping have produced little difficulty; the coping and adaptive strategies of others have worked in
the past but are not working as well now. Some people have diffi culties in one area of life but have
effectively negotiated and functioned in other areas. Individuals who have survived trauma vary
widely in how they experience and express traumatic stress [Link] stress reactions vary
in severity; they are often meas ured by the level of impairment or distress that clients report and
are determined by the mul tiple factors that characterize the trauma itself, individual history and
characteristics, devel opmental factors, sociocultural attributes, and available resources. The
characteristics of the trauma and the subsequent traumatic stress reactions can dramatically
influence how indi viduals respond to the environment, relation ships, interventions, and treatment
services, and those same characteristics can also shape the assumptions that clients/consumers
make about their world (e.g., their view of others, sense of safety), their future (e.g., hopefulness,
fear of a foreshortened future), and themselves (e.g., feeling resilient, feeling incompetent in
regulating emotions). The breadth of these effects may be observable or subtle. Once you become
aware of the significance of traumatic experiences in clients’ lives and begin to view their
presentation as adaptive, your identification and classification of their presenting symptoms and
behaviors can shift from a “pathology” mindset (i.e., defining cli ents strictly from a diagnostic label,
implying that something is wrong with them) to one of resilience—a mindset that views clients’ pre
senting difficulties, behaviors, and emotions as responses to surviving trauma. In essence, you will
come to view traumatic stress reactions as normal reactions to abnormal situations. In embracing
the belief that trauma-related reac tions are adaptive, you can begin relationships with clients from
a hopeful, strengths-based stance that builds upon the belief that their responses to traumatic
experiences reflect creativity, self-preservation, and determination. 13 Trauma-Informed Care in
Behavioral Health Services This will help build mutual and collaborative therapeutic relationships,
help clients identify what has worked and has not worked in their attempts to deal with the
aftermath of trauma from a nonjudgmental stance, and develop intervention and coping strategies
that are more likely to fit their strengths and resources. This view of trauma prevents further retrau
matization by not defining traumatic stress reactions as pathological or as symptoms of pathology.
View Trauma in the Context of Individuals’ Environments Many factors contribute to a person’s
response to trauma, whether it is an individual, group, or community-based trauma. Individual at
tributes, developmental factors (including pro tective and risk factors), life history, type of trauma,
specific characteristics of the trauma, amount and length of trauma exposure, cultur al meaning of
traumatic events, number of losses associated with the trauma, available resources (internal and
external, such as coping skills and family support), and community reactions are a few of the
determinants that influence a person’s responses to trauma across time. Refer to the “View Trauma
Through a Sociocultural Lens” section later in this chap ter for more specific information highlighting
the importance of culture in understanding and treating the effects of trauma. Trauma cannot be
viewed narrowly; instead, it needs to be seen through a broader lens—a contextual lens integrating
biopsychosocial, interpersonal, community, and societal (the degree of individualistic or collective
cultural values) characteristics that are evident preced ing and during the trauma, in the immediate
and sustained response to the event(s), and in the short-and long-term effects of the trau matic
event(s), which may include housing availability, community response, adherence to or maintenance
of family routines and struc ture, and level of family support. To more adequately understand
trauma, you must also consider the contexts in which it occurred. Understanding trauma from this
angle helps expand the focus beyond individu al characteristics and effects to a broader sys temic
perspective that acknowledges the influences of social interactions, communities, governments,
cultures, and so forth, while also examining the possible interactions among those various
influences. Bronfenbrenner’s (1979) and Bronfenbrenner and Ceci’s (1994) work on ecological
models sparked the devel opment of other contextual models. In recent years, the social-ecological
framework has been adopted in understanding trauma, in implementing health promotion and other
prevention strategies, and in developing treat ment interventions (Centers for Disease Con trol and
Prevention, 2009). Here are the three main beliefs of a social-ecological approach (Stokols, 1996): •
Environmental factors greatly influence emotional, physical, and social well-being. • A fundamental
determinant of health ver sus illness is the degree of fit between indi viduals’ biological, behavioral,
and sociocultural needs and the resources avail able to them. • Prevention, intervention, and
treatment approaches integrate a combination of strategies targeting individual, interperson al, and
community systems. This TIP uses a social-ecological model to explore trauma and its effects (Exhibit
1.1-2). The focus of this model is not only on nega tive attributes (risk factors) across each level, but
also on positive ingredients (protective factors) that protect against or lessen the im pact of trauma.
This model also guides the inclusion of certain targeted interventions in this text, including selective
and indicated 14 Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective Exhibit 1.1-
2: A Social-Ecological Model for Understanding Trauma and Its Effects prevention activities. In
addition, culture, de velopmental processes (including the devel opmental stage or characteristics of
the individual and/or community), and the specific era when the trauma(s) occurred can signifi
cantly influence how a trauma is perceived and processed, how an individual or community engages
in help-seeking, and the degree of accessibility, acceptability, and availability of individual and
community resources. Depending on the developmental stage and/or processes in play, children,
adolescents, and adults will perceive, interpret, and cope with traumatic experiences differently. For
example, a child may view a news story depicting a traumatic event on television and believe that
the trauma is recurring every time they see the scene replayed. Similarly, the era in which one lives
and the timing of the trauma can greatly influence an individual or community re sponse. Take, for
example, a pregnant woman who is abusing drugs and is wary of receiving medical treatment after
being beaten in a do mestic dispute. She may fear losing her chil dren or being arrested for child
neglect. Even though a number of States have adopted poli cies focused on the importance of
treatment for pregnant women who are abusing drugs and of the accessibility of prenatal care,
other States have approached this issue from a crim inality standpoint (e.g., with child welfare and
criminal laws) in the past few decades. Thus, the traumatic event’s timing is a significant 15 Trauma-
Informed Care in Behavioral Health Services component in understanding the context of trauma and
trauma-related responses. The social-ecological model depicted in Ex hibit 1.1-2 provides a systemic
framework for looking at individuals, families, and communi ties affected by trauma in general; it
highlights the bidirectional influence that multiple con texts can have on the provision of behavioral
health services to people who have experi enced trauma (see thin arrow). Each ring rep resents a
different system (refer to Exhibit 1.1-3 for examples of specific factors within each system). The
innermost ring represents the individual and his or her biopsychosocial characteristics. The
“Interpersonal” circle em bodies all immediate relationships including family, friends, peers, and
others. The “Com munity/Organizational” band represents social support networks, workplaces,
neighborhoods, and institutions that directly influence the individual and his/her relationships. The
“So cietal” circle signifies the largest system—State and Federal policies and laws, such as eco nomic
and healthcare policies, social norms, governmental systems, and political ideologies. The outermost
ring, “Period of Time in His tory,” reflects the significance of the period of time during which the
event occurred; it influ ences each other level represented in the circle. For example, making a
comparison of society’s attitudes and responses to veterans’ homecom ings across different wars
and conflicts through time shows that homecoming envi ronments can have either a protective or a
negative effect on healing from the psycholog ical and physical wounds of war, depending on the era
in question. The thicker arrows in the figure represent the key influences of culture, developmental
characteristics, and the type and characteristics of the trauma. All told, the context of traumatic
events can significantly influence both initial and sustained responses to trauma; treatment needs;
selection of pre vention, intervention, and other treatment Exhibit 1.1-3: Understanding the Levels
Within the Social-Ecological Model of Trauma and Its Effects Individual Factors Interpersonal Factors
Age, biophysi cal state, men tal health status, temper ament and other personal ity traits, edu cation,
gender, coping styles, socioeconomic status Family, peer, and significant other interac tion patterns,
parent/family mental health, parents’ histo ry of trauma, social network Community and
Organizational Factors Neighborhood quality, school system and/or work environ ment, behavioral
health system quality and acces sibility, faith based settings, transportation availability, com munity
socioeco nomic status, community em ployment rates Societal Factors Cultural and Developmen tal
Factors Period of Time in History Laws, State and Federal economic and social policies, media,
societal norms, judicial system Collective or individualistic cultural norms, eth nicity, cultural
subsystem norms, cogni tive and mat urational development Societal atti tudes related to military
service mem bers’ home comings, changes in diagnostic understanding between DSM III-R* and
DSM-5** *Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (American
Psychiatric Association [APA], 1987) 16 **Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (APA, 2013a) Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective Marisol
is a 28-year-old Latina woman working as a barista at a local coffee shop. One evening, she was
driving home in the rain when a drunk driver crossed into her lane and hit her head on. Marisol
remained conscious as she waited to be freed from the car and was then transported to the hospital.
She sustained fractures to both legs. Her recovery involved two surgeries and nearly 6 months of
rehabilitation, including initial hospitalization and outpatient physical therapy. She described her
friends and family as very supportive, saying that they often foresaw what she needed before she
had to ask. She added that she had an incredible sense of gratitude for her em ployer and
coworkers, who had taken turns visiting and driving her to appointments. Although she was able to
return to work after 9 months, Marisol continued experiencing considerable distress about her
inability to sleep well, which started just after the accident. Marisol describes repetitive dreams and
memories of waiting to be transported to the hospital after the crash. The other driver was charged
with driving under the influence (DUI), and it was reported that he had been convicted two other
times for a DUI misdemeanor. 2. 3. Answering the following questions will help you see how the
different levels of influence affect the impact and outcome of the traumatic event Marisol
experienced, as well as her responses to that event: 1. Based on the limited information provided in
this illustration, how might Marisol’s personality affect the responses of her family and friends, her
coworkers, and the larger community? In what ways could Marisol’s ethnic and cultural background
influence her recovery? What societal factors could play a role in the car crash itself and the
outcomes for Marisol and the other driver? Explore the influence of the period of time in history
during which the scenario occurs—compare the possible outcomes for both Marisol and the other
driver if the crash occurred 40 years ago versus in the present day. strategies; and ways of providing
hope and promoting recovery. Minimize the Risk of Retraumatization or Replicating Prior Trauma
Dynamics Trauma-informed treatment providers acknowledge that clients who have histories of
trauma may be more likely to experience par ticular treatment procedures and practices as negative,
reminiscent of specific characteristics of past trauma or abuse, or retraumatizing— feeling as if the
past trauma is reoccurring or as if the treatment experience is as dangerous and unsafe as past
traumas. For instance, cli ents may express feelings of powerlessness or being trapped if they are not
actively involved in treatment decisions; if treatment processes or providers mirror specific behavior
from the clients’ past experiences with trauma, they may voice distress or respond in the same way
as they did to the original trauma. Among the potentially retraumatizing elements of treat ment are
seclusion or “time-out” practices that isolate individuals, mislabeling client symp toms as personality
or other mental disorders rather than as traumatic stress reactions, in teractions that command
authority, treatment assignments that could humiliate clients (such as asking a client to wear a sign
in group that reflects one of their treatment issues, even if the assignment centers on positive
attributes of the client), confronting clients as resistant, or presenting treatment as conditional upon
conformity to the provider’s beliefs and defini tions of issues. Clients’ experiences are unique to the
specific traumas they have faced and the surrounding 17 Trauma-Informed Care in Behavioral Health
Services circumstances before, during, and after that trauma, so remember that even seemingly safe
and standard treatment policies and proce dures, including physical plant operations (e.g.,
maintenance, grounds, fire and safety proce dures), may feel quite the contrary for a client if one or
more of those elements is reminiscent of his or her experience of trauma in some way. Examples
include having limited privacy or personal space, being interviewed in a room that feels too isolating
or confining, undergo ing physical examination by a medical profes sional of the same sex as the
client’s previous perpetrator of abuse, attending a group session in which another client expresses
anger appro priately in a role play, or being directed not to talk about distressing experiences as a
means of deescalating traumatic stress reactions. Although some treatment policies or proce dures
are more obviously likely to solicit dis tress than others, all standard practices should be evaluated
for their potential to retraumatize a client; this cannot be done without knowing the specific
features of the individual’s history of trauma. Consider, for instance, a treatment program that
serves meals including entrees that combine more than one food group. Your client enters this
program and refuses to eat most of the time; he expresses anger toward dietary staff and claims that
food choices are limited. You may initially perceive your cli ent’s refusal to eat or to avoid certain
foods as an eating disorder or a behavioral problem. However, a trauma-aware perspective might
change your assumptions; consider that this client experienced neglect and abuse sur rounding food
throughout childhood (his mother forced him to eat meals prepared by combining anything in the
refrigerator and cooking them together). How often have you heard “We aren’t equipped to handle
trauma” or “We don’t have time to deal with reactions that surface if traumatic experiences are
discussed in treatment” from counselors and administrators in behavioral health services? For
agencies, staff members, and clients, these state ments present many difficulties and unwanted
outcomes. For a client, such comments may replicate his or her earlier encounters with others
(including family, friends, and previous behavioral health professionals) who had difficulty
acknowledging or talking about traumatic experiences with him or her. A hands-off approach to
trauma can also reinforce the client’s own desire to avoid such discus sions. Even when agencies and
staff are motivated in these sentiments by a good intention—to con tain clients’ feelings of being
overwhelmed—such a perspective sends strong messages to clients that their experiences are not
important, that they are not capable of handling their trauma associated feelings, and that dealing
with traumatic experiences is simply too dangerous. Statements like these imply that recovery is not
possible and provide no structured outlet to address memories of trauma or traumatic stress
reactions. Nevertheless, determining how and when to address traumatic stress in behavioral health
services can be a real dilemma, especially if there are no trauma-specific philosophical,
programmatic, or procedural processes in place. For example, it is difficult to provide an appropriate
forum for a client to address past traumas if no forethought has been given to developing
interagency and intra agency collaborations for trauma-specific services. By anticipating the need for
trauma-informed services and planning ahead to provide appropriate services to people who are
affected by trauma, behavioral health service providers and program administrators can begin to
develop informed inter vention strategies that send a powerful, positive message: • Both clients and
providers can competently manage traumatic experiences and reactions. • Providers are interested
in hearing clients’ stories and attending to their experiences. 18 • Recovery is possible. From the first
time you provide outpatient counseling to Mike, you explain that he can call an agency number that
will put him in direct contact with someone who can provide further assistance or sup port if he has
emotional difficulty after the session or after agency hours. However, when he attempts to call one
night, no one is available despite what you’ve described. Instead, Mike is directed by an operator to
either use his local emergency room if he perceives his situation to be a crisis or to wait for someone
on call to contact him. The inconsistency between what you told him in the session and what
actually happens when he calls makes Mike feel unsafe and vulnerable. Part 1, Chapter 1—Trauma-
Informed Care: A Sociocultural Perspective As a treatment provider, you cannot consist ently predict
what may or may not be upset ting or retraumatizing to clients. Therefore, it is important to
maintain vigilance and an atti tude of curiosity with clients, inquiring about the concerns that they
express and/or present in treatment. Remember that certain behaviors or emotional expressions
can reflect what has happened to them in the past. Foremost, a trauma-informed approach begins
with taking practical steps to reexamine treat ment strategies, program procedures, and or
ganizational polices that could solicit distress or mirror common characteristics of traumatic
experiences (loss of control, being trapped, or feeling disempowered). To better anticipate the
interplay between various treatment ele ments and the more idiosyncratic aspects of a particular
client’s trauma history, you can: • Work with the client to learn the cues he or she associates with
past trauma. • Obtain a good history. • Maintain a supportive, empathetic, and collaborative
relationship. • Encourage ongoing dialog. • Provide a clear message of availability and accessibility
throughout treatment. In sum, trauma-informed providers anticipate and respond to potential
practices that may be perceived or experienced as retraumatizing to clients; they are able to forge
new ways to re spond to specific situations that trigger a trauma-related response, and they can
provide clients with alternative ways of engaging in a particularly problematic element of treatment.
Create a Safe Environment The need to create a safe environment is not new to providers; it involves
an agency-wide effort supported by effective policies and pro cedures. However, creating safety
within a trauma-informed framework far exceeds the standard expectations of physical plant safety
(e.g., facility, environmental, and space-related concerns), security (of staff members, clients, and
personal property), policies and proce dures (including those specific to seclusion and restraint),
emergency management and disaster planning, and adherence to client rights. Providers must be
responsive and adapt the environment to establish and support cli ents’ sense of physical and
emotional safety. Beyond anticipating that various environ mental stimuli within a program may
generate strong emotions and reactions in a trauma survivor (e.g., triggers such as lighting, access to
exits, seating arrangements, emotionality within a group, or visual or auditory stimuli) and
implementing strategies to help clients cope with triggers that evoke their experiences with trauma,
other key elements in establish ing a safe environment include consistency in client interactions and
treatment processes, following through with what has been re viewed or agreed upon in sessions or
meetings, and dependability. Mike’s case illustration de picts ways in which the absence of these key
elements could erode a client’s sense of safety during the treatment process. Neither providers nor
service processes are always perfect. Sometimes, providers 19 Case Illustration: Jane Jane, a newly
hired female counselor, had a nephew who took his own life. The program that hired her was short
of workers at the time; therefore, Jane did not have an opportunity to engage suffi ciently in
orientation outside of reviewing the policies and procedure manual. In an attempt to pre sent well to
her new employer and supervisor, she readily accepted client assignments without considering her
recent loss. By not immersing herself in the program’s perspective and policies on staff well-being,
ethical and clinical considerations in client assignments, and how and when to seek supervision, Jane
failed to engage in the practices, heavily supported by the agency, that promoted safety for herself
and her clients. Subsequently, she felt emotionally overwhelmed at work and would often abruptly
request psychiatric evaluation for clients who expressed any feelings of hopelessness out of sheer
panic that they would attempt suicide. Trauma-Informed Care in Behavioral Health Services
unintentionally relay information inaccurately or inconsistently to clients or other staff mem bers;
other times, clients mishear something, or extenuating circumstances prevent provid ers from
responding as promised. Creating safety is not about getting it right all the time; it’s about how
consistently and forthrightly you handle situations with a client when cir cumstances provoke
feelings of being vulnera ble or unsafe. Honest and compassionate communication that conveys a
sense of han dling the situation together generates safety. It is equally important that safety extends
be yond the client. Counselors and other behav ioral health staff members, including peer support
specialists, need to be able to count on the agency to be responsive to and maintain their safety
within the environment as well. By incorporating an organizational ethos that recognizes the
importance of practices that promote physical safety and emotional well being, behavioral health
staff members may be more likely to seek support and supervision when needed and to comply with
clinical and programmatic practices that minimize risks for themselves and their clients. Beyond an
attitudinal promotion of safety, organizational leaders need to consider and create avenues of
professional development and assistance that will give their staff the means to seek support and
process distressing circumstances or events that occur within the agency or among their clientele,
such as case consultation and supervision, formal or infor mal processes to debrief service providers
about difficult clinical issues, and referral pro cesses for client psychological evaluations and
employee assistance for staff. Organizational practices are only effective if supported by unswerving
trauma awareness, training, and education among staff. Jane’s case illustration shows the impact of
a minor but necessary postponement in staff orientation for a new hire—not an unusual
circumstance in behav ioral health programs that have heavy case loads and high staff turnover.
Identify Recovery From Trauma as a Primary Goal Often, people who initiate or are receiving mental
health or substance abuse services don’t identify their experiences with trauma as a significant
factor in their current challenges or problems. In part, this is because people who have been
exposed to trauma, whether once or repeatedly, are generally reluctant to revisit it. They may
already feel stuck in repetitive memories or experiences, which may add to their existing belief that
any intervention will make matters worse or, at least, no better. For some clients, any introduction
to their trauma related memories or minor cues reminiscent of the trauma will cause them to
experience strong, quick-to-surface emotions, supporting their belief that addressing trauma is
danger ous and that they won’t be able to handle the 20 Part 1, Chapter 1—Trauma-Informed Care:
A Sociocultural Perspective emotions or thoughts that result from at tempting to do so. Others
readily view their experiences of trauma as being in the past; as a result, they engage in distraction,
dissociation, and/or avoidance (as well as adaptation) due to a belief that trauma has little impact on
their current lives and presenting problems. Even individuals who are quite aware of the impact that
trauma has had on their lives may still struggle to translate or connect how these events continue to
shape their choices, behav iors, and emotions. Many survivors draw no connection between trauma
and their mental health or substance abuse problems, which makes it more difficult for them to see
the value of trauma-informed or trauma-specific interventions, such as creating safety, engaging in
psychoeducation, enhancing coping skills, and so forth. As a trauma-informed provider, it is
important that you help clients bridge the gap between their mental health and substance-related is
sues and the traumatic experiences they may have had. All too often, trauma occurs before
substance use and mental disorders develop; then, such disorders and their associated symptoms
and consequences create opportuni ties for additional traumatic events to occur. If individuals
engage in mental health and sub stance abuse treatment without addressing the role that trauma
has played in their lives, they are less likely to experience recovery in the long run. For example, a
person with a history of trauma is more likely to have anxiety and depressive symptoms, use
substances to self medicate, and/or relapse after exposure to trauma-related cues. Thus,
collaboration with in and between behavioral health agencies is necessary to make integrated,
timely, trauma specific interventions available from the be ginning to clients/consumers who engage
in substance abuse and mental health services. Support Control, Choice, and Autonomy Not every
client who has experienced trauma and is engaged in behavioral health services wants, or sees the
need for, trauma-informed or trauma-specific treatment. Clients may think that they’ve already
dealt with their trauma adequately, or they may believe that the effects of past trauma cause
minimal dis tress for them. Other clients may voice the same sentiments, but without conviction—
instead using avoidant behavior to deter dis tressing symptoms or reactions. Still others may struggle
to see the role of trauma in their presenting challenges, not connecting their past traumatic
experiences with other, more current difficulties (e.g., using substances to self-medicate strong
emotions). Simply the idea of acknowledging trauma-related experi ences and/or stress reactions
may be too frightening or overwhelming for some clients, and others may fear that their reactions
will be dismissed. On the other hand, some individu als want so much to dispense with their trau
matic experiences and reactions that they hurriedly and repeatedly disclose their experi ences
before establishing a sufficiently safe environment or learning effective coping strat egies to offset
distress and other effects of re traumatization. As these examples show, not everyone affected by
trauma will approach trauma-informed services or recognize the impact of trauma in their lives in
the same manner. This can be challenging to behavioral health service pro viders who are
knowledgeable about the im pact of trauma and who perceive the importance of addressing trauma
and its ef fects with clients. As with knowing that dif ferent clients may be at different levels of
awareness or stages of change in substance abuse treatment services, you should acknowledge that
people affected by trauma 21 Trauma-Informed Care in Behavioral Health Services present an array
of reactions, various levels of trauma awareness, and different degrees of urgency in their need to
address trauma. Appreciating clients’ perception of their pre senting problems and viewing their
responses to the impact of trauma as adaptive—even when you believe their methods of dealing
with trauma to be detrimental—are equally important elements of TIC. By taking the time to engage
with clients and understand the ways they have perceived, adjusted to, and responded to traumatic
experiences, providers are more likely to project the message that clients possess valuable personal
expertise and knowledge about their own presenting prob lems. This shifts the viewpoint from
“Provid ers know best” to the more collaborative “Together, we can find solutions.” How often have
you heard from clients that they don’t believe they can handle symptoms that emerge from
reexperiencing traumatic cues or memories? Have you ever heard clients state that they can’t trust
themselves or their reactions, or that they never know when they are going to be triggered or how
they are go ing to react? How confident would you feel about yourself if, at any time, a loud noise
could initiate an immediate attempt to hide, duck, or dive behind something? Traumatic experiences
have traditionally been described as exposure to events that cause intense fear, helplessness,
horror, or feelings of loss of con trol. Participation in behavioral health services should not mirror
these aspects of traumatic experience. Working collaboratively to facili tate clients’ sense of control
and to maximize clients’ autonomy and choices throughout the treatment process, including
treatment plan ning, is crucial in trauma-informed services. For some individuals, gaining a sense of
con trol and empowerment, along with under standing traumatic stress reactions, may be pivotal
ingredients for recovery. By creating opportunities for empowerment, counselors and other
behavioral health service providers help reinforce, clients’ sense of competence, which is often
eroded by trauma and pro longed traumatic stress reactions. Keep in mind that treatment strategies
and procedures that prioritize client choice and control need not focus solely on major life decisions
or treatment planning; you can apply such ap proaches to common tasks and everyday inter actions
between staff and consumers. Try asking your clients some of the following questions (which are
only a sample of the types of questions that could be useful): • What information would be helpful
for us to know about what happened to you? • Where/when would you like us to call you? • How
would you like to be addressed? • Of the services I’ve described, which seem to match your present
concerns and needs? • From your experience, what responses from others appear to work best
when you feel overwhelmed by your emotions? Likewise, organizations need to reinforce the
importance of staff autonomy, choice, and sense of control. What resources can staff members
access, and what choices are availa ble to them, in processing emotionally charged content or events
in treatment? How often do administrators and supervisors seek out feed back on how to handle
problematic situations (e.g., staff rotations for vacations, case consul tations, changes in scheduling)?
Think about the parallel between administration and staff members versus staff members and
clients; often, the same philosophy, attitudes, and behaviors conveyed to staff members by ad
ministrative practices are mirrored in staff client interactions. Simply stated, if staff members do not
feel empowered, it will be a challenge for them to value the need for client empowerment. (For
more information on administrative and workforce development issues, refer to Part 2, Chapters 1
and 2.) 22 Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective Mina initially
sought counseling after her husband was admitted to an intensive outpatient drug and alcohol
program. She was self-referred for low-grade depression, resentment toward her spouse, and
codependency. When asked to define “codependency” and how the term applied to her, she
responded that she always felt guilty and responsible for everyone in her family and for events that
occurred even when she had little or no control over them. After the intake and screening process,
she expressed interest in attending group sessions that fo cused primarily on family issues and
substance abuse, wherein her presenting concerns could be explored. In addition to describing
dynamics and issues relating to substance abuse and its impact on her marriage, she referred to her
low mood as frozen grief. During treatment, she reluctantly began to talk about an event that she
described as life changing: the loss of her father. The story began to unfold in group; her father, who
had been 62 years old, was driving her to visit a cousin. During the ride, he had a heart attack and
drove off the road. As the car came to stop in a field, she remembered calling 911 and beginning
cardiopulmonary resuscitation while waiting for the ambu lance. She rode with the paramedics to
the hospital, watching them work to save her father’s life; however, he was pronounced dead soon
after arrival. She always felt that she never really said goodbye to her father. In group, she was asked
what she would need to do or say to feel as if she had revisited that opportunity. She responded in
quite a unique way, saying, “I can’t really answer this question; the lighting isn’t right for me to talk
about my dad.” The counselor encouraged her to adjust the lighting so that it felt “right” to her.
Being invited to do so turned out to be pivotal in her ability to address her loss and to say goodbye
to her father on her terms. She spent nearly 10 minutes moving the dimmer switch for the lighting
as oth ers in the group patiently waited for her to return to her chair. She then began to talk about
what happened during the evening of her father’s death, their relationship, the events leading up to
that evening, what she had wanted to say to him at the hospital, and the things that she had been
want ing to share with him since his death. Weeks later, as the group was coming to a close, each
member spoke about the most important experiences, tools, and insights that he or she had taken
from participating. Mina disclosed that the group helped her establish boundaries and coping
strategies within her marriage, but said that the event that made the most difference for her had
been having the ability to adjust the lighting in the room. She explained that this had allowed her to
control something over which she had been pow erless during her father’s death. To her, the lighting
had seemed to stand out more than other de tails at the scene of the accident, during the
ambulance ride, and at the hospital. She felt that the personal experience of losing her father and
needing to be with him in the emergency room was marred by the obtrusiveness of staff,
procedures, machines, and especially, the harsh lighting. She reflected that she now saw the lighting
as a representation of this tragic event and the lack of priva cy she had experienced when trying to
say goodbye to her father. Mina stated that this moment in group had been the greatest gift: “…to
be able to say my goodbyes the way I wanted… I was given an opportunity to have some control
over a tragic event where I couldn’t control the outcome no matter how hard I tried.” Create
Collaborative Relationships and Participation Opportunities This trauma-informed principle
encompasses three main tenets. First, ensure that the provider–client relationship is collaborative,
regardless of setting or service. Agency staff members cannot make decisions pertaining to
interventions or involvement in community services autocratically; instead, they should develop
trauma-informed, individualized care plans and/or treatment plans collaboratively with the client
and, when appropriate, with family and caregivers. The nonauthoritarian approach that
characterizes TIC views clients 23 Trauma-Informed Care in Behavioral Health Services as the experts
in their own lives and current struggles, thereby emphasizing that clients and providers can learn
from each other. The second tenet is to build collaboration beyond the provider–client relationship.
Building ongoing relationships across the ser vice system, provider networks, and the local
community enhances TIC continuity as cli ents move from one level of service to the next or when
they are involved in multiple services at one time. It also allows you to learn about resources
available to your clients in the ser vice system or community and to connect with providers who
have more advanced training in trauma-specific interventions and services. The third tenet
emphasizes the need to en sure client/consumer representation and participation in behavioral
health program development, planning, and evaluation as well as in the professional development of
behavioral health workers. To achieve trau ma-informed competence in an organization or across
systems, clients need to play an active role; this starts with providing program feed back. However,
consumer involvement should not end there; rather, it should be encouraged throughout the
implementation of trauma informed services. So too, clients, potential clients, their families, and the
community should be invited to participate in forming any behavioral health organization’s plans to
im prove trauma-informed competence, provide TIC, and design relevant treatment services and
organizational policies and procedures. Trauma-informed principles and practices generated without
the input of people affected by trauma are difficult to apply effectively. Likewise, staff trainings and
presentations should include individuals who have felt the impact of trauma. Their participation
reaches past the purely cognitive aspects of such edu cation to offer a personal perspective on the
strengths and resilience of people who have experienced trauma. The involvement of trauma
survivors in behavioral health educa tion lends a human face to subject matter that is all too easily
made cerebral by some staff members in an attempt to avoid the emotion ality of the topic.
Consumer participation also means giving clients/consumers the chance to obtain State training and
certification, as well as employ ment in behavioral health settings as peer spe cialists. Programs that
incorporate peer support services reinforce a powerful mes sage—that provider–consumer
partnership is important, and that consumers are valued. Peer support specialists are self-identified
in dividuals who have progressed in their own recovery from alcohol dependence, drug ad diction,
and/or a mental disorder and work within behavioral health programs or at peer support centers to
assist others with similar disorders and/or life experiences. Tasks and responsibilities may include
leading a peer support group; modeling effective coping, help-seeking, and self-care strategies;
helping clients practice new skills or monitor progress; promoting positive self-image to combat cli
ents’ potentially negative feelings about them selves and the discrimination they may perceive in the
program or community; han dling case management tasks; advocating for program changes; and
representing a voice of hope that views recovery as possible. Familiarize the Client With Trauma-
Informed Services Without thinking too much about it, you probably know the purpose of an intake
pro cess, the correct way to complete a screening device, the meaning of a lot of the jargon spe cific
to behavioral health, and your program’s expectations for client participation; in fact, maybe you’re
already involved in facilitating these processes in behavioral health services every day, and they’ve
become almost 24 Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective automatic
for you. This can make it easy to forget that nearly everything clients and their families encounter in
seeking behavioral health assistance is new to them. Thus, intro ducing clients to program services,
activities, and interventions in a manner that expects them to be unfamiliar with these processes is
essential, regardless of their clinical and treat ment history. Beyond addressing the unfamili arity of
services, educating clients about each process—from first contact all the way through recovery
services—gives them a chance to participate actively and make in formed decisions across the
continuum of care. Familiarizing clients with trauma-informed services extends beyond explaining
program services or treatment processes; it involves explaining the value and type of trauma related
questions that may be asked during an intake process, educating clients about trauma to help
normalize traumatic stress reactions, and discussing trauma-specific interventions and other
available services (including expla nations of treatment methodologies and of the rationale behind
specific interventions). De velopmentally appropriate psychoeducation about trauma-informed
services allows clients to be informed participants. Incorporate Universal Routine Screenings for
Trauma Screening universally for client histories, expe riences, and symptoms of trauma at intake
can benefit clients and providers. Most providers know that clients can be affected by trauma, but
universal screening provides a steady re minder to be watchful for past traumatic expe riences and
their potential influence upon a client’s interactions and engagement with ser vices across the
continuum of care. Screening should guide treatment planning; it alerts the staff to potential issues
and serves as a valuable tool to increase clients’ awareness of the possi ble impact of trauma and the
importance of addressing related issues during treatment. Nonetheless, screenings are only as useful
as the guidelines and processes established to address positive screens (which occur when clients
respond to screening questions in a way that signifies possible trauma-related symp toms or
histories). Staff should be trained to use screening tools consistently so that all cli ents are screened
in the same way. Staff mem bers also need to know how to score screenings and when specific
variables (e.g., race/ethnicity, native language, gender, culture) may influence screening results. For
example, a woman who has been sexually assaulted by a man may be wary of responding to
questions if a male staff member or interpreter administers the screening or provides translation
services. Likewise, a person in a current abusive or vio lent relationship may not acknowledge the
interpersonal violence in fear of retaliation or as a result of disconnection or denial of his or her
experience, and he or she may have diffi culty in processing and then living between two worlds—
what is acknowledged in treat ment versus what is experienced at home. In addition, staff training
on using trauma related screening tools needs to center on how and when to gather relevant
information after the screening is complete. Organizational pol icies and procedures should guide
staff mem bers on how to respond to a positive screening, such as by making a referral for an
indepth assessment of traumatic stress, providing the client with an introductory psychoeducational
session on the typical biopsychosocial effects of trauma, and/or coordinating care so that the client
gains access to trauma-specific services that meet his or her needs. Screening tool se lection is an
important ingredient in incorpo rating routine, universal screening practices into behavioral health
services. Many screen ing tools are available, yet they differ in format 25 Trauma-Informed Care in
Behavioral Health Services and in how they present questions. Select tools based not just on sound
test properties, but also according to whether they encompass a broad range of experiences
typically consid ered traumatic and are flexible enough to al low for an individual’s own
interpretation of traumatic events. For more information on screening and assessment of trauma
and trau ma-related symptoms and effects, see Chapter 4, “Screening and Assessment,” in this TIP.
View Trauma Through a Sociocultural Lens To understand how trauma affects an individ ual, family,
or community, you must first un derstand life experiences and cultural background as key contextual
elements for that trauma. As demonstrated in Exhibit 1.1 2, many factors shape traumatic
experiences and individual and community responses to it; one of the most significant factors is
culture. It influences the interpretation and meaning of traumatic events, individual beliefs regarding
personal responsibility for the trauma and subsequent responses, and the meaning and acceptability
of symptoms, support, and help seeking behaviors. As this TIP proceeds to describe the differences
among cultures per taining to trauma, remember that there are numerous cross-cutting factors that
can direct ly or indirectly influence the attitudes, beliefs, behaviors, resources, and opportunities
within a given culture, subculture, or racial and/or ethnic group (Exhibit 1.1-4). For an indepth
Exhibit 1.1-4: Cross-Cutting Factors of Culture 26 Part 1, Chapter 1—Trauma-Informed Care: A
Sociocultural Perspective Culture and Trauma • Some populations and cultures are more likely than
others to experience a traumatic event or a specific type of trauma. • Rates of traumatic stress are
high across all diverse populations and cultures that face military action and political violence. •
Culture influences not only whether certain events are perceived as traumatic, but also how an
individual interprets and assigns meaning to the trauma. • Some traumas may have greater impact
on a given culture because those traumas represent something significant for that culture or disrupt
cultural practices or ways of life. • Culture determines acceptable responses to trauma and shapes
the expression of distress. It significantly influences how people convey traumatic stress through
behavior, emotions, and thinking immediately following a trauma and well after the traumatic
experience has ceased. • Traumatic stress symptoms vary according to the type of trauma within the
culture. • Culture affects what qualifies as a legitimate health concern and which symptoms warrant
help. • In addition to shaping beliefs about acceptable forms of help-seeking behavior and healing
prac tices, culture can provide a source of strength, unique coping strategies, and specific resources.
exploration of these cross-cutting cultural fac tors, refer to the planned TIP, Improving Cul tural
Competence (SAMHSA, planned c). When establishing TIC, it is vital that behav ioral health systems,
service providers, licens ing agencies, and accrediting bodies build culturally responsive practices
into their cur ricula, standards, policies and procedures, and credentialing processes. The
implementation of culturally responsive practices will further guide the treatment planning process
so that trauma-informed services are more appropri ate and likely to succeed. Use a Strengths-
Focused Perspective: Promote Resilience Fostering individual strengths is a key step in prevention
when working with people who have been exposed to trauma. It is also an es sential intervention
strategy—one that builds on the individual’s existing resources and views him or her as a
resourceful, resilient survivor. Individuals who have experienced trauma de velop many strategies
and/or behaviors to adapt to its emotional, cognitive, spiritual, and physical consequences. Some
behaviors may be effective across time, whereas others may eventually produce difficulties and
disrupt the healing process. Traditionally, behavioral health services have tended to focus on pre
senting problems, risk factors, and symptoms in an attempt to prevent negative outcomes, provide
relief, increase clients’ level of func tioning, and facilitate healing. However, focus ing too much on
these areas can undermine clients’ sense of competence and hope. Target ing only presenting
problems and symptoms does not provide individuals with an oppor tunity to see their own
resourcefulness in managing very stressful and difficult experi ences. It is important for providers to
engage in interventions using a balanced approach that targets the strengths clients have “Trauma -
informed care recognizes symp toms as originating from adaptations to the traumatic event(s) or
context. Validat ing resilience is important even when past coping behaviors are now causing prob
lems. Understanding a symptom as an adaptation reduces a survivor’s guilt and shame, increases
their self -esteem and provides a guideline for developing new skills and resources to allow new and
bet ter adaptation to the current situation.” (Elliot et al., 2005, p. 467) 27 Trauma-Informed Care in
Behavioral Health Services Advice to Counselors and Administrators: Using Strengths-Oriented
Questions Knowing a client’s strengths can help you understand, redefine, and reframe the client’s
presenting problems and challenges. By focusing and building on an individual’s strengths,
counselors and other behavioral health professionals can shift the focus from “What is wrong with
you?” to “What has worked for you?” It moves attention away from trauma-related problems and
toward a perspective that honors and uses adaptive behaviors and strengths to move clients along in
recovery. Potential strengths-oriented questions include: • The history that you provided suggests
that you’ve accomplished a great deal since the trauma. What are some of the accomplishments
that give you the most pride? • What would you say are your strengths? • How do you manage your
stress today? • What behaviors have helped you survive your traumatic experiences (during and
afterward)? • What are some of the creative ways that you deal with painful feelings? • You have
survived trauma. What characteristics have helped you manage these experiences and the
challenges that they have created in your life? • If we were to ask someone in your life, who knew
your history and experience with trauma, to name two positive characteristics that help you survive,
what would they be? • What coping tools have you learned from your _____ (fill in: cultural history,
spiritual practices, athletic pursuits, etc.)? • Imagine for a moment that a group of people are
standing behind you showing you support in some way. Who would be standing there? It doesn’t
matter how briefly or when they showed up in your life, or whether or not they are currently in your
life or alive. • How do you gain support today? (Possible answers include family, friends, activities,
coaches, counselors, other supports, etc.) • What does recovery look like for you? developed to
survive their experiences and to thrive in recovery. A strengths-based, resilience-minded approach
lets trauma survi vors begin to acknowledge and appreciate their fortitude and the behaviors that
help them survive. Foster Trauma-Resistant Skills Trauma-informed services build a foundation on
which individuals can begin to explore the role of trauma in their lives; such services can also help
determine how best to address and tailor interventions to meet their needs. Pre vention, mental
health, and substance abuse treatment services should include teaching clients about how trauma
can affect their lives; these services should also focus on developing self-care skills, coping strategies,
supportive networks, and a sense of competence. Building trauma-resistant skills begins with
normaliz ing the symptoms of traumatic stress and 28 helping clients who have experienced trauma
connect the dots between current problems and past trauma when appropriate. Nevertheless, TIC
and trauma-specific inter ventions that focus on skill-building should not do so at the expense of
acknowledging individual strengths, creativity in adapting to trauma, and inherent attributes and
tools cli ents possesses to combat the effects of trauma. Some theoretical models that use skill
building strategies base the value of this ap proach on a deficit perspective; they assume that some
individuals lack the necessary tools to manage specific situations and, because of this deficiency,
they encounter problems that others with effective skills would not experi ence. This type of
perspective further assumes that, to recover, these individuals must learn new coping skills and
behavior. TIC, on the other hand, makes the assumption that clients Advice to Administrators: Self-
Assessment for Trauma-Informed Systems NCTIC has developed a self-assessment package for
trauma-informed systems to help administrators structurally incorporate trauma into programs and
services. The self-assessment can be used by sys tems of care to guide quality improvement with the
goal of establishing fully trauma-informed treat ment and recovery efforts (NCTIC, Center for Mental
Health Services, 2007). Behavioral health treatment program administrators can use these materials
and NCTIC as resources for improvement in delivering TIC. Part 1, Chapter 1—Trauma-Informed
Care: A Sociocultural Perspective are the experts in their own lives and have learned to adapt and
acquire skills to survive. The TIC approach honors each individual’s adaptations and acquired skills,
and it helps clients explore how these may not be working as well as they had in the past and how
their current repertoire of responses may not be as effective as other strategies. Demonstrate
Organizational and Administrative Commitment to TIC Becoming a trauma-informed organization
requires administrative guidance and support across all levels of an agency. Behavioral health staff
will not likely sustain TIC practices without the organization’s ongoing commit ment to support
professional development and to allocate resources that promote these prac tices. An agency that
wishes to commit to TIC will benefit from an organizational assessment of how staff members
identify and manage trauma and trauma-related reactions in their clients. Are they trauma aware—
do they rec ognize that trauma can significantly affect a client’s ability to function in one or more
areas of his or her life? Do the staff members under stand that traumatic experiences and trauma
related reactions can greatly influence clients’ engagement, participation, and response to services?
Agencies need to embrace specific strategies across each level of the organization to create trauma-
informed services; this begins with staff education on the impact of trauma among clients. Other
agency strategies that reflect a trauma-informed infrastructure in clude, but are not limited to: •
Universal screening and assessment proce dures for trauma. • Interagency and intra-agency
collaboration to secure trauma-specific services. • Referral agreements and networks to match
clients’ needs. • Mission and value statements endorsing the importance of trauma recognition. •
Consumer-and community-supported committees and trauma response teams. • Workforce
development strategies, includ ing hiring practices. • Professional development plans, including staff
training/supervision focused on TIC. • Program policies and procedures that en sure trauma
recognition and secure trauma informed practices, trauma-specific services, and prevention of
retraumatization. TIC requires organizational commitment, and often, cultural change. For more
information on implementing TIC in organizations, see Part 2, Chapter 1 of this TIP. Develop
Strategies To Address Secondary Trauma and Promote Self-Care Secondary trauma is a normal
occupational hazard for mental health and substance abuse professionals, particularly those who
serve populations that are likely to include survivors of trauma (Figley, 1995; Klinic Community
Health Centre, 2008). Behavioral health staff members who experience secondary trauma present a
range of traumatic stress reactions 29 Trauma is similar to a rock hitting the water’s surface. The
impact first creates the largest wave, which is followed by ever-expanding, but less intense, ripples.
Likewise, the influence of a given trauma can be broad, but generally, its effects are less intense for
individuals further removed from the trauma; eventually, its im pact dissipates all around. For
trauma survivors, the impact of trauma can be far-reaching and can affect life areas and
relationships long after the trauma occurred. This analogy can also broadly describe the recovery
process for indi viduals who have experienced trauma and for those who have the privilege of
hearing their stories. As survivors reveal their tra uma-related experiences and struggles to a
counselor or another caregiver, the trauma becomes a shared experience, although it is not likely to
be as intense for the caregiver as it was for the individual who experienced the trauma. The
caregiver may hold onto the trauma’s known and unknown effects or may consciously decide to
engage in behaviors that provide support to further dissipate the impact of this trauma and the risk
of secondary trauma. Trauma-Informed Care in Behavioral Health Services and effects from
providing services focused on trauma or listening to clients recount traumatic experiences. So too,
when a coun selor has a history of personal trauma, work ing with trauma survivors may evoke
memories of the counselor’s own trauma his tory, which may increase the potential for secondary
traumatization. The range of reactions that manifest with sec ondary trauma can be, but are not
necessarily, similar to the reactions presented by clients who have experienced primary trauma.
Symp toms of secondary trauma can produce varying levels of difficulty, impairment, or distress in
daily functioning; these may or may not meet diagnostic thresholds for acute stress, post traumatic
stress, or adjustment, anxiety, or mood disorders (Bober & Regehr, 2006). Symptoms may include
physical or psycholog ical reactions to traumatic memories clients have shared; avoidance behaviors
during client interactions or when recalling emotional con tent in supervision; numbness, limited
emo tional expression, or diminished affect; somatic complaints; heightened arousal, including in
somnia; negative thinking or depressed mood; and detachment from family, friends, and oth er
supports (Maschi & Brown, 2010). Working daily with individuals who have been traumatized can be
a burden for counselors and other behavioral health service providers, but all too often, they blame
the symptoms resulting from that burden on other stressors at work or at home. Only in the past 2
decades have literature and trainings begun paying attention to secondary trauma or compassion
fatigue; even so, agencies often do not trans late this knowledge into routine prevention practices.
Counselors and other staff members may find it difficult to engage in activities that could ward off
secondary trauma due to time constraints, workload, lack of agency re sources, and/or an
organizational culture that disapproves of help-seeking or provides inade quate staff support. The
demands of providing care to trauma survivors cannot be ignored, lest the provider become
increasingly impaired and less effective. Counselors with unacknowledged secondary trauma can
cause harm to clients via poorly enforced bounda ries, missed appointments, or even abandon ment
of clients and their needs (Pearlman & Saakvitne, 1995). Essential components of TIC include organi
zational and personal strategies to address The Impact of Trauma 30 Advice to Counselors:
Decreasing the Risk of Secondary Trauma and Promoting Self-Care • Peer support. Maintaining
adequate social support will help prevent isolation and depression. • Supervision and consultation.
Seeking professional support will enable you to understand your own responses to clients and to
work with them more effectively. • Training. Ongoing professional training can improve your belief
in your abilities to assist clients in their recoveries. • Personal therapy. Obtaining treatment can help
you manage specific problems and become better able to provide good treatment to your clients. •
Maintaining balance. A healthy, balanced lifestyle can make you more resilient in managing any
difficult circumstances you may face. Setting clear limits and boundaries with clients. Clearly
separating your personal and work life allows time to rejuvenate from stresses inherent in being a
professional caregiver. Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective
secondary trauma and its physical, cognitive, emotional, and spiritual consequences. In agencies and
among individual providers, it is key for the culture to promote acceptability, accessibility, and
accountability in seeking help, accessing support and supervision, and engaging in self-care
behaviors in and outside of the agency or office. Agencies should in volve staff members who work
with trauma in developing informal and formal agency prac tices and procedures to prevent or
address sec ondary trauma. Even though a number of community-based agencies face fiscal con
straints, prevention strategies for secondary trauma can be intertwined with the current
infrastructure (e.g., staff meetings, education, case consultations and group case discussions, group
support, debriefing sessions as appropri ate, supervision). For more information on strategies to
address and prevent secondary trauma, see Part 2, Chapter 2 of this TIP. Provide Hope—Recovery Is
Possible What defines recovery from trauma-related symptoms and traumatic stress disorders? Is it
the total absence of symptoms or conse quences? Does it mean that clients stop hav ing nightmares
or being reminded, by cues, of past trauma? When clients who have experi enced trauma enter into
a helping relationship to address trauma specifically, they are often looking for a cure, a remission of
symptoms, or relief from the pain as quickly as possible. However, they often possess a history of un
predictable symptoms and symptom intensity that reinforces an underlying belief that recov ery is
not possible. On one hand, clients are looking for a message that they can be cured, while on the
other hand, they have serious doubts about the likely success of any intervention. Clients often
express ambivalence about deal ing with trauma even if they are fully aware of trauma’s effects on
their lives. The idea of liv ing with more discomfort as they address the past or as they experiment
with alternative ways of dealing with trauma-related symptoms or consequences is not an appealing
prospect, and it typically elicits fear. Clients may inter pret the uncomfortable feelings as dangerous
or unsafe even in an environment and rela tionship that is safe and supportive. How do you promote
hope and relay a mes sage that recovery is possible? First, maintain consistency in delivering
services, promoting and providing safety for clients, and showing respect and compassion within the
client provider relationship. Along with clients’ commitment to learning how to create safety for
themselves, counselors and agencies need 31 Trauma-Informed Care in Behavioral Health Services
to be aware of, and circumvent, practices that could retraumatize clients. Projecting hope and
reinforcing the belief that recovery is pos sible extends well beyond the practice of es tablishing
safety; it also encompasses discussing what recovery means and how it looks to clients, as well as
identifying how they will know that they’ve entered into recov ery in earnest. Providing hope
involves projecting an attitude that recovery is possible. This attitude also involves viewing clients as
competent to make changes that will allow them to deal with trauma-related challenges, providing
opportu nities for them to practice dealing with diffi cult situations, and normalizing discomfort or
difficult emotions and framing these as man ageable rather than dangerous. If you convey this
attitude consistently to your clients, they will begin to understand that discomfort is not a signal to
avoid, but a sign to engage—and that behavioral, cognitive, and emotional re sponses to cues
associated with previous trau mas are a normal part of the recovery process. It’s not the absence of
responses to such trig gers that mark recovery, but rather, how clients experience and manage those
responses. Cli ents can also benefit from interacting with others who are further along in their
recovery from trauma. Time spent with peer support staff or sharing stories with other trauma sur
vivors who are well on their way to recovery is invaluable—it sends a powerful message that
recovery is achievable, that there is no shame in being a trauma survivor, and that there is a future
beyond the trauma. As You Proceed This chapter has established the foundation and rationale of this
TIP, reviewed trauma informed concepts and terminology, and pro vided an overview of TIC
principles and a guiding framework for this text. As you pro ceed, be aware of the wide-ranging
responses to trauma that occur not only across racially and ethnically diverse groups but also within
specific communities, families, and individuals. Counselors, prevention specialists, other be havioral
health workers, supervisors, and or ganizations all need to develop skills to create an environment
that is responsive to the unique attributes and experiences of each cli ent. As you read this TIP,
remember that many cross-cutting factors influence the expe riences, help-seeking behaviors,
intervention responses, and outcomes of individuals, fami lies, and populations who have survived
trau ma. Single, multiple, or chronic exposures to traumatic events, as well as the emotional,
cognitive, behavioral, and spiritual responses to trauma, need to be understood within a social
ecological framework that recognizes the many ingredients prior to, during, and after traumatic
experiences that set the stage for recovery. 32 2 IN THIS CHAPTER • Types of Trauma •
Characteristics of Trauma • Individual and Sociocultural Features Trauma Awareness Traumatic
experiences typically do not result in long-term im pairment for most individuals. It is normal to
experience such events across the lifespan; often, individuals, families, and com munities respond to
them with resilience. This chapter explores several main elements that influence why people
respond differ ently to trauma. Using the social-ecological model outlined in Part 1, Chapter 1, this
chapter explores some of the contextual and systemic dynamics that influence individual and
community perceptions of trauma and its impact. The three main foci are: types of trauma, objective
and subjective characteristics of trauma, and individual and sociocultural features that serve as risk
or pro tective factors. This chapter’s main objective is to highlight the key characteris tics of
traumatic experiences. Trauma-informed behavioral health service providers understand that many
influences shape the ef fects of trauma among individuals and communities—it is not just the event
that determines the outcome, but also the event’s context and the resultant interactions across
systems. Types of Trauma The following section reviews various forms and types of trauma. It does
not cover every conceivable trauma that an individual, group, or community may encounter. Specific
traumas are re viewed only once, even when they could fit in multiple categories of trauma.
Additionally, the order of appearance does not denote a specific trauma’s importance or prevalence,
and there is no lack of relevance implied if a given trauma is not specifically addressed in this
Treatment Improvement Protocol (TIP). The intent is to give a broad perspective of the various
categories and types of trauma to behavioral health workers who wish to be trauma in formed. 33
Trauma-Informed Care in Behavioral Health Services TIC Framework in Behavioral Health Services—
Trauma Awareness Natural or Human-Caused Traumas The classification of a trauma as natural or
caused by humans can have a significant im pact on the ways people react to it and on the types of
assistance mobilized in its aftermath (see Exhibit 1.2-1 for trauma examples). Nat ural traumatic
experiences can directly affect a small number of people, such as a tree falling on a car during a
rainstorm, or many people and communities, as with a hurricane. Natural events, often referred to
as “acts of God,” are typically unavoidable. Human-caused traumas are caused by human failure
(e.g., technologi cal catastrophes, accidents, malevolence) or by human design (e.g., war). Although
multiple factors contribute to the severity of a natural 34 or human-caused trauma, traumas
perceived as intentionally harmful often make the event more traumatic for people and
communities. For information on resources to prepare States, Territories, and local entities to
deliver effective mental health and sub stance abuse responses during disasters, contact the
Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Disaster Technical
Assistance Center: 4350 East -West Hwy, Suite 1100 Bethesda, MD 20814 -6233 Phone: 1 -800 -308 -
3515 Fax: 1 -800 -311 -7691 Email: DTAC@[Link] Part 1, Chapter 2—Trauma Awareness
Exhibit 1.2-1: Trauma Examples Caused Naturally Tornado Lightning strike Wildfire Avalanche
Physical ailment or disease Fallen tree Earthquake Dust storm Volcanic eruption Blizzard Hurricane
Cyclone Typhoon Meteorite Flood Tsunami Epidemic Famine Landslide or fallen boulder Caused by
People . Accidents, Technological Catastrophes Intentional Acts Train derailment Roofing fall
Structural collapse Mountaineering accident Aircraft crash Car accident due to malfunction Mine
collapse or fire Radiation leak Crane collapse Gas explosion Electrocution Machinery-related
accident Oil spill Maritime accident Accidental gun shooting Sports-related death Arson Terrorism
Sexual assault and abuse Homicides or suicides Mob violence or rioting Physical abuse and neglect
Stabbing or shooting Warfare Domestic violence Poisoned water supply Human trafficking School
violence Torture Home invasion Bank robbery Genocide Medical or food tampering How survivors of
natural trauma respond to the experience often depends on the degree of devastation, the extent of
individual and community losses, and the amount of time it takes to reestablish daily routines,
activities, and services (e.g., returning to school or work, being able to do laundry, having products
to buy in a local store). The amount, accessibil ity, and duration of relief services can signifi cantly
influence the duration of traumatic stress reactions as well as the recovery process. Alongside the
disruption of daily routines, the presence of community members or outsiders in affected areas may
add significant stress or create traumatic experiences in and of them selves. Examples include the
threat of others stealing what remains of personal property, restrictions on travel or access to
property or living quarters, disruption of privacy within shelters, media attention, and subsequent ex
posure to repetitive images reflecting the dev astation. Therefore, it isn’t just the natural disaster or
event that can challenge an indi vidual or community; often, the consequences of the event and
behavioral responses from others within and outside the community play a role in pushing survivors
away from effective coping or toward resilience and recovery. Human-caused traumas are
fundamentally different from natural disasters. They are ei ther intentional, such as a convenience
store robbery at gunpoint, or unintentional, such as the technological accident of a bridge collapse
(as occurred in Minneapolis, Minnesota, in 2007; U.S. Fire Administration, 2007). The subsequent
reactions to these traumas often depend on their intentionality. However, a person or group of
people is typically the tar get of the survivors’ anger and blame. Survi vors of an unintentionally
human-caused traumatic event may feel angry and frustrated because of the lack of protection or
care of fered by the responsible party or government, particularly if there has been a perceived act
of omission. After intentional human-caused acts, survivors often struggle to understand the 35
Trauma-Informed Care in Behavioral Health Services Case Illustrations: Quecreek Mine Flood and
Greensburg’s Tornado Quecreek Mine Flood The year following the rescue of nine miners from the
Quecreek mine in western Pennsylvania in 2002 was a difficult one for residents of Somerset County.
The dazzle of publicity surrounding a handful of workers from a small town, tension between miners
and rescuers, and animosity over money for movie and book deals, in addition to the trauma itself,
resulted in a rescuer’s suicide, a number of miners having trauma-related symptoms, and several
rescuers needing to seek treatment for posttraumatic stress disorder (PTSD; Goodell, 2003).
Greensburg’s Tornado Greensburg, a small town in southern Kansas, was hit by a large tornado in
2007 that killed 11 resi dents and leveled 95 percent of the town while causing severe damage to the
remaining 5 percent. Families and community members experienced significant grief and traumatic
stress after the disas ter. Yet today, Greensburg is rebuilding with a focus on being “green”—that is,
environmentally responsible—from design to construction and all the way through demolition. This
town has the highest number of Leadership in Energy and Environmental Design–certified buildings
in the world. A reality television show about the town’s reinvention ran for three seasons,
demonstrating the town’s residents and business owners working with local government and various
corporations to make their home an even better place than it was before the tornado. motives for
performing the act, the calculated or random nature of the act, and the psycho logical makeup of the
perpetrator(s). Individual, Group, Community, and Mass Traumas In recognizing the role of trauma
and under standing responses to it, consider whether the trauma primarily affected an individual
and perhaps his or her family (e.g., automobile accident, sexual or physical assault, severe ill ness);
occurred within the context of a group (e.g., trauma experienced by first responders or those who
have seen military combat) or community (e.g., gang-related shootings); transpired within a certain
culture; or was a large-scale disaster (e.g., hurricane, terrorist attack). This context can have
significant im plications for whether (and how) people expe rience shame as a result of the trauma,
the kinds of support and compassion they receive, whether their experiences are normalized or
diminished by others, and even the kinds of services they are offered to help them recover and cope.
36 Individual trauma An individual trauma refers to an event that only occurs to one person. It can
be a single event (e.g., mugging, rape, physical attack, work-related physical injury) or multiple or
prolonged events (e.g., a life-threatening ill ness, multiple sexual assaults). Although the trauma
directly affects just one individual, others who know the person and/or are aware of the trauma will
likely experience emotional repercussions from the event(s) as well, such as recounting what they
said to the person before the event, reacting in disbelief, or thinking that it could just as easily have
hap pened to them, too. Survivors of individual trauma may not receive the environmental support
and concern that members of collectively traumatized groups and communities receive. They are
less likely to reveal their traumas or to receive validation of their experiences. Often, shame distorts
their perception of responsibility for the trau ma. Some survivors of individual traumas, especially
those who have kept the trauma secret, may not receive needed comfort and Part 1, Chapter 2—
Trauma Awareness Advice to Counselors: Working With Clients Who Have Experienced Individual
Traumas In working with clients who have histories of individual trauma, counselors should consider
that: • Empathy, or putting oneself in the shoes of another, is more potent than sympathy
(expressing a feeling of sorrow for another person). • Some clients need to briefly describe the
trauma(s) they have experienced, particularly in the early stages of recovery. Strategies that focus on
reexperiencing the trauma, retrieving feelings related to the trauma, and bringing past experiences
to the forefront should only be implement ed if trauma-specific treatment planning and services are
available. • Understanding the trauma, especially in early recovery, should begin with educating the
client about and normalizing trauma-related symptoms, creating a sense of safety within the
treatment environment, and addressing how trauma symptoms may interfere with the client’s life in
the present. • It is helpful to examine how the trauma affects opportunities to receive substance
abuse and/or mental health treatment as well as treatment for and recovery from the trauma itself
(e.g., by lim iting one’s willingness to share in or participate in group counseling). Identifying and
exploring strengths in the client’s history can help the client apply those strengths to his or her
ability to function in the present. acceptance from others; they are also are more likely to struggle
with issues of causation (e.g., a young woman may feel unduly responsible for a sexual assault), to
feel isolated by the trauma, and to experience repeated trauma that makes them feel victimized.
Physical injuries Physical injuries are among the most prevalent individual traumas. Millions of
emergency room (ER) visits each year relate directly to physical injuries. Most trauma patients are
relatively young; about 70 percent of injury related ER cases are people younger than 45 years old
(McCaig & Burt, 2005). Dedicated ER hospital units, known as “trauma centers,” specialize in physical
traumas such as gunshot wounds, stabbings, and other immediate phys ical injuries. The term
“trauma” in relation to ERs does not refer to psychological trauma, which is the focus of this TIP, yet
physical injuries can be associated with psychological trauma. Sudden, unexpected, adverse health
related events can lead to extensive psycholog ical trauma for patients and their families. Excessive
alcohol use is the leading risk factor for physical injuries; it’s also the most promis ing target for
injury prevention. Studies con sistently connect injuries and substance use (Gentilello, Ebel,
Wickizer, Salkever, & Rivara, 2005); nearly 50 percent of patients admitted to trauma centers have
injuries at tributable to alcohol abuse and dependence (Gentilello et al., 1999). One study found that
two thirds of ambulatory assault victims pre senting to an ER had positive substance use urinalysis
results; more than half of all victims had PTSD 3 months later (Roy-Byrne et al., Acute stress disorder
(ASD) prevalence among patients at medical trauma centers is very high, making trauma -related
disor ders some of the most common complica tions seen in physically injured patients. Clients who
have sustained serious injuries in car crashes, fires, stabbings, shootings, falls, and other events have
an increased likelihood of developing trauma -related mental disorders. Research suggests that PTSD
and/or problem drinking is evident in nearly 50 percent of patients 1 year after discharge from
trauma surgical units. (Zatzick, Jurkovich, Gentilello, Wisner, & Rivara, 2002) 37 Trauma-Informed
Care in Behavioral Health Services 2004). Nearly 28 percent of patients whose drinking was
identified as problematic during an ER visit for a physical injury will have a new injury within 1 year
(Gentilello et al., 2005). For further information, see TIP 16, Alcohol and Other Drug Screening of
Hospital ized Trauma Patients (Center for Substance Abuse Treatment [CSAT], 1995a). Group trauma
The term “group trauma” refers to traumatic experiences that affect a particular group of people.
This TIP intentionally distinguishes group trauma from mass trauma to highlight the unique
experiences and characteristics of trauma-related reactions among small groups. These groups often
share a common identity and history, as well as similar activities and concerns. They include
vocational groups who specialize in managing traumas or who rou tinely place themselves in harm’s
way—for example, first responders, a group including police and emergency medical personnel.
Some examples of group trauma include crews and their families who lose members from a
commercial fishing accident, a gang whose members experience multiple deaths and inju ries, teams
of firefighters who lose members in a roof collapse, responders who attempt to save flood victims,
and military service mem bers in a specific theater of operation. Survivors of group trauma can have
different experiences and responses than survivors of individual or mass traumas. Survivors of group
trauma, such as military service members and first responders, are likely to experience re peated
trauma. They tend to keep the trauma experiences within the group, feeling that oth ers outside the
group will not understand; group outsiders are generally viewed as intrud ers. Members may
encourage others in the group to shut down emotionally and repress their traumatic experiences—
and there are some occupational roles that necessitate the repression of reactions to complete a
mission or to be attentive to the needs at hand. Group members may not want to seek help and may
discourage others from doing so out of fear that it may shame the entire group. In this environment,
members may see it as a viola tion of group confidentiality when a member seeks assistance outside
the group, such as by going to a counselor. Group members who have had traumatic experiences in
the past may not actively sup port traumatized colleagues for fear that ac knowledging the trauma
will increase the risk of repressed trauma-related emotions surfac ing. However, groups with
adequate resources for helping group members can develop a stronger and more supportive
environment for handling subsequent traumas. These main group features influence the course of
short and long-term adjustments, including the development of traumatic stress symptoms
associated with mental and substance use disorders. Certain occupational groups are at greater risk
of experiencing trauma—particularly multiple traumas. This TIP briefly reviews two main groups as
examples in the following sections: first responders and military service members. For more detailed
information on the impact of trauma and deployment, refer to the planned TIP, Reintegration-
Related Behavioral Health Issues in Veterans and Military Families (SAMHSA, planned f). First
responders First responders are usually emergency medi cal technicians, disaster management
person nel, police officers, rescue workers, medical and behavioral health professionals, journalists,
and volunteers from various backgrounds. They also include lifeguards, military person nel, and
clergy. Stressors associated with the kinds of traumatic events and/or disasters first responders are
likely to experience include 38 Part 1, Chapter 2—Trauma Awareness exposure to toxic agents,
feeling responsible for the lives of others, witnessing catastrophic devastation, potential exposure to
gruesome images, observing human and animal suffering and/or death, working beyond physical ex
haustion, and the external and internal pres sure of working against the clock. Military service
members Military personnel are likely to experience numerous stressors associated with trauma.
Service members who have repeatedly de ployed to a war zone are at a greater risk for traumatic
stress reactions (also known as com bat stress reaction or traumatic stress injury), other military
personnel who provide support services are also at risk for traumatic stress and secondary trauma
(refer to the glossary portion of the “How This TIP Is Organized” section that precedes Part 1,
Chapter 1, of this TIP). So too, service members who anticipate de ployment or redeployment may
exhibit psy chological symptoms associated with traumatic stress. Some stressors that military
service members may encounter include work ing while physically exhausted, exposure to gunfire,
seeing or knowing someone who has been injured or killed, traveling in areas known for roadside
bombs and rockets, ex tended hypervigilance, fear of being struck by an improvised explosive device,
and so forth. Trauma affecting communities and cultures Trauma that affects communities and
cultures covers a broad range of violence and atrocities that erode the sense of safety within a given
community, including neighborhoods, schools, towns, and reservations. It may in volve violence in
the form of physical or sexual assaults, hate crimes, robberies, workplace or gang-related violence,
threats, shootings, or stabbings—for example, the school shooting at Virginia Polytechnic Institute
and State University in 2007. It also includes actions that attempt to dismantle systemic cultural
practices, resources, and identities, such as making boarding school attendance mandato ry for
Native American children or placing them in non-Native foster homes. Cultural and/or community-
based trauma can also oc cur via indifference or limited responsiveness to specific communities or
cultures that are facing a potential catastrophe. Cultural trau mas are events that, whether
intentionally or not, erode the heritage of a culture—as with prejudice, disenfranchisement, and
health inequities (e.g., late prenatal care, inability to afford medications, limited access to culturally
appropriate health education, vicinity and quality of affordable medical services), among other
examples. “The excitement of the season had just begun, and then, we heard the news, oil in the
water, lots of oil killing lots of water. It is too shocking to understand. Never in the millen nium of
our tradition have we thought it possible for the water to die, but it is true.” —Chief Walter
Meganack, Port Graham, 1989 Of all the groups negatively affected by the Exxon Valdez oil spill, in
many ways Alaska Natives were the most devastated. The oil spill destroyed more than economic
resources; it shook the core cultural foundation of Native life. Alaska Native subsistence culture is
based on an intimate relationship with the environment. Not only does the environment have sacred
qualities for Alaska Natives; their sur vival also depends on the well-being of the ecosystem and the
maintenance of cultural norms of sub sistence. The spill directly threatened the well-being of the
environment, disrupted subsistence behavior, and severely disturbed the sociocultural milieu of
Alaska Natives. 39 Source: Gill & Picou, 1997, pp. 167–168. Trauma-Informed Care in Behavioral
Health Services Historical trauma Historical trauma, known also as generational trauma, refers to
events that are so widespread as to affect an entire culture; such events also have effects intense
enough to influence gen erations of the culture beyond those who ex perienced them directly. The
enslavement, torture, and lynching of African Americans; the forced assimilation and relocation of
American Indians onto reservations; the ex termination of millions of Jews and others in Europe
during World War II; and the geno cidal policies of the Hutus in Rwanda and the Khmer Rouge in
Cambodia are examples of historical trauma. In the past 50 years, research has explored the
generational effects of the Holocaust upon survivors and their families. More recent liter ature has
extended the concept of historical or generational trauma to the traumatic experi ences of Native
Americans. Reduced popula tion, forced relocation, and acculturation are some examples of
traumatic experiences that Native people have endured across centuries, beginning with the first
European presence in the Americas. These tragic experiences have led to significant loss of cultural
identity across generations and have had a significant impact on the well-being of Native
communities (Whitbeck, Chen, Hoyt, & Adams, 2004). Data are limited on the association of mental
and substance use disorders with historical trauma among Native people, but literature suggests
that historical trauma has repercus sions across generations, such as depression, grief, traumatic
stress, domestic violence, and substance abuse, as well as significant loss of cultural knowledge,
language, and identity (Gone, 2009). Historical trauma can increase the vulnerability of multiple
generations to the effects of traumas that occur in their own lifetimes. Mass trauma Mass traumas
or disasters affect large numbers of people either directly or indirectly. It is be yond the scope of this
TIP to cover any specif ic disaster in detail; note, however, that mass traumas include large-scale
natural and human-caused disasters (including intentional acts and accidents alike). Mass traumas
may involve significant loss of property and lives as well as the widespread disruption of normal
routines and services. Responding to such traumas often requires immediate and exten sive
resources that typically exceed the capaci ty of the affected communities, States, or countries in
which they occur. Recent exam ples of such large-scale catastrophes include: • In January 2010, a
massive earthquake hit Haiti, killing hundreds of thousands of people and leaving over a million
homeless. • A nuclear reactor meltdown in the Ukraine in 1986 resulted in a technological and en
vironmental disaster that affected tens of millions of people. • The tsunami in the Indian Ocean in
2005 left hundreds of thousands dead in nine countries. One factor that influences an individual’s
response to trauma is his or her ability to process one trauma before another trauma occurs. In mass
traumas, the initial event causes considerable destruction, the conse quences of which may spawn
additional traumas and other stressful events that lead to more difficulties and greater need for
adjust ments among survivors, first responders, and disaster relief agencies. Often, a chain reac tion
occurs. Take, for example, Hurricane Katrina and its impact on the people of Louisiana and other
coastal States. After the initial flooding, people struggled to obtain basic needs, including food,
drinking water, safe shelter, clothing, medicines, personal hygiene items, and so forth, all as concern
mounted about the safety of children and 40 Part 1, Chapter 2—Trauma Awareness other relatives,
friends, and neighbors. In this and similar cases, the destruction from the initial flooding led to mass
displacement of families and communities; many people had to relocate far from New Orleans and
other badly affected areas, while also needing to gain fi nancial assistance, reinitiate work to
generate income, and obtain stable housing. People could not assimilate one stressor before anoth
er appeared. Nevertheless, mass traumas can create an im mediate sense of commonality—many
people are “in the same boat,” thus removing much of the isolation that can occur with other types
of trauma. People can acknowledge their diffi culties and receive support, even from strangers. It is
easier to ask for help because blame is often externalized; large-scale disas ters are often referred to
as “acts of God” or, in cases of terrorism and other intentional events, as acts of “evil.” Even so,
survivors of mass trauma often encounter an initial rally of support followed by quickly diminishing
ser vices and dwindling care. When the disaster fades from the headlines, public attention and
concern are likely to decrease, leaving survi vors struggling to reestablish or reinvent their lives
without much outside acknowledgment. The experience of mass trauma can lead to the
development of psychological symptoms and substance use at either a subclinical or a diag nostic
level (refer to Part 3 of this TIP, availa ble online, for more information highlighting the relationship
between trauma and behav ioral health problems). Likewise, one of the greatest risks for traumatic
stress reactions after a mass tragedy is the presence of preex isting mental and co-occurring
disorders, and individuals who are in early recovery from substance use disorders are at greater risk
for such reactions as well. Nonetheless, people are amazingly resilient, and most will not develop
long-term mental or substance use disorders after an event; in fact, most trauma-related symptoms
will resolve in a matter of months (Keane & Piwowarczyk, 2006). Interpersonal Traumas
Interpersonal traumas are events that occur (and typically continue to reoccur) between people who
often know each other, such as spouses or parents and their children. Exam ples include physical and
sexual abuse, sexual assault, domestic violence, and elder abuse. Intimate partner violence Intimate
partner violence (IPV), often re ferred to as domestic violence, is a pattern of actual or threatened
physical, sexual, and/or emotional abuse. It differs from simple assault in that multiple episodes
often occur and the perpetrator is an intimate partner of the vic tim. Trauma associated with IPV is
normally ongoing. Incidents of this form of violence are rarely isolated, and the client may still be in
contact with and encountering abuse from the perpetrator while engaged in treatment. Intimate
partners include current and former spouses, boyfriends, and girlfriends. The ma jority of all nonfatal
acts of violence and inti mate partner homicides are committed against women; IPV accounts for
over 20 percent of nonfatal violence against women but only 3.6 percent of that committed against
men (Catalano, 2012). Children are the hidden casualties of IPV. They often witness the as saults or
threats directly, within earshot, or by being exposed to the aftermath of the violence (e.g., seeing
bruises and destruction of proper ty, hearing the pleas for it to stop or the prom ises that it will
never happen again). Substance abuse, particularly involving alco hol, is frequently associated with
IPV. It is the presence of alcohol-related problems in either partner, rather than the level of alcohol
con sumption itself, that is the important factor. 41 Child Neglect Child neglect occurs when a parent
or caregiver does not give a child the care he or she needs ac cording to his or her age, even though
that adult can afford to give that care or is offered help to give that care. Neglect can mean not
providing adequate nutrition, clothing, and/or shelter. It can mean that a parent or caregiver is not
providing a child with medical or mental health treatment or is not giving prescribed medicines the
child needs. Neglect can also mean neglecting the child’s educa tion. Keeping a child from school or
from special education can be neglect. Neglect also includes exposing a child to dangerous
environments (e.g., exposure to domestic violence). It can mean poor supervision for a child,
including putting the child in the care of someone incapable of caring for chil dren. It can mean
abandoning a child or expelling him or her from home. Lack of psychological care, including
emotional support, attention, or love, is also considered neglect—and it is the most com mon form
of abuse reported to child welfare authorities. Source: dePanfilis, 2006. Trauma-Informed Care in
Behavioral Health Services Drinking may or may not be the cause of the violence; that said, couples
with alcohol related disorders could have more tension and disagreement within the relationship in
gen eral, which leads to aggression and violence. The consumption of alcohol during a dispute is
likely to decrease inhibitions and increase impulsivity, thus creating an opportunity for an argument
to escalate into a physical alterca tion. More information on domestic violence and its effects on
partners and families, as well as its connection with substance use and trauma-related disorders, is
available in TIP 25, Substance Abuse Treatment and Domestic Violence (CSAT, 1997b), and from the
Na tional Online Resource Center on Violence Against Women ([Link]
Developmental Traumas Developmental traumas include specific events or experiences that occur
within a given devel opmental stage and influence later develop ment, adjustment, and physical and
mental health. Often, these traumas are related to adverse childhood experiences (ACEs), but they
can also result from tragedies that occur outside an expected developmental or life stage (e.g., a
child dying before a parent, being diagnosed with a life-threatening illness as a young adult) or from
events at any point in the life cycle that create significant loss and have life-altering consequences
(e.g., the death of a significant other in the later years that leads to displacement of the surviving
partner). Adverse childhood experiences Some people experience trauma at a young age through
sexual, physical, or emotional abuse and neglect. The Adverse Childhood Experi ences Study (Felitti
et al., 1998) examined the effects of several categories of ACEs on adult health, including physical
and emotional abuse; sexual abuse; a substance-dependent parent; an incarcerated, mentally ill, or
suicidal household member; spousal abuse between parents; and divorce or separation that meant
one parent was absent during childhood. The National Comorbidity Studies examined the prevalence
of trauma and defined childhood adversities as parental death, parental divorce/separation, life-
threatening illness, or extreme economic hardship in addition to the childhood experi ences included
in the Adverse Childhood Experiences Study (Green et al., 2010). ACEs can negatively affect a
person’s well being into adulthood. Whether or not these experiences occur simultaneously, are
time limited, or recur, they set the stage for in creased vulnerability to physical, mental, and
substance use disorders and enhance the risk 42 Torture and Captivity Torture traumatizes by taking
away an individual’s personhood. To survive, victims have to give up their sense of self and will. They
become the person the torturer designs or a nonperson, simply exist ing. Inevitably, the shame of
the victim is enormous, because the focus of torture is to humiliate and degrade. As a result, victims
often seek to hide their trauma and significant parts of their selfhood long after torture has ended
and freedom has been obtained. According to Judith Herman, “the methods of establishing control
over another person are based upon the systematic, repetitive inflic tion of psychological trauma.
They are organized techniques of disempowerment and disconnection. Methods of psychological
control are designed to instill terror and helplessness and to destroy the victim’s sense of self in
relation to others.” Source: Herman, 1997, p. 77. Part 1, Chapter 2—Trauma Awareness for repeated
trauma exposure across the life span. Childhood abuse is highly associated with major depression,
suicidal thoughts, PTSD, and dissociative symptoms. So too, ACEs are associated with a greater risk
of adult alcohol use. When a person experiences several adverse events in childhood, the risk of his
or her heavy drinking, self-reported alco hol dependence, and marrying a person who is alcohol
dependent is two to four times greater than that of a person with no ACEs (Dube, Anda, Felitti,
Edwards, & Croft, 2002). A detailed examination of the issues involved in providing substance abuse
treatment to survivors of child abuse and neglect is the sub ject of TIP 36, Substance Abuse
Treatment for Persons With Child Abuse and Neglect Issues (CSAT, 2000b). Political Terror and War
Political terror and war are likely to have last ing consequences for survivors. In essence, anything
that threatens the existence, beliefs, well-being, or livelihood of a community is likely to be
experienced as traumatic by com munity members. Whether counselors are working with an
immigrant or refugee enclave in the United States or in another country, they should be aware of
local events, local his tory, and the possibility that clients have en dured trauma. (For international
information about the clinical, historical, and theoretical aspects of trauma and terrorism, see
Danieli, Brom, & Sills, 2005.) Terrorism is a unique subtype of human-caused disasters. The over all
goal of terrorist attacks is to maximize the uncertainty, anxiety, and fear of a large com munity, so
the responses are often epidemic and affect large numbers of people who have had direct or indirect
exposure to an event (Silver et al., 2004; Suvak, Maguen, Litz, Silver, & Holman, 2008). Terrorism has
a vari ety of results not common to other disasters, such as reminders of the unpredictability of
terrorist acts; increases in security measures for the general population; intensified suspicion about
a particular population, ethnicity, or cul ture; and heightened awareness and/or arousal. Refugees
According to the World Refugee Survey, there are an estimated 12 million refugees and asylum
seekers, 21 million internally displaced people, and nearly 35 million uprooted people (U.S.
Committee for Refugees and Immi grants, 2006). Many of these people have sur vived horrendous
ordeals with profound and lasting effects for individuals and whole popu lations. In addition to
witnessing deaths by execution, starvation, or beatings, many survi vors have experienced horrific
torture. Refugees are people who flee their homes be cause they have experienced or have a reason
able fear of experiencing persecution. They 43 Trauma-Informed Care in Behavioral Health Services
differ from immigrants who willingly leave their homes or homeland to seek better op portunities.
Although immigrants may experi ence trauma before migrating to or after reaching their new
destination, refugees will often have greater exposure to trauma before migration. Refugees
typically come from war torn countries and may have been persecuted or tortured. Consequently,
greater exposure to trauma, such as torture, before migrating often leads to more adjustment-
related difficulties and psychological symptoms after relocation (Steel et al., 2009). Refugees
typically face substantial difficulties in assimilating into new countries and cul tures. Moreover, the
environment can create a new set of challenges that may include addi tional exposure to trauma and
social isolation (Miller et al., 2002). These as well as addition al factors influence adjustment, the
develop ment of mental illness (including PTSD), and Vietnamese Refugees the occurrence of
substance use disorders. Ad ditional factors that influence outcomes after relocation include
receptivity of the local community, along with opportunities for so cial support and culturally
responsive services. Among refugee populations in the United States, little research is available on
rates of mental illness and co-occurring substance use disorders and traumatic stress among refugee
populations. Substance use patterns vary based on cultural factors as well as assimilation, yet
research suggests that trauma increases the risk for substance use among refugees after war-related
experiences (Kozarić-Kovačić, Ljubin, & Grappe, 2000). Therefore, providers should expect to see
trauma-related disorders among refugees who are seeking treatment for a substance use disorder
and greater preva lence of substance use disorders among refu gees who seek behavioral health
services. “Wars always have consequences, both immediate and remote, and the consequences are
often tragic. One tragic circumstance often caused by war is the forceful, disorganized, and
uncontrollable mass movement of both civilians and soldiers trying to escape the horrors of the wars
or of an op pressive regime.… “Vietnamese communists, by taking power in the North in 1954 and
then in the South in 1975, caused two major upheavals in the Land of the Small Dragon, as Vietnam
was once called. The first Vietnam War led to the 1954 exodus during which 1 million people fled
from the North to the South. The sec ond Vietnam War resulted in the dispersion, from 1975-1992,
of approximately 2 million Vietnamese all over the world. These significant, unplanned, and
uncoordinated mass movements around the world not only dislocated millions of people, but also
caused thousands upon thousands of deaths at sea.… “The second and third wave of refugees from
1976 onward went through a more difficult time. They had to buy their way out and to hide from
soldiers and the police who hunted them down. After catching them, the police either asked for
brides or threw the escapees into jails. Those who evaded police still had to face engine failures, sea
storms, pirates…They then had to survive overcrowded boats for days or weeks, during which food
and water could not be replenished and living conditions were terrible… Many people died from
exhaustion, dehydration, and hunger. Others suffered at the hands of terrifying pirates… After the
sea ordeal came the overcrowded camps where living condi tions were most often substandard and
where security was painfully lacking.… “In the United States, within less than 3 decades, the
Vietnamese population grew from a minority of perhaps 1,000 persons to the second largest refugee
group behind Cubans.” Source: Vo, 2006, pp. 1–4. 44 Advice to Counselors: Addressing
Retraumatization • Anticipate and be sensitive to the needs of clients who have experienced trauma
regarding pro gram policies and procedures in the treatment setting that might trigger memories of
trauma, such as lack of privacy, feeling pushed to take psychotropic medications, perceiving that
they have limited choices within the program or in the selection of the program, and so forth. •
Attend to clients’ experiences. Ignoring clients’ behavioral and emotional reactions to having their
traumatic memories triggered is more likely to increase these responses than decrease t hem. •
Develop an individual coping plan in anticipation of triggers that the individual is likely to experi ence
in treatment based on his or her history. • Rehearse routinely the coping strategies highlighted in
the coping plan. If the client does not practice strategies prior to being triggered, the likelihood of
being able to use them effectively upon triggering is lessened. For example, it is far easier to practice
grounding exercises in the absence of severe fear than to wait for that moment when the client is
reexperiencing an aspect of a traumatic event. (For more information on grounding exercises, refer
to Seeking Safety: A Treatment Manual for PTSD and Substance Abuse; Najavits, 2002a, pp. 125–
131.) • Recognize that clinical and programmatic efforts to control or contain behavior in treatment
can cause traumatic stress reactions, particularly for trauma survivors for whom being trapped was
part of the trauma experience. • Listen for the specific trigger that seems to be driving the client’s
reaction. It will typically help both the counselor and client understand the behavior and normalize
the traumatic stress reactions. • Make sure that staff and other clients do not shame the trauma
survivor for his or her behavior, such a s through teasing or joking about the situation. • Respond
with consistency. The client should not get conflicting information or responses from different staff
members; this includes information and responses given by administrators. Part 1, Chapter 2—
Trauma Awareness System-Oriented Traumas: Retraumatization Retraumatization occurs when
clients experi ence something that makes them feel as though they are undergoing another trauma.
Unfortunately, treatment settings and clini cians can create retraumatizing experiences, often
without being aware of it, and some times clients themselves are not consciously aware that a
clinical situation has actually trig gered a traumatic stress reaction. Agencies that anticipate the risk
for retraumatization and actively work on adjusting program policies and procedures to remain
sensitive to the his tories and needs of individuals who have un dergone past trauma are likely to
have more success in providing care, retaining clients, and achieving positive outcomes. Staff and
agency issues that can cause retrau matization include: • Being unaware that the client’s traumatic
history significantly affects his or her life. • Failing to screen for trauma history prior to treatment
planning. • Challenging or discounting reports of abuse or other traumatic events. • Using isolation
or physical restraints. • Using experiential exercises that humiliate the individual. • Endorsing a
confrontational approach in counseling. • Allowing the abusive behavior of one client toward
another to continue without intervention. • Labeling behavior/feelings as pathological. • Failing to
provide adequate security and safety within the program. • Limiting participation of the client in
treatment decisions and planning processes. • Minimizing, discrediting, or ignoring client responses.
• Disrupting counselor–client relationships by changing counselors’ schedules and assignments. •
Obtaining urine specimens in a nonprivate setting. 45 Trauma-Informed Care in Behavioral Health
Services • Having clients undress in the presence of others. • Inconsistently enforcing rules and
allowing chaos in the treatment environment. • Imposing agency policies or rules without exceptions
or an opportunity for clients to question them. • Enforcing new restrictions within the pro gram
without staff–client communication. • Limiting access to services for ethnically diverse populations.
• Accepting agency dysfunction, including lack of consistent, competent leadership. Characteristics
of Trauma The following section highlights several se lected characteristics of traumatic experiences
that influence the effects of traumatic stress. Objective characteristics are those elements of a
traumatic event that are tangible or factual; subjective characteristics include internal pro cesses,
such as perceptions of traumatic experi ences and meanings assigned to them. Objective
Characteristics Was it a single, repeated, or sustained trauma? Trauma can involve a single event,
numerous or repeated events, or sustained/chronic expe riences. A single trauma is limited to a
single point in time. A rape, an automobile accident, the sudden death of a loved one—all are ex
amples of a single trauma. Some people who experience a single trauma recover without any
specific intervention. But for others— especially those with histories of previous trauma or mental or
substance use disorders, or those for whom the trauma experience is particularly horrific or
overwhelming—a sin gle trauma can result in traumatic stress symp toms and trauma-and stress-
related disorders. Single traumas do not necessarily have a lesser psychological impact than
repeated traumas. After the terrorist attacks on September 11, 2001—a significant single trauma—
many Manhattan residents experienced intrusive memories and sleep disruption whether they were
at the site of the attacks or watched tele vision coverage of it (Ford & Fournier, 2007; Galea et al.,
2002). A series of traumas happening to the same person over time is known as repeated trauma.
This can include repeated sexual or physical assaults, exposure to frequent injuries of oth ers, or
seemingly unrelated traumas. Military personnel, journalists covering stories of mass tragedies or
prolonged conflicts, and first re sponders who handle hundreds of cases each year typify repeated
trauma survivors. Repeti tive exposure to traumas can have a cumulative effect over one’s lifetime. A
person who was assaulted during adolescence, diagnosed with a life-threatening illness in his or her
thirties, and involved in a serious car accident later in life has experienced repeated trauma. Some
repeated traumas are sustained or chronic. Sustained trauma experiences tend to wear down
resilience and the ability to adapt. Some examples include children who endure ongoing sexual
abuse, physical neglect, or emotional abuse; people who are in violent relationships; and people
who live in chronic poverty. Individuals in chronically stressful, traumatizing environments are
particularly susceptible to traumatic stress reactions, sub stance use, and mental disorders.
Bidirectional relationships exist between trauma and substance use as well as trauma and mental
illness. For example, abuse of al cohol and drugs increases the risk of a trau matic experience and
creates greater vulnerability to the effects of trauma; sub stance abuse reduces a person’s ability to
take corrective and remedial actions that might reduce the impact of the trauma. Likewise,
traumatic stress leads to a greater likelihood of 46 Case Illustration: Yourself Think of a time that was
particularly stressful (but not traumatic) in your life. Revisit this period as an observer watching the
events unfold and then ask yourself, “What made this time particularly stress ful?” It is likely that a
part of your answer will include the difficulty of managing one situation before another circumstance
came along demanding your time. Stressful times denote being bombarded with many things at one
time, perceived or actual, without sufficient time or ability to address them emotionally, cognitively,
spiritually, and/or physically. The same goes for trauma—rapid exposure to numerous traumas one
after another lessens one’s ability to process the event before the next on slaught. This creates a
cumulative effect, making it more difficult to heal from any one trauma. Part 1, Chapter 2—Trauma
Awareness substance abuse that, in turn, increases the risk for additional exposure to trauma.
Paralleling this bidirectional relationship, mental illness increases vulnerability to the effects of
trauma and raises the risk for substance use disorders and for encountering additional traumatic
events. So too, early exposure to ACEs is as sociated with traumatic stress reactions and subsequent
exposure to trauma in adult years. People who have encountered multiple and longer doses of
trauma are at the greatest risk for developing traumatic stress. For example, military reservists and
other military service members who have had multiple long tours of duty are at greater risk for
traumatic stress reactions (see the planned TIP, Reintegration Related Behavioral Health Issues in
Veterans and Military Families; SAMHSA, planned f). In addition, people are more likely to encounter
greater impairment and distress from trauma if that trauma occurs with significant intensity and
continues sporadically or unceasingly for extended periods. Was there enough time to process the
experience? A particularly severe pattern of ongoing trau ma, sometimes referred to as “cascading
trau ma,” occurs when multiple traumas happen in a pattern that does not allow an individual to
heal from one traumatic event before another occurs. Take, for example, California resi dents—they
repeatedly face consecutive and/or simultaneous natural disasters includ ing fires, landslides, floods,
droughts, and earthquakes. In other cases, there is ample time to process an event, but processing is
limited because people don’t have supportive relationships or environments that model pre ventive
practices. This can lead to greater vul nerability to traumas that occur later in life. How many losses
has the trauma caused? Trauma itself can create significant distress, but often, the losses associated
with a trauma have more far-reaching effects. For instance, a child may be forced to assume adult
responsi bilities, such as serving as a confidant for a parent who is sexually abusing him or her, and
lose the opportunity of a childhood free from adult worries. In another scenario, a couple may
initially feel grateful to have escaped a house fire, but they may nevertheless face sig nificant
community and financial losses months afterward. In evaluating the impact of trauma, it is helpful to
access and discuss the losses associated with the initial trauma. The number of losses greatly
influences an individ ual’s ability to bounce back from the tragedy. In the case illustration on the
next page, Rasheed’s losses cause him to disconnect from his wife, who loves and supports him.
Success ful confrontation of losses can be difficult if the losses compound each other, as with
Rasheed’s loss of his friend, his disability, his employment struggles, and the threats to his marriage
and liberty. People can cite a specific 47 Trauma-Informed Care in Behavioral Health Services Case
Illustration: Rasheed Rasheed was referred to an employee assistance program by his employer. He
considered quitting his job, but his wife insisted he talk to a counselor. He is a 41-year-old auto
mechanic who, 4 years ago, caused a head-on collision while attempting to pass another vehicle. A
close friend, riding in the passenger’s seat, was killed, and two young people in the other vehicle
were seriously injured and permanently disabled. Rasheed survived with a significant back injury and
has only been able to work sporadically. He was convicted of negligent homicide and placed on
probation because of his physical disability. He is on probation for another 4 years, and if he is
convicted of another felony during that time, he will have to serve prison time for his prior offense.
While still in the hospital, Rasheed complained of feeling unreal, numb, and disinterested in the care
he received. He did not remember the crash but remembers waking up in the hospital 2 days later.
He had difficulty sleeping in the hospital and was aware of feelings of impending doom, although he
was unaware of the legal charges he would later face. He was diagnosed with ASD. He was
discharged from the hospital with a variety of medications, including pain pills and a sleep aid. He
rapidly became dependent on these medications, feeling he could not face the day without the pain
medication and being unable to sleep without sleep medicine in larger doses than had been
prescribed. Within 3 months of the accident, he was “doctor shopping” for pain pills and even had a
friend obtain a prescription for the sleeping medication from that friend’s doctor. In the 4
intervening years, Rasheed’s drug use escalated, and his blunted emotions and detachment from
friends became more profound. He became adept at obtaining pain pills from a variety of sources,
most of them illegal. He fears that if he seeks treatment for the drug problem, he will have to admit
to felony offenses and will probably be imprisoned. He also does not believe he can manage his life
without the pain pills. In the past 2 years, he has had recurring dreams of driving a car on the wrong
side of the road and into the headlights of an oncoming vehicle. In the dream, he cannot control the
car and wakes up just before the vehicles crash. At unusual times—for instance, when he is just
awakening in the morning, taking a shower, or walking alone—he will feel profound guilt over the
death of his friend in the accident. He becomes very anxious when driving in traffic or when he feels
he is driving faster than he should. His marriage of 18 years has been marked by increasing
emotional distance, and his wife has talked about separating if he does not do something about his
problem. He has been unable to work consistently because of back pain and depression. He was laid
off from one job be cause he could not concentrate and was making too many mistakes. The
counselor in the employee assistance program elicited information on Rasheed’s drug use, although
she suspected Rasheed was minimizing its extent and effects. Knowledgeable about psy chological
trauma, the counselor helped Rasheed feel safe enough to talk about the accident and how it had
affected his life. She was struck by how little Rasheed connected his present difficulties to the
accident and its aftermath. The counselor later commented that Rasheed talked about the acci dent
as if it had happened to someone else. Rasheed agreed to continue seeing the counselor for five
additional visits, during which time a plan would be made for Rasheed to begin treatment for drug
dependence and PTSD. event as precipitating their trauma, or, in oth er cases, the specific trauma
can symbolize a series of disabling events in which the person felt his or her life was threatened or in
which he or she felt emotionally overwhelmed, psy chologically disorganized, or significantly dis
connected from his or her surroundings. It 48 will be important for Rasheed to understand how his
losses played a part in his abuse of prescription medications to cope with symp toms associated with
traumatic stress and loss, (e.g., guilt, depression, fear). If not addressed, his trauma could increase
his risk for relapse. Part 1, Chapter 2—Trauma Awareness Was the trauma expected or unexpected?
When talking about a trauma, people some times say they didn’t see it coming. Being un prepared,
unaware, and vulnerable often increases the risk of psychological injury, but these are common
components of most trau mas, given that most traumatic events do oc cur without warning (e.g., car
crashes, terrorist attacks, sexual assaults). People with substance use disorders, mental illness,
and/or cognitive disabilities may be especially vulnerable in that they may attend less or have
competing con cerns that diminish attention to what is going on around them, even in high-risk
environ ments. However, most individuals attempt to gain some control over the tragedy by replay
ing the moments leading up to the event and processing how they could have anticipated it. Some
people perseverate on these thoughts for months or years after the event. Sometimes, a trauma is
anticipated but has unexpected or unanticipated consequences, as in the case of Hurricane Katrina.
Learning about what is likely to happen can reduce traumatization. For instance, training military
personnel in advance of going to combat over seas prepares them to handle traumas and can reduce
the impact of trauma. Were the trauma’s effects on the person’s life isolated or pervasive? When a
trauma is isolated from the larger context of life, a person’s response to it is more likely to be
contained and limited. For in stance, military personnel in combat situations can be significantly
traumatized by what they experience. On return to civilian life or non combat service, some are able
to isolate the traumatic experience so that it does not invade ordinary, day-to-day living. This does
not mean that the combat experience was not dis turbing or that it will not resurface if the indi
vidual encounters an experience that triggers memories of the trauma; it just means that the person
can more easily leave the trauma in the past and attend to the present. Conversely, people who
remain in the vicinity of the trauma may encounter greater chal lenges in recovery. The traumatic
event inter twines with various aspects of the person’s daily activities and interactions, thus increas
ing the possibility of being triggered by sur rounding cues and experiencing subsequent
psychological distress. However, another way to view this potential dilemma for the client is to
reframe it as an opportunity—the repetitive exposure to trauma-related cues may provide vital
guidance as to when and which treatment and coping techniques to use in the delivery of trauma-
informed and trauma-specific behav ioral health services. Who was responsible for the trauma and
was the act intentional? If the severity of a trauma is judged solely by whether the act was
intentional or not, events that reflect an intention to harm would be a primary indicator in predicting
subsequent difficulties among individuals exposed to this form of trauma. For most survivors, there
is an initial disbelief that someone would conceiva bly intend to harm others, followed by consid
erable emotional and, at times, behavioral investment in somehow making things right again or in
making sense of a senseless, mali cious act. For instance, in the wake of the World Trade Center
attacks in New York City, people responded via renewed patriot ism, impromptu candlelight vigils,
attacks on people of Arab and Muslim descent, and un precedented donations and willingness to
wait in long lines to donate blood to the Red Cross. Each example is a response that in some way
attempts to right the perceived wrong or attach new meaning to the event and subsequent
consequences. 49 Case Illustration: Frank Frank entered substance abuse treatment with diagnoses
of co-occurring PTSD and substance use disorder. While on a whitewater kayak trip with his wife, her
kayak became pinned on a rock, and Frank could only watch helplessly as she drowned. His drinking
had increased markedly after the ac cident. He acknowledged a vicious cycle of sleep disturbance
with intrusive nightmares followed by vivid memories and feelings of terror and helplessness after
he awoke. He drank heavily at night to quiet the nightmares and memories, but heavy alcohol
consumption perpetuated his trouble sleep ing. He withdrew from contact with many of his old
“couple friends” and his wife’s family, with whom he had been close. At treatment entry, he
described his life as “going to work and coming home.” The trauma occurred 3 years before he
sought treatment, but Frank continued to feel numb and dis connected from the world. His only
emotion was anger, which he tried to keep in check. Integrated treatment for PTSD and substance
abuse helped him sleep and taught him coping skills to use when the memories arose; it fostered his
engagement and retention in long-term care for both disorders. Trauma-Informed Care in Behavioral
Health Services When terrible things happen, it is human na ture to assign blame. Trauma survivors
can become heavily invested in assigning blame or finding out who was at fault, regardless of the
type of trauma. Often, this occurs as an at tempt to make sense of, give meaning to, and reestablish
a sense of predictability, control, and safety after an irrational or random act. It is far easier to accept
that someone, including oneself, is at fault or could have done some thing different than it is to
accept the fact that one was simply in the wrong place at the wrong time. For some trauma
survivors, needing to find out why a trauma occurred or who is at fault can become a significant
block to growth when the individual would be better served by asking, “What do I need to do to
heal?” Be havioral health professionals can help clients translate what they have learned about
respon sibility in recovery to other aspects of their lives. For instance, someone in treatment for co-
occurring disorders who has internalized that becoming depressed or addicted was not his or her
fault, but that recovery is a personal responsibility, can then apply the same princi ple to the
experience of childhood abuse and thereby overcome negative judgments of self (e.g., thinking
oneself to be a bad person who deserves abuse). The individual can then begin to reassign
responsibility by attaching the blame to the perpetrator(s) while at the same time assuming
responsibility for recovery. Was the trauma experienced directly or indirectly? Trauma that happens
to someone directly seems to be more damaging than witnessing trauma that befalls others. For
example, it is usually more traumatic to be robbed at gun point than to witness someone else being
robbed or hearing someone tell a story about being robbed. Yet, sometimes, experiencing another’s
pain can be equally traumatic. For instance, parents often internalize the pain and suffering of their
children when the chil dren are undergoing traumatic circumstances (e.g., treatments for
childinternment in concentration camps can be felt across generations—stories, coping behaviors,
and stress reactions can be passed across gen erational lines far removed from the actual events or
firsthand accounts. Known as histor ical trauma, this type of trauma can affect the functioning of
families, communities, and cultures for multiple generations. What happened since the trauma? In
reviewing traumatic events, it is important to assess the degree of disruption after the initial trauma
has passed, such as the loss of employment, assets, community events, behav ioral health services,
local stores, and recrea tional areas. There is typically an initial rally of services and support following
a trauma, par ticularly if it is on a mass scale. However, the reality of the trauma’s effects and their
disrup tiveness may have a more lasting impact. The deterioration of normalcy, including the dis
ruption of day-to-day activities and the dam age of structures that house these routines, will likely
erode the common threads that provide a sense of safety in individual lives and com munities.
Hence, the degree of disruption in resuming normal daily activities is a significant risk factor for
substance use disorders, subclin ical psychological symptoms, and mental dis orders. For example,
adults displaced from their homes because of Hurricanes Katrina or Rita had significantly higher
rates of past month cigarette use, illicit drug use, and binge drinking than those who were not
displaced (Office of Applied Studies, 2008). Subjective Characteristics Psychological meaning of
trauma An important clinical issue in understanding the impact of trauma is the meaning that the
survivor has attached to the traumatic experi ence. Survivors’ unique cognitive interpreta tions of an
event—that is, their beliefs and assumptions— contribute to how they process, react to, cope with,
and recov er from the trauma. Does the event repre sent retribution for past deeds committed by
the individual or his or her family? How does the individual attach meaning to his or her survival?
Does he or she believe that it is a sign of a greater purpose not yet revealed? People who attempt to
share their interpreta tion and meaning of the event can feel misun derstood and sometimes
alienated (Paulson & Krippner, 2007; Schein, Spitz, Burlingame, & Muskin, 2006). People interpret
traumatic events in vastly different ways, and many variables shape how an individual assigns
meaning to the experi ence (framing the meaning through culture, family beliefs, prior life
experiences and learn ing, personality and other psychological fea tures, etc.). Even in an event that
happens in a household, each family member may interpret the experience differently. Likewise, the
same type of event can occur at two different times in a person’s life, but his or her interpretation of
the events may differ considerably because of developmental differences acquired between events,
current cognitive and emotional pro cessing skills, availability of and access to envi ronmental
resources, and so forth. Disruption of core assumptions and beliefs Trauma often engenders a crisis
of faith (Frankl, 1992) that leads clients to question basic assumptions about life. Were the indi
vidual’s core or life-organizing assumptions (e.g., about safety, perception of others, fair ness,
purpose of life, future dreams) chal lenged or disrupted during or after the traumatic event? (See the
seminal work, 51 Resilience: Connection and Continuity Research suggests that reestablishing ties to
family, community, culture, and spiritual systems is not only vital to the individual, but it also
influences the impact of the trauma upon future generations. For example, Baker and Gippenreiter
(1998) studied the descendants of survivors of Joseph Stalin’s purge. They found that families who
were able to maintain a sense of connection and continuity with grandparents directly affected by
the purge experienced fewer negative effects than those who were emotionally or physically
severed from their grandparents. Whether the grandparents survived was less important than the
connection the grandchildren felt to their pasts. Trauma-Informed Care in Behavioral Health Services
Shattered Assumptions, by Janoff-Bulman, 1992.) For example, some trauma survivors see
themselves as irreparably wounded or beyond the possibility of healing. The following case
illustration (Sonja) explores not only the im portance of meaning, but also the role that trauma plays
in altering an individual’s core assumptions—the very assumptions that pro vide meaning and a
means to organize our lives and our interactions with the world and others. Cultural meaning of
trauma Counselors should strive to appreciate the cultural meaning of a trauma. How do cultural
interpretations, cultural support, and cultural responses affect the experience of trauma? It is critical
that counselors do not presume to un derstand the meaning of a traumatic experi ence without
considering the client’s cultural context. Culture strongly influences the per ceptions of trauma. For
instance, a trauma involving shame can be more profound for a person from an Asian culture than
for some one from a European culture. Likewise, an Alaska Native individual or community, de
pending upon their Tribal ancestry, may be lieve that the traumatic experience serves as a form of
retribution. Similarly, the sudden death of a family member or loved one can be less traumatic in a
culture that has a strong belief in a positive afterlife. It is important for counselors to recognize that
their perceptions of a specific trauma could be very different from their clients’ perceptions. Be
careful not to judge a client’s beliefs in light of your own value system. For more information on
culture and how to achieve cultural competence in providing behavioral health services, see
SAMHSA’s planned TIP, Improving Cultural Competence (SAMHSA, planned c). Individual and
Sociocultural Features A wide variety of social, demographic, envi ronmental, and psychological
factors influence a person’s experience of trauma, the severity of traumatic stress reactions
following the event, and his or her resilience in dealing with the short-and long-term environmental,
physical, sociocultural, and emotional consequences. This section addresses a few known factors
that influence the risk of trauma along with the development of subclinical and diagnostic traumatic
stress symptoms, such as mood and anxiety symptoms and disorders. It is not meant to be an
exhaustive exploration of these factors, but rather, a brief presentation to make counselors and
other behavioral health profes sionals aware that various factors influence risk for and protection
against traumatic stress and subsequent reactions. (For a broader perspective on such factors, refer
to Part 1, Chapter 1.) Individual Factors Several factors influence one’s ability to deal with trauma
effectively and increase one’s risk for traumatic stress reactions. Individual fac tors pertain to the
individual’s genetic, biologi cal, and psychological makeup and history as they influence the person’s
experience and 52 Part 1, Chapter 2—Trauma Awareness Case Illustration: Sonja Sonja began to talk
about how her life was different after being physically assaulted and robbed in a parking lot at a local
strip mall a year ago. She recounts that even though there were people in the parking lot, no one
came to her aid until the assailant ran off with her purse. She sustained a cheek bone fracture and
developed visual difficulties due to the inflammation from the fracture. She re cently sought
treatment for depressive symptoms and reported that she had lost interest in activities that typically
gave her joy. She reported isolating herself from others and said that her perception of others had
changed dramatically since the attack. Sonja had received a diagnosis of major depression with
psychotic features 10 years earlier and re ceived group therapy at a local community mental health
center for 3 years until her depression went into remission. She recently became afraid that her
depression was becoming more pro nounced, and she wanted to prevent another severe depressive
episode as well as the use of psy chotropic medications, which she felt made her lethargic. Thus, she
sought out behavioral health counseling. As the sessions progressed, and after a psychological
evaluation, it was clear that Sonja had some depressive symptoms, but they were subclinical. She
denied suicidal thoughts or i ntent, and her thought process was organized with no evidence of
hallucinations or delusions. She described her isolation as a reluctance to shop at area stores. On
one hand, Sonja was self-compassionate about her reasons for avoidance, but on the other hand,
she was concerned that the traumatic event had altered how she saw life and others. “I don’t see
people as very caring or kind, like I used to prior to the event. I don’t trust them, and I feel people
are too self-absorbed. I don’t feel safe, and this bothers me. I worry that I’m becoming paranoid
again. I guess I know better, but I just want to have the freedom to do what I want and go where I
want.” Two months after Sonja initiated counseling, she came to the office exclaiming that things
can in deed change. “You won’t believe it. I had to go to the grocery store, so I forced myself to go
the shopping center that had a grocery store attached to a strip mall. I was walking by a coffee shop,
quickly browsing the items in the front window, when a man comes out of the shop talking at me.
He says, ‘You look like you need a cup of coffee.’ What he said didn’t register immediately. I looked
at him blankly, and he said it again. ‘You look like you need a cup of coffee. I’m the owner of the
shop, and I noticed you looking in the window, and we have plenty of brewed coffee left before we
close the shop. Come on in, it’s on the house.’ So I did! From that moment on, I began to see peo ple
differently. He set it right for me—I feel as if I have myself back again, as if the assault was a sign that
I shouldn’t trust people, and now I see that there is some goodness in the world. As small as this
kindness was, it gave me the hope that I had lost.” For Sonja, the assault changed her assumptions
about safety and her view of others. She also at tached meaning to the event. She believed that the
event was a sign that she shouldn’t trust people and that people are uncaring. Yet these beliefs
bothered her and contradicted how she saw herself in the world, and she was afraid that her
depressive symptoms were returning. For an inexperienced professional, her presentation may have
ignited suspicions that she was be ginning to present with psychotic features. However, it is common
for trauma survivors to experi ence changes in core assumptions immediately after the event and to
attach meaning to the trauma. Often, a key ingredient in the recovery process is first identifying the
meaning of the event and the beliefs that changed following the traumatic experience. So when you
hear a client say “I will never see life the same,” this expression should trigger further exploration
into how life is different, what meaning has been assigned to the trauma, and how the individual has
changed his or her perception of self, others, and the future. (Continued on the next page.) 53
Trauma-Informed Care in Behavioral Health Services Case Illustration: Sonja (continued) Sometimes,
reworking the altered beliefs and assumptions occurs with no formal intervention, as with Sonja. In
her situation, a random stranger provided a moment that challenged an assumption generated from
the trauma. For others, counseling may be helpful in identifying how beliefs and thoughts about self,
others, and the world have changed since the event and how to rework them to move beyond the
trauma. It is important to understand that the meaning that an individual attaches to the event(s)
can either undermine the healing process (e.g., believing that you should not have survived, feeling
shame about the trauma, continuing to engage in high-risk activities) or pave the road to recovery
(e.g., volunteering to protect victim rights after being sexually assaulted). The fol lowing questions
can help behavioral health staff members introduce topics surrounding assump tions, beliefs,
interpretations, and meanings related to trauma: • In what ways has your life been different since
the trauma? • What meaning does this experience have for you? • How do you understand your
survival? (This is an important question for clients who have been exposed to ACEs or cumulative
trauma and those who survived a tragedy when others did not.) • Do you believe that there are
reasons that this event happened to you? What are they? • Do you feel that you are the same
person as before the trauma? In what ways are you the same? In what ways do you feel different? •
How did this experience change you as a person? Would you like to return to the person you once
were? What would you need to do, or what would need to happen, for this to occur? • Did the
traumatic experience change you in a way that you don’t like? In what ways? • How do you view
others and your future differently since the trauma? • What would you like to believe now about the
experience? interpretation of, as well as his or her reactions to, trauma. However, many factors
influence individual responses to trauma; it is not just individual characteristics. Failing to recognize
that multiple factors aside from individual attributes and history influence experiences during and
after trauma can lead to blaming the victim for having traumatic stress. History of prior psychological
trauma People with histories of prior psychological trauma appear to be the most susceptible to
severe traumatic responses (Nishith, Mechanic, & Resick, 2000; Vogt, Bruce, Street, & Stafford,
2007), particularly if they have avoided addressing past traumas. Because minimization, dissociation,
and avoidance are common defenses for many trauma survivors, prior traumas are not always
consciously avail able, and when they are, memories can be distorted to avoid painful affects. Some
survi vors who have repressed their experiences de 54 ny a history of trauma or are unable to
explain their strong reactions to present situations. Remember that the effects of trauma are cu
mulative; therefore, a later trauma that out wardly appears less severe may have more impact upon
an individual than a trauma that occurred years earlier. Conversely, individuals who have
experienced earlier traumas may have developed effective coping strategies or report positive
outcomes as they have learned to adjust to the consequences of the trauma(s). This outcome is
often referred to as posttrau matic growth or psychological growth. Clients in behavioral health
treatment who have histories of trauma can respond negative ly to or seem disinterested in
treatment efforts. They may become uncomfortable in groups that emphasize personal sharing;
likewise, an individual who experiences brief bouts of dis sociation (a reaction of some trauma
survivors) may be misunderstood by others in treatment and seen as uninterested. Providers need
to Part 1, Chapter 2—Trauma Awareness attend to histories, adjust treatment to avoid
retraumatization, and steer clear of labeling clients’ behavior as pathological. History of resilience
Resilience—the ability to thrive despite nega tive life experiences and heal from traumatic events—is
related to the internal strengths and environmental supports of an individual. Most individuals are
resilient despite experiencing traumatic stress. The ability to thrive beyond the trauma is associated
with individual factors as well as situational and contextual factors. There are not only one or two
primary factors that make an individual resilient; many factors contribute to the development of
resilience. There is little research to indicate that there are specific traits predictive of resilience;
instead, it appears that more general characteristics influ ence resilience, including neurobiology
(Feder, Charney, & Collins, 2011), flexibility in adapt ing to change, beliefs prior to trauma, sense of
self-efficacy, and ability to experience positive emotions (Bonanno & Mancini, 2011). History of
mental disorders The correlations among traumatic stress, sub stance use disorders, and co-
occurring mental disorders are well known. According to the Diagnostic and Statistical Manual of
Mental Dis orders, Fifth Edition (American Psychiatric Association, 2013a), traumatic stress reactions
are linked to higher rates of mood, substance related, anxiety, trauma, stress-related, and other
mental disorders, each of which can pre cede, follow, or emerge concurrently with trauma itself. A
co-occurring mental disorder is a significant determinant of whether an individual can successfully
address and resolve trauma as it emerges from the past or occurs in the present. Koenen, Stellman,
Stellman, and Sommer (2003) found that the risk of developing PTSD following combat trauma was
higher for individuals with preexisting conduct disorder, panic disorder, generalized anxiety disorder,
and/or major depression than for those without preexisting mental disorders. For additional
information on comorbidity of trauma and other mental disorders, see TIP 42, Substance Abuse
Treatment for Persons With Co-Occurring Disorders (CSAT, 2005c). Sociodemographic Factors
Demographic variables are not good predic tors of who will experience trauma and subse quent
traumatic stress reactions. Gender, age, race and ethnicity, sexual orientation, marital status,
occupation, income, and education can all have some influence, but not enough to determine who
should or should not receive screening for trauma and traumatic stress symptoms. The following
sections cover a few selected variables. (For more information, please refer to Part 3 of this TIP, the
online literature review.) Gender In the United States, men are at greater risk than women for being
exposed to stressful events. Despite the higher prevalence among men, lifetime PTSD occurs at
about twice the rate among women as it does in men. Less is known about gender differences with
subclini cal traumatic stress reactions. There are also other gender differences, such as the types of
trauma experienced by men and women. Women are more likely to experience physical and sexual
assault, whereas men are most like ly to experience combat and crime victimiza tion and to witness
killings and serious injuries (Breslau, 2002; Kimerling, Ouimette, & Weitlauf, 2007; Tolin & Foa,
2006). Women in military service are subject to the same risks as men and are also at a greater risk
for mili tary sexual trauma. Men’s traumas often occur in public; women’s are more likely to take
place in private settings. Perpetrators of trau mas against men are often strangers, but wom en are
more likely to know the perpetrator. 55 Resilience: Cultural, Racial, and Ethnic Characteristics The
following list highlights characteristics that often nurture resilience among individuals from di verse
cultural, racial, and ethnic groups: • Strong kinship bonds • Respect for elders and the importance of
extended family • Spirituality and religious practices (e.g., shrine visitations or the use of traditional
healers) • Value in friendships and warm personal relationships • Expression of humor and creativity
• Instilling a sense of history, heritage, and historical traditions • Community orientation, activities,
and socialization • Strong work ethic • Philosophies and beliefs about life, suffering, and
perseverance “Fortune owes its existence to misfortune, and misfortune is hidden in fortune.” –Lao-
Tzu teaching, Taoism (Wong & Wong, 2006) Trauma-Informed Care in Behavioral Health Services
Age In general, the older one becomes, the higher the risk of trauma—but the increase is not
dramatic. Age is not particularly important in predicting exposure to trauma, yet at no age is one
immune to the risk. However, trauma that occurs in the earlier and midlife years appears to have
greater impact on people for different reasons. For younger individuals, the trauma can affect
developmental processes, attach ment, emotional regulation, life assumptions, cognitive
interpretations of later experiences, and so forth (for additional resources, visit the National Child
Traumatic Stress Network; [Link] For adults in midlife, trauma may have a greater
impact due to the enhanced stress or burden of care that often characterizes this stage of life—
caring for their children and their parents at the same time. Older adults are as likely as younger
adults to recover quickly from trauma, yet they may have greater vulnerabilities, including their
ability to survive without injury and their ability to address the current trauma without psychological
interference from earlier stress ful or traumatic events. Older people are natu rally more likely to
have had a history of trauma because they have lived longer, thus creating greater vulnerability to
the effects of cumulative trauma. Race, ethnicity, and culture The potential for trauma exists in all
major racial and ethnic groups in American society, yet few studies analyze the relationship of race
and ethnicity to trauma exposure and/or trau matic stress reactions. Some studies show that certain
racial and ethnic groups are at greater risk for specific traumas. For example, African Americans
experienced higher rates of overall violence, aggravated assault, and robbery than Whites but were
as likely to be victims of rape or sexual assault (Catalano, 2004). Literature reflects that diverse
ethnic, racial, and cultural groups are more likely to experience adverse effects from various traumas
and to meet crite ria for posttraumatic stress (Bell, 2011). Sexual orientation and gender identity
Lesbian, gay, bisexual, and transgender indi viduals are likely to experience various forms of trauma
associated with their sexual orienta tion, including harsh consequences from fami lies and faith
traditions, higher risk of assault from casual sexual partners, hate crimes, lack of legal protection,
and laws of exclusion (Brown, 2008). Gay and bisexual men as well as transgender people are more
likely to expe rience victimization than lesbians and bisexual women. Dillon (2001) reported a
trauma ex posure rate of 94 percent among lesbian, gay, 56 Part 1, Chapter 2—Trauma Awareness
and bisexual individuals; more than 40 percent of respondents experienced harassment due to their
sexual orientation. Heterosexual orienta tion is also a risk for women, as women in relationships
with men are at a greater risk of being physically and sexually abused. People who are homeless
Homelessness is typically defined as the lack of an adequate or regular dwelling, or having a
nighttime dwelling that is a publicly or pri vately supervised institution or a place not intended for
use as a dwelling (e.g., a bus sta tion). The U.S. Department of Housing and Urban Development
(HUD) estimates that between 660,000 and 730,000 individuals were homeless on any given night in
2005 (HUD, 2007). Two thirds were unaccompa nied persons; the other third were people in
families. Adults who are homeless and unmar ried are more likely to be male than female. About 40
percent of men who are homeless are veterans (National Coalition for the Homeless, 2002); this
percentage has grown, including the number of veterans with de pendent children (Kuhn &
Nakashima, 2011). Rates of trauma symptoms are high among people who are homeless (76 to 100
percent of women and 67 percent of men; Christensen et al., 2005; Jainchill, Hawke, & Yagelka,
2000), and the diagnosis of PTSD is among the most prevalent non-substance use Axis I disorders
(Lester et al., 2007; McNamara, Schumacher, Milby, Wallace, & Usdan, 2001). People who are
homeless report high levels of trauma (es pecially physical and sexual abuse in childhood or as
adults) preceding their homeless status; assault, rape, and other traumas frequently happen while
they are homeless. Research suggests that many women are homeless be cause they are fleeing
domestic violence (National Coalition for the Homeless, 2002). Other studies suggest that women
who are homeless are more likely to have histories of childhood physical and sexual abuse and to
have experienced sexual assault as adults. A history of physical and/or sexual abuse is even more
common among women who are home less and have a serious mental illness. Youth who are
homeless, especially those who live without a parent, are likely to have experi enced physical and/or
sexual abuse. Between 21 and 42 percent of youth runaways report having been sexually abused
before leaving their homes; for young women, rates range from 32 to 63 percent (Administration on
Children, Youth and Families, 2002). Addi tionally, data reflect elevated rates of substance abuse for
youth who are homeless and have histories of abuse. More than half of people who are homeless
have a lifetime prevalence of mental illness and substance use disorders. Those who are homeless
have higher rates of substance abuse (84 percent of men and 58 percent of women), and substance
use disorders, including alcohol and drug abuse/dependence, increase with longer lengths of
homelessness (North, Eyrich, Pollio, & Spitznagel, 2004). For more information on providing trauma
informed behavioral health services to clients who are homeless, and for further discussion of the
incidence of trauma in this population, see TIP 55-R, Behavioral Health Services for People Who Are
Homeless (SAMHSA, 2013b). 57 Understanding the 3 Impact of Trauma IN THIS CHAPTER • Sequence
of Trauma Reactions • Common Experiences and Responses to Trauma • Subthreshold Trauma
Related Symptoms • Specific Trauma -Related Psychological Disorders • Other Trauma -Related and
Co -Occurring Disorders Trauma-informed care (TIC) involves a broad understanding of traumatic
stress reactions and common responses to trauma. Pro viders need to understand how trauma can
affect treatment presen tation, engagement, and the outcome of behavioral health services. This
chapter examines common experiences survivors may encoun ter immediately following or long
after a traumatic experience. Trauma, including one-time, multiple, or long-lasting repetitive events,
affects everyone differently. Some individuals may clearly display criteria associated with
posttraumatic stress disorder (PTSD), but many more individuals will exhibit resilient responses or
brief subclinical symptoms or consequences that fall outside of diagnostic criteria. The impact of
trauma can be subtle, insidious, or outright destructive. How an event affects an individual depends
on many factors, including characteristics of the individual, the type and characteristics of the
event(s), developmental processes, the meaning of the trauma, and sociocultural factors. This
chapter begins with an overview of common responses, emphasizing that traumatic stress reactions
are normal reactions to abnormal circumstances. It highlights common short- and long term
responses to traumatic experiences in the context of individuals who may seek behavioral health
[Link] chapter discusses psychological symptoms not represented in the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA],
2013a), and responses associated with trauma that either fall below the threshold of mental
disorders or reflect resilience. It also addresses common disorders associated with traumatic
[Link] chapter explores the role of culture in defining mental illness, particularly PTSD, and ends
by addressing co-occurring mental and substance-related disorders. 59 Trauma-Informed Care in
Behavioral Health Services TIC Framework in Behavioral Health Services—The Impact of Trauma
Sequence of Trauma Reactions Survivors’ immediate reactions in the after math of trauma are quite
complicated and are affected by their own experiences, the accessi bility of natural supports and
healers, their coping and life skills and those of immediate family, and the responses of the larger
com munity in which they live. Although reactions range in severity, even the most acute responses
are natural responses to manage trauma— they are not a sign of psychopathology. Cop ing styles
vary from action oriented to reflec tive and from emotionally expressive to reticent. Clinically, a
response style is less im portant than the degree to which coping ef forts successfully allow one to
continue 60 necessary activities, regulate emotions, sustain self-esteem, and maintain and enjoy
interper sonal contacts. Indeed, a past error in trau matic stress psychology, particularly regarding
group or mass traumas, was the assumption that all survivors need to express emotions associated
with trauma and talk about the trauma; more recent research indicates that survivors who choose
not to process their trauma are just as psychologically healthy as Foreshortened future: Trauma can
affect one’s beliefs about the future via loss of hope, limited expectations about life, fear that life
will end abruptly or early, or anticipation that normal life events won’t occur (e.g., access to
education, ability to have a significant and committed relationship, good opportunities for work).
Part 1, Chapter 3—Understanding the Impact of Trauma those who do. The most recent
psychological debriefing approaches emphasize respecting the individual’s style of coping and not
valuing one type over another. Initial reactions to trauma can include exhaus tion, confusion,
sadness, anxiety, agitation, numbness, dissociation, confusion, physical arousal, and blunted affect.
Most responses are normal in that they affect most survivors and are socially acceptable,
psychologically effec tive, and self-limited. Indicators of more se vere responses include continuous
distress without periods of relative calm or rest, severe dissociation symptoms, and intense intrusive
recollections that continue despite a return to safety. Delayed responses to trauma can in clude
persistent fatigue, sleep disorders, nightmares, fear of recurrence, anxiety focused on flashbacks,
depression, and avoidance of emotions, sensations, or activities that are as sociated with the
trauma, even remotely. Ex hibit 1.3-1 outlines some common reactions. Common Experiences and
Responses to Trauma A variety of reactions are often reported and/or observed after trauma. Most
survivors exhibit immediate reactions, yet these typically resolve without severe long-term
consequences. This is because most trauma survivors are highly resilient and develop appropriate
coping strategies, including the use of social sup ports, to deal with the aftermath and effects of
trauma. Most recover with time, show min imal distress, and function effectively across major life
areas and developmental stages. Even so, clients who show little impairment may still have
subclinical symptoms or symp toms that do not fit diagnostic criteria for acute stress disorder (ASD)
or PTSD. Only a small percentage of people with a history of trauma show impairment and
symptoms that meet criteria for trauma-related stress disor ders, including mood and anxiety
disorders. The following sections focus on some com mon reactions across domains (emotional,
physical, cognitive, behavioral, social, and de velopmental) associated with singular, multi ple, and
enduring traumatic events. These reactions are often normal responses to trauma but can still be
distressing to experience. Such responses are not signs of mental illness, nor do they indicate a
mental disorder. Traumatic stress-related disorders comprise a specific constellation of symptoms
and criteria. Emotional Emotional reactions to trauma can vary great ly and are significantly
influenced by the indi vidual’s sociocultural history. Beyond the initial emotional reactions during the
event, those most likely to surface include anger, fear, sadness, and shame. However, individuals
may encounter difficulty in identifying any of these feelings for various reasons. They might lack
experience with or prior exposure to emotional expression in their family or community. They may
associate strong feelings with the past trauma, thus believing that emotional expres sion is too
dangerous or will lead to feeling out of control (e.g., a sense of “losing it” or going crazy). Still others
might deny that they have any feelings associated with their traumatic experiences and define their
reactions as numbness or lack of emotions. Emotional dysregulation Some trauma survivors have
difficulty regulat ing emotions such as anger, anxiety, sadness, and shame—this is more so when the
trauma occurred at a young age (van der Kolk, Roth, Pelcovitz, & Mandel, 1993). In individuals who
are older and functioning well 61 Trauma-Informed Care in Behavioral Health Services Exhibit 1.3-1:
Immediate and Delayed Reactions to Trauma Immediate Emotional Reactions Delayed Emotional
Reactions Numbness and detachment Irritability and/or hostility Anxiety or severe fear Depression
Guilt (including survivor guilt) Mood swings, instability Exhilaration as a result of surviving Anxiety
(e.g., phobia, generalized anxiety) Anger Fear of trauma recurrence Sadness Grief reactions
Helplessness Shame Feeling unreal; depersonalization (e.g., feeling Feelings of fragility and/or
vulnerability as if you are watching yourself) Emotional detachment from anything that re
Disorientation quires emotional reactions (e.g., significant Feeling out of control and/or family
relationships, conversations Denial about self, discussion of traumatic events or Constriction of
feelings reactions to them) Feeling overwhelmed Immediate Physical Reactions Delayed Physical
Reactions Nausea and/or gastrointestinal distress Sleep disturbances, nightmares Sweating or
shivering Somatization (e.g., increased focus on and Faintness worry about body aches and pains)
Muscle tremors or uncontrollable shaking Appetite and digestive changes Elevated heartbeat,
respiration, and blood Lowered resistance to colds and infection pressure Persistent fatigue Extreme
fatigue or exhaustion Elevated cortisol levels Greater startle responses Hyperarousal
Depersonalization Long-term health effects including heart, liver, autoimmune, and chronic
obstructive pulmo nary disease Immediate Cognitive Reactions Difficulty concentrating Rumination
or racing thoughts (e.g., replaying the traumatic event over and over again) Distortion of time and
space (e.g., traumatic event may be perceived as if it was happen ing in slow motion, or a few
seconds can be perceived as minutes) Memory problems (e.g., not being able to re call important
aspects of the trauma) Strong identification with victims Delayed Cognitive Reactions Intrusive
memories or flashbacks Reactivation of previous traumatic events Self-blame Preoccupation with
event Difficulty making decisions Magical thinking: belief that certain behaviors, including avoidant
behavior, will protect against future trauma Belief that feelings or memories are dangerous
Generalization of triggers (e.g., a person who experiences a home invasion during the day time may
avoid being alone during the day) Suicidal thinking Immediate Behavioral Reactions Delayed
Behavioral Reactions Startled reaction Avoidance of event reminders Restlessness Social relationship
disturbances Sleep and appetite disturbances Decreased activity level Difficulty expressing oneself
Engagement in high-risk behaviors Argumentative behavior Increased use of alcohol and drugs
Increased use of alcohol, drugs, and tobacco Withdrawal Withdrawal and apathy Avoidant behaviors
(Continued on the next page.) 62 Part 1, Chapter 3—Understanding the Impact of Trauma Exhibit
1.3-1: Immediate and Delayed Reactions to Trauma (continued) Immediate Existential Reactions
Intense use of prayer Restoration of faith in the goodness of others (e.g., receiving help from others)
Loss of self-efficacy Despair about humanity, particularly if the event was intentional Delayed
Existential Reactions Questioning (e.g., “Why me?”) Increased cynicism, disillusionment Increased
self-confidence (e.g., “If I can sur vive this, I can survive anything”) Loss of purpose Renewed faith
Immediate disruption of life assumptions (e.g., fairness, safety, goodness, predictability of life)
Hopelessness Reestablishing priorities Redefining meaning and importance of life Reworking life’s
assumptions to accommodate the trauma (e.g., taking a self-defense class to reestablish a sense of
safety) Sources: Briere & Scott, 2006b; Foa, Stein, & McFarlane, 2006; Pietrzak, Goldstein, Southwick,
& Grant, 2011. prior to the trauma, such emotional dysregula tion is usually short lived and
represents an immediate reaction to the trauma, rather than an ongoing pattern. Self-medication—
namely, substance abuse—is one of the methods that traumatized people use in an attempt to
regain emotional control, although ultimately it causes even further emotional dysregulation (e.g.,
substance-induced changes in affect during and after use). Other efforts toward emotional
regulation can include engagement in high risk or self-injurious behaviors, disordered eating,
compulsive behaviors such as gambling or overworking, and repression or denial of emotions;
however, not all behaviors associated with self-regulation are considered negative. In fact, some
individuals find crea tive, healthy, and industrious ways to manage strong affect generated by
trauma, such as through renewed commitment to physical activity or by creating an organization to
sup port survivors of a particular trauma. Traumatic stress tends to evoke two emotional extremes:
feeling either too much (over whelmed) or too little (numb) emotion. Treatment can help the client
find the optimal level of emotion and assist him or her with appropriately experiencing and
regulating dif ficult emotions. In treatment, the goal is to help clients learn to regulate their
emotions without the use of substances or other unsafe behavior. This will likely require learning
new coping skills and how to tolerate distressing emotions; some clients may benefit from
mindfulness practices, cognitive restructuring, and trauma-specific desensitization approaches, such
as exposure therapy and eye movement desensitization and reprocessing (EMDR; refer to Part 1,
Chapter 6, for more infor mation on trauma-specific therapies). Numbing Numbing is a biological
process whereby emo tions are detached from thoughts, behaviors, and memories. In the following
case illustra tion, Sadhanna’s numbing is evidenced by her limited range of emotions associated with
in terpersonal interactions and her inability to associate any emotion with her history of abuse. She
also possesses a belief in a foreshort ened future. A prospective longitudinal study (Malta, Levitt,
Martin, Davis, & Cloitre, 2009) that followed the development of PTSD in disaster workers
highlighted the importance of understanding and appreciating numbing as a traumatic stress
reaction. Because numbing 63 Case Illustration: Sadhanna Sadhanna is a 22-year-old woman
mandated to outpatient mental health and substance abuse treat ment as the alternative to
incarceration. She was arrested and charged with assault after arguing and fighting with another
woman on the street. At intake, Sadhanna reported a 7-year history of alcohol abuse and one
depressive episode at age 18. She was surprised that she got into a fight but admit ted that she was
drinking at the time of the incident. She also reported severe physical abuse at the hands of her
mother’s boyfriend between ages 4 and 15. Of particular note to the intake worker was Sadhanna’s
matter-of-fact way of presenting the abuse history. During the interview, she clearly indi cated that
she did not want to attend group therapy and hear other people talk about their feelings, saying, “I
learned long ago not to wear emotions on my sleeve.” Sadhanna reported dropping out of 10th
grade, saying she never liked school. She didn’t expect much from life. In Sadhanna’s first weeks in
treatment, she reported feeling disconnected from other group members and questioned the
purpose of the group. When asked about her own history, she denied that she had any difficulties
and did not understand why she was mandated to treatment. She further denied having feelings
about her abuse and did not believe that it affected her life now. Group members often commented
that she did not show much empathy and maintained a flat affect, even when group discussions
were emotionally charged. Trauma-Informed Care in Behavioral Health Services symptoms hide
what is going on inside emo tionally, there can be a tendency for family members, counselors, and
other behavioral health staff to assess levels of traumatic stress symptoms and the impact of trauma
as less severe than they actually are. Physical Diagnostic criteria for PTSD place considera ble
emphasis on psychological symptoms, but some people who have experienced traumatic stress may
present initially with physical symptoms. Thus, primary care may be the first and only door through
which these individuals seek assistance for trauma-related symptoms. Moreover, there is a
significant connection between trauma, including adverse childhood experiences (ACEs), and chronic
health con ditions. Common physical disorders and symptoms include somatic complaints; sleep
disturbances; gastrointestinal, cardiovascular, neurological, musculoskeletal, respiratory, and
dermatological disorders; urological problems; and substance use disorders. Somatization
Somatization indicates a focus on bodily symptoms or dysfunctions to express emotion al distress.
Somatic symptoms are more likely to occur with individuals who have traumatic stress reactions,
including PTSD. People from certain ethnic and cultural backgrounds may initially or solely present
emotional distress via physical ailments or concerns. Many individu als who present with
somatization are likely unaware of the connection between their emo tions and the physical
symptoms that they’re experiencing. At times, clients may remain resistant to exploring emotional
content and remain focused on bodily complaints as a means of avoidance. Some clients may insist
that their primary problems are physical even when medical evaluations and tests fail to con firm
ailments. In these situations, somatiza tion may be a sign of a mental illness. However, various
cultures approach emotional distress through the physical realm or view emotional and physical
symptoms and well being as one. It is important not to assume that clients with physical complaints
are using somatization as a means to express emotional pain; they may have specific conditions or
disorders that require medical attention. Foremost, counselors need to refer for medical evaluation.
64 Part 1, Chapter 3—Understanding the Impact of Trauma Advice to Counselors: Using Information
About Biology and Trauma • Educate your clients: Frame reexperiencing the event(s), hyperarousal,
sleep disturbances, and other physical symptoms as physiological reactions to extreme stress.
Communicate that treatment and other wellness activities can improve both psychological and
physiological symptoms (e.g., therapy, meditation, exercise, yoga). You may need to refer certain
clients to a psychiatrist who can evaluate them and, if warranted, prescribe psycho tropic
medication to address severe symptoms. Discuss traumatic stress symptoms and their physiological
components. Explain links between traumatic stress symptoms and substance use disorders, if
appropriate. Normalize trauma symptoms. For example, explain to clients that their symptoms are
not a sign of weakness, a character flaw, being damaged, or going crazy. • Support your clients and
provide a message of hope—that they are not alone, they are not at fault, and recovery is possible
and anticipated. Biology of trauma Trauma biology is an area of burgeoning re search, with the
promise of more complex and explanatory findings yet to come. Although a thorough presentation
on the biological as pects of trauma is beyond the scope of this publication, what is currently known
is that exposure to trauma leads to a cascade of bio logical changes and stress responses. These
biological alterations are highly associated with PTSD, other mental illnesses, and sub stance use
disorders. These include: • Changes in limbic system functioning. • Hypothalamic–pituitary–adrenal
axis ac tivity changes with variable cortisol levels. • Neurotransmitter-related dysregulation of
arousal and endogenous opioid systems. As a clear example, early ACEs such as abuse, neglect, and
other traumas affect brain Case Illustration: Kimi development and increase a person’s vulnera bility
to encountering interpersonal violence as an adult and to developing chronic diseases and other
physical illnesses, mental illnesses, substance-related disorders, and impairment in other life areas
(Centers for Disease Control and Prevention, 2012). Hyperarousal and sleep disturbances A common
symptom that arises from trau matic experiences is hyperarousal (also called hypervigilance).
Hyperarousal is the body’s way of remaining prepared. It is characterized by sleep disturbances,
muscle tension, and a lower threshold for startle responses and can persist years after trauma
occurs. It is also one of the primary diagnostic criteria for PTSD. Hyperarousal is a consequence of
biological changes initiated by trauma. Although it Kimi is a 35-year-old Native American woman
who was group raped at the age of 16 on her walk home from a suburban high school. She recounts
how her whole life changed on that day. “I never felt safe being alone after the rape. I used to enjoy
walking everywhere. Afterward, I couldn’t tolerate the fear that would arise when I walked in the
neighborhood. It didn’t matter whether I was alone or with friends—every sound that I heard would
throw me into a state of fear. I felt like the same thing was going to happen again. It’s gotten better
with time, but I often feel as if I’m sitting on a tree limb waiting for it to break. I have a hard time
relaxing. I can easily get startled if a leaf blows across my path or if my children scream while playing
in the yard. The best way I can describe how I experience life is by comparing it to watching a scary,
suspenseful movie—anxiously waiting for something to happen, palms sweating, heart pounding, on
the edge of your chair.” 65 Trauma-Informed Care in Behavioral Health Services serves as a means of
self-protection after trauma, it can be detrimental. Hyperarousal can interfere with an individual’s
ability to take the necessary time to assess and appropri ately respond to specific input, such as loud
noises or sudden movements. Sometimes, hyperarousal can produce overreactions to situations
perceived as dangerous when, in fact, the circumstances are safe. Along with hyperarousal, sleep
disturbances are very common in individuals who have ex perienced trauma. They can come in the
form of early awakening, restless sleep, difficulty falling asleep, and nightmares. Sleep disturb
Cognitions and Trauma ances are most persistent among individuals who have trauma-related
stress; the disturb ances sometimes remain resistant to interven tion long after other traumatic
stress symptoms have been successfully treated. Numerous strategies are available beyond
medication, including good sleep hygiene practices, cognitive rehearsals of nightmares, relaxation
strategies, and nutrition. Cognitive Traumatic experiences can affect and alter cognitions. From the
outset, trauma challeng es the just-world or core life assumptions that The following examples
reflect some of the types of cognitive or thought-process changes that can occur in response to
traumatic stress. Cognitive errors: Misinterpreting a current situation as dangerous because it
resembles, even re motely, a previous trauma (e.g., a client overreacting to an overturned canoe in 8
inches of water, as if she and her paddle companion would drown, due to her previous experience of
nearly drowning in a rip current 5 years earlier). Excessive or inappropriate guilt: Attempting to make
sense cognitively and gain control over a traumatic experience by assuming responsibility or
possessing survivor’s guilt, because others who experienced the same trauma did not survive.
Idealization: Demonstrating inaccurate rationalizations, idealizations, or justifications of the perpe
trator’s behavior, particularly if the perpetrator is or was a caregiver. Other similar reactions mirror
idealization; traumatic bonding is an emotional attachment that develops (in part to secure survival)
between perpetrators who engage in interpersonal trauma and their victims, and Stockholm syn
drome involves compassion and loyalty toward hostage takers (de Fabrique, Van Hasselt, Vecchi, &
Romano, 2007). Trauma-induced hallucinations or delusions: Experiencing hallucinations and
delusions that, although they are biological in origin, contain cognitions that are congruent with
trauma content (e.g., a woman believes that a person stepping onto her bus is her father, who had
sexually abused her repeatedly as child, because he wore shoes similar to those her father once
wore). Intrusive thoughts and memories: Experiencing, without warning or desire, thoughts and
memories associated with the trauma. These intrusive thoughts and memories can easily trigger
strong emo tional and behavioral reactions, as if the trauma was recurring in the present. The
intrusive thoughts and memories can come rapidly, referred to as flooding, and can be disruptive at
the time of their occurrence. If an individual experiences a trigger, he or she may have an increase in
intrusive thoughts and memories for a while. For instance, individuals who inadvertently are
retraumatized due to program or clinical practices may have a surge of intrusive thoughts of past
trauma, thus mak ing it difficult for them to discern what is happening now versus what happened
then. Whenever counseling focuses on trauma, it is likely that the client will experience some
intrusive thoughts and memories. It is important to develop coping strategies before, as much as
possible, and during the delivery of trauma-informed and trauma-specific treatment. 66 Part 1,
Chapter 3—Understanding the Impact of Trauma help individuals navigate daily life (Janoff Bulman,
1992). For example, it would be dif ficult to leave the house in the morning if you believed that the
world was not safe, that all people are dangerous, or that life holds no promise. Belief that one’s
efforts and inten tions can protect oneself from bad things makes it less likely for an individual to per
ceive personal vulnerability. However, trau matic events—particularly if they are unexpected—can
challenge such beliefs. Let’s say you always considered your driving time as “your time”—and your
car as a safe place to spend that time. Then someone hits you from behind at a highway entrance. Al
most immediately, the accident affects how you perceive the world, and from that moment onward,
for months following the crash, you feel unsafe in any car. You become hypervigi lant about other
drivers and perceive that oth er cars are drifting into your lane or failing to stop at a safe distance
behind you. For a time, your perception of safety is eroded, often lead ing to compensating
behaviors (e.g., excessive glancing into the rearview mirror to see whether the vehicles behind you
are stopping) until the belief is restored or reworked. Some individuals never return to their previous
belief systems after a trauma, nor do they find a way to rework them—thus leading to a worldview
that life is unsafe. Still, many other individuals are able to return to organiz ing core beliefs that
support their perception of safety. Many factors contribute to cognitive patterns prior to, during,
and after a trauma. Adopting Beck and colleagues’ cognitive triad model (1979), trauma can alter
three main cognitive patterns: thoughts about self, the world (others/environment), and the future.
To clarify, trauma can lead individuals to see themselves as incompetent or damaged, to see others
and the world as unsafe and unpredictable, and to see the future as hopeless—believing that
personal suffering will continue, or negative outcomes will pre side for the foreseeable future (see
Exhibit 1.3-2). Subsequently, this set of cognitions can greatly influence clients’ belief in their ability
to use internal resources and external support effectively. From a cognitive behavioral perspective,
these cognitions have a bidirectional relationship in sustaining or con tributing to the development
of depressive and anxiety symptoms after trauma. However, it is possible for cognitive patterns to
help protect against debilitating psychological symptoms as well. Many factors contribute to
cognitive patterns prior to, during, and after a trauma. Feeling different An integral part of
experiencing trauma is feeling different from others, whether or not the trauma was an individual or
group experi ence. Traumatic experiences typically feel sur real and challenge the necessity and
value of mundane activities of daily life. Survivors Exhibit 1.3-2: Cognitive Triad of Traumatic Stress
67 Advice to Counselors: Helping Clients Manage Flashbacks and Triggers If a client is triggered in a
session or during some aspect of treatment, help the client focus on what is happening in the here
and now; that is, use grounding techniques. Behavioral health service provid ers should be prepared
to help the client get regrounded so that they can distinguish between what is happening now
versus what had happened in the past (see Covington, 2008, and Najavits, 2002b, 2007b, for more
grounding techniques). Offer education about the experience of triggers and flash backs, and then
normalize these events as common traumatic stress reactions. Afterward, some cli ents need to
discuss the experience and understand why the flashback or trigger occurred. It often helps for the
client to draw a connection between the trigger and the traumatic event(s). This can be a preventive
strategy whereby the client can anticipate that a given situation places him or her at higher risk for
retraumatization and requires use of coping strategies, including seeking support. Source: Green
Cross Academy of Traumatology, 2010. Trauma-Informed Care in Behavioral Health Services often
believe that others will not fully under stand their experiences, and they may think that sharing their
feelings, thoughts, and reac tions related to the trauma will fall short of expectations. However
horrid the trauma may be, the experience of the trauma is typically profound. The type of trauma
can dictate how an indi vidual feels different or believes that they are different from others. Traumas
that generate shame will often lead survivors to feel more alienated from others—believing that
they are “damaged goods.” When individuals believe that their experiences are unique and incom
prehensible, they are more likely to seek sup port, if they seek support at all, only with others who
have experienced a similar trauma. Triggers and flashbacks Triggers A trigger is a stimulus that sets
off a memory of a trauma or a specific portion of a traumatic experience. Imagine you were trapped
briefly in a car after an accident. Then, several years later, you were unable to unlatch a lock after
using a restroom stall; you might have begun to feel a surge of panic reminiscent of the ac cident,
even though there were other avenues of escape from the stall. Some triggers can be identified and
anticipated easily, but many are subtle and inconspicuous, often surprising the individual or catching
him or her off guard. In treatment, it is important to help clients iden tify potential triggers, draw a
connection be tween strong emotional reactions and triggers, and develop coping strategies to
manage those moments when a trigger occurs. A trigger is any sensory reminder of the traumatic
event: a noise, smell, temperature, other physical sensa tion, or visual scene. Triggers can generalize
to any characteristic, no matter how remote, that resembles or represents a previous trauma, such
as revisiting the location where the trauma occurred, being alone, having your children reach the
same age that you were when you experienced the trauma, seeing the same breed of dog that bit
you, or hearing loud voices. Triggers are often associated with the time of day, season, holiday, or
anniversary of the event. Flashbacks A flashback is reexperiencing a previous trau matic experience
as if it were actually happen ing in that moment. It includes reactions that often resemble the
client’s reactions during the trauma. Flashback experiences are very brief and typically last only a
few seconds, but the emotional aftereffects linger for hours or long er. Flashbacks are commonly
initiated by a trigger, but not necessarily. Sometimes, they occur out of the blue. Other times,
specific physical states increase a person’s vulnerability to reexperiencing a trauma, (e.g., fatigue,
high 68 Potential Signs of Dissociation • Fixed or “glazed” eyes • Sudden flattening of affect • Long
periods of silence • Monotonous voice • Stereotyped movements • Responses not congruent with
the present context or situation • Excessive intellectualization (Briere, 1996a) Part 1, Chapter 3—
Understanding the Impact of Trauma stress levels). Flashbacks can feel like a brief movie scene that
intrudes on the client. For example, hearing a car backfire on a hot, sunny day may be enough to
cause a veteran to re spond as if he or she were back on military patrol. Other ways people
reexperience trau ma, besides flashbacks, are via nightmares and intrusive thoughts of the trauma.
Dissociation, depersonalization, and derealization Dissociation is a mental process that severs
connections among a person’s thoughts, memories, feelings, actions, and/or sense of identity. Most
of us have experienced dissocia tion—losing the ability to recall or track a particular action (e.g.,
arriving at work but not remembering the last minutes of the drive). Dissociation happens because
the person is engaged in an automatic activity and is not paying attention to his or her immediate
envi ronment. Dissociation can also occur during severe stress or trauma as a protective element
whereby the individual incurs distortion of time, space, or identity. This is a common symptom in
traumatic stress reactions. Dissociation helps distance the experience from the individual. People
who have experi enced severe or developmental trauma may have learned to separate themselves
from dis tress to survive. At times, dissociation can be very pervasive and symptomatic of a mental
disorder, such as dissociative identity disorder (DID; formerly known as multiple personality
disorder). According to the DSM-5, “disso ciative disorders are characterized by a disrup tion of
and/or discontinuity in the normal integration of consciousness, memory, identi ty, emotion,
perception, body representation, motor control, and behavior” (APA, 2013a, p. 291). Dissociative
disorder diagnoses are closely associated with histories of severe childhood trauma or pervasive,
human-caused, intentional trauma, such as that experienced by concentration camp survivors or
victims of ongoing political imprisonment, torture, or long-term isolation. A mental health profes
sional, preferably with significant training in working with dissociative disorders and with trauma,
should be consulted when a dissocia tive disorder diagnosis is suspected. The characteristics of DID
can be commonly accepted experiences in other cultures, rather than being viewed as symptomatic
of a trau matic experience. For example, in non Western cultures, a sense of alternate beings within
oneself may be interpreted as being inhabited by spirits or ancestors (Kirmayer, 1996). Other
experiences associated with dis sociation include depersonalization— psychologically “leaving one’s
body,” as if watching oneself from a distance as an observer or through derealization, leading to a
sense that what is taking place is unfamiliar or is not real. If clients exhibit signs of dissociation,
behav ioral health service providers can use ground ing techniques to help them reduce this defense
strategy. One major long-term conse quence of dissociation is the difficulty it causes in connecting
strong emotional or physical reactions with an event. Often, individuals may believe that they are
going crazy because they are not in touch with the nature of their reactions. By educating clients on
the resilient qualities of dissociation while also emphasiz ing that it prevents them from addressing
or 69 Resilient Responses to Trauma Many people find healthy ways to cope with, respond to, and
heal from trauma. Often, people auto matically reevaluate their values and redefine what is
important after a trauma. Such resilient re sponses include: • Increased bonding with family and
community. • Redefined or increased sense of purpose and meaning. • Increased commitment to a
personal mission. • Revised priorities. • Increased charitable giving and volunteerism. Trauma-
Informed Care in Behavioral Health Services validating the trauma, individuals can begin to
understand the role of dissociation. All in all, it is important when working with trauma survivors
that the intensity level is not so great that it triggers a dissociative reaction and pre vents the person
from engaging in the process. Behavioral Traumatic stress reactions vary widely; often, people
engage in behaviors to manage the aftereffects, the intensity of emotions, or the distressing aspects
of the traumatic experience. Some people reduce tension or stress through avoidant, self-
medicating (e.g., alcohol abuse), compulsive (e.g., overeating), impulsive (e.g., high-risk behaviors),
and/or self-injurious behaviors. Others may try to gain control over their experiences by being
aggressive or sub consciously reenacting aspects of the trauma. Behavioral reactions are also the
consequences of, or learned from, traumatic experiences. For example, some people act like they
can’t con trol their current environment, thus failing to take action or make decisions long after the
trauma (learned helplessness). Other associate elements of the trauma with current activities, such
as by reacting to an intimate moment in a significant relationship as dangerous or un safe years after
a date rape. The following sec tions discuss behavioral consequences of trauma and traumatic stress
reactions. Reenactments A hallmark symptom of trauma is reexperi encing the trauma in various
ways. Reexperi encing can occur through reenactments (liter ally, to “redo”), by which trauma
survivors repetitively relive and recreate a past trauma in their present lives. This is very apparent in
children, who play by mimicking what oc curred during the trauma, such as by pretend ing to crash a
toy airplane into a toy building after seeing televised images of the terrorist attacks on the World
Trade Center on Sep tember 11, 2001. Attempts to understand reenactments are very complicated,
as reen actments occur for a variety of reasons. Some times, individuals reenact past traumas to
master them. Examples of reenactments in clude a variety of behaviors: self-injurious be haviors,
hypersexuality, walking alone in unsafe areas or other high-risk behaviors, driv ing recklessly, or
involvement in repetitive destructive relationships (e.g., repeatedly get ting into romantic
relationships with people who are abusive or violent), to name a few. Self-harm and self-destructive
behaviors Self-harm is any type of intentionally self inflicted harm, regardless of the severity of injury
or whether suicide is intended. Often, self-harm is an attempt to cope with emotion al or physical
distress that seems overwhelm ing or to cope with a profound sense of dissociation or being
trapped, helpless, and “damaged” (Herman, 1997; Santa Mina & Gallop, 1998). Self-harm is
associated with past childhood sexual abuse and other forms of trauma as well as substance abuse.
Thus, 70 Part 1, Chapter 3—Understanding the Impact of Trauma Case Illustration: Marco Marco, a
30-year-old man, sought treatment at a local mental health center after a 2-year bout of anxiety
symptoms. He was an active member of his church for 12 years, but although he sought help from
his pastor about a year ago, he reports that he has had no contact with his pastor or his church since
that time. Approximately 3 years ago, his wife took her own life. He describes her as his soul mate
and has had a difficult time understanding her actions or how he could have prevented them. In the
initial intake, he mentioned that he was the first person to find his wife after the suicide and
reported feelings of betrayal, hurt, anger, and devastation since her death. He claimed that everyone
leaves him or dies. He also talked about his difficulty sleeping, having repetitive dreams of his wife,
and avoiding relationships. In his first session with the counselor, he initially rejected the counselor
before the counselor had an opportunity to begin reviewing and talking about the events and dis
comfort that led him to treatment. In this scenario, Marco is likely reenacting his feelings of
abandonment by attempting to reject others before he experiences another rejection or
abandonment. In this situation, the counselor will need to recognize the reenactment, explore the
behavior, and examine how reenactments appear in other situations in Marco’s life. addressing self-
harm requires attention to the client’s reasons for self-harm. More than like ly, the client needs help
recognizing and cop ing with emotional or physical distress in manageable amounts and ways.
Among the self-harm behaviors reported in the literature are cutting, burning skin by heat (e.g.,
cigarettes) or caustic liquids, punching hard enough to self-bruise, head banging, hair pulling, self-
poisoning, inserting foreign ob jects into bodily orifices, excessive nail biting, excessive scratching,
bone breaking, gnawing at flesh, interfering with wound healing, tying off body parts to stop
breathing or blood flow, swallowing sharp objects, and suicide. Cutting and burning are among the
most common forms of self-harm. Self-harm tends to occur most in people who have experienced
repeated and/or early trauma (e.g., childhood sexual abuse) rather than in those who have
undergone a single adult trauma (e.g., a community-wide disaster or a serious car accident). There
are strong associa tions between eating disorders, self-harm, and substance abuse (Claes
&Vandereycken, 2007; for discussion, see Harned, Najavits, & Weiss, 2006). Self-mutilation is also
associated with (and part of the diagnostic criteria for) a num ber of personality disorders, including
border line and histrionic, as well as DID, depression, and some forms of schizophrenia; these disor
ders can co-occur with traumatic stress reac tions and disorders. It is important to distinguish self-
harm that is suicidal from self-harm that is not suicidal and to assess and manage both of these very
serious dangers carefully. Most people who engage in self-harm are not doing so with the intent to
kill themselves (Noll, Horowitz, Bonanno, Trickett, & Putnam, 2003)—although self harm can be life
threatening and can escalate into suicidality if not managed therapeutically. Self-harm can be a way
of getting attention or manipulating others, but most often it is not. Self-destructive behaviors such
as substance abuse, restrictive or binge eating, reckless au tomobile driving, or high-risk impulsive be
havior are different from self-harming behaviors but are also seen in clients with a history of trauma.
Self-destructive behaviors differ from self-harming behaviors in that there may be no immediate
negative impact of the behavior on the individual; they differ from suicidal behavior in that there is
no in tent to cause death in the short term. 71 Trauma-Informed Care in Behavioral Health Services
Advice to Counselors: Working With Clients Who Are Self-Injurious Counselors who are unqualified
or uncomfortable working with clients who demonstrate self harming, self-destructive, or suicidal or
homicidal ideation, intent, or behavior should work with their agencies and supervisors to refer such
clients to other counselors. They should consider seeking specialized supervision on how to manage
such clients effectively and safely and how to manage their feelings about these issues. The
following suggestions assume that the counselor has had suffi cient training and experience to work
with clients who are self-injurious. To respond appropriately to a client who engages in self-harm,
counselors should: • Screen the client for self-harm and suicide risk at the initial evaluation and
throughout treatment. • Learn the client’s perspective on self-harm and how it “helps.” •
Understand that self-harm is often a coping strategy to manage the intensity of emotional and/or
physical distress. • Teach the client coping skills that improve his or her management of emotions
without self-harm. • Help the client obtain the level of care needed to manage genuine risk of
suicide or severe self injury. This might include hospitalization, more intensive programming (e.g.,
intensive outpa tient, partial hospitalization, residential treatment), or more frequent treatment
sessions. The goal is to stabilize the client as quickly as possible, and then, if possible, begin to focus
treat ment on developing coping strategies to manage self-injurious and other harmful impulses. •
Consult with other team members, supervisors, and, if necessary, legal experts to determine
whether one’s efforts with and conceptualization of the self-harming client fit best practice
guidelines. See, for example, Treatment Improvement Protocol (TIP) 42, Substance Abuse Treatment
for Persons With Co-Occurring Disorders (Center for Substance Abuse Treatment [CSAT], 2005c).
Document such consultations and the decisions made as a result of them thor oughly and frequently.
• Help the client identify how substance use affects self-harm. In some cases, it can increase the
behavior (e.g., alcohol disinhibits the client, who is then more likely to self-harm). In other cases, it
can decrease the behavior (e.g., heroin evokes relaxation and, thus, can lessen the urge to self-
harm). In either case, continue to help the client understand how abstinence from substances is
necessary so that he or she can learn more adaptive coping. • Work collaboratively with the client to
develop a plan to create a sense of safety. Individuals are affected by trauma in different ways;
therefore, safety or a safe environment may mean some thing entirely different from one person to
the next. Allow the client to define what safety means to him or her. Counselors can also help the
client prepare a safety card that the client can carry at all times. The card might include the
counselor’s contact information, a 24-hour crisis number to call in emergen cies, contact information
for supportive individuals who can be contacted when needed, and, if ap propriate, telephone
numbers for emergency medical services. The counselor can discuss with the client the types of signs
or crises that might warrant using the numbers on the card. Additionally, the counselor might check
with the client from time to time to confirm that the information on the card is current. TIP 50,
Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment (CSAT, 2009a), has
examples of safety agreements specifically for suicidal clients and discusses their uses in more detail.
There is no credible evidence that a safety agreement is effective in preventing a suicide at tempt or
death. Safety agreements for clients with suicidal thoughts and behaviors should only be used as an
adjunct support accompanying professional screening, assessment, and treatment for people with
suicidal thoughts and behaviors. Keep in mind that safety plans or agreements may be perceived by
the trauma survivor as a means of controlling behavior, subsequently replicating or triggering
previous traumatic experiences. All professionals—and in some States, anyone—could have ethical
and legal responsibilities to those clients who pose an imminent danger to themselves or others.
Clinicians should be aware of the pertinent State laws where they practice and the relevant Federal
and professional regulations. 72 Part 1, Chapter 3—Understanding the Impact of Trauma However,
as with self-harming behavior, self destructive behavior needs to be recognized and addressed and
may persist—or worsen— without intervention. Consumption of substances Substance use often is
initiated or increased after trauma. Clients in early recovery— especially those who develop PTSD or
have it reactivated—have a higher relapse risk if they experience a trauma. In the first 2 months
after September 11, 2001, more than a quarter of New Yorker residents who smoked ciga rettes,
drank alcohol, or used marijuana (about 265,000 people) increased their consumption. The increases
continued 6 months after the attacks (Vlahov, Galea, Ahern, Resnick, & Kilpatrick, 2004). A study by
the Substance Abuse and Mental Health Services Admin istration (SAMHSA, Office of Applied
Studies, 2002) used National Survey on Drug Use and Health data to compare the first three quarters
of 2001 with the last quarter and re ported an increase in the prevalence rate for alcohol use among
people 18 or older in the New York metropolitan area during the fourth quarter. Interviews with
New York City residents who were current or former cocaine or heroin users indicated that many
who had been clean for 6 months or less relapsed after September 11, 2001. Others, who lost their
income and could no longer support their habit, enrolled in methadone programs (Weiss et al.,
2002). After the Oklahoma City bombing in 1995, Oklahomans reported double the normal rate of
alcohol use, smoking more cigarettes, and a higher incidence of initiating smoking months and even
years after the bombing (Smith, Christiansen, Vincent, & Hann, 1999). Self-medication Khantzian’s
self-medication theory (1985) suggests that drugs of abuse are selected for their specific effects.
However, no definitive pattern has yet emerged of the use of particu lar substances in relation to
PTSD or trauma symptoms. Use of substances can vary based on a variety of factors, including which
trauma symptoms are most prominent for an individ ual and the individual’s access to particular
substances. Unresolved traumas sometimes lurk behind the emotions that clients cannot allow
themselves to experience. Substance use and abuse in trauma survivors can be a way to self-
medicate and thereby avoid or displace difficult emotions associated with traumatic experiences.
When the substances are with drawn, the survivor may use other behaviors to self-soothe, self-
medicate, or avoid emotions. As likely, emotions can appear after abstinence in the form of anxiety
and depression. Avoidance Avoidance often coincides with anxiety and the promotion of anxiety
symptoms. Individu als begin to avoid people, places, or situations to alleviate unpleasant emotions,
memories, or circumstances. Initially, the avoidance works, but over time, anxiety increases and the
per ception that the situation is unbearable or dangerous increases as well, leading to a great er
need to avoid. Avoidance can be adaptive, but it is also a behavioral pattern that reinforces
perceived danger without testing its validity, and it typically leads to greater problems across major
life areas (e.g., avoiding emotion ally oriented conversations in an intimate rela tionship). For many
individuals who have traumatic stress reactions, avoidance is com monplace. A person may drive 5
miles longer to avoid the road where he or she had an acci dent. Another individual may avoid
crowded places in fear of an assault or to circumvent strong emotional memories about an earlier
assault that took place in a crowded area. Avoidance can come in many forms. When people can’t
tolerate strong affects associated with traumatic memories, they avoid, project, 73 Trauma-
Informed Care in Behavioral Health Services deny, or distort their trauma-related emotional and
cognitive experiences. A key ingredient in trauma recovery is learning to manage triggers, memories,
and emotions without avoidance— in essence, becoming desensitized to traumatic memories and
associated symptoms. Social/Interpersonal A key ingredient in the early stage of TIC is to establish,
confirm, or reestablish a support system, including culturally appropriate activi ties, as soon as
possible. Social supports and relationships can be protective factors against traumatic stress.
However, trauma typically affects relationships significantly, regardless of whether the trauma is
interpersonal or is of some other type. Relationships require emo tional exchanges, which means
that others who have close relationships or friendships with the individual who survived the
trauma(s) are often affected as well—either through sec ondary traumatization or by directly experi
encing the survivor’s traumatic stress reactions. In natural disasters, social and community supports
can be abruptly eroded and difficult to rebuild after the initial disaster relief efforts have waned.
Survivors may readily rely on family members, friends, or other social supports—or they may avoid
support, either because they believe that no one will be understanding or trustworthy or because
they perceive their own needs as a burden to others. Survivors who have strong emotional or
physical reactions, including outbursts during nightmares, may pull away further in fear of being
unable to predict their own reactions or to protect their own safety and that of others. Often,
trauma survivors feel ashamed of their stress reactions, which further hampers their ability to use
their sup port systems and resources adequately. Many survivors of childhood abuse and inter
personal violence have experienced a signifi cant sense of betrayal. They have often en countered
trauma at the hands of trusted care givers and family members or through significant relationships.
This history of be trayal can disrupt forming or relying on sup portive relationships in recovery, such
as peer supports and counseling. Although this fear of trusting others is protective, it can lead to dif
ficulty in connecting with others and greater vigilance in observing the behaviors of others, including
behavioral health service providers. It is exceptionally difficult to override the feel ing that someone
is going to hurt you, take advantage of you, or, minimally, disappoint you. Early betrayal can affect
one’s ability to develop attachments, yet the formation of supportive relationships is an important
anti dote in the recovery from traumatic stress. Developmental Each age group is vulnerable in
unique ways to the stresses of a disaster, with children and the elderly at greatest risk. Young
children may display generalized fear, nightmares, heightened arousal and confusion, and physi cal
symptoms, (e.g., stomachaches, head aches). School-age children may exhibit symptoms such as
aggressive behavior and anger, regression to behavior seen at younger ages, repetitious traumatic
play, loss of ability to concentrate, and worse school performance. Adolescents may display
depression and social withdrawal, rebellion, increased risky activities such as sexual acting out, wish
for revenge and action-oriented responses to trauma, and sleep and eating disturbances (Hamblen,
2001). Adults may display sleep problems, increased agitation, hypervigilance, isolation or with
drawal, and increased use of alcohol or drugs. Older adults may exhibit increased withdrawal and
isolation, reluctance to leave home, wors ening of chronic illnesses, confusion, depres sion, and fear
(DeWolfe & Nordboe, 2000b). 74 Part 1, Chapter 3—Understanding the Impact of Trauma
Neurobiological Development: Consequences of Early Childhood Trauma Findings in developmental
psychobiology suggest that the consequences of early maltreatment pro duce enduring negative
effects on brain development (DeBellis, 2002; Liu, Diorio, Day, Francis, & Meaney, 2000; Teicher,
2002). Research suggests that the first stage in a cascade of events pro duced by early trauma
and/or maltreatment involves the disruption of chemicals that function as neurotransmitters (e.g.,
cortisol, norepinephrine, dopamine), causing escalation of the stress re sponse (Heim, Mletzko,
Purselle, Musselman, & Nemeroff, 2008; Heim, Newport, Mletzko, Miller, & Nemeroff, 2008;
Teicher, 2002). These chemical responses can then negatively affect critical neural growth during
specific sensitive periods of childhood development and can even lead to cell death. Adverse brain
development can also result from elevated levels of cortisol and catecholamines by contributing to
maturational failures in other brain regions, such as the prefrontal cortex (Meaney, Brake, &
Gratton, 2002). Heim, Mletzko et al. (2008) found that the neuropeptide oxytocin— important for
social affiliation and support, attachment, trust, and management of stress and anxie ty—was
markedly decreased in the cerebrospinal fluid of women who had been exposed to child hood
maltreatment, particularly those who had experienced emotional abuse. The more childhood
traumas a person had experienced, and the longer their duration, the lower that person’s current
level of oxytocin was likely to be and the higher her rating of current anxiety was likely to be. Using
data from the Adverse Childhood Experiences Study, an analysis by Anda, Felitti, Brown et al. (2006)
confirmed that the risk of negative outcomes in affective, somatic, substance abuse, memory,
sexual, and aggression-related domains increased as scores on a measure of eight ACEs increased.
The researchers concluded that the association of study scores with these outcomes can serve as a
theoretical parallel for the effects of cumulative exposure to stress on the developing brain and for
the resulting impairment seen in multiple brain structures and functions. The National Child
Traumatic Stress Network ([Link] offers information about child hood abuse, stress,
and physiological responses of children who are traumatized. Materials are avail able for counselors,
educators, parents, and caregivers. There are special sections on the needs of children in military
families and on the impact of natural disasters on children’s mental health. Subthreshold Trauma
Related Symptoms Many trauma survivors experience symptoms that, although they do not meet
the diagnostic criteria for ASD or PTSD, nonetheless limit their ability to function normally (e.g., regu
late emotional states, maintain steady and rewarding social and family relationships, function
competently at a job, maintain a steady pattern of abstinence in recovery). These symptoms can be
transient, only arising in a specific context; intermittent, appearing for several weeks or months and
then reced ing; or a part of the individual’s regular pattern of functioning (but not to the level of
DSM-5 diagnostic criteria). Often, these patterns are termed “subthreshold” trauma symptoms. Like
PTSD, the symptoms can be misdiag nosed as depression, anxiety, or another men tal illness.
Likewise, clients who have experienced trauma may link some of their symptoms to their trauma
and diagnose them selves as having PTSD, even though they do not meet all criteria for that
disorder. Combat Stress Reaction A phenomenon unique to war, and one that counselors need to
understand well, is combat stress reaction (CSR). CSR is an acute anxiety reaction occurring during or
shortly after par ticipating in military conflicts and wars as well as other operations within the war
zone, known as the theater. CSR is not a formal diagnosis, nor is it included in the DSM-5 (APA,
2013a). It is similar to acute stress 75 Case Illustration: Frank Frank is a 36-year-old man who was
severely beaten in a fight outside a bar. He had multiple injuries, including broken bones, a
concussion, and a stab wound in his lower abdomen. He was hospitalized for 3.5 weeks and was
unable to return to work, thus losing his job as a warehouse forklift operator. For several years,
when faced with situations in which he perceived himself as helpless and over whelmed, Frank
reacted with violent anger that, to others, appeared grossly out of proportion to the situation. He
has not had a drink in almost 3 years, but the bouts of anger persist and occur three to five times a
year. They leave Frank feeling even more isolated from others and alienated from those who love
him. He reports that he cannot watch certain television shows that depict violent anger; he has to
stop watching when such scenes occur. He sometimes daydreams about getting revenge on the
people who assaulted him. Psychiatric and neurological evaluations do not reveal a cause for Frank’s
anger attacks. Other than these symptoms, Frank has progressed well in his abstinence from alcohol.
He attends a support group regularly, has acquired friends who are also abstinent, and has
reconciled with his family of origin. His marriage is more stable, although the episodes of rage limit
his wife’s willingness to com mit fully to the relationship. In recounting the traumatic event in
counseling, Frank acknowledges that he thought he was going to die as a result of the fight,
especially when he realized he had been stabbed. As he described his experience, he began to
become very anxious, and the counselor ob served the rage beginning to appear. After his initial
evaluation, Frank was referred to an outpatient program that provided trauma-specific interventions
to address his subthreshold trauma symptoms. With a combination of cognitive– behavioral
counseling, EMDR, and anger management techniques, he saw a gradual decrease in symptoms
when he recalled the assault. He started having more control of his anger when memories of the
trauma emerged. Today, when feeling trapped, helpless, or overwhelmed, Frank has re sources for
coping and does not allow his anger to interfere with his marriage or other relationships. Trauma-
Informed Care in Behavioral Health Services reaction, except that the precipitating event or events
affect military personnel (and civil ians exposed to the events) in an armed con flict situation. The
terms “combat stress reaction” and “posttraumatic stress injury” are relatively new, and the intent
of using these new terms is to call attention to the unique experiences of combat-related stress as
well as to decrease the shame that can be associated with seeking behavioral health services for
PTSD (for more information on veterans and combat stress reactions, see the planned TIP,
Reintegration-Related Behavioral Health Issues for Veterans and Military Families; SAMHSA, planned
f). Although stress mobilizes an individual’s physical and psychological resources to per form more
effectively in combat, reactions to the stress may persist long after the actual danger has ended. As
with other traumas, the nature of the event(s), the reactions of others, and the survivor’s
psychological history and resources affect the likelihood and severity of CSR. With combat veterans,
this translates to the number, intensity, and duration of threat factors; the social support of peers in
the vet erans’ unit; the emotional and cognitive resili ence of the service members; and the quality
of military leadership. CSR can vary from manageable and mild to debilitating and se vere. Common,
less severe symptoms of CSR include tension, hypervigilance, sleep prob lems, anger, and difficulty
concentrating. If left untreated, CSR can lead to PTSD. Common causes of CSR are events such as a
direct attack from insurgent small arms fire or a military convoy being hit by an improvised explosive
device, but combat stressors encom pass a diverse array of traumatizing events, such as seeing grave
injuries, watching others 76 Part 1, Chapter 3—Understanding the Impact of Trauma Advice to
Counselors: Understanding the Nature of Combat Stress Several sources of information are available
to help counselors deepen their understanding of com bat stress and postdeployment adjustment.
Friedman (2006) explains how a prolonged combat-ready stance, which is adaptive in a war zone,
becomes hypervigilance and overprotectiveness at home. He makes the point that the “mutual
interdependence, trust, and affection” (p. 587) that are so neces sarily a part of a combat unit are
different from relationships with family members and colleagues in a civilian workplace. This
complicates the transition to civilian life. Wheels Down: Adjusting to Life After Deployment (Moore
& Kennedy, 2011) provides practical advice for military service members, includ ing inactive or active
duty personnel and veterans, in transitioning from the theater to home. The following are just a few
of the many resources and reports focused on combat-related psycho logical and stress issues: •
Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to
Assist Recovery (Tanielian & Jaycox, 2008) • On Killing (Grossman, 1995), an indepth analysis of the
psychological dynamics of combat • Haunted by Combat (Paulson & Krippner, 2007), which contains
specific chapters on Reserve and National Guard troops and female veterans • Treating Young
Veterans: Promoting Resilience Through Practice and Advocacy (Kelly, Howe Barksdale, & Gitelson,
2011) die, and making on-the-spot decisions in am biguous conditions (e.g., having to determine
whether a vehicle speeding toward a military checkpoint contains insurgents with explosives or a
family traveling to another area). Such circumstances can lead to combat stress. Mili tary personnel
also serve in noncombat posi tions (e.g., healthcare and administrative roles), and personnel filling
these supportive roles can be exposed to combat situations by proximity or by witnessing their
results. Specific Trauma-Related Psychological Disorders Part of the definition of trauma is that the
individual responds with intense fear, help lessness, or horror. Beyond that, in both the short term
and the long term, trauma com prises a range of reactions from normal (e.g., being unable to
concentrate, feeling sad, having trouble sleeping) to warranting a diagnosis of a trauma-related
mental disorder. Most people who experience trauma have no long-lasting disabling effects; their
coping skills and the support of those around them are sufficient to help them overcome their
difficulties, and their ability to function on a daily basis over time is unimpaired. For others, though,
the symptoms of trauma are more severe and last longer. The most common diagnoses associat ed
with trauma are PTSD and ASD, but trauma is also associated with the onset of other mental
disorders—particularly substance use disorders, mood disorders, various anxiety disorders, and
personality disorders. Trauma also typically exacerbates symptoms of preex isting disorders, and, for
people who are pre disposed to a mental disorder, trauma can precipitate its onset. Mental
disorders can oc cur almost simultaneously with trauma expo sure or manifest sometime thereafter.
Acute Stress Disorder ASD represents a normal response to stress. Symptoms develop within 4
weeks of the trauma and can cause significant levels of dis tress. Most individuals who have acute
stress reactions never develop further impairment or PTSD. Acute stress disorder is highly associ
ated with the experience of one specific trau ma rather than the experience of long-term exposure
to chronic traumatic stress. Diagnos tic criteria are presented in Exhibit 1.3-3. 77 Trauma-Informed
Care in Behavioral Health Services Exhibit 1.3-3: DSM-5 Diagnostic Criteria for ASD A. Exposure to
actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s). 2. 3. 4. B. Witnessing, in person, the event(s) as it
occurred to others. Learning that the event(s) occurred to a close family member or close friend.
Note: In cases of actual or threatened death of a family member or friend, the event(s) must have
been vio lent or accidental. Experiencing repeated or extreme exposure to aversive details of the
traumatic event(s) (e.g., first responders collecting human remains, police officers repeatedly
exposed to de tails of child abuse). Note: This does not apply to exposure through electronic media,
televi sion, movies, or pictures, unless this exposure is work related. Presence of nine (or more) of
the following symptoms from any of the five categories of intru sion, negative mood, dissociation,
avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred: Intrusion
Symptoms: 1. 2. 3. 4. Recurrent, involuntary, and intrusive distressing memories of the traumatic
event(s). Note: In children, repetitive play may occur in which themes or aspects of the traumatic
event(s) are expressed. Recurrent distressing dreams in which the content and/or affect of the
dream are related to the event(s). Note: In children, there may be frightening dreams without
recognizable content. Negative Mood: 5. Dissociative Symptoms: Avoidance Symptoms: Arousal
Symptoms: Dissociative reactions (e.g., flashbacks), during which the individual feels or acts as if the
traumatic event(s) were recurring. Such reactions may occur on a continuum, with the most extreme
expression being a complete loss of awareness of present surroundings. Note: In children, trauma-
specific reenactment may occur in play. Intense or prolonged psychological distress or marked
physiological reactions in response to internal or external cues that symbolize or resemble an aspect
of the traumatic event(s). Persistent inability to experience positive emotions (e.g., inability to
experience happiness, satisfaction, or loving feelings). 6. An altered sense of the reality of one’s
surroundings or oneself (e.g., seeing oneself from an other’s perspective, being in a daze, time
slowing). 7. Inability to remember an important aspect of the traumatic event(s) (typically due to
dissocia tive amnesia and not to other factors, such as head injury, alcohol, or drugs). 8. Efforts to
avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic
event(s). 9. Efforts to avoid external reminders (e.g., people, places, conversations, activities,
objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associat
ed with the traumatic event(s). 10. Sleep disturbance (e.g., difficulty falling or staying asleep, restless
sleep). 11. Irritable behavior and angry outbursts (with little or no provocation), typically expressed
as verbal or physical aggression toward people or objects. 12. Hypervigilance. 13. Problems with
concentration. 14. Exaggerated startle response. 78 (Continued on the next page.) Part 1, Chapter 3
—Understanding the Impact of Trauma Exhibit 1.3-3: DSM-5 Diagnostic Criteria for ASD (continued)
C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure.
Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and
up to a month is needed to meet disorder criteria. D. The disturbance causes clinically significant
distress or impairment in social, occupational, or oth er important areas of functioning. E. The
disturbance is not attributable to the physiological effects of a substance (e.g., medication or
alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not better ex plained
by brief psychotic disorder. Source: APA, 2013a, pp. 280–281. The primary presentation of an
individual with an acute stress reaction is often that of someone who appears overwhelmed by the
traumatic experience. The need to talk about the experience can lead the client to seem self
centered and unconcerned about the needs of others. He or she may need to describe, in repetitive
detail, what happened, or may seem obsessed with trying to understand what hap pened in an effort
to make sense of the experi ence. The client is often hypervigilant and avoids circumstances that are
reminders of the trauma. For instance, someone who was in a serious car crash in heavy traffic can
become anxious and avoid riding in a car or driving in traffic for a finite time afterward. Partial am
nesia for the trauma often accompanies ASD, and the individual may repetitively question others to
fill in details. People with ASD symptoms sometimes seek assurance from others that the event
happened in the way they remember, that they are not “going crazy” or “losing it,” and that they
could not have prevented the event. The next case illustration demonstrates the time-limited nature
of ASD. Differences between ASD and PTSD It is important to consider the differences be tween ASD
and PTSD when forming a diag nostic impression. The primary difference is the amount of time the
symptoms have been present. ASD resolves 2 days to 4 weeks after an event, whereas PTSD
continues beyond the 4-week period. The diagnosis of ASD can change to a diagnosis of PTSD if the
condi tion is noted within the first 4 weeks after the event, but the symptoms persist past 4 weeks.
ASD also differs from PTSD in that the ASD diagnosis requires 9 out of 14 symptoms from five
categories, including intrusion, negative mood, dissociation, avoidance, and arousal. These
symptoms can occur at the time of the trauma or in the following month. Studies indicate that
dissociation at the time of trau ma is a good predictor of subsequent PTSD, so the inclusion of
dissociative symptoms makes it more likely that those who develop ASD will later be diagnosed with
PTSD (Bryant & Harvey, 2000). Additionally, ASD is a transient disorder, meaning that it is pre sent in
a person’s life for a relatively short time and then passes. In contrast, PTSD typically becomes a
primary feature of an individual’s life. Over a lengthy period, PTSD can have profound effects on
clients’ perceptions of safety, their sense of hope for the future, their relationships with others, their
physical health, the appearance of psychiatric symptoms, and their patterns of substance use and
abuse. There are common symptoms between PTSD and ASD, and untreated ASD is a possible
predisposing factor to PTSD, but it is un known whether most people with ASD are likely to develop
PTSD. There is some sug gestion that, as with PTSD, ASD is more 79 Trauma-Informed Care in
Behavioral Health Services Case Illustration: Sheila Two months ago, Sheila, a 55-year-old married
woman, experienced a tornado in her home town. In the previous year, she had addressed a long-
time marijuana use problem with the help of a treat ment program and had been abstinent for
about 6 months. Sheila was proud of her abstinence; it was something she wanted to continue. She
regarded it as a mark of personal maturity; it improved her relationship with her husband, and their
business had flourished as a result of her abstinence. During the tornado, an employee reported that
Sheila had become very agitated and had grabbed her assistant to drag him under a large table for
cover. Sheila repeatedly yelled to her assistant that they were going to die. Following the storm,
Sheila could not remember certain details of her behav ior during the event. Furthermore, Sheila
said that after the storm, she felt numb, as if she was float ing out of her body and could watch
herself from the outside. She stated that nothing felt real and it was all like a dream. Following the
tornado, Sheila experienced emotional numbness and detachment, even from people close to her,
for about 2 weeks. The symptoms slowly decreased in intensity but still disrupted her life. Sheila
reported experiencing disjointed or unconnected images and dreams of the storm that made no real
sense to her. She was unwilling to return to the building where she had been during the storm,
despite having maintained a business at this location for 15 years. In addition, she began smoking
marijuana again because it helped her sleep. She had been very irritable and had uncharac teristic
angry outbursts toward her husband, children, and other family members. As a result of her earlier
contact with a treatment program, Sheila returned to that program and engaged in
psychoeducational, supportive counseling focused on her acute stress reaction. She re gained
abstinence from marijuana and returned shortly to a normal level of functioning. Her symp toms
slowly diminished over a period of 3 weeks. With the help of her counselor, she came to understand
the link between the trauma and her relapse, regained support from her spouse, and again felt in
control of her life. prevalent in women than in men (Bryant & Harvey, 2003). However, many people
with PTSD do not have a diagnosis or recall a histo ry of acute stress symptoms before seeking
treatment for or receiving a diagnosis of PTSD. Effective interventions for ASD can signifi cantly
reduce the possibility of the subsequent development of PTSD. Effective treatment of ASD can also
reduce the incidence of other co-occurring problems, such as depression, anxiety, dissociative
disorders, and compulsive behaviors (Bryant & Harvey, 2000). Interven tion for ASD also helps the
individual develop coping skills that can effectively prevent the recurrence of ASD after later
traumas. Although predictive science for ASD and PTSD will continue to evolve, both disorders are
associated with increased substance use and mental disorders and increased risk of 80 relapse;
therefore, effective screening for ASD and PTSD is important for all clients with these disorders.
Individuals in early recovery— lacking well-practiced coping skills, lacking environmental supports,
and already operating at high levels of anxiety—are particularly sus ceptible to ASD. Events that
would not nor mally be disabling can produce symptoms of intense helplessness and fear, numbing
and depersonalization, disabling anxiety, and an inability to handle normal life events. Counse lors
should be able to recognize ASD and treat it rather than attributing the symptoms to a client’s lack of
motivation to change, be ing “dry drunk” (for those in substance abuse recovery), or being
manipulative. Posttraumatic Stress Disorder The trauma-related disorder that receives the greatest
attention is PTSD; it is the most Part 1, Chapter 3—Understanding the Impact of Trauma Case
Illustration: Michael Michael is a 62-year-old Vietnam veteran. He is a divorced father of two
children and has four grand children. Both of his parents were dependent on alcohol. He describes
his childhood as isolated. His father physically and psychologically abused him (e.g., he was beaten
with a switch until he had welts on his legs, back, and buttocks). By age 10, his parents regarded him
as incorrigible and sent him to a reformatory school for 6 months. By age 15, he was using
marijuana, hallucinogens, and alcohol and was frequently truant from school. At age 19, Michael was
drafted and sent to Vietnam, where he witnessed the deaths of six American military personnel. In
one incident, the soldier he was next to in a bunker was shot. Michael felt help less as he talked to
this soldier, who was still conscious. In Vietnam, Michael increased his use of both alcohol and
marijuana. On his return to the United States, Michael continued to drink and use mari juana. He
reenlisted in the military for another tour of duty. His life stabilized in his early 30s, as he had a
steady job, supportive friends, and a relatively stable family life. However, he divorced in his late
30s. Shortly thereafter, he married a second time, but that marriage ended in divorce as well. He
was chronically anxious and depressed and had insomnia and frequent nightmares. He periodically
binged on alcohol. He complained of feeling empty, had suicidal ideation, and frequently stated that
he lacked purpose in his life. In the 1980s, Michael received several years of mental health treatment
for dysthymia. He was hospital ized twice and received 1 year of outpatient psychotherapy. In the
mid-1990s, he r eturned to outpa tient treatment for similar symptoms and was diagnosed with
PTSD and dysthymia. He no longer used marijuana and rarely drank. He reported that he didn’t like
how alcohol or other substances made him feel anymore—he felt out of control with his emotions
when he used them. Michael reported symp toms of hyperarousal, intrusion (intrusive memories,
nightmares, and preoccupying thoughts about Vietnam), and avoidance (isolating himself from
others and feeling “numb”). He reported that these symptoms seemed to relate to his childhood
abuse and his experiences in Vietnam. In treatment, he expressed relief that he now understood the
connection between his symptoms and his history. commonly diagnosed trauma-related disor der,
and its symptoms can be quite debilitat ing over time. Nonetheless, it is important to remember that
PTSD symptoms are repre sented in a number of other mental illnesses, including major depressive
disorder (MDD), anxiety disorders, and psychotic disorders (Foa et al., 2006). The DSM-5 (APA,
2013a) identifies four symptom clusters for PTSD: presence of intrusion symptoms, persistent
avoidance of stimuli, negative alterations in cognitions and mood, and marked alterations in arousal
and reactivity. Individuals must have been exposed to actual or threatened death, serious injury, or
sexual violence, and the symptoms must produce significant dis tress and impairment for more than
4 weeks (Exhibit 1.3-4). Certain characteristics make people more sus ceptible to PTSD, including
one’s unique per sonal vulnerabilities at the time of the traumatic exposure, the support (or lack of
support) received from others at the time of the trauma and at the onset of trauma-related
symptoms, and the way others in the person’s environment gauge the nature of the traumatic event
(Brewin, Andrews, & Valentine, 2000). People with PTSD often present varying clin ical profiles and
histories. They can experience symptoms that are activated by environmental triggers and then
recede for a period of time. Some people with PTSD who show mostly psychiatric symptoms
(particularly depression and anxiety) are misdiagnosed and go untreat ed for their primary condition.
For many peo ple, the trauma experience and diagnosis 81 Trauma-Informed Care in Behavioral
Health Services Exhibit 1.3-4: DSM-5 Diagnostic Criteria for PTSD Note: The following criteria apply to
adults, adolescents, and children older than 6 years. For chil dren 6 years and younger, see the DSM-
5 section titled “Posttraumatic Stress Disorder for Children 6 Years and Younger” (APA, 2013a). A.
Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the
following ways: 1. Directly experiencing the traumatic event(s). 2. 3. 4. B. Witnessing, in person, the
event(s) as it occurred to others. Learning that the traumatic event(s) occurred to a close family
member or close friend. In cases of actual or threatened death of a family member or friend, the
event(s) must have been violent or accidental. Experiencing repeated or extreme exposure to
aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police
officers repeatedly exposed to de tails of child abuse). Note: Criterion A4 does not apply to exposure
through electronic me dia, television, movies, or pictures, unless this exposure is work related.
Presence of one (or more) of the following intrusion symptoms associated with the traumatic
event(s), beginning after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive
distressing memories of the traumatic event(s). Note: In children older than 6 years, repetitive play
may occur in which themes or aspects of the traumatic event(s) are expressed. 2. 3. 4. 5. 2.
Recurrent distressing dreams in which the content and/or affect of the dream are related to the
traumatic event(s). Note: In children, there may be frightening dreams without recog nizable
content. 2. 3. 4. 5. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if
the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most
extreme expression being a complete loss of awareness of present surroundings.) Note: In children,
trauma-specific reenactment may occur in play. Intense or prolonged psychological distress at
exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of
the traumatic event(s). C. Persistent avoidance of stimuli associated with the traumatic event(s),
beginning after the trau matic event(s) occurred, as evidenced by one or both of the following: 1.
Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely
associated with the traumatic event(s). Avoidance of or efforts to avoid external reminders (people,
places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or
feelings about or closely associated with the traumatic event(s). D. Negative alterations in cognitions
and mood associated with the traumatic event(s), beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or more) of the following: 1. Inability to remember an
important aspect of the traumatic event(s) (typically due to dis sociative amnesia, and not to other
factors such as head injury, alcohol, or drugs). Persistent and exaggerated negative beliefs or
expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The
world is completely dangerous,” “My whole nervous system is permanently ruined”). Persistent,
distorted cognitions about the cause or consequences of the traumatic event(s) that lead the
individual to blame himself/herself or others. Persistent negative emotional state (e.g., fear, horror,
anger, guilt, or shame). Markedly diminished interest or participation in significant activities. 6. 7. 82
Feelings of detachment or estrangement from others. Persistent inability to experience positive
emotions (e.g., inability to experience happi ness, satisfaction, or loving feelings). (Continued on the
next page.) Part 1, Chapter 3—Understanding the Impact of Trauma Exhibit 1.3-4: DSM-5 Diagnostic
Criteria for PTSD (continued) E. F. Marked alterations in arousal and reactivity associated with the
traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by
two (or more) of the following: 1. Irritable behavior and angry outbursts (with little or no
provocation), typically expressed as verbal or physical aggression toward people or objects. 2. 3. 4. 5.
6. Reckless or self-destructive behavior. Hypervigilance. Exaggerated startle response. Problems with
concentration. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Duration
of the disturbance (Criteria B, C, D and E) is more than 1 month. G. The disturbance causes clinically
significant distress or impairment in social, occupational, or other important areas of functioning. H.
The disturbance is not attributable to the physiological effects of a substance (e.g., medication,
alcohol) or another medical condition. Specify whether: With dissociative symptoms: The individual’s
symptoms meet the criteria for posttraumatic stress disorder, and in addition, in response to the
stressor, the individual experiences persistent or recurrent symptoms of either of the following: 1. 2.
Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were
an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream;
feeling a sense of unreality of self or body or of time moving slowly). Derealization: Persistent or
recurrent experiences of unreality of surroundings (e.g., the world around the individual is
experienced as unreal, dreamlike, distant, or distorted). Note: To use this subtype, the dissociative
symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts,
behavior during alcohol intoxication) or another med ical condition (e.g., complex partial seizures).
Specify whether: With delayed expression: If the full diagnostic criteria are not met until at least 6
months after the event (although the onset and expression of some symptoms may be immediate).
Source: APA, 2013a, pp. 271–272. are obscured by co-occurring substance use disorder symptoms.
The important feature of PTSD is that the disorder becomes an orient ing feature of the individual’s
life. How well the person can work, with whom he or she associates, the nature of close and intimate
relationships, the ability to have fun and reju venate, and the way in which an individual goes about
confronting and solving problems in life are all affected by the client’s trauma experiences and his or
her struggle to recover. Posttraumatic stress disorder: Timing of symptoms Although symptoms of
PTSD usually begin within 3 months of a trauma in adulthood, there can be a delay of months or
even years before symptoms appear for some people. Some people may have minimal symptoms
after a trauma but then experience a crisis later in life. Trauma symptoms can appear suddenly, even
without conscious memory of the original trauma or without any overt provocation. Sur vivors of
abuse in childhood can have a delayed response triggered by something that happens to them as
adults. For example, seeing a movie about child abuse can trigger symptoms related 83 Advice to
Counselors: Helping Clients With Delayed Trauma Responses Clients who are experiencing a delayed
trauma response can benefit if you hel p them to: • Create an environment that allows
acknowledgment of the traumatic event(s). • Discuss their initial recall or first suspicion that they
were having a traumatic response. • Become educated on delayed trauma responses. • Draw a
connection between the trauma and presenting trauma-related symptoms. • Create a safe
environment. • Explore their support systems and fortify them as needed. • Understand that
triggers can precede traumatic stress reactions, including delayed responses to trauma. • Identify
their triggers. • Develop coping strategies to navigate and manage symptoms. Trauma-Informed
Care in Behavioral Health Services to the trauma. Other triggers include return ing to the scene of
the trauma, being reminded of it in some other way, or noting the anniver sary of an event. Likewise,
combat veterans and survivors of community-wide disasters may seem to be coping well shortly
after a trauma, only to have symptoms emerge later when their life situations seem to have stabi
lized. Some clients in substance abuse recovery only begin to experience trauma symptoms when
they maintain abstinence for some time. As individuals decrease tension-reducing or self-medicating
behaviors, trauma memories and symptoms can emerge. Culture and posttraumatic stress Although
research is limited across cultures, PTSD has been observed in Southeast Asian, South American,
Middle Eastern, and Native American survivors (Osterman & de Jong, 2007; Wilson & Tang, 2007). As
Stamm and Friedman (2000) point out, however, simply observing PTSD does not mean that it is the
“best conceptual tool for characterizing post traumatic distress among non-Western indi viduals” (p.
73). In fact, many trauma-related symptoms from other cultures do not fit the DSM-5 criteria. These
include somatic and psychological symptoms and beliefs about the origins and nature of traumatic
events. More over, religious and spiritual beliefs can affect how a survivor experiences a traumatic
event and whether he or she reports the distress. For example, in societies where attitudes toward
karma and the glorification of war veterans are predominant, it is harder for war veterans to come
forward and disclose that they are emo tionally overwhelmed or struggling. It would be perceived as
inappropriate and possibly demoralizing to focus on the emotional dis tress that he or she still bears.
(For a review of cultural competence in treating trauma, refer to Brown, 2008.) Methods for
measuring PTSD are also cultur ally specific. As part of a project begun in 1972, the World Health
Organization (WHO) and the National Institutes of Health (NIH) embarked on a joint study to test the
cross-cultural applicability of classification systems for various diagnoses. WHO and NIH identified
apparently universal factors of psychological disorders and developed specific instruments to
measure them. These instru ments, the Composite International Diagnos tic Interview and the
Schedules for Clinical Assessment in Neuropsychiatry, include cer tain criteria from the DSM (Fourth
Edition, Text Revision; APA, 2000a) as well as criteria from the International Statistical Classifica tion
of Diseases and Related Health Prob lems, 10th revision (ICD-10; Exhibit 1.3-5). 84 Part 1, Chapter 3
—Understanding the Impact of Trauma Exhibit 1.3-5: ICD-10 Diagnostic Criteria for PTSD A. The
patient must have been exposed to a stressful event or situation (either brief or long-lasting) of
exceptionally threatening or catastrophic nature, which would be likely to cause pervasive dis tress
in almost anyone. B. There must be persistent remembering or “reliving” of the stressor in intrusive
“flashbacks,” vivid memories, or recurring dreams, or in experiencing distress when exposed to
circumstances re sembling or associated with the stressor. C. The patient must exhibit an actual or
preferred avoidance of circumstances resembling or associ ated with the stressor, which was not
present before exposure to the stressor. D. Either of the following must be present: 1. 2. E. Inability
to recall, either partially or completely, some important aspects of the period of ex posure to the
stressor. Persistent symptoms of increased psychological sensitivity and arousal (not present before
exposure to the stressor), shown by any two of the following: a. Difficulty in falling or staying asleep.
b. Irritability or outbursts of anger. c. Difficulty in concentrating. d. Exaggerated startle response.
Criteria B, C, and D must all be met within 6 months of the stressful event or at the end of a pe riod
of stress. (For some purposes, onset delayed more than 6 months can be included, but this should
be clearly specified.) Source: WHO, 1992. Complex trauma and complex traumatic stress When
individuals experience multiple trau mas, prolonged and repeated trauma during childhood, or
repetitive trauma in the context of significant interpersonal relationships, their reactions to trauma
have unique characteristics (Herman, 1992). This unique constellation of reactions, called complex
traumatic stress, is not recognized diagnostically in the DSM-5, but theoretical discussions and
research have begun to highlight the similarities and differ ences in symptoms of posttraumatic
stress versus complex traumatic stress (Courtois & Ford, 2009). Often, the symptoms generated from
complex trauma do not fully match PTSD criteria and exceed the severity of PTSD. Overall, literature
reflects that PTSD criteria or subthreshold symptoms do not fully account for the persistent and
more impairing clinical presentation of complex trauma. Even though current research in the study
of trau matology is prolific, it is still in the early stages of development. The idea that there may be
more diagnostic variations or subtypes is forthcoming, and this will likely pave the way for more
client-matching interventions to better serve those individuals who have been repeatedly exposed
to multiple, early child hood, and/or interpersonal traumas. Other Trauma-Related and Co-Occurring
Disorders The symptoms of PTSD and other mental disorders overlap considerably; these disorders
often coexist and include mood, anxiety, The term “co -occurring disorders” refers to cases when a
person has one or more mental disorders as well as one or more substance use disorders (including
sub stance abuse). Co -occurring disorders are common among individuals who have a history of
trauma and are seeking help. 85 Advice to Counselors: Universal Screening and Assessment Only
people specifically trained and licensed in mental health assessment should make diagnoses; trauma
can result in complicated cases, and many symptoms can be present, whether or not they meet full
diagnostic criteria for a specific disorder. Only a trained assessor can distinguish accurately among
various symptoms and in the presence of co-occurring disorders. However, behavioral health
professionals without specific assessment training can still serve an important role in screening for
possible mental disorders using established screening tools (CSAT, 2005c; see also Chapter 4 of this
TIP). In agencies and clinics, it is critical to provide such screenings systematically—for each client—
as PTSD and other co-occurring disorders are typically underdiagnosed or misdiagnosed. Many
survivors with severe mental disorders function fairly well following trauma, including disasters, as
long as essential services aren’t interrupted. For others, additional mental health supports may be
necessary. For more information, see Responding to the Needs of People With Serious and
Persistent Mental Illness in Times of Major Disaster (Center for Mental Health Services, 1996).
Trauma-Informed Care in Behavioral Health Services substance use, and personality disorders. Thus,
it’s common for trauma survivors to be under diagnosed or misdiagnosed. If they have not been
identified as trauma survivors, their psy chological distress is often not associated with previous
trauma, and/or they are diagnosed with a disorder that marginally matches their presenting
symptoms and psychological se quelae of trauma. The following sections pre sent a brief overview of
some mental disorders that can result from (or be worsened by) traumatic stress. PTSD is not the
only diag nosis related to trauma nor its only psycholog ical consequence; trauma can broadly
influence mental and physical health in clients who already have behavioral health disorders. People
With Mental Disorders MDD is the most common co-occurring dis order in people who have
experienced trauma and are diagnosed with PTSD. A well established causal relationship exists
between stressful events and depression, and a prior history of MDD is predictive of PTSD after
exposure to major trauma (Foa et al., 2006). Co-occurrence is also linked with greater im pairment
and more severe symptoms of both disorders, and the person is less likely to experi ence remission
of symptoms within 6 months. Generalized anxiety, obsessive–compulsive, and other anxiety
disorders are also associated with PTSD. PTSD may exacerbate anxiety disorder symptoms, but it is
also likely that preexisting anxiety symptoms and anxiety dis orders increase vulnerability to PTSD.
Preex isting anxiety primes survivors for greater hyperarousal and distress. Other disorders, such as
personality and somatization disorders, are also associated with trauma, but the histo ry of trauma is
often overlooked as a signifi cant factor or necessary target in treatment. The relationship between
PTSD and other disorders is complex. More research is now examining the multiple potential
pathways among PTSD and other disorders and how various sequences affect clinical presentation.
TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT, 2005c), is
valuable in understanding the relationship of substance use to other mental disorders. People With
Substance Use Disorders There is clearly a correlation between trauma (including individual, group,
or mass trauma) and substance use as well as the presence of posttraumatic stress (and other
trauma-related disorders) and substance use disorders. Alco hol and drug use can be, for some, an
effort to 86 Part 1, Chapter 3—Understanding the Impact of Trauma Co-Occurring PTSD and Other
Mental Disorders • Individuals with PTSD often have at least one additional diagnosis of a mental
disorder. • The presence of other disorders typically worsens and prolongs the course of PTSD and
compli cates clinical assessment, diagnosis, and treatment. • The most common co-occurring
disorders, in addition to substance use disorders, include mood disorders, various anxiety disorders,
eating disorders, and personality disorders. • Exposure to early, severe, and chronic trauma is linked
to more complex symptoms, including impulse control deficits, greater difficulty in emotional
regulation and establishing stable relation ships, and disruptions in consciousness, memory, identity,
and/or perception of the environment (Dom, De, Hulstijn, & Sabbe, 2007; Waldrop, Back, Verduin, &
Brady, 2007). • Certain diagnostic groups and at-risk populations (e.g., people with developmental
disabilities, people who are homeless or incarcerated) are more susceptible to trauma exposure and
to de veloping PTSD if exposed but less likely to receive appropriate diagnosis and treatment. •
Given the prevalence of traumatic events in clients who present for substance abuse treatment,
counselors should assess all clients for possible trauma-related disorders. manage traumatic stress
and specific PTSD symptoms. Likewise, people with substance use disorders are at higher risk of
developing PTSD than people who do not abuse sub stances. Counselors working with trauma sur
vivors or clients who have substance use disorders have to be particularly aware of the possibility of
the other disorder arising. Timeframe: PTSD and the onset of substance use disorders Knowing
whether substance abuse or PTSD came first informs whether a causal relation ship exists, but
learning this requires thorough assessment of clients and access to complete data on PTSD;
substance use, abuse, and de pendence; and the onset of each. Much cur rent research focuses
solely on the age of onset of substance use (not abuse), so determining causal relationships can be
difficult. The relationship between PTSD and sub stance use disorders is thought to be bidirec tional
and cyclical: substance use increases trauma risk, and exposure to trauma escalates substance use to
manage trauma-related symptoms. Three other causal pathways de scribed by Chilcoat and
Breslau’s seminal work (1998) further explain the relationship be tween PTSD and substance use
disorders: 1. The “self-medication” hypothesis suggests that clients with PTSD use substances to
manage PTSD symptoms (e.g., intrusive memories, physical arousal). Substances such as alcohol,
cocaine, barbiturates, opi oids, and amphetamines are frequently abused in attempts to relieve or
numb emotional pain or to forget the event. 2. The “high-risk” hypothesis states that drug and
alcohol use places people who use substances in high-risk situations that increase their chances of
being exposed to events that lead to PTSD. 3. The “susceptibility” hypothesis suggests that people
who use substances are more susceptible to developing PTSD after ex posure to trauma than people
who do not. Increased vulnerability may result from failure to develop effective stress manage ment
strategies, changes in brain chemis try, or damage to neurophysiological systems due to extensive
substance use. PTSD and substance abuse treatment PTSD can limit progress in substance abuse
recovery, increase the potential for relapse, and complicate a client’s ability to achieve success in
various life areas. Each disorder can mask or hide the symptoms of the other, and both need 87 Case
Illustration: Maria Maria is a 31-year-old woman diagnosed with PTSD and alcohol dependence.
From ages 8 to 12, she was sexually abused by an uncle. Maria never told anyone about the abuse
for fear that she would not be believed. Her uncle remains close to the family, and Maria still sees
him on certain holidays. When she came in for treatment, she described her emotions and thoughts
as out of control. Maria often experiences intrusive memories of the abuse, which at times can be
vivid and unrelenting. She cannot predict when the thoughts will come; efforts to distract herself
from them do not always work. She often drinks in response to these thoughts or his presence, as
she has found that alcohol can dull her level of distress. Maria also has difficulty falling asleep and is
often awakened by night mares. She does not usually remember the dreams, but she wakes up
feeling frightened and alert and cannot go back to sleep. Maria tries to avoid family gatherings but
often feels pressured to go. Whenever she sees her uncle, she feels intense panic and anger but says
she can usually “hold it together” if she avoids him. Af terward, however, she describes being
overtaken by these feelings and unable to calm down. She also describes feeling physically ill and
shaky. At these times, she often isolates herself, stays in her apartment, and drinks steadily for
several days. Maria also reports distress pertaining to her relation ship with her boyfriend. In the
beginning of their relationship, she found him comforting and enjoyed his affection, but more
recently, she has begun to feel anxious and unsettled around him. Maria tries to avoid sex with him,
but she sometimes gives in for fear of losing the relationship. She finds it easi er to have sex with him
when she is drunk, but she often experiences strong feelings of dread and disgust reminiscent of her
abuse. Maria feels guilty and confused about these feelings. Trauma-Informed Care in Behavioral
Health Services to be assessed and treated if the individual is to have a full recovery. There is a risk
of misin terpreting trauma-related symptoms in sub stance abuse treatment settings. For example,
avoidance symptoms in an individual with PTSD can be misinterpreted as lack of moti vation or
unwillingness to engage in substance abuse treatment; a counselor’s efforts to ad dress substance
abuse–related behaviors in early recovery can likewise provoke an exag gerated response from a
trauma survivor who has profound traumatic experiences of being trapped and controlled. Exhibit
1.3-6 lists important facts about PTSD and substance use disorders for counselors. Sleep, PTSD, and
substance use Many people have trouble getting to sleep and/or staying asleep after a traumatic
event; consequently, some have a drink or two to help them fall asleep. Unfortunately, any ini tially
helpful effects are likely not only to wane quickly, but also to incur a negative rebound effect. When
someone uses a substance before going to bed, “sleep becomes lighter and more easily disrupted,”
and rapid eye movement sleep (REM) “increases, with an associated increase in dreams and
nightmares,” as the effects wear off (Auerbach, 2003, p. 1185). People with alcohol dependence
report multi ple types of sleep disturbances over time, and it is not unusual for clients to report that
they cannot fall asleep without first having a drink. Both REM and slow wave sleep are reduced in
clients with alcohol dependence, which is also associated with an increase in the amount of time it
takes before sleep occurs, decreased overall sleep time, more nightmares, and re duced sleep
efficiency. Sleep during withdraw al is “frequently marked by severe insomnia and sleep
fragmentation…a loss of restful sleep and feelings of daytime fatigue. Night mares and vivid dreams
are not uncommon” (Auerbach, 2003, pp. 1185–1186). Confounding changes in the biology of sleep
that occur in clients with PTSD and substance use disorders often add to the problems of 88 Part 1,
Chapter 3—Understanding the Impact of Trauma Exhibit 1.3-6: PTSD and Substance Use Disorders:
Important Treatment Facts Profile Severity • PTSD is one of the most common co-occurring mental
disorders found in clients in substance abuse treatment (CSAT, 2005c). • People in treatment for
PTSD tend to abuse a wide range of substances, including opioids, co caine, marijuana, alcohol, and
prescription medications. • People in treatment for PTSD and substance abuse have a more severe
clinical profile than those with just one of these disorders. • PTSD, with or without major depression,
significantly increases risk for suicidality (CSAT, 2009a). Gender Differences • Rates of trauma-
related disorders are high in men and women in substance abuse treatment. Risk of Continued Cycle
of Violence Treatment Complications • Women with PTSD and a substance use disorder most
frequently experienced rape or witnessed a killing or injury; men with both disorders typically
witnessed a killing or injury or were the victim of sudden injury or accident (Cottler, Nishith, &
Compton, 2001). • While under the influence of substances, a person is more vulnerable to
traumatic events (e.g., automobile crashes, assaults). • Perpetrators of violent assault often are
under the influence of substances or test positive for substances at the time of arrest. • It is
important to recognize and help clients understand that becoming abstinent from sub stances does
not resolve PTSD; in fact, some PTSD symptoms become worse with abstinence for some people.
Both disorders must be addressed in treatment. • Treatment outcomes for clients with PTSD and a
substance use disorder are worse than for clients with other co-occurring disorders or who only
abuse substances (Brown, Read, & Kahler, 2003). recovery. Sleep can fail to return to normal for
months or even years after abstinence, and the persistence of sleep disruptions appears related to
the likelihood of relapse. Of particular clin ical importance is the vicious cycle that can also begin
during “slips”; relapse initially im proves sleep, but continued drinking leads to sleep disruption. This
cycle of initial reduction of an unpleasant symptom, which only ends up exacerbating the process as
a whole, can take place for clients with PTSD as well as for clients with substance use disorders.
There are effective cognitive–behavioral therapies and nonaddictive pharmacological interventions
for sleep difficulties. 89 Screening and 4 Assessment IN THIS CHAPTER • Screening and Assessment •
Barriers and Challenges to Trauma -Informed Screening and Assessment • Cross -Cultural Screening
and Assessment • Choosing Instruments • Trauma -Informed Screening and Assessment •
Concluding Note Why screen universally for trauma in behavioral health services? Ex posure to
trauma is common; in many surveys, more than half of re spondents report a history of trauma, and
the rates are even higher among clients with mental or substance use disorders. Furthermore,
behavioral health problems, including substance use and mental dis orders, are more difficult to
treat if trauma-related symptoms and disorders aren’t detected early and treated effectively (Part 3,
Section 1, of this Treatment Improvement Protocol [TIP], available online, summarizes research on
the prevalence of trauma and its relation ship with other behavioral health problems). Not
addressing traumatic stress symptoms, trauma-specific disor ders, and other symptoms/disorders
related to trauma can impede successful mental health and substance abuse treatment. Unrecog
nized, unaddressed trauma symptoms can lead to poor engagement in treatment, premature
termination, greater risk for relapse of psy chological symptoms or substance use, and worse
outcomes. Screening can also prevent misdiagnosis and inappropriate treat ment planning. People
with histories of trauma often display symptoms that meet criteria for other disorders. Without
screening, clients’ trauma histories and related symptoms often go undetected, leading providers to
direct services toward symptoms and disorders that may only partially explain client presentations
and distress. Universal screening for trauma history and trauma related symptoms can help
behavioral health practitioners identify individuals at risk of developing more pervasive and se vere
symptoms of traumatic stress. Screening, early identification, and inter vention serves as a
prevention strategy. Screening to identify clients who have histories of trauma and experience
trauma related symptoms is a prevention strategy. 91 Trauma-Informed Care in Behavioral Health
Services Trauma-Informed Care Framework in Behavioral Health Services—Screening and
Assessment The chapter begins with a discussion of screening and assessment concepts, with a
particular focus on trauma-informed screen ing. It then highlights specific factors that influence
screening and assessment, including timing and environment. Barriers and chal lenges in providing
trauma-informed screen ing are discussed, along with culturally specific screening and assessment
considerations and guidelines. Instrument selection, trauma informed screening and assessment
tools, and trauma-informed screening and assessment processes are reviewed as well. For a more
research-oriented perspective on screening and assessment for traumatic stress disorders, please
refer to the literature review provided in Part 3 of this TIP, which is available online. 92 Screening
and Assessment Screening The first two steps in screening are to deter mine whether the person has
a history of trauma and whether he or she has trauma related symptoms. Screening mainly obtains
answers to “yes” or “no” questions: “Has this client experienced a trauma in the past?” and “Does
this client at this time warrant further assessment regarding trauma-related symp toms?” If
someone acknowledges a trauma history, then further screening is necessary to determine whether
trauma-related symptoms are present. However, the presence of such symptoms does not
necessarily say anything about their severity, nor does a positive screen indicate that a disorder
actually exists. Positive Screening is often the first contact between the client and the treatment
provider, and the client forms his or her first impression of treatment during this intake process.
Thus, how screening is conducted can be as important as the actual information gathered, as it sets
the tone of treatment and begins the relationship with the client. Part 1, Chapter 4—Screening and
Assessment screens only indicate that assessment or fur ther evaluation is warranted, and negative
screens do not necessarily mean that an indi vidual doesn’t have symptoms that warrant
intervention. Screening procedures should always define the steps to take after a positive or
negative screening. That is, the screening process es tablishes precisely how to score responses to
screening tools or questions and clearly defines what constitutes a positive score (called a “cut off
score”) for a particular potential problem. The screening procedures detail the actions to take after a
client scores in the positive range. Clinical supervision is helpful—and some times necessary—in
judging how to proceed. Trauma-informed screening is an essential part of the intake evaluation and
the treatment planning process, but it is not an end in itself. Screening processes can be developed
that allow staff without advanced degrees or gradu ate-level training to conduct them, whereas
assessments for trauma-related disorders re quire a mental health professional trained in
assessment and evaluation processes. The most important domains to screen among individuals
with trauma histories include: • Trauma-related symptoms. • Depressive or dissociative symptoms,
sleep disturbances, and intrusive experiences. • Past and present mental disorders, includ ing
typically trauma-related disorders (e.g., mood disorders). • Severity or characteristics of a specific
trauma type (e.g., forms of interpersonal vi olence, adverse childhood events, combat experiences).
• Substance abuse. • Social support and coping styles. • Availability of resources. • Risks for self-
harm, suicide, and violence. • Health screenings. Assessment When a client screens positive for
substance abuse, trauma-related symptoms, or mental disorders, the agency or counselor should fol
low up with an assessment. A positive screen ing calls for more action—an assessment that
determines and defines presenting struggles to develop an appropriate treatment plan and to make
an informed and collaborative decision about treatment placement. Assessment de termines the
nature and extent of the client’s problems; it might require the client to re spond to written
questions, or it could involve a clinical interview by a mental health or sub stance abuse professional
qualified to assess the client and arrive at a diagnosis. A clinical assessment delves into a client’s past
and cur rent experiences, psychosocial and cultural history, and assets and resources. Assessment
protocols can require more than a single session to complete and should also use multiple avenues
to obtain the necessary clini cal information, including self-assessment tools, past and present
clinical and medical records, structured clinical interviews, assess ment measures, and collateral
information from significant others, other behavioral health professionals, and agencies. Qualifica
tions for conducting assessments and clinical interviews are more rigorous than for screen ing.
Advanced degrees, licensing or certifica tion, and special training in administration, scoring, and
interpretation of specific assess ment instruments and interviews are often 93 Advice to Counselors:
Screening and Assessing Clients • Ask all clients about any possible history of trauma; use a checklist
to increase proper identifica tion of such a history (see the online Adverse Childhood Experiences
Study Score Calculator [[Link] for specific questions about adverse
childhood experiences). • Use only validated instruments for screening and assessment. • Early in
treatment, screen all clients who have histories of exposure to traumatic events for psy chological
symptoms and mental disorders related to trauma. • When clients screen positive, also screen for
suicidal thoughts and behaviors (see TIP 50, Ad dressing Suicidal Thoughts and Behaviors in
Substance Abuse Treatment; Center for Substance Abuse Treatment [CSAT], 2009a). • Do not delay
screening; do not wait for a period of abstinence or stabilization of symptoms. • Be aware that some
clients will not make the connection between trauma in their histories and their current patterns of
behavior (e.g., alcohol and drug use and/or avoidant behavior). • Do not require clients to describe
emotionally overwhelming traumatic events in detail. • Focus assessment on how trauma symptoms
affect clients’ current functioning. • Consider using paper-and-pencil instruments for screening and
assessment as well as self-report measures when appropriate; they are less threatening for some
clients than a clinical interview. • Talk about how you will use the findings to plan the client’s
treatment, and discuss any immediate action necessary, such as arranging for interpersonal support,
referrals to community agencies, or moving directly into the active phase of treatment. It is helpful
to explore the strategies clients have used in the past that have worked to relieve strong emotions
(Fallot & Harris, 2001). • At the end of the session, make sure the client is grounded and safe before
leaving the interview room (Litz, Miller, Ruef, & McTeague, 2002). Readiness to leave can be
assessed by checking on the degree to which the client is c onscious of the current environment,
what the client’s plan is for maintaining personal safety, and what the client’s plans are for the rest
of the day. Trauma-Informed Care in Behavioral Health Services required. Counselors must be
familiar with (and obtain) the level of training required for any instruments they consider using. For
people with histories of traumatic life events who screen positive for possible trauma related
symptoms and disorders, thorough assessment gathers all relevant information necessary to
understand the role of the trauma in their lives; appropriate treatment objectives, goals, planning,
and placement; and any ongo ing diagnostic and treatment considerations, including reevaluation or
follow-up. Overall, assessment may indicate symptoms that meet diagnostic criteria for a substance
use or mental disorder or a milder form of symptomatology that doesn’t reach a diagnos tic level—
or it may reveal that the positive screen was false and that there is no significant cause for concern.
Information from an as sessment is used to plan the client’s treatment. The plan can include such
domains as level of care, acute safety needs, diagnosis, disability, strengths and skills, support
network, and cultural context. Assessments should reoccur throughout treatment. Ongoing
assessment during treatment can provide valuable infor mation by revealing further details of
trauma history as clients’ trust in staff members grows and by gauging clients’ progress. Timing of
Screening and Assessment As a trauma-informed counselor, you need to offer psychoeducation and
support from the outset of service provision; this begins with explaining screening and assessment
and with proper pacing of the initial intake and evalua tion process. The client should understand the
screening process, why the specific questions are important, and that he or she may choose to delay
a response or to not answer a question 94 Conduct Assessments Throughout Treatment Ongoing
assessments let counselors: • Track changes in the presence, frequency, and intensity of symptoms.
• Learn the relationships among the client’s trauma, presenting psychological symp toms, and
substance abuse. • Adjust diagnoses and treatment plans as needed. • Select prevention strategies
to avoid more pervasive traumatic stress symptoms. Part 1, Chapter 4—Screening and Assessment
at all. Discussing the occurrence or conse quences of traumatic events can feel as unsafe and
dangerous to the client as if the event were reoccurring. It is important not to en courage avoidance
of the topic or reinforce the belief that discussing trauma-related material is dangerous, but be
sensitive when gathering information in the initial screening. Initial questions about trauma should
be general and gradual. Taking the time to prepare and ex plain the screening and assessment
process to the client gives him or her a greater sense of control and safety over the assessment
process. Clients with substance use disorders No screening or assessment of trauma should occur
when the client is under the influence of alcohol or drugs. Clients under the influence are more likely
to give inaccurate information. Although it’s likely that clients in an active phase of use (albeit not at
the assessment it self ) or undergoing substance withdrawal can provide consistent information to
obtain a valid screening and assessment, there is insuf ficient data to know for sure. Some theorists
state that no final assessment of trauma or posttraumatic stress disorder (PTSD) should occur during
these early phases (Read, Bollinger, & Sharkansky, 2003), asserting that symptoms of withdrawal can
mimic PTSD and thus result in overdiagnosis of PTSD and other trauma-related disorders. Alcohol or
drugs can also cause memory impairment that clouds the client’s history of trauma symp toms.
However, Najavits (2004) and others note that underdiagnosis, not overdiagnosis, of trauma and
PTSD has been a significant issue in the substance abuse field and thus claim that it is essential to
obtain an initial assess ment early, which can later be modified if needed (e.g., if the client’s
symptom pattern changes). Indeed, clinical observations suggest that assessments for both trauma
and PTSD— even during active use or withdrawal—appear robust (Coffey, Schumacher, Brady, &
Dansky, 2003). Although some PTSD symptoms and trauma memories can be dampened or in
creased to a degree, their overall presence or absence, as assessed early in treatment, appears
accurate (Najavits, 2004). The Setting for Trauma Screening and Assessment Advances in the
development of simple, brief, and public-domain screening tools mean that at least a basic screening
for trauma can be done in almost any setting. Not only can cli ents be screened and assessed in
behavioral health treatment settings; they can also be evaluated in the criminal justice system, edu
cational settings, occupational settings, physi cians’ offices, hospital medical and trauma units, and
emergency rooms. Wherever they occur, trauma-related screenings and subse quent assessments
can reduce or eliminate wasted resources, relapses, and, ultimately, treatment failures among
clients who have histories of trauma, mental illness, and/or sub stance use disorders. Creating an
effective screening and assessment environment You can greatly enhance the success of treat ment
by paying careful attention to how you approach the screening and assessment pro cess. Take into
account the following points: 95 Trauma-Informed Care in Behavioral Health Services • Clarify for
the client what to expect in the screening and assessment process. For exam ple, tell the client that
the screening and as sessment phase focuses on identifying issues that might benefit from
treatment. Inform him or her that during the trauma screening and assessment process, uncom
fortable thoughts and feelings can arise. Provide reassurance that, if they do, you’ll assist in dealing
with this distress—but also let them know that, even with your assis tance, some psychological and
physical re actions to the interview may last for a few hours or perhaps as long as a few days after
the interview, and be sure to highlight the fact that such reactions are normal (Read et al., 2003). •
Approach the client in a matter-of-fact, yet supportive, manner. Such an approach helps create an
atmosphere of trust, respect, acceptance, and thoughtfulness (Melnick & Bassuk, 2000). Doing so
helps to normalize symptoms and experiences generated by the trauma; consider informing clients
that such events are common but can cause con tinued emotional distress if they are not treated.
Clients may also find it helpful for you to explain the purpose of certain diffi cult questions. For
example, you could say, “Many people have experienced troubling events as children, so some of my
questions are about whether you experienced any such events while growing up.” Demon strate
kindness and directness in equal measure when screening/assessing clients (Najavits, 2004). •
Respect the client’s personal space. Cultural and ethnic factors vary greatly regarding the
appropriate physical distance to maintain during the interview. You should respect the client’s
personal space, sitting neither too far from nor too close to the client; let your observations of the
client’s comfort level during the screening and assessment pro cess guide the amount of distance.
Clients with trauma may have particular sensitivity about their bodies, personal space, and
boundaries. • Adjust tone and volume of speech to suit the client’s level of engagement and degree
of comfort in the interview process. Strive to maintain a soothing, quiet demeanor. Be sensitive to
how the client might hear what you have to say in response to personal dis closures. Clients who
have been trauma tized may be more reactive even to benign or well-intended questions. • Provide
culturally appropriate symbols of safety in the physical environment. These include paintings,
posters, pottery, and other room decorations that symbolize the safety of the surroundings to the cli
ent population. Avoid culturally inappro priate or insensitive items in the physical environment. • Be
aware of one’s own emotional responses to hearing clients’ trauma histories. Hearing about clients’
traumas may be very painful and can elicit strong [Link] client may interpret your reaction to
his or her revelations as disinterest, disgust for the cli ent’s behavior, or some other inaccurate in
terpretation. It is important for you to monitor your interactions and to check in with the client as
necessary. You may also feel emotionally drained to the point that it interferes with your ability to
accurately lis ten to or assess [Link] effect of expo sure to traumatic stories, known as
secondary traumatization, can result in symptoms similar to those experienced by the client (e.g.,
nightmares, emotional numbing); if necessary, refer to a colleague for assessment (Valent, 2002).
Secondary traumatization is addressed in greater detail in Part 2, Chapter 2, of this TIP. • Overcome
linguistic barriers via an inter preter. Deciding when to add an interpreter requires careful
[Link] interpreter should be knowledgeable of behavioral 96 Part 1, Chapter 4—Screening
and Assessment health terminology, be familiar with the concepts and purposes of the interview and
treatment programming, be unknown to the client, and be part of the treatment team. Avoid asking
family members or friends of the client to serve as interpreters. • Elicit only the information
necessary for determining a history of trauma and the possible existence and extent of traumatic
stress symptoms and related disorders. There is no need to probe deeply into the details of a client’s
traumatic experiences at this stage in the treatment process. Given the lack of a therapeutic
relationship in which to process the information safely, pursuing details of trauma can cause re
traumatization or produce a level of re sponse that neither you nor your client is prepared to handle.
Even if a client wants to tell his or her trauma story, it’s your job to serve as “gatekeeper” and
preserve the client’s safety. Your tone of voice when sug gesting postponement of a discussion of
trauma is very important. Avoid conveying the message, “I really don’t want to hear about it.”
Examples of appropriate state ments are: − “Your life experiences are very im portant, but at this
early point in our work together, we should start with what’s going on in your life currently rather
than discussing past experiences in detail. If you feel that certain past experiences are having a big
effect on your life now, it would be helpful for us to discuss them as long as we focus on your safety
and recovery right now.” − “Talking about your past at this point could arouse intense feelings—
even more than you might be aware of right now. Later, if you choose to, you can talk with your
counselor about how to work on exploring your past.” − “Often, people who have a history of
trauma want to move quickly into the details of the trauma to gain relief. I understand this desire,
but my concern for you at this moment is to help you establish a sense of safety and support before
moving into the traumatic expe riences. We want to avoid retraumati zation—meaning, we want to
establish resources that weren’t available to you at the time of the trauma before delv ing into more
content.” • Give the client as much personal control as possible during the assessment by: −
Presenting a rationale for the interview and its stress-inducing potential, mak ing clear that the client
has the right to refuse to answer any and all questions. − Giving the client (where staffing per mits)
the option of being interviewed by someone of the gender with which he or she is most
comfortable. − Postponing the interview if necessary (Fallot & Harris, 2001). • Use self-administered,
written checklists rather than interviews when possible to as sess trauma. Traumas can evoke
shame, guilt, anger, or other intense feelings that can make it difficult for the client to report them
aloud to an interviewer. Clients are more likely to report trauma when they use self-administered
screening tools; however, these types of screening instruments only guide the next step. Interviews
should coin cide with self-administered tools to create a sense of safety for the client (someone is
present as he or she completes the screen ing) and to follow up with more indepth data gathering
after a self-administered screening is complete. The Trauma History Questionnaire (THQ) is a self
administered tool (Green, 1996). It has been used successfully with clinical and nonclinical
populations, including medi cal patients, women who have experi enced domestic violence, and
people with serious mental illness (Hooper, Stockton, 97 Trauma-Informed Care in Behavioral Health
Services Krupnick, & Green, 2011). Screening in struments (including the THQ) are includ ed in
Appendix D of this TIP. • Interview the client if he or she has trouble reading or writing or is
otherwise unable to complete a checklist. Clients who are likely to minimize their trauma when using
a checklist (e.g., those who exhibit significant symptoms of dissociation or repression) benefit from a
clinical interview. A trained interviewer can elicit information that a self-administered checklist does
not cap ture. Overall, using both a self-administered Exhibit 1.4-1: Grounding Techniques
questionnaire and an interview can help achieve greater clarity and context. • Allow time for the
client to become calm and oriented to the present if he or she has very intense emotional responses
when recalling or acknowledging a trauma. At such times, avoid responding with such exclamations
as “I don’t know how you survived that!” (Bernstein, 2000). If the client has difficul ty self-soothing,
guide him or her through grounding techniques (Exhibit 1.4-1), which are particularly useful—
perhaps even critical—to achieving a successful Grounding techniques are important skills for
assessors and all other behavioral health service pro viders who interact with traumatized clients
(e.g., nurses, security, administrators, clinicians). Even if you do not directly conduct therapy,
knowledge of grounding can help you defuse an escalating situation or calm a client who is triggered
by the assessment process. Grounding strategies help a person who is overwhelmed by memories or
strong emotions or is dissociating; they help the person become aware of the here and now. A useful
metaphor is the experience of walking out of a movie theater. When the person dissociates or has a
flashback, it’s like watching a mental movie; ground ing techniques help him or her step out of the
movie theater into the daylight and the present envi ronment. The client’s task is not only to hold on
to moments from the past, but also to acknowledge that what he or she was experiencing is from
the past. Try the following techniques: 1. 2. 3. 4. Ask the client to state what he or she observes.
Guide the client through this exercise by using statements like, “You seem to feel very scared/angry
right now. You’re probably feeling things related to what happened in the past. Now, you’re in a safe
situation. Let’s try to stay in the present. Take a slow deep breath, relax your shoulders, put your
feet on the floor; let’s talk about what day and time it is, notice what’s on the wall, etc. What else
can you do to feel okay in your body right now?” Help the client decrease the intensity of affect. •
“Emotion dial”: A client imagines turning down the volume on his or her emotions. • Guided imagery
can be used to visualize a safe place. • Distraction (see #3 below). • Clenching fists can move the
energy of an emotion into fists, which the client can then re lease. • Use strengths-based questions
(e.g., “How did you survive?” or “What strengths did you possess to survive the trauma?”). Distract
the client from unbearable emotional states. • Have the client focus on the external environment
(e.g., name red objects in the room). • Ask the client to focus on recent and future events (e.g., “to
do” list for the day). • Help the client use self-talk to remind himself or herself of current safety. •
Use distractions, such as counting, to return the focus to current reality. • Somatosensory
techniques (toe-wiggling, touching a chair) can remind clients of current reality. Ask the client to use
breathing techniques. • Ask the client to inhale through the nose and exhale through the mouth. •
Have the client place his or her hands on his or her abdomen and then watch the hands go up and
down while the belly expands and contracts. 98 Source: Melnick & Bassuk, 2000. Part 1, Chapter 4—
Screening and Assessment interview when a client has dissociated or is experiencing intense feelings
in response to screening and/or interview questions. • Avoid phrases that imply judgment about the
trauma. For example, don’t say to a cli ent who survived Hurricane Katrina and lost family members,
“It was God’s will,” or “It was her time to pass,” or “It was meant to be.” Do not make assumptions
about what a person has experienced. Ra ther, listen supportively without imposing personal views
on the client’s experience. • Provide feedback about the results of the screening. Keep in mind the
client’s vulner ability, ability to access resources, strengths, and coping strategies. Present results in
a synthesized manner, avoiding complicated, overly scientific jargon or explanations. Al low time to
process client reactions during the feedback session. Answer client ques tions and concerns in a
direct, honest, and compassionate manner. Failure to deliver feedback in this way can negatively
affect clients’ psychological status and severely weaken the potential for developing a ther apeutic
alliance with the client. • Be aware of the possible legal implications of assessment. Information you
gather dur ing the screening and assessment process can necessitate mandatory reporting to au
thorities, even when the client does not want such information disclosed (Najavits, 2004). For
example, you can be required to report a client’s experience of child abuse even if it happened many
years ago or the client doesn’t want the information report ed. Other legal issues can be quite com
plex, such as confidentiality of records, pursuing a case against a trauma perpetra tor and divulging
information to third par ties while still protecting the legal status of information used in prosecution,
and child custody issues (Najavits, 2004). It’s essen tial that you know the laws in your State, have an
expert legal consultant available, and access clinical supervision. Barriers and Challenges to Trauma-
Informed Screening and Assessment Barriers It is not necessarily easy or obvious to identify an
individual who has survived trauma with out screening. Moreover, some clients may deny that they
have encountered trauma and its effects even after being screened or asked direct questions aimed
at identifying the oc currence of traumatic events. The two main barriers to the evaluation of trauma
and its related disorders in behavioral health settings are clients not reporting trauma and providers
overlooking trauma and its effects. Concerning the first main barrier, some events will be
experienced as traumatic by one person but considered nontraumatic by another. A history of
trauma encompasses not only the experience of a potentially traumatic event, but also the person’s
responses to it and the mean ings he or she attaches to the event. Certain situations make it more
likely that the client will not be forthcoming about traumatic events or his or her responses to those
events. Some clients might not have ever thought of a particular event or their response to it as trau
matic and thus might not report or even recall the event. Some clients might feel a reluctance to
discuss something that they sense might bring up uncomfortable feelings (especially with a
counselor whom they’ve only recently met). Clients may avoid openly discussing traumatic events or
have difficulty recognizing or articulating their experience of trauma for other reasons, such as
feelings of shame, guilt, or fear of retribution by others associated with the event (e.g., in cases of
interpersonal or 99 Common Reasons Why Some Providers Avoid Screening Clients for Trauma
Treatment providers may avoid screening for traumatic events and trauma-related symptoms due
to: • A reluctance to inquire about traumatic events and symptoms because these questions are not
a part of the counselor’s or program’s standard intake procedures. • Underestimation of the impact
of trauma on clients’ physical and mental health. • A belief that treatment of substance abuse issues
needs to occur first and exclusively, before treating other behavioral health disorders. • A belief that
treatment should focus solely on presenting symptoms rather than exploring the potential origins or
aggravators of symptoms. • A lack of training and/or feelings of incompetence in effectively treating
trauma-related problems (Salyers, Evans, Bond, & Meyer, 2004). • Not knowing how to respond
therapeutically to a client’s report of trauma. • Fear that a probing trauma inquiry will be too
disturbing to clients. • Not using common language with clients that will elicit a report of trauma
(e.g., asking clients if they were abused as a child without describing what is meant by abuse). •
Concern that i f disorders are identified, clients will require treatment that the counselor or pro gram
does not feel capable of providing (Fallot & Harris, 2001). • Insufficient time for assessment to
explore trauma histories or symptoms. • Untreated trauma-related symptoms of the counselor,
other staff members, and administrators. Trauma-Informed Care in Behavioral Health Services
domestic violence). Still others may deny their history because they are tired of being inter viewed
or asked to fill out forms and may be lieve it doesn’t matter anyway. A client may not report past
trauma for many reasons, including: • Concern for safety (e.g., fearing more abuse by a perpetrator
for revealing the trauma). • Fear of being judged by service providers. • Shame about victimization.
• Reticence about talking with others in re sponse to trauma. • Not recalling past trauma through
dissocia tion, denial, or repression (although genuine blockage of all trauma memory is rare among
trauma survivors; McNally, 2003). • Lack of trust in others, including behavior al health service
providers. • Not seeing a significant event as traumatic. Regarding the second major barrier,
counselors and other behavioral health service providers may lack awareness that trauma can signifi
cantly affect clients’ presentations in treatment and functioning across major life areas, such as
relationships and work. In addition, some counselors may believe that their role is to treat only the
presenting psychological and/or substance abuse symptoms, and thus they may not be as sensitive
to histories and effects of trauma. Other providers may believe that a client should abstain from
alcohol and drugs for an extended period before exploring trau ma symptoms. Perhaps you fear that
address ing a clients’ trauma history will only exacerbate symptoms and complicate treat ment.
Behavioral health service providers who hold biases may assume that a client doesn’t have a history
of trauma and thus fail to ask the “right” questions, or they may be uncom fortable with emotions
that arise from listen ing to client experiences and, as a result, redirect the screening or counseling
focus. Challenges Awareness of acculturation and language Acculturation levels can affect screening
and assessment [Link], indepth discus sions may be a more appropriate way to gain an
understanding of trauma from the client’s point of view. During the intake, prior to trauma
screening, determine the client’s history of 100 Common Assessment Myths Several common myths
contribute to underassessment of trauma-related disorders (Najavits, 2004): • Myth #1: Substance
abuse itself is a trauma. However devastating substance abuse is, it does not meet the Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association
[APA], 2013a), criteria for trauma per se. Nevertheless, high-risk behaviors that are more likely to
occur during addiction, such as interpersonal violence and self harm, significantly increase the
potential for traumatic injury. • Myth #2: Assessment of trauma is enough. Thorough assessment is
the best way to identify the existence and extent of trauma-related problems. However, simply
identifying trauma-related symptoms and disorders is just the first step. Also needed are
individualized treatment protocols and action to implement these protocols. • Myth #3: It is best to
wait until the client has ended substance use and withdrawal to assess for PTSD. Research does not
provide a clear answer to the controversial question of when to as sess for PTSD; however, Najavits
(2004) and others note that underdiagnosis of trauma and PTSD has been more significant in the
substance abuse field than overdiagnosis. Clinical experience shows that the PTSD diagnosis is rather
stable during substance use or withdrawal, but symptoms can become more or less intense; memory
impairment from alcohol or drugs can also cloud the symptom picture. Thus, it is advisable to
establish a tentative diagnosis and then reassess after a period of abstinence, if possible. Part 1,
Chapter 4—Screening and Assessment migration, if applicable, and primary language. Questions
about the client’s country of birth, length of time in this country, events or reasons for migration,
and ethnic self-identification are also appropriate at intake. Also be aware that even individuals who
speak English well might have trouble understanding the subtleties of questions on standard
screening and assessment tools. It is not adequate to translate items simp ly from English into
another language; words, idioms, and examples often don’t translate di rectly into other languages
and therefore need to be adapted. Screening and assessment should be conducted in the client’s
preferred language by trained staff members who speak the lan guage or by professional translators
familiar with treatment jargon. Awareness of co-occurring diagnoses A trauma-informed assessor
looks for psycho logical symptoms that are associated with trauma or simply occur alongside it.
Symptom screening involves questions about past or present mental disorder symptoms that may
indicate the need for a full mental health as sessment. A variety of screening tools are available,
including symptom checklists. However, you should only use symptom checklists when you need
information about how your client is currently feeling; don’t use them to screen for specific
disorders. Responses will likely change from one administration of the checklist to the next. Basic
mental health screening tools are availa ble. For example, the Mental Health Screening Form-III
screens for present or past symptoms of most mental disorders (Carroll & McGinley, 2001); it is
available at no charge from Project Return Foundation, Inc. and is also reproduced in TIP 42,
Substance Abuse Treatment for Per sons With Co-Occurring Disorders (CSAT, 2005c). Other
screening tools, such as the Beck Depression Inventory II and the Beck Anxiety Inventory (Beck,
Wright, Newman, & Liese, 1993), also screen broadly for mental and sub stance use disorders, as
well as for specific dis orders often associated with trauma. For further screening information and
resources on depression and suicide, see TIP 48, Managing Depressive Symptoms in Substance
Abuse Clients During Early Recovery (CSAT, 2008), and TIP 50, Addressing Suicidal Thoughts and
Behaviors in Substance Abuse Treatment (CSAT, 2009a). 101 Trauma-Informed Care in Behavioral
Health Services For screening substance use disorders, see TIP 11, Simple Screening Instruments for
Outreach for Alcohol and Other Drug Abuse and Infectious Diseases (CSAT, 1994); TIP 24, A Guide to
Substance Abuse Services for Primary Care Cli nicians (CSAT, 1997a); TIP 31, Screening and Assessing
Adolescents for Substance Use Disorders (CSAT, 1999c); TIP 42, Substance Abuse Treatment for
Persons With Co-Occurring Dis orders (CSAT, 2005c); and TIP 51, Substance Abuse Treatment:
Addressing the Specific Needs of Women (CSAT, 2009d). A common dilemma in the assessment of
trauma-related disorders is that certain trauma symptoms are also symptoms of other disor ders.
Clients with histories of trauma typically present a variety of symptoms; thus, it is im portant to
determine the full scope of symp toms and/or disorders present to help improve treatment
planning. Clients with trauma related and substance use symptoms and dis orders are at increased
risk for additional Axis I and/or Axis II mental disorders (Brady, Killeen, Saladin, Dansky, & Becker,
1994; Cottler, Nishith, & Compton, 2001). These symptoms need to be distinguished so that other
presenting subclinical features or disor ders do not go unidentified and untreated. To accomplish
this, a comprehensive assessment of the client’s mental health is recommended. Misdiagnosis and
underdiagnosis Many trauma survivors are either misdiagnosed (i.e., given diagnoses that are not
accurate) or underdiagnosed (i.e., have one or more diagno ses that have not been identified at all).
Such diagnostic errors could result, in part, from the fact that many general instruments to evaluate
mental disorders are not sufficiently sensitive to identify posttraumatic symptoms and can mis
classify them as other disorders, including per sonality disorders or psychoses. Intrusive
posttraumatic symptoms, for example, can show up on general measures as indicative of
hallucinations or obsessions. Dissociative symptoms can be interpreted as indicative of
schizophrenia. Trauma-based cognitive symp toms can be scored as evidence for paranoia or other
delusional processes (Briere, 1997). Some of the most common misdiagnoses in clients with PTSD
and substance abuse are: • Mood and anxiety disorders. Overlapping symptoms with such disorders
as major de pression, generalized anxiety disorder, and bipolar disorder can lead to misdiagnosis. •
Borderline personality disorder. Historically, this has been more frequently diagnosed than PTSD.
Many of the symptoms, in cluding a pattern of intense interpersonal relationships, impulsivity, rapid
and unpre dictable mood swings, power struggles in the treatment environment, underlying anxiety
and depressive symptoms, and tran sient, stress-related paranoid ideation or se vere dissociative
symptoms overlap. The effect of this misdiagnosis on treatment can be particularly negative;
counselors often view clients with a borderline personality diagnosis as difficult to treat and
unrespon sive to treatment. • Antisocial personality disorder. For men and women who have been
traumatized in childhood, “acting out” behaviors, a lack of empathy and conscience, impulsivity, and
self-centeredness can be functions of trau ma and survival skills rather than true anti social
characteristics. • Attention def icit hyperactivity disorder (ADHD). For children and adolescents,
impulsive behaviors and concentration problems can be diagnosed as ADHD ra ther than PTSD. It is
possible, however, for clients to legiti mately have any of these disorders in addition to trauma-
related disorders. Given the overlap of posttraumatic symptoms with those of oth er disorders, a
wide variety of diagnoses often needs to be considered to avoid misidentifying 102 Culture-Specific
Stress Responses Culture-bound concepts of distress exist that don’t necessarily match diagnostic
criteria. Culture specific symptoms and syndromes can involve physical complaints, broad emotional
reactions, or specific cognitive features. Many such syndromes are unique to a specific culture but
can broaden to cultures that have similar beliefs or characteristics. Culture-bound syndromes are
typically treated by traditional medicine and are known throughout the culture. Cultural concepts of
distress include: • Ataques de nervios. Recognized in Latin America and among individuals of Latino
descent, the primary features of this syndrome include intense emotional upset (e.g., shouting,
crying, trem bling, dissociative or seizure-like episodes). It frequently occurs in response to a
traumatic or stressful event in the family. • Nervios. This is considered a common idiom of distress
among Latinos; it includes a wide range of emotional distress symptoms including headaches,
nervousness, tearfulness, stomach discom fort, difficulty sleeping, and dizziness. Symptoms can vary
widely in intensity, as can impairment from them. This often occurs in response to stressful or
difficult life events. • Susto. This term, meaning “fright,” refers to a concept found in Latin American
cultures, but it is not recognized among Latinos from the Caribbean. Susto is attributed to a
traumatic or frighten ing event that causes the soul to leave the body, thus resulting in illness and
unhappiness; ex treme cases may result in death. Symptoms include appetite or sleep disturbances,
sadness, lack of motivation, low self-esteem, and somatic symptoms. • Taijin kyofusho. Recognized
in Japan and among some American Japanese, this “interpersonal fear” syndrome is characterized by
anxiety about and avoidance of interpersonal circumstances. The individual presents worry or a
conviction that his or her appearance or social interactions are inadequate or offensive. Other
cultures have similar cultural descriptions or syndromes associ ated with social anxiety. Sources:
APA, 2013, pp. 833–837; Briere & Scott, 2006b. Part 1, Chapter 4—Screening and Assessment other
disorders as PTSD and vice versa. A trained and experienced mental health profes sional will be
required to weigh differential diagnoses. TIP 42 (CSAT, 2005c) explores issues related to differential
diagnosis. Cross-Cultural Screening and Assessment Many trauma-related symptoms and disorders
are culture specific, and a client’s cultural background must be considered in screening and
assessment (for review of assessment and cultural considerations when working with trauma, see
Wilson & Tang, 2007). Behavioral health service providers must approach screen ing and assessment
processes with the influ ences of culture, ethnicity, and race firmly in mind. Cultural factors, such as
norms for ex pressing psychological distress, defining trau ma, and seeking help in dealing with
trauma, can affect: • How traumas are experienced. • The meaning assigned to the event(s). • How
trauma-related symptoms are ex pressed (e.g., as somatic expressions of dis tress, level of
emotionality, types of avoidant behavior). • Willingness to express distress or identify trauma with a
behavioral health service provider and sense of safety in doing so. • Whether a specific pattern of
behavior, emotional expression, or cognitive process is considered abnormal. • Willingness to seek
treatment inside and outside of one’s own culture. • Response to treatment. • Treatment outcome.
When selecting assessment instruments, coun selors and administrators need to choose, 103 The
DSM-5 and Updates to Screening and Assessment Instruments The recent publication of the DSM-5
(APA, 2013a) reflects changes to certain diagnostic criteria, which will affect screening tools and
criteria for trauma-related disorders. Criterion A2 (specific to traumatic stress disorders, acute
stress, and posttraumatic stress disorders), included in the fourth edition (text revision) of the DSM
(DSM-IV-TR; APA, 2000a), has been eliminated; this criterion stated that the individual’s response to
the trauma needs to involve intense fear, helplessness, or horror. There are now four cluster
symptoms, not three: reexperiencing, avoidance, arousal, and persistent negative alterations in
cognitions and mood. Changes to the DSM-5 were made to symptoms within each cluster. Thus,
screening will need modification to adjust to this change (APA, 2012b). Trauma-Informed Care in
Behavioral Health Services whenever possible, instruments that are cul turally appropriate for the
client. Instruments that have been normed for, adapted to, and tested on specific cultural and
linguistic groups should be used. Instruments that are not normed for the population are likely to
con tain cultural biases and produce misleading results. Subsequently, this can lead to misdiag nosis,
overdiagnosis, inappropriate treatment plans, and ineffective interventions. Thus, it is important to
interpret all test results cautious ly and to discuss the limitations of instruments with clients from
diverse ethnic populations and cultures. For a review of cross-cultural screening and assessment
considerations, refer to the planned TIP, Improving Cultural Com petence (Substance Abuse and
Mental Health Services Administration, planned c). Choosing Instruments Numerous instruments
screen for trauma his tory, indicate symptoms, assess trauma-related and other mental disorders,
and identify relat ed clinical phenomena, such as dissociation. One instrument is unlikely to meet all
screen ing or assessment needs or to determine the existence and full extent of trauma symptoms
and traumatic experiences. The following sec tions present general considerations in select ing
standardized instruments. Purpose Define your assessment needs. Do you need a standardized
screening or assessment instru ment for clinical purposes? Do you need in formation on a specific
aspect of trauma, such as history, PTSD, or dissociation? Do you wish to make a formal diagnosis,
such as PTSD? Do you need to determine quickly whether a client has experienced a trauma? Do you
want an assessment that requires a clini cian to administer it, or can the client com plete the
instrument himself or herself? Does the instrument match the current and specific diagnostic criteria
established in the DSM-5? Population Consider the population to be assessed (e.g., women, children,
adolescents, refugees, disaster survivors, survivors of physical or sexual vio lence, survivors of
combat-related trauma, peo ple whose native language is not English); some tools are appropriate
only for certain populations. Is the assessment process devel opmentally and culturally appropriate
for your client? Exhibit 1.4-2 lists considerations in choosing a screening or assessment instrument
for trauma and/or PTSD. Instrument Quality An instrument should be psychometrically adequate in
terms of sensitivity and specificity or reliability and validity as measured in sever al ways under
varying conditions. Published research offers information on an instrument’s psychometric
properties as well as its utility in both research and clinical settings. For further information on a
number of widely used trauma evaluation tools, see Appendix D and Antony, Orsillo, and Roemer’s
paper (2001). 104 Part 1, Chapter 4—Screening and Assessment Exhibit 1.4-2: Key Areas of Trauma
Screening and Assessment Trauma Key question: Did the client experience a trauma? Examples of
measures: Life Stressor Checklist-Revised (Wolfe & Kimerling, 1997); Trauma History Questionnaire
(Green, 1996); Traumatic Life Events Questionnaire (Kubany et al., 2000). Note: A good trauma
measure identifies events a person experienced (e.g., rape, assault, accident) and also evaluates
other trauma-related symptoms (e.g., presence of fear, helplessness, or horror). Acute Stress
Disorder (ASD) and PTSD Key question: Does the client meet criteria for ASD or PTSD? Examples of
measures: Clinician-Administered PTSD Scale (CAPS; Blake et al., 1990); Modified PTSD Symptom
Scale (Falsetti, Resnick, Resnick, & Kilpatrick, 1993); PTSD Checklist (Weathers, Litz, Herman, Huska,
& Keane, 1993); Stanford Acute Stress Reaction Questionnaire (Cardena, Koopman, Classen, Waelde,
& Spiegel, 2000). Note: A PTSD diagnosis requires the person to meet criteria for having experienced
a trauma; some measures include this, but others do not and require use of a separate trauma
measure. The CAPS is an interview; the others listed are self-report questionnaires and take less
time. Other Trauma-Related Symptoms Key question: Does the client have other symptoms related
to trauma? These include depressive symptoms, self-harm, dissociation, sexuality problems, and
relationship issues, such as distrust. Examples of measures: Beck Depression Inventory II (Beck,
1993; Beck et al., 1993); Dissociative Experiences Scale (Bernstein & Putnam, 1986; Carlson &
Putnam, 1993); Impact of Event Scale (measures intrusion and avoidance due to exposure to
traumatic events; Horowitz, Wilner, & Alvarez, 1979; Weiss & Marmar, 1997); Trauma Symptom
Inventory (Briere, 1995); Trauma Symptom Checklist for Children (Briere, 1996b); Modified PTSD
Symptom Scale (Falsetti et al., 1993). Note: These measures can be helpful for clinical purposes and
for outcome assessment because they gauge levels of symptoms. Trauma-related symptoms are
broader than diagnostic criteria and thus useful to measure, even if the patient doesn’t meet criteria
for any specific diagnoses. Other Trauma-Related Diagnoses Key question: Does the client have other
disorders related to trauma? These include mood disor ders, anxiety disorders besides traumatic
stress disorders, and dissociative disorders. Examples of measures: Mental Health Screening Form III
(Carroll & McGinley, 2001); The Mini International Neuropsychiatric Interview (M.I.N.I.) Structured
Clinical Interview for DSM-IV-TR, Pa tient Edition (First, Spitzer, Gibbon, & Williams, revised 2011);
Structured Clinical Interview for DSM IV-TR, Non-Patient Edition (First, Spitzer, Gibbon, & Williams,
revised 2011a). Note: For complex symptoms and diagnoses such as dissociation and dissociative
disorders, inter views are recommended. Look for measures that incorporate DSM-5 criteria.
Sources: Antony et al., 2001; Najavits, 2004. Practical Issues Is the instrument freely and readily
available, or is there a fee? Is costly and extensive train ing required to administer it? Is the instru
ment too lengthy to be used in the clinical setting? Is it easily administered and scored with
accompanying manuals and/or other training materials? How will results be pre sented to or used
with the client? Is technical support available for difficulties in administra tion, scoring, or
interpretation of results? Is special equipment required such as a micro phone, a video camera, or a
touch-screen com puter with audio? Trauma-Informed Screening and Assessment The following
sections focus on initial screen ing. For more information on screening and assessment tools,
including structured inter views, see Exhibit 1.4-2. Screening is only as good as the actions taken
afterward to address a positive screen (when clients acknowledge that they experience symptoms or
have en countered events highlighted within the screening). Once a screening is complete and a
positive screen is acquired, the client then needs referral for a more indepth assessment to ensure
development of an appropriate treatment plan that matches his or her pre senting problems.
Establish a History of Trauma A person cannot have ASD, PTSD, or any trauma-related symptoms
without experienc ing trauma; therefore, it is necessary to inquire about painful, difficult, or
overwhelming past experiences. Initial information should be gathered in a way that is minimally
intrusive yet clear. Brief questionnaires can be less threatening to a client than face-to-face inter
views, but interviews should be an integral part of any screening and assessment process. If the
client initially denies a history of trauma (or minimizes it), administer the questionnaire later or delay
additional trauma-related ques tions until the client has perhaps developed more trust in the
treatment setting and feels safer with the thoughts and emotions that might arise in discussing his or
her trauma experiences. The Stressful Life Experiences (SLE) screen (Exhibit 1.4-3) is a checklist of
traumas that also considers the client’s view of the impact of those events on life functioning. Using
the SLE can foster the client–counselor relation ship. By going over the answers with the cli ent, you
can gain a deep understanding of your client, and the client receives a demonstration of your
sensitivity and concern for what the client has experienced. The National Center for PTSD Web site
offers similar instruments ([Link]
sessments/[Link]). In addition to broad screening tools that cap ture various traumatic
experiences and symp toms, other screening tools, such as the Combat Exposure Scale (Keane et al.,
1989) and the Intimate Partner Violence Screening Tool (Exhibit 1.4-4), focus on acknowledging a
specific type of traumatic event. Screen for Trauma-Related Symptoms and Disorders in Clients With
Histories of Trauma This step evaluates whether the client’s trauma resulted in subclinical or
diagnosable disor ders. The counselor can ask such questions as, “Have you received any counseling
or therapy? Have you ever been diagnosed or treated for a psychological disorder in the past? Have
you ever been prescribed medications for your emotions in the past?” Screening is typically
conducted by a wide variety of behavioral health service providers with different levels of training
and education; however, all 106 Part 1, Chapter 4—Screening and Assessment Exhibit 1.4-3: SLE
Screening Sources: Hudnall Stamm, 1996, 1997. Used with permission. 107 Exhibit 1.4-4: STaT
Intimate Partner Violence Screening Tool 1. Have you ever been in a relationship where your partner
has pushed or Slapped you? 2. Have you ever been in a relationship where your partner Threatened
you with violence? 3. Have you ever been in a relationship where your partner has thrown, broken,
or punched Things? Source: Paranjape & Liebschutz, 2003. Used with permission Exhibit 1.4-5: PC-
PTSD Screen In your life, have you ever had any experience that was so frightening, horrible, or
upsetting that, in the past month, you… 1. Have had nightmares about it or thought about it when
you did not want to? YES NO 2. Tried hard not to think about it or went out of your way to avoid
situations that remind ed you of it? YES NO 3. Were constantly on guard, watchful, or easily startled?
YES NO 4. Felt numb or detached from others, activi ties, or your surroundings? YES NO Source: Prins
et al., 2004. Material used is in the public domain. Exhibit 1.4-6: The SPAN The SPAN instrument is a
brief screening tool that asks clients to identify the trauma in their past that is most disturbing to
them currently. It then poses four questions that ask clients to rate the frequency and severity with
which they have experienced, in the past week, different types of trauma-related symptoms (startle,
physiological arousal, anger, and numbness). To order this screening instrument, use the following
contact information: Multi-Health Systems, Inc. P.O. Box 950 North Tonawanda, NY 14120-0950
Phone: 800-456-3003 Source: Meltzer-Brody et al., 1999. Trauma-Informed Care in Behavioral
Health Services individuals who administer screenings, regard less of education level and experience,
should be aware of trauma-related symptoms, grounding techniques, ways of creating safety for the
client, proper methods for introducing screening tools, and the protocol to follow when a positive
screen is obtained. (See Ap pendix D for information on specific instru ments.) Exhibit 1.4-5 is an
example of a screening instrument for trauma symptoms, the Primary Care PTSD (PC-PTSD) Screen.
Current research (Prins et al., 2004) suggests that the optimal cutoff score for the PC-PTSD is 3. If
sensitivity is of greater concern than efficiency, a cutoff score of 2 is recommended. Another
instrument that can screen for trau matic stress symptoms is the four-item self report SPAN,
summarized in Exhibit 1.4-6, which is derived from the 17-item Davidson Trauma Scale (DTS). SPAN
is an acronym for the four items the screening addresses: startle, physiological arousal, anger, and
numbness. It was developed using a small, diverse sample of adult patients (N=243; 72 percent
women; 17.4 percent African American; average age = 37 years) participating in several clinical stud
ies, including a family study of rape trauma, combat veterans, and Hurricane Andrew sur vivors,
among others. The SPAN has a high diagnostic accuracy of 0.80 to 0.88, with sensitivity (percentage
of true positive instances) of 0.84 and specificity (percentage of true negative instances) of 0.91
(Meltzer-Brody, Churchill, & Davidson, 1999). SPAN scores correlated highly with the full DTS (r =
0.96) and other measures, such as the Impact of Events Scale (r = 0.85) and the Sheehan Disability
Scale (r = 0.87). The PTSD Checklist (Exhibit 1.4-7), devel oped by the National Center for PTSD, is in
the public domain. Originally developed for combat veterans of the Vietnam and Persian 108 Part 1,
Chapter 4—Screening and Assessment Exhibit 1.4-7: The PTSD Checklist Instructions to Client: Below
is a list of problems and complaints that people sometimes have in response to stressful
experiences. Please read each one carefully and circle the number that indi cates how much you
have been bothered by that problem in the past month. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
16. 17. Repeated, disturbing memories, thoughts, or images of a stressful experience? 1. Not at all 2.
A little bit 3. Moderately 4. Quite a bit 5. Extremely Repeated, disturbing dreams of a stressful
experience? 1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5. Extremely Suddenly acting or
feeling as if a stressful experience were happening again (as if you were reliving it)? 1. Not at all 2. A
little bit 3. Moderately 4. Quite a bit 5. Extremely Feeling very upset when something reminded you
of a stressful experience? 1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5. Extremely Having
physical reactions (e.g., heart pounding, trouble breathing, sweating) when some thing reminded
you of a stressful experience? 1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5. Extremely
Avoiding thinking about or talking about a stressful experience or avoiding having feelings related to
it? 1. Not at all 2. A little bit Avoiding activities or situations because they reminded you of a stressful
experience? 1. Not at all 2. A little bit Trouble remembering important parts of a stressful
experience? 1. Not at all 2. A little bit Loss of interest in activities that you used to enjoy? 1. Not at all
2. A little bit Feeling distant or cut off from other people? 1. Not at all 2. A little bit 2. A little bit
Trouble falling or staying asleep? 1. Not at all 3. Moderately 4. Quite a bit 5. Extremely 3. Moderately
4. Quite a bit 5. Extremely 3. Moderately 4. Quite a bit 5. Extremely 3. Moderately 4. Quite a bit 5.
Extremely 3. Moderately 4. Quite a bit 5. Extremely Feeling emotionally numb or being unable to
have loving feelings for those close to you? 1. Not at all 3. Moderately 4. Quite a bit 5. Extremely
Feeling as if your future will somehow be cut short? 1. Not at all 2. A little bit 2. A little bit 3.
Moderately 4. Quite a bit 5. Extremely 3. Moderately 4. Quite a bit 5. Extremely Feeling irritable or
having angry outbursts? 1. Not at all 2. A little bit Having difficulty concentrating? 1. Not at all 2. A
little bit 3. Moderately 4. Quite a bit 5. Extremely 3. Moderately 4. Quite a bit 5. Extremely Being
“super-alert” or watchful or on guard? 1. Not at all 2. A little bit Feeling jumpy or easily startled? 1.
Not at all 2. A little bit 3. Moderately 4. Quite a bit 5. Extremely 3. Moderately 4. Quite a bit 5.
Extremely Source: Weathers et al., 1993. Material used is in the public domain. 109 Exhibit 1.4-8:
Resilience Scales A number of scales with good psychometric properties measure resilience: •
Resilience Scale (Wagnild & Young, 1993) • Resilience Scale for Adults (Friborg, Hjemdal, Rosenvinge,
& Martinussen, 2003) • Connor Davidson Resilience Scale, 25-,10-, and 2-Item (Connor & Davidson,
2003; Campbell-Sills & Stein, 2007; Vaishnavi, Connor, & Davidson, 2007, respectively) •
Dispositional Resilience Scale, 45-,30-, 15 item forms (Bartone, Roland, Picano, &Williams, 2008)
Trauma-Informed Care in Behavioral Health Services Gulf Wars, it has since been validated on a
variety of noncombat traumas (Keane, Brief, Pratt, & Miller, 2007). When using the checklist, identify
a specific trauma first and then have the client answer questions in rela tion to that one specific
trauma. Other Screening and Resilience Measures Along with identifying the presence of trauma-
related symptoms that warrant as sessment to determine the severity of symp toms as well as
whether or not the individual possesses subclinical symptoms or has met criteria for a trauma-
related disorder, clients should receive other screenings for symptoms associated with trauma (e.g.,
depression, sui cidality). It is important that screenings ad dress both external and internal resources
(e.g., support systems, strengths, coping styles). Knowing the client’s strengths can significant ly
shape the treatment planning process by allowing you to use strategies that have already worked for
the client and incorporating strat egies to build resilience (Exhibit 1.4-8). Preliminary research shows
improvement of individual resilience through treatment inter ventions in other populations
(Lavretsky, Siddarth, & Irwin, 2010). Screen for suicidality All clients—particularly those who have
expe rienced trauma—should be screened for sui cidality by asking, “In the past, have you ever had
suicidal thoughts, had intention to com mit suicide, or made a suicide attempt? Do you have any of
those feelings now? Have you had any such feelings recently?” Behavioral health service providers
should receive training to screen for suicide. Additionally, clients with substance use disorders and a
history of psy chological trauma are at heightened risk for suicidal thoughts and behaviors; thus,
screen ing for suicidality is indicated. See TIP 50, Addressing Suicidal Thoughts and Behaviors in
Substance Abuse Treatment (CSAT, 2009a). For additional descriptions of screening processes for
suicidality, see TIP 42 (CSAT, 2005c). Concluding Note Screenings are only beneficial if there are
follow-up procedures and resources for han dling positive screens, such as the ability to review
results with and provide feedback to the individual after the screening, sufficient resources to
complete a thorough assessment or to make an appropriate referral for an as sessment, treatment
planning processes that can easily incorporate additional trauma informed care objectives and goals,
and availa bility and access to trauma-specific services that match the client’s needs. Screening is
only the first step! 110 Clinical Issues Across 5 Services IN THIS CHAPTER • Trauma -Informed
Prevention and Treatment Objectives • Treatment Issues • Making Referrals to Trauma -Specific
Services Many clients in behavioral health treatment may have histories of trauma, so counselors
should be prepared to help them address is sues that arise from those histories. This chapter begins
with a thorough discussion of trauma-informed prevention and treatment objectives along with
practical counselor strategies. Specific treat ment issues related to working with trauma survivors in
a clinical setting are discussed as well, including client engagement, pacing and timing, traumatic
memories, and culturally appropriate and gender-responsive services. The chapter ends with
guidelines for making referrals to trauma-specific services. Trauma-Informed Prevention and
Treatment Objectives Trauma-informed care (TIC) not only focuses on identifying indi viduals who
have histories of trauma and traumatic stress symp toms; it also places considerable effort in
creating an environment that helps them recognize the impact of trauma and determine the next
course of action in a safe place. For some individuals, psy choeducation and development or
reinforcement of coping strate gies will be the most suitable and effective strategy, whereas others
may request or warrant a referral for more trauma-specific inter ventions (see Part 1, Chapter 6, of
this Treatment Improvement Protocol [TIP]). Although research is limited in the area of build ing
resilience to prevent exacerbation of trauma symptoms and traumatic stress disorders, TIC also
focuses on prevention strate gies to avoid retraumatization in treatment, to promote resilience, and
to prevent the development of trauma-related disorders. The following sections highlight key
trauma-informed prevention and treatment objectives. 111 Trauma-Informed Care in Behavioral
Health Services TIC Framework in Behavioral Health Services—Clinical Issues Across Services
Establish Safety Beyond identifying trauma and trauma-related symptoms, the initial objective of TIC
is es tablishing safety. Borrowing from Herman’s (1992) conceptualization of trauma recovery, safety
is the first goal of treatment. Establish ing safety is especially crucial at the outset of trauma-
informed treatment and often be comes a recurrent need when events or thera peutic changes raise
safety issues, such as a change in treatment staffing due to vacations. In the context of TIC, safety
has a variety of meanings. Perhaps most importantly, the cli ent has to have some degree of safety
from trauma symptoms. Recurring intrusive night mares; painful memories that burst forth
seemingly without provocation; feelings of sadness, anger, shame, or being overwhelmed; or not
having control over sudden disconnec tions from others make moment-to-moment living feel
unsafe. Clients might express feel ing unsafe through statements such as, “I can’t control my
feelings,” or, “I just space out and disconnect from the world for no reason,” or, “I’m afraid to go to
sleep because of the nightmares.” The intense feelings that accom pany trauma can also make
clients feel unsafe. They may wake up in the morning feeling fine but become immobilized by
depression as the day progresses. Clients with histories of trau ma may experience panicky feelings
of being trapped or abandoned. An early effort in trauma treatment is thus helping the client 112
Advice to Counselors: Strategies To Promote Safety Strategy #1: Teach clients how and when to use
grounding exercises when they feel unsafe or overwhelmed. Strategy #2: Establish some specific
routines in individual, group, or family therapy (e.g., have an opening ritual or routine when starting
and ending a group session). A structured setting can provide a sense of safety and familiarity for
clients with histories of trauma. Strategy #3: Facilitate a discussion on safe and unsafe behaviors.
Have clients identify, on paper, behaviors that promote safety and behaviors that feel unsafe for
them today. Strategy #4: Refer to Seeking Safety: A Treatment Manual for PTSD and Substance
Abuse (Najavits, 2002a). This menu-based manual covers an array of treatment topics, including the
core concept of safety. Each topic consists of several segments, including preparing for the session,
session format, session content, handouts, and guidelines. Strategy #5: Encourage the development
of a safety plan. Depending on the type of trauma, per sonal safety can be an issue; work with the
client to develop a plan that will help him or her feel in control and prepared for the unexpected. If
the trauma was a natural or human-caused disaster, en courage thinking about how family and
friends will respond and connect in the event of another cri sis. If sexual abuse or rape was the
event, encourage thinking about future steps that could help make the client safer. There is a
delicate balance between preparation and the realization that one cannot prepare for all possible
traumatic events. Nonetheless, an action plan can help the client re gain a sense of environmental
balance. Part 1, Chapter 5—Clinical Issues Across Services gain more control over trauma symptoms
(and be able to label them as such) by learning more about the client and helping him or her develop
new coping skills to handle symptoms when they arise and stay more grounded when flooded with
feelings or memories. A second aspect is safety in the environment. Trauma reactions can be
triggered by sudden loud sounds (e.g., television at high volume, raised voices), tension between
people, certain smells, or casual touches that are perceived as invasions of physical boundaries. The
vulnera bility of exposing one’s history in the treat ment setting can manifest in the client as feeling
physically vulnerable and unsafe in the treatment environment. Sudden or inade quately explained
treatment transitions, such as moving from one level of treatment to an other or changing
counselors, can also evoke feelings of danger, abandonment, or instabil ity. Early in treatment,
trauma survivors gen erally value routine and predictability. The counselor should recognize these
needs and respond appropriately by offering information in advance, providing nonshaming
responses to a client’s reactions to stimuli in his or her environment, and helping the client build a
daily structure that feels safe. A third aspect of safety is preventing a recur rence of trauma. People
with histories of trauma and substance abuse are more likely to engage in high-risk behaviors and to
experi ence subsequent traumas. Early treatment should focus on helping clients stop using unsafe
coping mechanisms, such as substance abuse, self-harm, and other self-destructive behaviors, and
replacing them with safe and healthy coping strategies. Helping clients learn to protect themselves
in reasonable ways is a positive goal of treatment. Prevent Retraumatization A key objective in TIC is
to prevent retrauma tization generated by intervention and treat ment practices and policies.
Unfortunately, treatment settings and clinicians can 113 Advice to Counselors: Strategies To Prevent
Retraumatization Strategy #1: Be sensitive to the needs of clients who have experienced trauma
regarding behaviors in the treatment setting that might trigger memories of the trauma. Strategy #2:
Do not ignore clients’ symptoms and demands when clients with trauma histories act out in
response to triggered trauma memories; doing so may replicate t he original traumatic experience.
Strategy #3: Be mindful that efforts to control and contain a client’s behaviors in treatment can pro
duce an abnormal reaction, particularly for trauma survivors for whom being trapped was part of the
trauma experience. Strategy #4: Listen for specific triggers that seem to be driving the client’s
reaction. An important step in recovery is helping the client identify these cues and thereby reach a
better understanding of reactions and behaviors. Trauma-Informed Care in Behavioral Health
Services unintentionally create retraumatizing experi ences (for a review of traumas that can occur
when treating serious mental illness, see Frueh et al., 2005). For instance, compassionate in quiry
into a client’s history can seem similar to the interest shown by a perpetrator many years before.
Direct confrontation by counselors about behaviors related to substance abuse can be seen, by
someone who has been repeatedly physically assaulted, as provocation building up to assault.
Counselor and program efforts to help clients constrain destructive behaviors can be interpreted as
efforts to control and dominate the individual. Intrusive shaming or insensitive behavior
demonstrated by another client in the program can threaten a trauma survivor whose boundaries
have been disre garded in the past—thus making the experi ence of treatment feel dangerous rather
than safe. Some staff and agency issues that can result in retraumatization include: • Disrespectfully
challenging reports of abuse or other traumatic events. • Discounting a client’s report of a traumatic
event. • Using isolation. • Using physical restraints. • Allowing the abusive behavior of one client
toward another to continue without intervention. • Labeling intense rage and other feelings as
pathological. • Minimizing, discrediting, or ignoring client responses. • Disrupting counselor–client
relationships by changing counselors’ schedules and as signments. • Obtaining urine specimens in a
nonprivate and/or disrespectful manner. • Having clients undress in the presence of others. • Being
insensitive to a client’s physical or emotional boundaries. • Inconsistently enforcing rules and
allowing chaos in the treatment environment. • Applying rigid agency policies or rules without an
opportunity for clients to ques tion them. • Accepting agency dysfunction, including a lack of
consistent, competent leadership. Provide Psychoeducation Trauma-informed education informs
clients about traumatic stress and trauma-related symptoms and disorders as well as the related
consequences of trauma exposure. It focuses on giving information to clients to help nor malize
presenting symptoms, to highlight po tential short-term and long-term consequences of trauma and
various paths to recovery, and to underscore the message that recovery is possible. Education
frequently takes place prior to or immediately following an initial screening as a way to prepare
clients 114 Part 1, Chapter 5—Clinical Issues Across Services Advice to Counselors: Strategies To
Implement Psychoeducation Strategy #1: Remember that this may be the client’s first experience
with treatment. It’s easy to use program or clinical jargon when you’re around it every day, but most
individuals who seek help are unfamiliar with clinical language, how the program works, and
treatment objectives. Psychoeducation begins with understanding the client’s expectations and
reasons for seeking help, followed by edu cating the client and other family members about the
program. Remember that this is all new for them. Strategy #2: After obtaining acknowledgment of a
trauma history, provide an overview of common symptoms and consequences of traumatic stress,
regardless of whether the client affirms having trauma-related symptoms. It is equally important to
educate the client on resilience factors associat ed with recovery from trauma (Wessely et al., 2008).
A trauma-informed perspective provides a mes sage that trauma reactions are normal responses to
an abnormal situation. Strategy #3: Develop a resource box that provides an array of printed or
multimedia educational materials that address the program, specific symptoms and tools to combat
trauma-related symp toms, treatment options and therapy approaches, advantages of peer support,
and steps in develop ing specific coping strategies. Strategy #4: Develop a rotating educational group
that matches services and client schedules to complement treatment. Remember that education can
play a pivotal role in enhancing motivation, in normalizing experiences, and in creating a sense of
safety as individuals move further into treatment. For some survivors, education can be a powerful
intervention or prevention strategy. for hearing results or to place the screening and subsequent
assessment findings in proper context. Education in and of itself, however, does not necessarily
constitute a stand-alone treatment; rather, it can be conceptualized as a first step and/or
component of more compre hensive treatment. Nonetheless, education may be a prevention and
intervention strategy for individuals who have histories of trauma without current consequences or
symptoms and/or those who have reported a resolution of past trauma(s). For example, some
clients may have significantly delayed onset of trau matic stress symptoms. In this scenario, earlier
education can enhance recognition of symp toms and ease the path of seeking treatment. Some
clients do not recognize the link be tween their current difficulties and their trau ma histories;
education can help them understand the possible origin of their diffi culties. Psychoeducation
presents trauma related symptoms that follow a trauma as normal reactions. By identifying the
source of clients’ current difficulties and framing them as normal thoughts, emotions, and behaviors
in response to trauma, many trauma survivors report a reduction in the intensity of the diffi culties
or symptoms. Often, a client will ex press relief that his or her reactions are normal. You may find the
U.S. Department of Veterans Affairs (VA) National Center on PTSD’s educational handouts on
traumatic stress reactions useful. Psychoeducation goes beyond the identifica tion of traumatic
stress symptoms and/or learning about the psychological, cognitive, and physical impacts of trauma.
Numerous curricula are available that use psychoeduca tion as a first-line or complementary
approach to trauma-specific therapies to enhance coping strategies in key areas, including safety,
emo tional regulation, help-seeking, avoidant be havior, and so forth. An example is S.E.L.F., a
trauma-informed psychoeducational group curriculum with educational components re lated to
trauma recovery in the following 115 Trauma-Informed Care in Behavioral Health Services Case
Illustration: Linda Linda served as an Army nurse in an evacuation hospital in Vietnam. She reported
her postdeploy ment adjustment as difficult and isolating but denied any significant symptoms of
traumatic stress throughout her life. Four years ago, Linda sought treatment for alcohol
dependence; during the in take, she recalls denying trauma-related symptoms. “I distinctly
remember the session,” she re counts. “The counselor first took my history but then gave
information on typical symptoms and reactions to trauma. I thought, ‘Why do I need to hear this?
I’ve survived the worst trauma in my life.’ I didn’t see the value of this information. Then 3 weeks
ago, I began to have recurrent nightmares, the same graphic type I occasionally had when I was in
Vietnam. Since then, I’ve been very anxious, reliving horrible scenes that I’d experienced as a nurse
and postponing going to bed in fear of having the dreams again. I didn’t understand it. I am 70 years
old, and the war happened a long time ago. Then I began putting it together. Recently, the
emergency helicopter flight pattern and approach to the area’s hospital changed. I began hearing
the helicopter periodically in my living room, and it re minded me of Vietnam. I knew then that I
needed help; I couldn’t stop shaking. I felt as if I was losing control of my emotions. I remembered
how the intake counselor took the time to explain common symptoms of trauma. That’s why I’m
here today.” “This might not sound like a big deal, but for many people relationships have become
all about getting: telling your problem story and then getting help with it. There is little, if any,
emphasis placed on giving back. That’s a big deal!!! Service relationships are like a one -way street
and both people’s roles are clearly defined. But in ‘regular’ relationships in your community, people
give and take all the time. No one is permanently on the taking side or the giving side. This exchange
contributes to people feeling ok about being vulnerable (needing help) as well as confident about
what they’re offering. For many of us, being the role of ‘getter’ all the time has shaken our
confidence, making us feel like we have nothing worthwhile to contribute. Peer support breaks that
all down. It gets complicated somewhat when one of us is paid, but modeling this kind of
relationship in which both of us learn, offers us the real practice we need to feel like a ‘regular’
community member as opposed to an ‘integrated mental patient’.” (Mead, 2008, p.7) 116 areas:
creating Safety, regulating Emotions, addressing Loss, and redefining the Future (Bloom, Foderaro, &
Ryan, 2006). Offer Trauma-Informed Peer Support Living with a history of trauma can be isolat ing
and consuming. The experience of trauma can reinforce beliefs about being different, alone, and
marred by the experience. At times, behavioral health treatment for trauma-related effects can
inadvertently reinforce these be liefs. Simply engaging in treatment or receiv ing specialized services
(although warranted) can further strengthen clients’ beliefs that there is something wrong with
them. Formal ized peer support can enhance the treatment experience. Treatment plus peer
support can break the cycle of beliefs that reinforce trau matic stress (e.g., believing that one is
perma nently damaged; that nobody could understand; that no one should or could toler ate one’s
story). Peer support provides oppor tunities to form mutual relationships; to learn how one’s history
shapes perspectives of self, others, and the future; to move beyond trau ma; and to mirror and learn
alternate coping strategies. Peer support defines recovery as an Part 1, Chapter 5—Clinical Issues
Across Services Advice to Counselors: Strategies To Enhance Peer Support Strategy #1: Provide
education on what peer support is and is not. Roles and expectations of peer support can be
confusing, so providing clarification in the beginning can be quite useful. It is im portant to provide
initial education about peer support and the value of using this resource. Strategy #2: Use an
established peer support curriculum to guide the peer support process. For ex ample, Intentional
Peer Support: An Alternative Approach (Mead, 2008) is a workbook that highlights four main tasks
for peer support: building connections, understanding one’s worldview, developing mutuality, and
helping each other move toward set desires and goals. This curriculum provides exten sive materials
for peer support staff members as well as for the individuals seeking peer support. interactive
process, not as a definitive moment wherein someone fixes the “problem.” Normalize Symptoms
Symptoms of trauma can become serious bar riers to recovery from substance use and men tal
disorders, including trauma-related ones. Counselors should be aware of how trauma Advice to
Counselors: Strategies To Normalize Symptoms Strategy #1: Provide psychoeducation on the
common symptoms of traumatic stress. Strategy #2: Research the client’s most preva lent symptoms
specific to trauma, and then provide education to the client. For example, an individual who was
conscious and trapped during or as a result of a traumatic event will more likely be hypervigilant
about exits, plan escape routes even in safe environments, and have strong reactions to
interpersonal and environmental situations that are perceived as having no options for avoidance or
resolution (e.g., feeling stuck in a work environment where the boss is emotionally abusive). Strategy
#3: First, have the client list his or her symptoms. After each symptom, ask the client to list the
negative and positive consequences of the symptom. Remember that symptoms serve a purpose,
even if they may not appear to work well or work as well as they had in the past. Focus on how the
symptoms have served the client in a positive way (see Case Illustra tion: Hector). This exercise can
be difficult, because clients as well as counselors often don’t focus on the value of symptoms.
symptoms can present and how to respond to them when they do appear. A significant step in
addressing symptoms is normalizing them. People with traumatic stress symptoms need to know
that their symptoms are not unique and that their reactions are common to their experience(s).
Often, normalizing symptoms gives considerable relief to clients who may have thought that their
symptoms signified some pervasive, untreatable mental disorder. Case Illustration: Hector Hector
was referred to a halfway house special izing in co-occurring disorders after inpatient treatment for
methamphetamine dependence and posttraumatic stress disorder (PTSD). In the halfway house, he
continued to feel over whelmed with the frequency and intensity of flashbacks. He often became
frustrated, ex pressing anger and a sense of hopelessness, followed by emotional withdrawal from
others in the house. Normalization strategy #3 was introduced in the session. During this exercise,
he began to identify many negative aspects of flashbacks. He felt that he couldn’t control the
occurrence of flashbacks even though he want ed to, and he realized that he often felt shame
afterward. In the same exercise, he was also urged to identify positive aspects of flashbacks.
Although this was difficult, he realized that flashbacks were clues about content that he needed to
address in trauma-specific treat ment. “I realized that a flashback, for me, was a billboard advertising
what I needed to focus on in therapy.” 117 Trauma-Informed Care in Behavioral Health Services
Identify and Manage Trauma Related Triggers Many clients who have traumatic stress are caught off
guard with intrusive thoughts, feel ings, sensations, or environmental cues of the trauma. This
experience can be quite discon certing, but often, the individual does not draw an immediate
connection between the internal or external trigger and his or her reac tions. At other times, the
trigger is so potent that the individual is unable to discern the present trigger from the past trauma
and be gins to respond as if the trauma is reoccurring. Key steps in identifying triggers are to reflect
back on the situation, surroundings, or sensa tions prior to the strong reaction. By doing so, you and
your client may be able to determine the connections among these cues, the past trauma(s), and the
client’s reaction. Once the cue is identified, discuss the ways in which it is connected to past trauma.
For some cues, there will be an obvious and immediate con nection (e.g., having someone say “I love
you” in a significant relationship as an adult and connecting this to an abuser who said the same
thing prior to a sexual assault). Other Advice to Counselors: Strategies To Identify and Manage
Trauma-Related Triggers Strategy #1: Use the Sorting the Past From the Present technique for
cognitive realignment (Blackburn, 1995) to help separate the current situation from the past trauma.
Identify one trigger at a time, and then discuss the following questions with the client: • When and
where did you begin to notice a reaction? • How does this situation remind you of your past history
or past trauma? • How are your reactions to the current situation similar to your past reactions to
the trauma(s)? • How was this current situation different from the past trauma? • How did you react
differently to the current situation than to the previous trauma? • How are you different today (e.g.,
factors such as age, abilities, strength, level of support)? • What choices can you make that are
different from the past and that can help you address the current situation (trigger)? After reviewing
this exercise several times in counseling, put the questions on a card for the client to carry and use
outside of treatment. Clients with substance use disorders can benefit from using the same
questions (slightly reworded) to address relapse triggers. Strategy #2: After the individual identifies
the trigger and draws connections between the trigger and past trauma, work with him or her to
establish responses and coping strategies to deal with triggers as they occur. Initially, the planned
responses will not immediately occur after a trigger, but with practice, the planned responses will
move closer to the time of the trigger. Some strategies include an acronym that reflects coping
strategies (Exhibit 1.5-1), positive self-talk generated by cognitive–behavioral covert modeling
exercises (rehearsal of coping statements), breathing retrain ing, and use of support systems (e.g.,
calling someone). Strategy #3: Self-monitoring is any strategy that asks a client to observe and
record the number of times something happens, to note the intensity of specific experiences, or to
describe a specific behavioral, emotional, or cognitive phenomenon each time it occurs. For
individuals with histories of trauma, triggers and flashbacks can be quite frightening, intense, and
powerful. Even if the client has had just one or two triggers or flashbacks, he or she may perceive
flashbacks as happening constantly. Often, it takes time to recover from these experiences. Using
self-monitoring and asking the client to record each time a trigger occurs, along with describing the
trigger and its intensity level (using a scale from 1–10), clients and counselors will gain an
understanding of the type of triggers present and the level of distress that each one produces.
Moreover, the client may begin to see that the triggers don’t actually happen all the time, even
though they may seem to occur frequently. 118 Part 1, Chapter 5—Clinical Issues Across Services
Exhibit 1.5-1: The OBSERVATIONS Coping Strategy • Take a moment to just Observe what is
happening. Pay attention to your body, your senses, and your environment. • Focus on your
Breathing. Allow your feel ings and sensations to wash over you. Breathe. • Name the Situation that
initiated your response. In what way is this situation fa miliar to your past? How is it different? •
Remember that Emotions come and go. They may be intense now, but later they will be less so.
Name your feelings. • Recognize that this situation does not de fine you or your future. It does not
dictate how things will be, nor is it a sign of things to come. Even if it is familiar, it is only one event.
• Validate your experience. State, at least internally, what you are feeling, thinking, and
experiencing. • Ask for help. You don’t have to do this alone. Seek support. Other people care for
you. Let them! • This too shall pass. Remember: There are times that are good and times that are
not so good. This hard time will pass. • I can handle this. Name your strengths. Your strengths have
helped you survive. • Keep an Open mind. Look for and try out new solutions. • Name strategies that
have worked before. Choose one and apply it to this situation. • Remember you have survived. You
are a Survivor! cues will not be as obvious. With practice, the client can begin to track back through
what occurred immediately before an emotional, physical, or behavioral reaction and then ex amine
how that experience reminds him or her of the past. Draw Connections Mental health and substance
abuse treatment providers have historically underestimated the effects of trauma on their clients for
many reasons. Some held a belief that substance Advice to Counselors: Strategies To Help Clients
Draw Connections Strategy #1: Writing about trauma can help clients gain awareness of their
thoughts, feel ings, and current experiences and can even improve physical health outcomes
(Pennebaker, Kiecolt-Glaser, & Glaser, 1988; Smyth, Hockemeyer, & Tulloch, 2008). Although this
tool may help some people draw connections between current experiences and past traumas, it
should be used with caution; others may find that it brings up too much intense trauma mate rial
(especially among vulnerable trauma survi vors with co-occuring substance abuse, psychosis, and
current domestic violence). Jour nal writing is safest when you ask clients to write about present-day
specific targets, such as log ging their use of coping strategies or identifying strengths with examples.
Writing about trauma can also be done via key questions or a work book that provides questions
centered upon trauma experiences and recovery. Strategy #2: Encourage clients to explore the links
among traumatic experiences and mental and substance use disorders. Recognition that a mental
disorder or symptom developed after the trauma occurred can provide relief and hope that the
symptoms may abate if the trauma is addressed. Ways to help clients con nect substance use with
trauma histories in clude (Najavits, 2002b; Najavits, Weiss, & Shaw, 1997): • Identifying how
substances have helped “solve” trauma or PTSD symptoms in the short term (e.g., drinking to get to
sleep). • Teaching clients how trauma, mental, and substance use disorders commonly co occur so
that they will not feel so alone and ashamed about these issues. • Discussing how substance abuse
has im peded healing from trauma (e.g., by block ing feelings and memories). • Helping clients
recognize trauma symp toms as triggers for relapse to substance use and mental distress. • Working
on new coping skills to recover from trauma and substance abuse at the same time. • Recognizing
how both trauma and sub stance abuse often occur in families through multiple generations. 119
The Subjective Units of Distress Scale (SUDS) uses a 0 –10 rating scale, with 0 representing content
that causes no or minimal distress and 10 representing content that is exceptionally distressing and
overwhelming. (Wolpe & Abrams, 1991) Advice to Counselors: Strategy To Teach Balance Strategy
#1: Teach and use the SUDS in counseling. This scale can be useful from the outset as a barometer
for the client and counselor to measure the level of distress during and outside of sessions. It
provides a common language for the client and counselor, and it can also be used to guide the
intensity of sessions. SUDS can tangibly show a client’s progress in managing experiences. Without a
scale, it is more difficult to grasp that a distressing symptom or circumstance is becoming less and
less severe without some repeated measure. Trauma-Informed Care in Behavioral Health Services
abuse should be addressed before attending to any co-occurring conditions. Others did not have the
knowledge and training to evaluate trauma issues or were uncomfortable or reluc tant to discuss
these sensitive issues with cli ents (Ouimette & Brown, 2003). Similarly, in other behavioral health
settings, clinicians sometimes address trauma-related symptoms but do not have experience or
training in the treatment of substance abuse. So too, people who have histories of trauma will often
be unaware of the connection be tween the traumas they’ve experienced and their traumatic stress
[Link] may no tice depression, anger, or anxiety, or they may describe themselves as “going
crazy” without being able to pinpoint a specific experience that produced the trauma symptoms.
Even if clients recognize the events that precipitated their trauma symptoms, they may not
understand how others with similar experiences can have different reactions. Thus,a treatment goal
for trauma survivors is helping them gain aware ness of the connections between their histories of
trauma and subsequent consequences. Seeing the connections can improve clients’ ability to work
on recovery in an integrated fashion. Teach Balance You and your clients need to walk a thin line
when addressing trauma. Too much work focused on highly distressing content can turn a
desensitization process into a session where by the client dissociates, shuts down, or be comes
emotionally overwhelmed. On the other hand, too little focus by the client or counselor can easily
reinforce avoidance and confirm the client’s internal belief that it is too dangerous to deal with the
aftermath of the trauma. Several trauma-specific theories offer guidelines on acceptable levels of
distress asso ciated with the traumatic content that the therapy addresses. For example, some tradi
tional desensitization processes start at a very low level of subjective distress, gradually work ing up
through a hierarchy of trauma memo ries and experiences until those experiences produce minimal
reactions when paired with some coping strategy, such as relaxation train ing. Other desensitization
processes start at a higher level of intensity to provide more rapid extinction of traumatic
associations and to decrease the risk of avoidance—a behavior that reinforces traumatic stress.
Working with trauma is a delicate balancing act between the development and/or use of coping
strategies and the need to process the traumatic experiences. Individuals will choose different paths
to recovery; it’s a myth that every traumatic experience needs to be ex pressed and every story told.
For some indi viduals, the use of coping skills, support, and spirituality are enough to recover.
Regardless of theoretical beliefs, counselors must teach 120 Advice to Counselors: Strategies To
Build Resilience Strategy #1: Help clients reestablish personal and social connections. Access
community and cultural resources; reconnect the person to healing resources such as mutual-help
groups and spiritual supports in the community. Strategy #2: Encourage t he client to take ac tion.
Recovery requires activity. Actively taking care of one’s own needs early in treatment can evolve into
assisting others later on, such as by volunteering at a community organization or helping military
families. Strategy #3: Encourage stability and predicta bility in the daily routine. Traumatic stress
reac tions can be debilitating. Keeping a daily routine of sleep, eating, work, errands, house hold
chores, and hobbies can help the client see that life continues. Like exercise, daily liv ing skills take
time to take hold as the client learns to live through symptoms. Strategy #4: Nurture a positive view
of per sonal, social, and cultural resources. Help cli ents recall ways in which they successfully
handled hardships in the past, such as the loss of a loved one, a divorce, or a major illness. Revisit
how those crises were addressed. Strategy #5: Help clients gain perspective. All things pass, even
when facing very painful events. Foster a long-term outlook; help clients consider stress and
suffering in a spiritual context. Strategy #6: Help maintain a hopeful outlook. An optimistic outlook
enables visions of good things in life and can keep people going even in the hardest times. There are
positive aspects to everyone’s life. Taking time to identify and appreciate these enhances the client’s
outlook and helps him or her persevere. Strategy #7: Encourage participation in peer support, 12-
Step, and other mutual-help programs. Source: American Psychological Association, 2003. Part 1,
Chapter 5—Clinical Issues Across Services coping strategies as soon as possible. Retrau matization is
a risk whenever clients are ex posed to their traumatic histories without sufficient tools, supports,
and safety to manage emotional, behavioral, and physical reactions. Build Resilience Survivors are
resilient! Often, counselors and clients who are trauma survivors focus on the negative
consequences of trauma while failing to recognize the perseverance and attributes that have helped
them survive. It is natural to focus on what’s not working rather than what has worked. To promote
growth after trauma and establish a strengths-based approach, fo cus on building on clients’
resilience. Current resilience theories claim that building or rein forcing resilience prevents further
development of trauma-related symptoms and [Link] following Advice to Counselors box is
adapted from the American Psychological Association’s 2003 statement on resilience. Address Sleep
Disturbances Sleep disturbances are one of the most endur ing symptoms of traumatic stress and
are a particularly common outcome of severe and prolonged trauma. Sleep disturbances increase
one’s risk of developing traumatic stress; they significantly alter physical and psychological
processes, thus causing problems in daytime functioning (e.g., fatigue, cognitive difficulty, excessive
daytime sleepiness). People with sleep disturbances have worse general health and quality of life.
The cardiovascular and immune systems, among others, may be affect ed as well. Sleep disturbances
can worsen traumatic stress symptoms and interfere with healing by impeding the brain’s ability to
pro cess and consolidate traumatic memories (Caldwell & Redeker, 2005). Sleep disturbances vary
among trauma survi vors and can include decreased ability to stay asleep, frequent awakenings,
early morning unintentional awakening, trouble falling asleep, poor quality of sleep, and disordered
121 Trauma-Informed Care in Behavioral Health Services Advice to Counselors: Strategies To
Conduct a Sleep Intervention Strategy #1: Conduct a sleep history assessment focused first on the
client’s perception of his or her sleep patterns. Assess whether there is difficulty initiating or staying
asleep, a history of frequent or early morning awakenings, physically restless sleep, sleepwalking,
bedtime aversion, and/or disrup tive physical and emotional states upon awakening (e.g., confusion,
agitation, feeling unrested). Also determine total sleep time, pattern of nightmares, and use of
medications, alcohol, and/or caffeine (see Moul, Hall, Pikonis, & Buysse, 2004, for a review of self-
report measures). Strategy #2: Use a sleep hygiene measure to determine the presence of habits
that typically inter fere with sleep (e.g., falling asleep while watching television). The National Sleep
Foundation Web site ([Link] provides simple steps for promoting good
sleep hygiene.. Strategy #3: Provide education on sleep hygiene practices. Introduce clients to the
idea that practic ing good sleep hygiene is one step toward gaining control over their sleep
disturbances. Strategy #4: Reassess sleep patterns and history during the course of treatment. Sleep
patterns often reflect current client status. For example, clients who are struggling are more likely to
have disturbed sleep patterns; sleep disturbances significantly influence clients’ mental health
status. Strategy #5: Use interventions such as nightmare rehearsals to target recurrent nightmares.
There are numerous examples of imagery-based nightmare rehearsals. Clients may be instructed to
re hearse repetitively the recurrent nightmare a few hours before bedtime. In this instruction, the
client either rehearses the entire nightmare with someone or visualizes the nightmare several times
to gain control over the material and become desensitized to the content. Other strategies involve
imagin ing a change in the outcome of the nightmare (e.g., asking the client to picture getting
assistance from others, even though his or her original nightmare reflects dealing with the
experience alone). breathing during sleep (Caldwell & Redeker, 2005). Most traumatic stress
literature focuses on nightmares, insomnia, and frequent awak enings. These disturbances are
connected to two main symptoms of traumatic stress: hy perarousal (which causes difficulty in
falling and remaining asleep) and reexperiencing the trauma (e.g., through recurrent nightmares).
Case Illustration: Selena Other sleep disturbances trauma survivors report include sleep avoidance or
resistance to sleep (see Case Illustration: Selena), panic awakenings, and restless or unwanted body
movements (e.g., hitting your spouse uninten tionally in bed while asleep; Habukawa, Maeda, &
Uchimura, 2010). Selena initially sought treatment for ongoing depression (dysthymia). During
treatment, she identified being sexually assaulted while attending a party at college. At times, she
blames herself for the inci dent because she didn’t insist that she and her girlfriends stay together
during the party and on the way back to their dorm afterward. Selena reported that she only had
two drinks that night: “I could never manage more than two drinks before I wanted to just sleep, so I
never drank much socially.” She was assaulted by someone she barely knew but considered a “big
brother” in the brother frater nity of her sorority. “I needed a ride home. During that ride, it
happened,” she said. For years there after, Selena reported mild bouts of depression that began
lasting longer and increasing in number. She also reported nightmares and chronic difficulty in falling
asleep. In therapy, she noted avoiding her bed until she’s exhausted, saying, “I don’t like going to
sleep; I know what’s going to happen.” She describes fear of sleeping due to nightmares. “It’s
become a habit at night. I get very involved in playing computer games to lose track of time. I also
leave the television on through the night be cause then I don’t sleep as soundly and have fewer
nightmares. But I’m always exhausted.” 122 Advice to Counselors: Strategies To Build Trust Strategy
#1: Clients can benefit from a support or counseling group composed of other trauma sur vivors. By
comparing themselves with others in the group, they can be inspired by those who are further along
in the recovery process and helpful to those who are not faring as well as they are. These groups also
motivate clients to trust others by experiencing acceptance and empathy. Strategy #2: Use conflicts
that arise in the program as opportunities. Successful negotiation of a conflict between the client
and the counselor is a major milestone (van der Kolk, McFarlane, & Van der Hart, 1996). Helping
clients understand that conflicts are healthy and inevitable in relationships (and that they can be
resolved while retaining the dignity and respect of all involved) is a key lesson for those whose
relationship conflicts have been beset by violence, bitterness, and humiliation. Strategy #3: Prepare
clients for staff changes, vacations, or other separations. Some clients may feel rejected or
abandoned if a counselor goes on vacation or is absent due to illness, especially during a period of
vulnerability or intense work. A phone call to the client during an unexpected absence can reinforce
the importance of the relationship and the client’s trust. You can use these opportunities in
treatment to help the client understand that separation is part of relationships; work with the client
to view separation in a new light. Strategy #4: Honor the client–counselor relationship, and treat it
as significant and mutual. You can support the development of trust by establishing clear
boundaries, being dependable, working with the client to define explicit treatment goals and
methods, and demonstrating respect for the client’s difficulty in trusting you and the therapeutic
setting. Part 1, Chapter 5—Clinical Issues Across Services Build Trust Some traumatic experiences
result from trust ing others (e.g., interpersonal trauma). In oth er cases, trust was violated during or
after the traumatic experience, as in cases when help was late to arrive on the scene of a natural
disaster. This lack of trust can leave individuals alienated, socially isolated, and terrified of
developing relationships. Some feel that the trauma makes them different from others who haven’t
had similar experiences. Sometimes, a client’s trust issues arise from a lack of trust in self—for
instance, a lack of trust in one’s per ceptions, judgment, or memories. People who have also
experienced severe mental or sub stance use disorders may have difficulty trust ing others because,
during the course of their illness, they felt alienated or discriminated against for behaviors and
emotions generated by or associated with the disorders. Some client groups (e.g., gay, lesbian, and
bi sexual clients; people from diverse cultures; those with serious mental illness) evidence significant
mistrust because their trust has been repeatedly violated in the past. Traumatic experiences then
compound this mistrust. Mistrust can come from various sources, is usually unstated, and, if left
unaddressed, can impede treatment. For example, some clients leave treatment early or do not
engage in po tentially beneficial treatments. Others avoid issues of trust and commitment by leaving
treatment when those issues begin to arise. Establishing a safe, trusting relationship is paramount to
healing—yet this takes time in the counseling process. Counselors and other behavioral health
professionals need to be consistent throughout the course of treatment; this includes maintaining
consistency in the parameters set for availability, attendance, and level of empathy. Trust is built on
behavior shown inside and outside of treatment; you should immediately address any behavior that
may even slightly injure the relationship (e.g., being 5 minutes late for an appointment, not
responding to a phone message in a timely manner, being distracted in a session). 123 Trauma-
Informed Care in Behavioral Health Services Support Empowerment Strong feelings of
powerlessness can arise in trauma survivors seeking to regain some con trol of their lives. Whether a
person has sur vived a single trauma or chronic trauma, the survivor can feel crushed by the weight
of powerlessness. Mental illness and substance abuse, too, can be disempowering; clients may feel
that they’ve lost control over their daily lives, over a behavior such as drug use, or over Case
Illustration: Abby powerful emotions such as fear, sadness, or anger. Empowerment means helping
clients feel greater power and control over their lives, as long as such control is within safe and
healthy bounds. A key facet of empowerment is to help clients build on their strengths. Em
powerment is more than helping clients dis cover what they “should” do; it is also helping them take
the steps they feel ready to take. Abby, a 30-year-old, nervous-looking woman, is brought by her
parents to a community mental health clinic near their home in rural Indiana. During the intake
process, the counselor learns that Abby is an Army Reservist who returned from 12 months of
combat duty 3 years ago. The war expe rience changed her in many ways. Her deployment pulled
her away from veterinary school as well as the strong emotional support of family, friends, and
fellow classmates. She got along with her unit in Iraq and had no disciplinary problems. While there,
she served as a truck driver in the Sunni Triangle. Her convoy was attacked often by small arms fire
and was once struck by an improvised explosive device. Although Abby sustained only minor injuries,
two of her close friends were killed. With each successive convoy, her level of fear and foreboding
grew, but she continued performing as a driver. Since returning to the United States, she has mostly
stayed at home and has not returned to school, although she i s helping out on the farm with various
chores. Abby has isolated herself from both family members and lifelong friends, saying she doesn’t
think others can understand what she went through and that she prefers being alone. She reports to
her parents and the counselor that she is vaguely afraid to be in cars and feels most comfortable in
her room or working alone, doing routine tasks, at home. Abby also says that she now understands
how fragile life can be. She has admitted to her parents that she drinks alcohol on a regular basis,
something she did not do before her deployment, and that on occasion, she has experienced
blackouts. Abby feels she needs a drink before talking with strangers or joining in groups of friends
or family. She confided to her father that she isolates herself so that she can drink without having to
explain her drinking to others. The counselor recognizes Abby’s general sense of lacking internal
control and feeling powerless over what will happen to her in the future. He adopts a motivational
interviewing style to establish rapport and a working alliance with Abby. During sessions, the
counselor asks Abby to elaborate on her strengths; he reinforces strengths that involve taking action
in life, positive self-statements, and comments that deal with future plans. He also introduces Abby
to an Iraq War veteran who came home quite discouraged about putting his life together but has
done well getting reintegrated. The counselor urges Abby go to the local VA center so that she can
meet and bond with other recently returned veterans. He also encourages Abby to attend Alcoholics
Anonymous meetings, emphasiz ing that she won’t be pressured to talk or interact with others more
than she chooses to. The counselor continues to see Abby every week and begins using cognitive–
behavioral techniques to help her examine some of her irrational fears about not being able to direct
her life. He asks Abby to keep a daily diary of activities related to achieving her goals of getting back
to school and reestablishing a social network. In each session, Abby reviews her progress using the
diary as a memory aid, and the counselor reinforces these positive efforts. After 4 months of
treatment, Abby reenrolls in college and is feeling optimistic about her ability to achieve her career
plans. 124 Part 1, Chapter 5—Clinical Issues Across Services Advice to Counselors: Strategies To
Support Empowerment Strategy #1: Offer clients information about treatment; help them make
informed choices. Placing appropriate control for treatment choices in the hands of clients improves
their chances of success. Strategy #2: Give clients the chance to collaborate in the development of
their initial treatment plan, in the evaluation of treatment progress, and in treatment plan updates.
Incorporate client input into treatment case consultations and subsequent feedback. Strategy #3:
Encourage clients to assume an active role in how the delivery of treatment services occurs. An
essential avenue is regularly scheduled and structured client feedback on program and clinical
services (e.g., feedback surveys). Some of the most effective initiatives to reinforce client em
powerment are the development of peer support services and the involvement of former clients in
parts of the organizational structure, such as the advisory board or other board roles. Strategy #4:
Establish a sense of self-efficacy in clients; their belief in their own ability to carry out a specific task
successfully—is key. You can help clients come to believe in the possibility of change and in the hope
of alternative approaches to achieving change. Supporting clients in accepting in creasing
responsibility for choosing and carrying out personal change can facilitate their return to
empowerment (Miller & Rollnick, 2002). Acknowledge Grief and Bereavement The experience of loss
is common after trau mas, whether the loss is psychological (e.g., no longer feeling safe) or physical
(e.g., death of a loved one, destruction of community, physical impairment). Loss can cause public
displays of grief, but it is more often a private experience. Grieving processes can be emotionally
over whelming and can lead to increased substance use and other impulsive behaviors as a way to
manage grief and other feelings associated with the loss. Even for people who experi enced trauma
years prior to treatment, grief is still a common psychological issue. Delayed or absent reactions of
acute grief can cause ex haustion, lack of strength, gastrointestinal symptoms, and avoidance of
emotions. Risk factors of chronic bereavement (grief lasting more than 6 months) can include: •
Perceived lack of social support. • Concurrent crises or stressors (including reactivation of PTSD
symptoms). • High levels of ambivalence about the loss. • An extremely dependent relationship
prior to the loss. • Loved one’s death resulting from disaster: unexpected, untimely, sudden, and
shock ing (New South Wales Institute of Psychi atry & Centre for Mental Health, 2000). Advice to
Counselors: Strategies To Acknowledge and Address Grief Strategy #1: Help the client grieve by
being present, by normalizing the grief, and by as sessing social supports and resources. Strategy #2:
When the client begins to discuss or express grief, focus on having him or her voice the losses he or
she experienced due to trauma. Remember to clarify that losses include internal experiences, not
just physical losses. Strategy #3: For a client who has difficulty connecting feelings to experiences,
assign a feelings journal in which he or she can log and name each feeling he or she experiences, rate
the feeling’s intensity numerically, and describe the situation during which the feeling occurred. The
client may choose to share the journal in an individual or group session. Strategy #4: Note that some
clients benefit from developing a ritual or ceremony to honor their losses, whereas others prefer
offering time or resources to an association that repre sents the loss. 125 Advice to Counselors:
Strategies To Monitor and Facilitate Stability Strategy #1: If destabilization occurs during the intake
process or treatment, stop exploring the material that triggered the reaction, offer emotional
support, and demonstrate ways for the client to self-soothe. Strategy #2: Seek consultation from
supervi sors and/or colleagues (e.g., to explore wheth er a new case conceptualization is needed at
this point). Strategy #3: Refer the client for a further as sessment to determine whether a referral is
necessary for trauma-specific therapy or a higher level of care, or use of multiple levels of care (e.g.,
intensive outpatient care, partial hospitalization, residential treatment). Strategy #4: Focus on coping
skills and en courage participation in a peer support program. Strategy #5: When a client becomes
agitated and distressed, carefully explore with the client what is causing this state. When such
feelings arise because of current threats in the client’s life or environment, it is dangerous to halt or
soothe away responses that act as warning signals (Pope & Brown, 1996). When a client is in a
situation involving domestic violence, lives in a dangerous neighborhood, or has run out of money
for food, he or she requires direct and concrete assistance rather than simple emo tional support.
Source: Briere & Scott, 2006b. Managing Destabilization When a client becomes destabilized during
a session, you can respond in the following man ner: “Let’s slow down and focus on helping you be
and feel safe. What can we do to allow you to take care of yourself at this moment? Then, when you
feel ready, we can decide what to focus on next.” Trauma-Informed Care in Behavioral Health
Services Monitor and Facilitate Stability Stability refers to an ongoing psychological and physical
state whereby one is not over whelmed by disruptive internal or external stimuli (Briere & Scott,
2006b). It’s common for individuals to have an increase in symp toms, distress, or impairment when
dealing with the impact of their trauma or talking about specific aspects of their trauma. There is a
thin line that the client and counselor need to negotiate and then walk when addressing trauma. Too
much work focused on highly distressing content can turn a desensitization process into a session
that causes the client to dissociate, shut down, or become emotionally overwhelmed. On the other
hand, too little focus by the client or counselor can easily rein force avoidance and confirm the
client’s inter nal belief that it is too dangerous to deal with the aftermath of the trauma. Clients
should have some psychological stabil ity to engage in trauma-related work. An im portant
distinction can be made between a normative increase in symptoms (e.g., the typ ical up-and-down
course of traumatic stress reactions or substance abuse) and destabiliza tion (dangerous, significant
decrease in func tioning). Signs of destabilization include (Green Cross Academy of Traumatology,
2007; Najavits, 2002b): • Increased substance use or other unsafe behavior (e.g., self-harm). •
Increased psychiatric symptoms (e.g., de pression, agitation, anxiety, withdrawal, anger). • Increased
symptoms of trauma (e.g., severe dissociation). • Helplessness or hopelessness expressed verbally or
behaviorally. • Difficulty following through on commit ments (e.g., commitment to attend treat ment
sessions). • Isolation. • Notable decline in daily activities (e.g., self-care, hygiene, care of children or
pets, going to work). 126 Advice to Counselors: Strategies To Foster Engagement Strategy #1:
According to Mahalik (2001), the standard method of handling clients’ lack of engagement is
exploring it with them, clari fying the situation through discussion with them, reinterpreting (e.g.,
from “can’t” to “won’t” to “willing”), and working through the situation toward progress. Strategy
#2: To improve engagement into treatment, try motivational interviewing and enhancement
techniques. For additional in formation on such techniques, see TIP 35, En hancing Motivation for
Change in Substance Abuse Treatment (Center for Substance Abuse Treatment [CSAT], 1999b). Part
1, Chapter 5—Clinical Issues Across Services Treatment Issues The treatment environment itself can
signifi cantly affect how clients experience traumatic stress and how the client responds to treat
ment. Some specific issues related to working with trauma survivors in a clinical setting are discussed
in the following sections. Client Engagement A lack of engagement in treatment is the cli ent’s
inability to make progress toward treat ment goals, deal with important topics in treatment, or
complete treatment. Clients who have histories of trauma will express ambiva lence about
treatment similarly to others, ex cept that clients who have traumatic stress can feel more “stuck”
and perceive themselves as having fewer options. In addition, clients may be avoiding engagement
in treatment because it is one step closer to addressing their trauma. You should attend to the
client’s motivation to change, implement strategies that address am bivalence toward treatment,
and use approach es that help clients overcome avoidant behavior. Pacing and Timing Although your
training or role as a counselor may prohibit you from providing trauma specific services, you must
still be prepared for the fact that clients are not as focused on when or where it is most appropriate
to ad dress trauma—they want relief, and most lay and professional people have been taught that
the only path to recovery is disclosure. Some clients are reluctant to talk about anything associated
with their histories of trauma. Oth er clients immediately want to delve into the memories of their
trauma without developing a safe environment. The need to gain any relief for the traumatic stress
pushes some individu als to disclose too quickly, without having the necessary support and coping
skills to manage the intensity of their memories. Clients who enter treatment and immediately
disclose past trauma often don’t return because the initial encounter was so intense or because they
ex perienced considerable emotional distress for several days afterward and/or in anticipation of the
next session. Proper pacing of sessions, disclosure, and in tensity is paramount. Clients who
immediate ly disclose without proper safety nets are actually retraumatizing themselves by reliving
the experience without adequate support— often placing themselves in the same circum stances
that occurred during the actual trau mas they experienced. Although you should not adamantly
direct clients not to talk about what happened, it is important to discuss with the clients, even if you
have to interrupt them empathically and respectfully, the potential consequences of disclosing too
soon and too fast. Ask whether they have done this before, and then inquire about the outcome.
Rein force with clients that trauma heals when there are support, trust, and skills in place to manage
the memories of the traumatic experi ences. Ideally, disclosure begins after these elements are
secured, but realistically, it is a 127 Trauma-Informed Care in Behavioral Health Services Advice to
Counselors: Strategies To Establish Appropriate Pacing and Timing Strategy #1: Frequently discuss
and request feedback from clients about pacing and timing. Moving too quickly into discussion of the
trauma can increase the risk of dissociation, overactivation of memories, and feeling overwhelmed.
Strategy #2: Use the SUDS as a barometer of intensity to determine the level of work. Strategy #3:
Slowly increase the speed of interventions and continually adjust the intensity of inter ventions;
move in and out of very intense work, or use strategies that decrease the intensity when necessary.
One approach that typically decreases the intensity of traumatic memories is to ask the individual to
imagine that he or she is seeing the scene through a window or on a television screen. This helps
decrease intensity and the risk of dissociation. It provides an opportunity for the client to view the
trauma from a different perspective and a strategy to use outside of treatment to shift from reliving
the trauma to observing it from a neutral position. Strategy #4: Monitor clients to ensure that
treatment does not overwhelm their internal capacities, retraumatize them, or result in excessive
avoidance; make sure therapy occurs in the “therapeutic window” (Briere & Scott, 2006b). Strategy
#5: Be alert to signs that discussions of trauma, including screening, assessment, and in take
processes, are going too fast. Mild to moderate signs are: • Missing counseling appointments after
discussions of important material. • Periods of silence. • Dissociation. • Misunderstanding what are
usually understandable concepts. • Redirecting the focus of the discussion when certain issues arise.
• Persistent resistance to addressing trauma symptoms. • Repetitive flashbacks. • Increase in
dissociation. • Regression. • Substance use relapses. Strategy #6: Observe the client’s emotional
state. Slow down; seek consultation if the client exhibits: • Difficulty in daily functioning (e.g.,
trouble maintaining everyday self-care tasks). • Self-harm or suicidal thoughts/behaviors (e.g.,
talking about suicide). Strategy #7: Use caution and avoid (Briere, 1996b, p. 115): • Encouraging
clients to describe traumatic material in detail before they can deal with the conse quences of
disclosure. • Using overly stressful interventions (e.g., intensive role-plays, group confrontation,
guided imagery). • Confrontations or interpretations that are too challenging given the client’s
current functioning. • Demanding that the client work harder and stop resisting. Source: Strategies
1–6: Green Cross Academy of Traumatology, 2001. Adapted with permission. balancing act for both
the counselor and client as to when and how much should be ad dressed in any given session.
Remember not to inadvertently give a message that it is too dan gerous to talk about trauma;
instead, reinforce the importance of addressing trauma without further retraumatization. Length of
Treatment Many factors influence decisions regarding the length of treatment for a given client.
Severity of addiction, type of substance abused, type of trauma, age at which the trauma occurred,
level of social support, and the existence of 128 Memories of Trauma Points for c ounselors to
remember are: • Some people are not able to completely remember past events, particularly events
that occurred during high-stress and de stabilizing moments. • In addition to exploring the memories
themselves, it can be beneficial to explore how a memory of an event helps the client understand his
or her feeling, thinking, and behaving in the present. • Persistently trying to recall all the details of a
traumatic event can impair focus on the present. Part 1, Chapter 5—Clinical Issues Across Services
mental disorders all influence length of treat ment. External factors, such as transportation and
childcare, caps on insurance coverage, and limitations in professional resources, can also affect
length of treatment. In general, longer treatment experiences should be expected for clients who
have histories of multiple or early traumas, meet diagnostic criteria for multiple Axis I or Axis II
diagnoses, and/or require intensive case management. Most of the em pirically studied and/or
manual-based models described in the next chapter are short-term models (e.g., lasting several
months); however, ongoing care is indicated for clients with more complex co-occurring trauma
disorders. Traumatic Memories One of the most controversial issues in the trauma field is the
phenomenon of “recovered memories” or “traumatic amnesia” (Brewin, 2007). Practitioners
working with traumatized individuals are particularly concerned about the possibility of new
memories of the trau matic event emerging during the course of therapy and the possibility of these
memories being induced by the clinician. Scientific re views indicate that people can experience am
nesia and delayed recall for some memories of a wide variety of traumas, including military combat
and prisoner of war experiences, natural disasters and accidents, childhood sexual abuse, and
political torture (Bowman & Mertz, 1996; Brewin, 2007; Karon & Widener, 1997; McNally, 2005). In
some cases, the survivor will not remember some of what happened, and the counselor may need to
help the client face the prospect of never knowing all there is to know about the past and accept
moving on with what is known. Legal Issues Legal issues can emerge during treatment. A client, for
instance, could seek to prosecute a perpetrator of trauma (e.g., for domestic vio lence) or to sue for
damages sustained in an accident or natural disaster. The counselor’s role is not to provide legal
advice, but rather, to offer support during the process and, if needed, refer the client to appropriate
legal help (see Advice to Counselors box on p. 131). A legal matter can dominate the treatment
atmosphere for its duration. Some clients have difficulty making progress in treatment until most or
all legal matters are resolved and no longer act as ongoing stressors. Forgiveness Clients may have all
sorts of reactions to what has happened to them. They may feel grateful for the help they received,
joy at having sur vived, and dedication to their recovery. At the other extreme, they may have
fantasies of re venge, a loss of belief that the world is a good place, and feelings of rage at what has
hap pened. They may hold a wide variety of beliefs associated with these feelings. One issue that
comes up frequently among counselors is whether to encourage clients to forgive. The issue of
forgiveness is a very deli cate one. It is key to allow survivors their feel ings, even if they conflict with
the counselor’s own responses. Some may choose to forgive the perpetrator, whereas others may
remain angry or seek justice through the courts and other legal means. Early in recovery from 129
Trauma-Informed Care in Behavioral Health Services Advice to Counselors: Strategies To Manage
Traumatic Memories Strategy #1: Most people who were sexually abused as children remember all
or part of what hap pened to them, although they do not necessarily fully understand or disclose it.
Do not assume that the role of the clinician is to investigate, corroborate, or substantiate allegations
or memories of abuse (American Psychiatric Association [APA], 2000b). Strategy #2: Be aware that
forgotten memories of childhood abuse can be remembered years later. Clinicians should maintain
an empathic, nonjudgmental, neutral stance toward reported memories of sexual abuse or other
trauma. Avoid prejudging the cause of the client’s difficulties or the veracity of the client’s reports. A
counselor’s prior belief that physical or sexual abuse, or other factors, are or are not the cause of the
client’s problems can interfere with appropriate assessment and treatment (APA, 2000b). Strategy
#3: Focus on assisting clients in coming to their own conclusions about the accuracy of their
memories or in adapting to uncertainty regarding what actually occurred. The therapeutic goal is to
help clients understand the impact of the memories or abuse experiences on their lives and to
reduce their detrimental consequences in the present and future (APA, 2000b). Strategy #4: Some
clients have concerns about whether or not a certain traumatic event did or did not happen. In such
circumstances, educate clients about traumatic memories, including the fact that memories aren’t
always exact representations of past events; subsequent events and emotions can have the effect of
altering the original memory. Inform clients that it is not always possible to deter mine whether an
event occurred but that treatment can still be effective in alleviating distress. Strategy #5: There is
evidence that suggestibility can be enhanced and pseudomemories can devel op in some individuals
when hypnosis is used as a memory enhancement or retrieval strategy. Hyp nosis and guided
imagery techniques can enhance relaxation and teach self-soothing strategies with some clients;
however, use of these techniques is not recommended in the active exploration of memories of
abuse (Academy of Traumatology, 2007). Strategy #6: When clients are highly distressed by intrusive
flashbacks of delayed memories, help them move through the distress. Teach coping strategies and
techniques on how to tolerate strong affect and distress (e.g., mindfulness practices). trauma, it is
best to direct clients toward fo cusing on stabilization and a return to normal functioning; suggest
that, if possible, they de lay major decisions about forgiveness until they have a clearer mind for
making decisions (Herman, 1997). Even in later stages of recov ery, it ’s not essential for the client to
forgive in order to recover. Forgiveness is a personal choice independent of recovery. Respect cli
ents’ personal beliefs and meanings; don’t push clients to forgive or impose your own beliefs about
forgiveness onto clients. In the long-term healing process, typically months or years after the
trauma(s), for giveness may become part of the discussion for 130 some people and some
communities. For ex ample, in South Africa, years after the bitter and bloody apartheid conflicts, a
Truth and Reconciliation Commission was established by the Government. Public hearings created
dia log and aired what had been experienced as a means, ultimately, to promote forgiveness and
community healing. By addressing very diffi cult topics in public, all could potentially benefit from
the discourse. Similarly, a paren tal survivor of the Oklahoma City bombing was, at first, bitter about
his daughter’s early, unfair, and untimely death. Today, he gives talks around the world about the
abolition of the death penalty. He sat with convicted Part 1, Chapter 5—Clinical Issues Across
Services Advice to Counselors: Strategies To Manage Legal Proceedings Strategy #1: If you’re aware
of legal proceedings, you can play a key role in helping your client pre pare emotionally for their
impact, such as what it might be like to describe the trauma to a judge or jury, or how to cope with
seeing the perpetrator in court. When helping a client prepare, however, be careful not to provide
legal advice. Strategy #2: Help clients separate a successful legal outcome from a successful
treatment outcome. If clients connect these two outcomes, difficulties can arise. For example, a
client may discontinue treatment after his or her assailant is sentenced to serve prison time,
believing that the symptoms will abate without intervention. Strategy #3: If clients express interest
in initiating a civil or criminal suit, encourage them to consider the ways in which they are and are
not prepared for this, including their own mental states, capacity for resilience, and inevitable loss of
confidentiality (Pope & Brown, 1996). Inform clients coping with legal issues that involvement in the
legal process can be retraumatizing. • What to expect during police investigations. • Court
procedures. • Full information on all possible outcomes. Strategy #4: Emphasize, for trauma
survivors who are involved in legal proceedings against an as sailant, that “not guilty” is a legal
finding—it is based on the degree of available evidence and is not a claim that certain events in
question did not occur. They should also receive, from an attorney or other qualified individual,
information on: • The nature of the legal process as it pertains to the clients’ specific cases. • The
estimated duration and cost of legal services, if applicable. • What to expect during cross-
examination. Strategy #5: Counselors can be called on to assist with a legal case involving trauma.
The court may require you to provide treatment records, to write a letter summarizing your client’s
progress, or to testify at a trial. Always seek supervisory and legal advice in such situations and
discuss with the cli ent the possible repercussions that this might have for the therapeutic
relationship. As a general rule, it is best practice to avoid dual roles or relationships. bomber Timothy
McVeigh’s father while the man’s son was executed in Indiana at a Federal prison several years after
the bombing. For this man, forgiveness and acceptance helped him attain personal peace. Other
trauma survivors may choose never to forgive what happened, and this, too, is a legitimate
response. Culturally and Gender Responsive Services Culture is the lens through which reality is
interpreted. Without an understanding of cul ture, it is difficult to gauge how individuals organize,
interpret, and resolve their traumas. The challenge is to define how culture affects individuals who
have been traumatized. Increased knowledge of PTSD (Wilson & Tang, 2007), mental illness, and
substance use disorders and recovery (Westermeyer, 2004) requires behavioral health practitioners
to con sider the complicated interactions between culture, personality, mental illness, and sub
stance abuse in adapting treatment protocols. This section offers some general guidelines for
working with members of cultures other than one’s own. Treatment for traumatic stress, mental
illness, substance use disorders, and co occurring trauma-related symptoms is more effective if it is
culturally responsive. 131 Cultural Competence Cultural competence includes a counselor’s
knowledge of: • Whether the client is a survivor of cultural trauma (e.g., genocide, war, government
oppression, torture, terrorism). • How to use cultural brokers (i.e., authorities within the culture
who can help interpret cultural patterns and serve as liaisons to those outside the culture). • How
trauma is viewed by an individual’s sociocultural support network. • How to differentiate PTSD,
trauma-related symptoms, and other mental disorders in the culture. For more specific information
on cultural com petence in trauma therapy, see Brown (2008). Trauma-Informed Care in Behavioral
Health Services The U.S. Department of Health and Human Services (2003) has defined the term
“cultural competence” as follows: Cultural competence is a set of values, behav iors, attitudes, and
practices within a system, organization, program, or among individuals that enables people to work
effectively across cultures. It refers to the ability to honor and respect the beliefs, language,
interpersonal styles, and behaviors of individuals and fami lies receiving services, as well as staff who
are providing such services. Cultural competence is a dynamic, ongoing, developmental process that
requires a long-term commitment and is achieved over time (p. 12). Cultural competence is a
process that begins with an awareness of one’s own culture and beliefs and includes an
understanding of how those beliefs affect one’s attitudes toward peo ple of other cultures. It is
rooted in respect, validation, and openness toward someone whose social and cultural background
is differ ent from one’s own. For a thorough review of cultural competence, see the planned TIP, Im
proving Cultural Competence (Substance Abuse and Mental Health Services Administration
[SAMHSA], planned c). In some cultures, an individual’s needs take precedence over group needs
(Hui & Triandis, 1986), and problems are seen as deriving from the self. In other cultures, however,
complex family, kin, and community systems take prec edence over individual needs. Considerable
heterogeneity exists within and across most ethnic subcultures and across lines of gender, class, age,
and political groups (CSAT, 1999b). Subcultures abound in every culture, such as gangs; populations
that are homeless or use substances; orphaned or disenfranchised peo ple; religious, ethnic, and
sexual minorities; indigenous people; and refugee and immigrant populations. Some subcultures
have more in common with similar subcultures in other countries than with their own cultures (e.g.,
nonheterosexual populations). Trauma and substance abuse can themselves be a basis for affiliation
with a subculture. De Girolamo (1993) reports that “disaster subcul tures” exist within many
cultures. These cul tures of victimization, like all subcultures, have unique worldviews, codes of
conduct, and per ceptions of the larger society. In a disaster sub culture, people are, to some extent,
inured to disaster and heedless of warnings of impend ing disaster. For example, riverbank erosion in
Bangladesh displaces thousands of people each year, yet few believe that it is a serious problem or
that the displacement will be permanent (Hutton, 2000). Israelis who have lived with unpredictable
violence for many years behave differently in public areas and have adapted to different norms than
people who don’t com monly experience violence (Young, 2001). Many people identify with more
than one subculture. Some identify with a particular culture or subculture, but not with all of its
values. Individual identities are typically a mo saic of factors, including developmental achievements,
life experiences, behavioral health histories, traumatic experiences, and 132 Part 1, Chapter 5—
Clinical Issues Across Servicesmatization is a risk whenever clients are ex posed to their traumatic
histories without sufficient tools, supports, and safety to manage emotional, behavioral, and physical
reactions. Build Resilience Survivors are resilient! Often, counselors and clients who are trauma
survivors focus on the negative consequences of trauma while failing to recognize the perseverance
and attributes that have helped them survive. It is natural to focus on what’s not working rather
than what has worked. To promote growth after trauma and establish a strengths-based approach,
fo cus on building on clients’ resilience. Current resilience theories claim that building or rein forcing
resilience prevents further development of trauma-related symptoms and [Link] following
Advice to Counselors box is adapted from the American Psychological Association’s 2003 statement
on resilience. Address Sleep Disturbances Sleep disturbances are one of the most endur ing
symptoms of traumatic stress and are a particularly common outcome of severe and prolonged
trauma. Sleep disturbances increase one’s risk of developing traumatic stress; they significantly alter
physical and psychological processes, thus causing problems in daytime functioning (e.g., fatigue,
cognitive difficulty, excessive daytime sleepiness). People with sleep disturbances have worse
general health and quality of life. The cardiovascular and immune systems, among others, may be
affect ed as well. Sleep disturbances can worsen traumatic stress symptoms and interfere with
healing by impeding the brain’s ability to pro cess and consolidate traumatic memories (Caldwell &
Redeker, 2005). Sleep disturbances vary among trauma survi vors and can include decreased ability
to stay asleep, frequent awakenings, early morning unintentional awakening, trouble falling asleep,
poor quality of sleep, and disordered 121 Trauma-Informed Care in Behavioral Health Services
Advice to Counselors: Strategies To Conduct a Sleep Intervention Strategy #1: Conduct a sleep
history assessment focused first on the client’s perception of his or her sleep patterns. Assess
whether there is difficulty initiating or staying asleep, a history of frequent or early morning
awakenings, physically restless sleep, sleepwalking, bedtime aversion, and/or disrup tive physical
and emotional states upon awakening (e.g., confusion, agitation, feeling unrested). Also determine
total sleep time, pattern of nightmares, and use of medications, alcohol, and/or caffeine (see Moul,
Hall, Pikonis, & Buysse, 2004, for a review of self-report measures). Strategy #2: Use a sleep hygiene
measure to determine the presence of habits that typically inter fere with sleep (e.g., falling asleep
while watching television). The National Sleep Foundation Web site
([Link] provides simple steps for promoting good sleep hygiene..
Strategy #3: Provide education on sleep hygiene practices. Introduce clients to the idea that practic
ing good sleep hygiene is one step toward gaining control over their sleep disturbances. Strategy #4:
Reassess sleep patterns and history during the course of treatment. Sleep patterns often reflect
current client status. For example, clients who are struggling are more likely to have disturbed sleep
patterns; sleep disturbances significantly influence clients’ mental health status. Strategy #5: Use
interventions such as nightmare rehearsals to target recurrent nightmares. There are numerous
examples of imagery-based nightmare rehearsals. Clients may be instructed to re hearse repetitively
the recurrent nightmare a few hours before bedtime. In this instruction, the client either rehearses
the entire nightmare with someone or visualizes the nightmare several times to gain control over the
material and become desensitized to the content. Other strategies involve imagin ing a change in the
outcome of the nightmare (e.g., asking the client to picture getting assistance from others, even
though his or her original nightmare reflects dealing with the experience alone). breathing during
sleep (Caldwell & Redeker, 2005). Most traumatic stress literature focuses on nightmares, insomnia,
and frequent awak enings. These disturbances are connected to two main symptoms of traumatic
stress: hy perarousal (which causes difficulty in falling and remaining asleep) and reexperiencing the
trauma (e.g., through recurrent nightmares). Case Illustration: Selena Other sleep disturbances
trauma survivors report include sleep avoidance or resistance to sleep (see Case Illustration: Selena),
panic awakenings, and restless or unwanted body movements (e.g., hitting your spouse uninten
tionally in bed while asleep; Habukawa, Maeda, & Uchimura, 2010). Selena initially sought treatment
for ongoing depression (dysthymia). During treatment, she identified being sexually assaulted while
attending a party at college. At times, she blames herself for the inci dent because she didn’t insist
that she and her girlfriends stay together during the party and on the way back to their dorm
afterward. Selena reported that she only had two drinks that night: “I could never manage more
than two drinks before I wanted to just sleep, so I never drank much socially.” She was assaulted by
someone she barely knew but considered a “big brother” in the brother frater nity of her sorority. “I
needed a ride home. During that ride, it happened,” she said. For years there after, Selena reported
mild bouts of depression that began lasting longer and increasing in number. She also reported
nightmares and chronic difficulty in falling asleep. In therapy, she noted avoiding her bed until she’s
exhausted, saying, “I don’t like going to sleep; I know what’s going to happen.” She describes fear of
sleeping due to nightmares. “It’s become a habit at night. I get very involved in playing computer
games to lose track of time. I also leave the television on through the night be cause then I don’t
sleep as soundly and have fewer nightmares. But I’m always exhausted.” 122 Advice to Counselors:
Strategies To Build Trust Strategy #1: Clients can benefit from a support or counseling group
composed of other trauma sur vivors. By comparing themselves with others in the group, they can
be inspired by those who are further along in the recovery process and helpful to those who are not
faring as well as they are. These groups also motivate clients to trust others by experiencing
acceptance and empathy. Strategy #2: Use conflicts that arise in the program as opportunities.
Successful negotiation of a conflict between the client and the counselor is a major milestone (van
der Kolk, McFarlane, & Van der Hart, 1996). Helping clients understand that conflicts are healthy and
inevitable in relationships (and that they can be resolved while retaining the dignity and respect of
all involved) is a key lesson for those whose relationship conflicts have been beset by violence,
bitterness, and humiliation. Strategy #3: Prepare clients for staff changes, vacations, or other
separations. Some clients may feel rejected or abandoned if a counselor goes on vacation or is
absent due to illness, especially during a period of vulnerability or intense work. A phone call to the
client during an unexpected absence can reinforce the importance of the relationship and the
client’s trust. You can use these opportunities in treatment to help the client understand that
separation is part of relationships; work with the client to view separation in a new light. Strategy #4:
Honor the client–counselor relationship, and treat it as significant and mutual. You can support the
development of trust by establishing clear boundaries, being dependable, working with the client to
define explicit treatment goals and methods, and demonstrating respect for the client’s difficulty in
trusting you and the therapeutic setting. Part 1, Chapter 5—Clinical Issues Across Services Build Trust
Some traumatic experiences result from trust ing others (e.g., interpersonal trauma). In oth er cases,
trust was violated during or after the traumatic experience, as in cases when help was late to arrive
on the scene of a natural disaster. This lack of trust can leave individuals alienated, socially isolated,
and terrified of developing relationships. Some feel that the trauma makes them different from
others who haven’t had similar experiences. Sometimes, a client’s trust issues arise from a lack of
trust in self—for instance, a lack of trust in one’s per ceptions, judgment, or memories. People who
have also experienced severe mental or sub stance use disorders may have difficulty trust ing others
because, during the course of their illness, they felt alienated or discriminated against for behaviors
and emotions generated by or associated with the disorders. Some client groups (e.g., gay, lesbian,
and bi sexual clients; people from diverse cultures; those with serious mental illness) evidence
significant mistrust because their trust has been repeatedly violated in the past. Traumatic
experiences then compound this mistrust. Mistrust can come from various sources, is usually
unstated, and, if left unaddressed, can impede treatment. For example, some clients leave
treatment early or do not engage in po tentially beneficial treatments. Others avoid issues of trust
and commitment by leaving treatment when those issues begin to arise. Establishing a safe, trusting
relationship is paramount to healing—yet this takes time in the counseling process. Counselors and
other behavioral health professionals need to be consistent throughout the course of treatment; this
includes maintaining consistency in the parameters set for availability, attendance, and level of
empathy. Trust is built on behavior shown inside and outside of treatment; you should immediately
address any behavior that may even slightly injure the relationship (e.g., being 5 minutes late for an
appointment, not responding to a phone message in a timely manner, being distracted in a session).
123 Trauma-Informed Care in Behavioral Health Services Support Empowerment Strong feelings of
powerlessness can arise in trauma survivors seeking to regain some con trol of their lives. Whether a
person has sur vived a single trauma or chronic trauma, the survivor can feel crushed by the weight
of powerlessness. Mental illness and substance abuse, too, can be disempowering; clients may feel
that they’ve lost control over their daily lives, over a behavior such as drug use, or over Case
Illustration: Abby powerful emotions such as fear, sadness, or anger. Empowerment means helping
clients feel greater power and control over their lives, as long as such control is within safe and
healthy bounds. A key facet of empowerment is to help clients build on their strengths. Em
powerment is more than helping clients dis cover what they “should” do; it is also helping them take
the steps they feel ready to take. Abby, a 30-year-old, nervous-looking woman, is brought by her
parents to a community mental health clinic near their home in rural Indiana. During the intake
process, the counselor learns that Abby is an Army Reservist who returned from 12 months of
combat duty 3 years ago. The war expe rience changed her in many ways. Her deployment pulled
her away from veterinary school as well as the strong emotional support of family, friends, and
fellow classmates. She got along with her unit in Iraq and had no disciplinary problems. While there,
she served as a truck driver in the Sunni Triangle. Her convoy was attacked often by small arms fire
and was once struck by an improvised explosive device. Although Abby sustained only minor injuries,
two of her close friends were killed. With each successive convoy, her level of fear and foreboding
grew, but she continued performing as a driver. Since returning to the United States, she has mostly
stayed at home and has not returned to school, although she i s helping out on the farm with various
chores. Abby has isolated herself from both family members and lifelong friends, saying she doesn’t
think others can understand what she went through and that she prefers being alone. She reports to
her parents and the counselor that she is vaguely afraid to be in cars and feels most comfortable in
her room or working alone, doing routine tasks, at home. Abby also says that she now understands
how fragile life can be. She has admitted to her parents that she drinks alcohol on a regular basis,
something she did not do before her deployment, and that on occasion, she has experienced
blackouts. Abby feels she needs a drink before talking with strangers or joining in groups of friends
or family. She confided to her father that she isolates herself so that she can drink without having to
explain her drinking to others. The counselor recognizes Abby’s general sense of lacking internal
control and feeling powerless over what will happen to her in the future. He adopts a motivational
interviewing style to establish rapport and a working alliance with Abby. During sessions, the
counselor asks Abby to elaborate on her strengths; he reinforces strengths that involve taking action
in life, positive self-statements, and comments that deal with future plans. He also introduces Abby
to an Iraq War veteran who came home quite discouraged about putting his life together but has
done well getting reintegrated. The counselor urges Abby go to the local VA center so that she can
meet and bond with other recently returned veterans. He also encourages Abby to attend Alcoholics
Anonymous meetings, emphasiz ing that she won’t be pressured to talk or interact with others more
than she chooses to. The counselor continues to see Abby every week and begins using cognitive–
behavioral techniques to help her examine some of her irrational fears about not being able to direct
her life. He asks Abby to keep a daily diary of activities related to achieving her goals of getting back
to school and reestablishing a social network. In each session, Abby reviews her progress using the
diary as a memory aid, and the counselor reinforces these positive efforts. After 4 months of
treatment, Abby reenrolls in college and is feeling optimistic about her ability to achieve her career
plans. 124 Part 1, Chapter 5—Clinical Issues Across Services Advice to Counselors: Strategies To
Support Empowerment Strategy #1: Offer clients information about treatment; help them make
informed choices. Placing appropriate control for treatment choices in the hands of clients improves
their chances of success. Strategy #2: Give clients the chance to collaborate in the development of
their initial treatment plan, in the evaluation of treatment progress, and in treatment plan updates.
Incorporate client input into treatment case consultations and subsequent feedback. Strategy #3:
Encourage clients to assume an active role in how the delivery of treatment services occurs. An
essential avenue is regularly scheduled and structured client feedback on program and clinical
services (e.g., feedback surveys). Some of the most effective initiatives to reinforce client em
powerment are the development of peer support services and the involvement of former clients in
parts of the organizational structure, such as the advisory board or other board roles. Strategy #4:
Establish a sense of self-efficacy in clients; their belief in their own ability to carry out a specific task
successfully—is key. You can help clients come to believe in the possibility of change and in the hope
of alternative approaches to achieving change. Supporting clients in accepting in creasing
responsibility for choosing and carrying out personal change can facilitate their return to
empowerment (Miller & Rollnick, 2002). Acknowledge Grief and Bereavement The experience of loss
is common after trau mas, whether the loss is psychological (e.g., no longer feeling safe) or physical
(e.g., death of a loved one, destruction of community, physical impairment). Loss can cause public
displays of grief, but it is more often a private experience. Grieving processes can be emotionally
over whelming and can lead to increased substance use and other impulsive behaviors as a way to
manage grief and other feelings associated with the loss. Even for people who experi enced trauma
years prior to treatment, grief is still a common psychological issue. Delayed or absent reactions of
acute grief can cause ex haustion, lack of strength, gastrointestinal symptoms, and avoidance of
emotions. Risk factors of chronic bereavement (grief lasting more than 6 months) can include: •
Perceived lack of social support. • Concurrent crises or stressors (including reactivation of PTSD
symptoms). • High levels of ambivalence about the loss. • An extremely dependent relationship
prior to the loss. • Loved one’s death resulting from disaster: unexpected, untimely, sudden, and
shock ing (New South Wales Institute of Psychi atry & Centre for Mental Health, 2000). Advice to
Counselors: Strategies To Acknowledge and Address Grief Strategy #1: Help the client grieve by
being present, by normalizing the grief, and by as sessing social supports and resources. Strategy #2:
When the client begins to discuss or express grief, focus on having him or her voice the losses he or
she experienced due to trauma. Remember to clarify that losses include internal experiences, not
just physical losses. Strategy #3: For a client who has difficulty connecting feelings to experiences,
assign a feelings journal in which he or she can log and name each feeling he or she experiences, rate
the feeling’s intensity numerically, and describe the situation during which the feeling occurred. The
client may choose to share the journal in an individual or group session. Strategy #4: Note that some
clients benefit from developing a ritual or ceremony to honor their losses, whereas others prefer
offering time or resources to an association that repre sents the loss. 125 Advice to Counselors:
Strategies To Monitor and Facilitate Stability Strategy #1: If destabilization occurs during the intake
process or treatment, stop exploring the material that triggered the reaction, offer emotional
support, and demonstrate ways for the client to self-soothe. Strategy #2: Seek consultation from
supervi sors and/or colleagues (e.g., to explore wheth er a new case conceptualization is needed at
this point). Strategy #3: Refer the client for a further as sessment to determine whether a referral is
necessary for trauma-specific therapy or a higher level of care, or use of multiple levels of care (e.g.,
intensive outpatient care, partial hospitalization, residential treatment). Strategy #4: Focus on coping
skills and en courage participation in a peer support program. Strategy #5: When a client becomes
agitated and distressed, carefully explore with the client what is causing this state. When such
feelings arise because of current threats in the client’s life or environment, it is dangerous to halt or
soothe away responses that act as warning signals (Pope & Brown, 1996). When a client is in a
situation involving domestic violence, lives in a dangerous neighborhood, or has run out of money
for food, he or she requires direct and concrete assistance rather than simple emo tional support.
Source: Briere & Scott, 2006b. Managing Destabilization When a client becomes destabilized during
a session, you can respond in the following man ner: “Let’s slow down and focus on helping you be
and feel safe. What can we do to allow you to take care of yourself at this moment? Then, when you
feel ready, we can decide what to focus on next.” Trauma-Informed Care in Behavioral Health
Services Monitor and Facilitate Stability Stability refers to an ongoing psychological and physical
state whereby one is not over whelmed by disruptive internal or external stimuli (Briere & Scott,
2006b). It’s common for individuals to have an increase in symp toms, distress, or impairment when
dealing with the impact of their trauma or talking about specific aspects of their trauma. There is a
thin line that the client and counselor need to negotiate and then walk when addressing trauma. Too
much work focused on highly distressing content can turn a desensitization process into a session
that causes the client to dissociate, shut down, or become emotionally overwhelmed. On the other
hand, too little focus by the client or counselor can easily rein force avoidance and confirm the
client’s inter nal belief that it is too dangerous to deal with the aftermath of the trauma. Clients
should have some psychological stabil ity to engage in trauma-related work. An im portant
distinction can be made between a normative increase in symptoms (e.g., the typ ical up-and-down
course of traumatic stress reactions or substance abuse) and destabiliza tion (dangerous, significant
decrease in func tioning). Signs of destabilization include (Green Cross Academy of Traumatology,
2007; Najavits, 2002b): • Increased substance use or other unsafe behavior (e.g., self-harm). •
Increased psychiatric symptoms (e.g., de pression, agitation, anxiety, withdrawal, anger). • Increased
symptoms of trauma (e.g., severe dissociation). • Helplessness or hopelessness expressed verbally or
behaviorally. • Difficulty following through on commit ments (e.g., commitment to attend treat ment
sessions). • Isolation. • Notable decline in daily activities (e.g., self-care, hygiene, care of children or
pets, going to work). 126 Advice to Counselors: Strategies To Foster Engagement Strategy #1:
According to Mahalik (2001), the standard method of handling clients’ lack of engagement is
exploring it with them, clari fying the situation through discussion with them, reinterpreting (e.g.,
from “can’t” to “won’t” to “willing”), and working through the situation toward progress. Strategy
#2: To improve engagement into treatment, try motivational interviewing and enhancement
techniques. For additional in formation on such techniques, see TIP 35, En hancing Motivation for
Change in Substance Abuse Treatment (Center for Substance Abuse Treatment [CSAT], 1999b). Part
1, Chapter 5—Clinical Issues Across Services Treatment Issues The treatment environment itself can
signifi cantly affect how clients experience traumatic stress and how the client responds to treat
ment. Some specific issues related to working with trauma survivors in a clinical setting are discussed
in the following sections. Client Engagement A lack of engagement in treatment is the cli ent’s
inability to make progress toward treat ment goals, deal with important topics in treatment, or
complete treatment. Clients who have histories of trauma will express ambiva lence about
treatment similarly to others, ex cept that clients who have traumatic stress can feel more “stuck”
and perceive themselves as having fewer options. In addition, clients may be avoiding engagement
in treatment because it is one step closer to addressing their trauma. You should attend to the
client’s motivation to change, implement strategies that address am bivalence toward treatment,
and use approach es that help clients overcome avoidant behavior. Pacing and Timing Although your
training or role as a counselor may prohibit you from providing trauma specific services, you must
still be prepared for the fact that clients are not as focused on when or where it is most appropriate
to ad dress trauma—they want relief, and most lay and professional people have been taught that
the only path to recovery is disclosure. Some clients are reluctant to talk about anything associated
with their histories of trauma. Oth er clients immediately want to delve into the memories of their
trauma without developing a safe environment. The need to gain any relief for the traumatic stress
pushes some individu als to disclose too quickly, without having the necessary support and coping
skills to manage the intensity of their memories. Clients who enter treatment and immediately
disclose past trauma often don’t return because the initial encounter was so intense or because they
ex perienced considerable emotional distress for several days afterward and/or in anticipation of the
next session. Proper pacing of sessions, disclosure, and in tensity is paramount. Clients who
immediate ly disclose without proper safety nets are actually retraumatizing themselves by reliving
the experience without adequate support— often placing themselves in the same circum stances
that occurred during the actual trau mas they experienced. Although you should not adamantly
direct clients not to talk about what happened, it is important to discuss with the clients, even if you
have to interrupt them empathically and respectfully, the potential consequences of disclosing too
soon and too fast. Ask whether they have done this before, and then inquire about the outcome.
Rein force with clients that trauma heals when there are support, trust, and skills in place to manage
the memories of the traumatic experi ences. Ideally, disclosure begins after these elements are
secured, but realistically, it is a 127 Trauma-Informed Care in Behavioral Health Services Advice to
Counselors: Strategies To Establish Appropriate Pacing and Timing Strategy #1: Frequently discuss
and request feedback from clients about pacing and timing. Moving too quickly into discussion of the
trauma can increase the risk of dissociation, overactivation of memories, and feeling overwhelmed.
Strategy #2: Use the SUDS as a barometer of intensity to determine the level of work. Strategy #3:
Slowly increase the speed of interventions and continually adjust the intensity of inter ventions;
move in and out of very intense work, or use strategies that decrease the intensity when necessary.
One approach that typically decreases the intensity of traumatic memories is to ask the individual to
imagine that he or she is seeing the scene through a window or on a television screen. This helps
decrease intensity and the risk of dissociation. It provides an opportunity for the client to view the
trauma from a different perspective and a strategy to use outside of treatment to shift from reliving
the trauma to observing it from a neutral position. Strategy #4: Monitor clients to ensure that
treatment does not overwhelm their internal capacities, retraumatize them, or result in excessive
avoidance; make sure therapy occurs in the “therapeutic window” (Briere & Scott, 2006b). Strategy
#5: Be alert to signs that discussions of trauma, including screening, assessment, and in take
processes, are going too fast. Mild to moderate signs are: • Missing counseling appointments after
discussions of important material. • Periods of silence. • Dissociation. • Misunderstanding what are
usually understandable concepts. • Redirecting the focus of the discussion when certain issues arise.
• Persistent resistance to addressing trauma symptoms. • Repetitive flashbacks. • Increase in
dissociation. • Regression. • Substance use relapses. Strategy #6: Observe the client’s emotional
state. Slow down; seek consultation if the client exhibits: • Difficulty in daily functioning (e.g.,
trouble maintaining everyday self-care tasks). • Self-harm or suicidal thoughts/behaviors (e.g.,
talking about suicide). Strategy #7: Use caution and avoid (Briere, 1996b, p. 115): • Encouraging
clients to describe traumatic material in detail before they can deal with the conse quences of
disclosure. • Using overly stressful interventions (e.g., intensive role-plays, group confrontation,
guided imagery). • Confrontations or interpretations that are too challenging given the client’s
current functioning. • Demanding that the client work harder and stop resisting. Source: Strategies
1–6: Green Cross Academy of Traumatology, 2001. Adapted with permission. balancing act for both
the counselor and client as to when and how much should be ad dressed in any given session.
Remember not to inadvertently give a message that it is too dan gerous to talk about trauma;
instead, reinforce the importance of addressing trauma without further retraumatization. Length of
Treatment Many factors influence decisions regarding the length of treatment for a given client.
Severity of addiction, type of substance abused, type of trauma, age at which the trauma occurred,
level of social support, and the existence of 128 Memories of Trauma Points for c ounselors to
remember are: • Some people are not able to completely remember past events, particularly events
that occurred during high-stress and de stabilizing moments. • In addition to exploring the memories
themselves, it can be beneficial to explore how a memory of an event helps the client understand his
or her feeling, thinking, and behaving in the present. • Persistently trying to recall all the details of a
traumatic event can impair focus on the present. Part 1, Chapter 5—Clinical Issues Across Services
mental disorders all influence length of treat ment. External factors, such as transportation and
childcare, caps on insurance coverage, and limitations in professional resources, can also affect
length of treatment. In general, longer treatment experiences should be expected for clients who
have histories of multiple or early traumas, meet diagnostic criteria for multiple Axis I or Axis II
diagnoses, and/or require intensive case management. Most of the em pirically studied and/or
manual-based models described in the next chapter are short-term models (e.g., lasting several
months); however, ongoing care is indicated for clients with more complex co-occurring trauma
disorders. Traumatic Memories One of the most controversial issues in the trauma field is the
phenomenon of “recovered memories” or “traumatic amnesia” (Brewin, 2007). Practitioners
working with traumatized individuals are particularly concerned about the possibility of new
memories of the trau matic event emerging during the course of therapy and the possibility of these
memories being induced by the clinician. Scientific re views indicate that people can experience am
nesia and delayed recall for some memories of a wide variety of traumas, including military combat
and prisoner of war experiences, natural disasters and accidents, childhood sexual abuse, and
political torture (Bowman & Mertz, 1996; Brewin, 2007; Karon & Widener, 1997; McNally, 2005). In
some cases, the survivor will not remember some of what happened, and the counselor may need to
help the client face the prospect of never knowing all there is to know about the past and accept
moving on with what is known. Legal Issues Legal issues can emerge during treatment. A client, for
instance, could seek to prosecute a perpetrator of trauma (e.g., for domestic vio lence) or to sue for
damages sustained in an accident or natural disaster. The counselor’s role is not to provide legal
advice, but rather, to offer support during the process and, if needed, refer the client to appropriate
legal help (see Advice to Counselors box on p. 131). A legal matter can dominate the treatment
atmosphere for its duration. Some clients have difficulty making progress in treatment until most or
all legal matters are resolved and no longer act as ongoing stressors. Forgiveness Clients may have all
sorts of reactions to what has happened to them. They may feel grateful for the help they received,
joy at having sur vived, and dedication to their recovery. At the other extreme, they may have
fantasies of re venge, a loss of belief that the world is a good place, and feelings of rage at what has
hap pened. They may hold a wide variety of beliefs associated with these feelings. One issue that
comes up frequently among counselors is whether to encourage clients to forgive. The issue of
forgiveness is a very deli cate one. It is key to allow survivors their feel ings, even if they conflict with
the counselor’s own responses. Some may choose to forgive the perpetrator, whereas others may
remain angry or seek justice through the courts and other legal means. Early in recovery from 129
Trauma-Informed Care in Behavioral Health Services Advice to Counselors: Strategies To Manage
Traumatic Memories Strategy #1: Most people who were sexually abused as children remember all
or part of what hap pened to them, although they do not necessarily fully understand or disclose it.
Do not assume that the role of the clinician is to investigate, corroborate, or substantiate allegations
or memories of abuse (American Psychiatric Association [APA], 2000b). Strategy #2: Be aware that
forgotten memories of childhood abuse can be remembered years later. Clinicians should maintain
an empathic, nonjudgmental, neutral stance toward reported memories of sexual abuse or other
trauma. Avoid prejudging the cause of the client’s difficulties or the veracity of the client’s reports. A
counselor’s prior belief that physical or sexual abuse, or other factors, are or are not the cause of the
client’s problems can interfere with appropriate assessment and treatment (APA, 2000b). Strategy
#3: Focus on assisting clients in coming to their own conclusions about the accuracy of their
memories or in adapting to uncertainty regarding what actually occurred. The therapeutic goal is to
help clients understand the impact of the memories or abuse experiences on their lives and to
reduce their detrimental consequences in the present and future (APA, 2000b). Strategy #4: Some
clients have concerns about whether or not a certain traumatic event did or did not happen. In such
circumstances, educate clients about traumatic memories, including the fact that memories aren’t
always exact representations of past events; subsequent events and emotions can have the effect of
altering the original memory. Inform clients that it is not always possible to deter mine whether an
event occurred but that treatment can still be effective in alleviating distress. Strategy #5: There is
evidence that suggestibility can be enhanced and pseudomemories can devel op in some individuals
when hypnosis is used as a memory enhancement or retrieval strategy. Hyp nosis and guided
imagery techniques can enhance relaxation and teach self-soothing strategies with some clients;
however, use of these techniques is not recommended in the active exploration of memories of
abuse (Academy of Traumatology, 2007). Strategy #6: When clients are highly distressed by intrusive
flashbacks of delayed memories, help them move through the distress. Teach coping strategies and
techniques on how to tolerate strong affect and distress (e.g., mindfulness practices). trauma, it is
best to direct clients toward fo cusing on stabilization and a return to normal functioning; suggest
that, if possible, they de lay major decisions about forgiveness until they have a clearer mind for
making decisions (Herman, 1997). Even in later stages of recov ery, it ’s not essential for the client to
forgive in order to recover. Forgiveness is a personal choice independent of recovery. Respect cli
ents’ personal beliefs and meanings; don’t push clients to forgive or impose your own beliefs about
forgiveness onto clients. In the long-term healing process, typically months or years after the
trauma(s), for giveness may become part of the discussion for 130 some people and some
communities. For ex ample, in South Africa, years after the bitter and bloody apartheid conflicts, a
Truth and Reconciliation Commission was established by the Government. Public hearings created
dia log and aired what had been experienced as a means, ultimately, to promote forgiveness and
community healing. By addressing very diffi cult topics in public, all could potentially benefit from
the discourse. Similarly, a paren tal survivor of the Oklahoma City bombing was, at first, bitter about
his daughter’s early, unfair, and untimely death. Today, he gives talks around the world about the
abolition of the death penalty. He sat with convicted Part 1, Chapter 5—Clinical Issues Across
Services Advice to Counselors: Strategies To Manage Legal Proceedings Strategy #1: If you’re aware
of legal proceedings, you can play a key role in helping your client pre pare emotionally for their
impact, such as what it might be like to describe the trauma to a judge or jury, or how to cope with
seeing the perpetrator in court. When helping a client prepare, however, be careful not to provide
legal advice. Strategy #2: Help clients separate a successful legal outcome from a successful
treatment outcome. If clients connect these two outcomes, difficulties can arise. For example, a
client may discontinue treatment after his or her assailant is sentenced to serve prison time,
believing that the symptoms will abate without intervention. Strategy #3: If clients express interest
in initiating a civil or criminal suit, encourage them to consider the ways in which they are and are
not prepared for this, including their own mental states, capacity for resilience, and inevitable loss of
confidentiality (Pope & Brown, 1996). Inform clients coping with legal issues that involvement in the
legal process can be retraumatizing. • What to expect during police investigations. • Court
procedures. • Full information on all possible outcomes. Strategy #4: Emphasize, for trauma
survivors who are involved in legal proceedings against an as sailant, that “not guilty” is a legal
finding—it is based on the degree of available evidence and is not a claim that certain events in
question did not occur. They should also receive, from an attorney or other qualified individual,
information on: • The nature of the legal process as it pertains to the clients’ specific cases. • The
estimated duration and cost of legal services, if applicable. • What to expect during cross-
examination. Strategy #5: Counselors can be called on to assist with a legal case involving trauma.
The court may require you to provide treatment records, to write a letter summarizing your client’s
progress, or to testify at a trial. Always seek supervisory and legal advice in such situations and
discuss with the cli ent the possible repercussions that this might have for the therapeutic
relationship. As a general rule, it is best practice to avoid dual roles or relationships. bomber Timothy
McVeigh’s father while the man’s son was executed in Indiana at a Federal prison several years after
the bombing. For this man, forgiveness and acceptance helped him attain personal peace. Other
trauma survivors may choose never to forgive what happened, and this, too, is a legitimate
response. Culturally and Gender Responsive Services Culture is the lens through which reality is
interpreted. Without an understanding of cul ture, it is difficult to gauge how individuals organize,
interpret, and resolve their traumas. The challenge is to define how culture affects individuals who
have been traumatized. Increased knowledge of PTSD (Wilson & Tang, 2007), mental illness, and
substance use disorders and recovery (Westermeyer, 2004) requires behavioral health practitioners
to con sider the complicated interactions between culture, personality, mental illness, and sub
stance abuse in adapting treatment protocols. This section offers some general guidelines for
working with members of cultures other than one’s own. Treatment for traumatic stress, mental
illness, substance use disorders, and co occurring trauma-related symptoms is more effective if it is
culturally responsive. 131 Cultural Competence Cultural competence includes a counselor’s
knowledge of: • Whether the client is a survivor of cultural trauma (e.g., genocide, war, government
oppression, torture, terrorism). • How to use cultural brokers (i.e., authorities within the culture
who can help interpret cultural patterns and serve as liaisons to those outside the culture). • How
trauma is viewed by an individual’s sociocultural support network. • How to differentiate PTSD,
trauma-related symptoms, and other mental disorders in the culture. For more specific information
on cultural com petence in trauma therapy, see Brown (2008). Trauma-Informed Care in Behavioral
Health Services The U.S. Department of Health and Human Services (2003) has defined the term
“cultural competence” as follows: Cultural competence is a set of values, behav iors, attitudes, and
practices within a system, organization, program, or among individuals that enables people to work
effectively across cultures. It refers to the ability to honor and respect the beliefs, language,
interpersonal styles, and behaviors of individuals and fami lies receiving services, as well as staff who
are providing such services. Cultural competence is a dynamic, ongoing, developmental process that
requires a long-term commitment and is achieved over time (p. 12). Cultural competence is a
process that begins with an awareness of one’s own culture and beliefs and includes an
understanding of how those beliefs affect one’s attitudes toward peo ple of other cultures. It is
rooted in respect, validation, and openness toward someone whose social and cultural background
is differ ent from one’s own. For a thorough review of cultural competence, see the planned TIP, Im
proving Cultural Competence (Substance Abuse and Mental Health Services Administration
[SAMHSA], planned c). In some cultures, an individual’s needs take precedence over group needs
(Hui & Triandis, 1986), and problems are seen as deriving from the self. In other cultures, however,
complex family, kin, and community systems take prec edence over individual needs. Considerable
heterogeneity exists within and across most ethnic subcultures and across lines of gender, class, age,
and political groups (CSAT, 1999b). Subcultures abound in every culture, such as gangs; populations
that are homeless or use substances; orphaned or disenfranchised peo ple; religious, ethnic, and
sexual minorities; indigenous people; and refugee and immigrant populations. Some subcultures
have more in common with similar subcultures in other countries than with their own cultures (e.g.,
nonheterosexual populations). Trauma and substance abuse can themselves be a basis for affiliation
with a subculture. De Girolamo (1993) reports that “disaster subcul tures” exist within many
cultures. These cul tures of victimization, like all subcultures, have unique worldviews, codes of
conduct, and per ceptions of the larger society. In a disaster sub culture, people are, to some extent,
inured to disaster and heedless of warnings of impend ing disaster. For example, riverbank erosion in
Bangladesh displaces thousands of people each year, yet few believe that it is a serious problem or
that the displacement will be permanent (Hutton, 2000). Israelis who have lived with unpredictable
violence for many years behave differently in public areas and have adapted to different norms than
people who don’t com monly experience violence (Young, 2001). Many people identify with more
than one subculture. Some identify with a particular culture or subculture, but not with all of its
values. Individual identities are typically a mo saic of factors, including developmental achievements,
life experiences, behavioral health histories, traumatic experiences, and 132 Part 1, Chapter 5—
Clinical Issues Across Services Community-Based Treatment for Native American Historical Trauma
Key beliefs in community healing: • Clients carry childhood pain that has led to adult dysfunction. •
Childhood pain must be confronted, con fessed, and addressed, if relief is to be obtained. • Cathartic
expression is the initial step in the healing journey toward a lifelong pursuit of introspection and self-
improvement. • The healing journey entails reclamation of indigenous heritage, identity, spirituality,
and practices to remedy the pathogenic ef fects of colonization and other sources of historical
trauma. Source: Gone, 2009. alcohol and illicit drug use; levels of accultura tion and/or assimilation
vary from one indi vidual to the next as well. Importance of the trauma aftermath Counselors
working in the immediate after math of trauma—whether individual, group, or community in nature
—face many challenges. For example, survivors may be forced to adjust without access to other
health services, em ployment, support, or insurance. In these in stances, counselors must often work
with individuals and communities coping with the trauma while struggling daily to meet basic needs.
Research suggests that reestablishing ties to family, community, culture, and spiritual systems can
not only be vital to the individual, but can also influence the impact of the trau ma upon future
generations. For example, Baker and Gippenreiter (1998) studied the descendants of people
victimized by Joseph Stalin’s purge. They found that families who were able to maintain a sense of
connection and continuity with grandparents affected by the purge experienced fewer negative
effects than did those who were emotionally or physi cally severed from their grandparents. The
researchers also found that whether the grandparents survived was less important than the
connection the grandchildren managed to keep to their past. Ties to family and commu nity can also
have an adverse effect, especially if the family or community downplays the trauma or blames the
victim. Counselors need to have a full understanding of available sup port before advocating a
particular approach. Treatment strategies Many traditional healing ways have been damaged,
forgotten, or lost—yet much wis dom remains. Drawing on the best traditional and contemporary
approaches to human dis tress and defining culturally competent curric ula regarding identity and
healing (Huriwai, 2002; Wilson & Tang, 2007) both require respect and appreciation for the many
ways in which various people characterize and resolve trauma and how they use addictive
substances to bear the burdens of human distress. It is not yet known how well existing PTSD
treatments work for individuals who identify primarily with cultures other than mainstream
American culture. It is possible that such treatments do work for clients of other cul tures, though
some cultural adaptation and translation may be required. For example, some PTSD treatments that
have been used with subculture groups without adaptation other than language translation and that
ap pear to be effective across cultures include eye movement desensitization and reprocessing
(Bleich, Gelkopf, & Solomon, 2003) and Seeking Safety (Daouest et al., 2012). Gender Gender
differences exist in traumatic stress, mental disorders, and substance use disorders. For example,
women have higher rates of PTSD, whereas men have higher rates of sub stance abuse (Kessler,
Chiu, Demler, Merikangas, & Walters, 2005; Stewart, Ouimette, & Brown, 2002; Tolin & Foa, 2006).
133 Working With Clients From Diverse Cultures: Trauma and Substance Abuse • In socially
appropriate ways, educate clients, their loved ones, and possibly members of their extended
community about the relationship between substance abuse and PTSD, how substance abuse is
often used to cope with trauma, and what treatment entails. • Make serious efforts to connect
clients to supportive and understanding people (preferably within culturally identified groups). •
Help clients understand that many who have not experienced trauma or do not have substance use
disorders will not understand the psychological, spiritual, and interpersonal insights that they have
gained during their recovery processes. Trauma-Informed Care in Behavioral Health Services The
types of interpersonal trauma experienced by men and by women are often different. A number of
studies (Kimerling, Ouimette, & Weitlauf, 2007) indicate that men experience more combat and
crime victimization and women experience more physical and/or sexu al assault—implying that
men’s traumas often occur in public, whereas the traumatization of women is more likely to take
place in a private setting, such as a home. Men’s abusers are more often strangers. Those who abuse
wom en, on the other hand, are more often in a rela tionship with them. Women (and girls) often
are told, “I love you,” during the same time period when the abuse occurs. However, wom en now
serve in the military and thus are in creasingly subject to some of the same traumas as men and also
to military sexual trauma, which is much more common for women to experience. Similarly, men can
be subject to domestic violence or sexual abuse. In treatment, gender considerations are rele vant in
a variety of ways, including, but not limited to, the role and impact of societal gen der stereotypes
upon assessment processes, treatment initiation, and engagement of ser vices (e.g., peer support
systems); the selection and implementation of gender-specific and gender-responsive approaches
for both men and women at each level of intervention; and the best selection of trauma-related
interven tions that account for gender-specific differ ences related to traumatic stress. For an
extensive review and discussion of gender specific and gender-responsive care for trau matic stress
and substance use, see the TIP 51, Substance Abuse Treatment: Addressing the Specific Needs of
Women (CSAT, 2009d), and TIP 56, Addressing the Specific Behavioral Health Needs of Men
(SAMHSA, 2013a). Beyond the complexities of gender considera tions, one must also consider
whether clients should be given the choice of working with a male or a female counselor. Some
clients who have been traumatized have no preference, particularly if their trauma wasn’t associated
with gender (e.g., a natural disaster, act of ter rorism, fire, serious accident). If gender did play a role
in trauma (e.g., childhood sexual abuse), clients can have strong fears of work ing with a counselor
who is the same gender as the perpetrator. Many women who experi enced sexual abuse (whose
perpetrators are typically men) feel uncomfortable being treat ed by men because of the intense
emotions that can be evoked (e.g., anger, fear). Men who experienced sexual abuse (whose
perpetrators are also typically men) can feel uncomfortable for the same reasons, or they may feel
shame when talking to men due to feelings evoked about masculinity, homosexuality, and so forth.
However, not all clients with trauma histories prefer female therapists. Discuss with clients the
possible risks (e.g., initial emotional discomfort) and benefits of being treated by a woman or man
(e.g., devel oping a therapeutic relationship with a man might challenge a client’s belief that all men
are dangerous), and, if possible, let them then choose the gender of their counselor. Tell 134 Part 1,
Chapter 5—Clinical Issues Across Services them that if they experience initial emotional discomfort,
and the discomfort does not de crease, they can switch to a counselor of the opposite gender. For
group therapy that focuses on trauma, similar considerations apply. Gener ally, gender-specific
groups are recommended when possible, but mixed-gender groups also work. Gender also comes
into play in substance abuse treatment. Research and clinical observa tion indicate that significant
gender differences occur in many facets of substance abuse and its treatment. For example, men
and women expe rience different physical repercussions of sub stance use (e.g., women have more
health problems), different trajectories (e.g., women become addicted more quickly), and different
treatment considerations (e.g., traditional sub stance abuse treatment was designed for men).
Sexual orientation Lesbian, gay, bisexual, and transgender (LGBT) clients face specific issues in behav
ioral health treatment settings, including his tories of abuse and discrimination relating to sexual
orientation, homophobia in treatment on the part of counselors or other clients, po tential difficulty
addressing traumatic experi ences related to their sexuality or sexual orientation, and often, a
significant lack of trust toward others. LGBT people sometimes think that others can’t understand
them and their specific needs and thus are reluctant to engage in treatment programs in which the
clientele is predominantly heterosexual. Some clients react with judgment, anger, or embar
rassment when an LGBT client attempts to describe sexual trauma relating to homosexual behavior,
making it even harder for LGBT clients to describe their experiences. Often, individual counseling can
address issues the LGBT client isn’t comfortable discussing in group treatment. “Providing one-on-
one services may decrease the difficulty of mixing heterosexual and LGBT clients in treatment groups
and decrease the likelihood that hetero sexism or homophobia will become an issue” (CSAT, 2001, p.
56). For more on treating LGBT individuals, see A Provider’s Introduc tion to Substance Abuse
Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals (CSAT, 2001). Making Referrals to
Trauma-Specific Services Many people who experience trauma do not exhibit persistent traumatic
stress symptoms. In fact, people do recover on their own. So how do you determine who is at higher
risk for developing more persistent symptoms of traumatic stress, trauma-related disorders, and
traumatic stress disorders? One main factor is the severity of symptoms at the time of screening and
assessment. Other factors, be yond trauma characteristics and pretrauma individual characteristics,
to consider in mak ing referrals include (Ehlers & Clark, 2003): • Cognitive appraisals that are
excessively negative regarding trauma sequelae, includ ing consequences, changes after the
event(s), responses of other people to the trauma, and symptoms. • Acknowledgment of intrusive
memories. • Engagement in behaviors that reinforce or prevent resolution of trauma, including
avoidance, dissociation, and substance use. • History of physical consequences of trauma (e.g.,
chronic pain, disfigurement, health problems). • Experiences of more traumas or stressful life events
after the prior trauma. • Identification of co-occurring mood disor ders or serious mental illness. The
next chapter provides an overview of trauma-specific services to complement this chapter and to
provide trauma-informed counselors with a general knowledge of trauma-specific treatment
approaches. 135 6 Trauma-Specific Services IN THIS CHAPTER • Introduction • Trauma -Specific
Treatment Models • Integrated Models for Trauma • Emerging Interventions • Concluding Note This
chapter covers various treatment approaches designed specifi cally to treat trauma-related
symptoms, trauma-related disorders, and specific disorders of traumatic stress. The models
presented do not comprise an exhaustive list, but rather, serve as examples. These models require
training and supervised experience to be conducted safely and effectively. The chapter begins with a
section on trauma-specific treatment models, providing a brief overview of interventions that can be
delivered immediately after a trauma, as well as trauma-specific interventions for use beyond the
immediate crisis. The second segment focuses on integrated care that targets trauma-specific
treatment for mental, substance use, and co occurring disorders. Even though entry-level, trauma-
informed behavioral health service providers are unlikely to be in a position to use these
interventions, having some knowledge of them is nev ertheless important. Currently, more research
is needed to tease out the most important ingredients of early interventions and their role in the
prevention of more pervasive traumatic stress symp toms. More science-based evidence is available
for trauma-specific treatments that occur and extend well beyond the immediate reac tions to
trauma. The last part of the chapter provides a brief review of selected emerging interventions that
have not been covered elsewhere in this Treatment Improvement Protocol (TIP). Introduction
Trauma-specific therapies vary in their approaches and objectives. Some are present focused, some
are past focused, and some are combinations (Najavits, 2007a). Present-focused approaches pri
marily address current coping skills, psychoeducation, and manag ing symptoms for better
functioning. Past-focused approaches primarily focus on telling the trauma story to understand the
im pact of the trauma on how the person functions today, experienc ing emotions that were too
overwhelming to experience in the past, and helping clients more effectively cope in the present
with their 137 Trauma-Informed Care in Behavioral Health Services Trauma-Informed Care
Framework in Behavioral Health Services—Trauma Specific Services traumatic experiences. Clients
participating in present-focused approaches may reveal some of their stories; past-focused
approaches em phasize how understanding the past influences current behavior, emotion, and
thinking, thereby helping clients cope more effectively with traumatic experiences in the present.
The distinction between these approaches lies in the primary emphasis of the approach. De pending
on the nature of the trauma and the specific needs of the client, one approach may be more suitable
than the other. For instance, in short-term treatment for clients in early recovery from mental illness
and/or substance abuse, present-focused, cognitive–behavioral, or psychoeducational approaches
are generally more appropriate. For clients who are stable in their recovery and have histories of
develop mental trauma where much of the trauma has been repressed, a past-focused orientation
may be helpful. Some clients may benefit from both types, either concurrently or sequentially. This
chapter discusses a number of treatment models, general approaches, and techniques. A treatment
model is a set of practices designed to alleviate symptoms, promote psychological well-being, or
restore mental health. Treat ment techniques are specific procedures that can be used as part of a
variety of models. Some models and techniques described in this chapter can be used with groups,
some with individuals, and some with both. This chapter is selective rather than comprehensive;
addi tional models are described in the literature. See, for example, the PILOTS database on the Web
site of the National Center for PTSD 138 Federal Agencies Both the American Red Cross and the
Federal Emergency Management Agency (FEMA) re spond to disasters. Behavioral health service
providers should understand the basics about these major emergency response agencies. For
example, the Red Cross can respond rapidly with funding for food, shelter, and immediate needs,
whereas FEMA assistance r equires a period of gearing up but provides for longer term needs.
SAMHSA, along with o ther Federal agencies, assists FEMA in a number of areas of emergency
response planning activities. See also SAMHSA’s Disaster Technical Assistance Center Web site
([Link] and Technical Assistance Publication 34, Disas ter Planning
Handbook for Behavioral Health Treatment Programs (SAMHSA, 2013). Part 1, Chapter 6—Trauma-
Specific Services (NCPTSD; [Link] for treatment literature related to trauma and
posttraumatic stress disorder (PTSD). For an overview of models for use with both adult and child
populations, refer to Models for De veloping Trauma-Informed Behavioral Health Systems and
Trauma-Specific Services (Center for Mental Health Services, 2008). Some treatments discussed in
this chapter are described as evidence based. Because research on integrated treatment models is
so new, many have only been examined in a few studies. Giv en these circumstances and the fact
that an outcome study provides only limited evidence of efficacy, the term “evidence based” should
be interpreted cautiously. Additional scientific study is needed to determine whether some
treatments discussed herein are, in fact, evi dence based. A good resource for evaluating evidence-
based, trauma-specific treatment models is Effective Treatments for PTSD (Foa, Keane, Friedman, &
Cohen, 2009). Although evidence-based interventions should be a pri mary consideration in selecting
appropriate treatment models for people with symptoms of trauma that co-occur with mental and
sub stance use disorders (see Allen, 2001, for an indepth discussion of trauma and serious men tal
illness), other factors must also be weighed, including the specific treatment needs of the client; his
or her history of trauma, psychosocial and cultural background, and experiences in prior trauma
treatment; the overall treatment plan for the client; and the competencies of the program’s clinical
staff. Although behavioral health counselors can prepare to help their cli ents address some of the
issues discussed in Chapter 5, specialized training is necessary to provide treatment for co-occurring
substance use and mental disorders related to trauma. The Substance Abuse and Mental Health Ser
vices Administration (SAMHSA) has created the National Registry of Evidence-Based Pro grams and
Practices (NREPP) as a resource for reviewing and identifying effective treatment programs.
Programs can be nominated for con sideration as co-occurring disorders programs or substance
abuse prevention or treatment programs, and their quality of evidence, readi ness for dissemination,
and training considera tions are then reviewed. For more detailed information, including details
about several evidence-based co-occurring trauma treatment programs, visit the NREPP Web site
([Link] Program mod els for specialized groups, such as adolescents, can
also be found on the NREPP Web site. For specific research-oriented information on trauma-specific
treatments, refer to Part 3 of this TIP, which provides a literature review and links to select abstracts
(available online). Trauma-Specific Treatment Models Immediate Interventions Intervention in the
first 48 hours The acute intervention period comprises the first 48 hours after a traumatic event. In a
139 “One day I was called out of bed at 5:00 a.m. to go to a town approximately 30 miles away
because a levee had broken…. By 6:00 a.m., my colleagues and I were there with many of the
townspeople, with helicopters flying overhead, with t rucks going in and out by the main road trying
to empty the factories. When we got there, as far as you could see was farmland. By 11 a.m., you
could see a ‘lake’ in the dis tance. By 2 p.m., the water was on the edge of the town. Being there, at
that town, before, during, and after the water came was probably the most valuable function we
performed. We were able to share in the grief of the hundreds of people as we stayed with them
while their fields, houses, and workplaces were flooded. We witnessed the death of a town, and the
people reacted with disbelief, anger, sad ness, and numbness. Each person had a different story, but
all grieved, and we provided many an op portunity to express it. People cried as the water started
rising into their houses. Some had to watch. Some had to leave. At times it was utterly silent as we
all waited. There was a woman whose parents sent her away during the floods of ‘43 and she had
been angry for 50 years about it. She was deter mined that her children and grandchildren would
see everything. I spent 12 hours that day just giving support, listening, giving information, and
sometimes shedding a tear or two myself.” —Rosemary Schwartzbard, Ph.D., responder to floods
along the Mississippi River in 1993 Source: Schwartzbard, 1997. Trauma-Informed Care in Behavioral
Health Services disaster, rescue operations usually begin with local agencies prior to other
organizations ar riving on the scene. Law enforcement is likely to take a primary role on site.
Whether it is a disaster, group trauma, or individual trauma (including a trauma that affects an entire
fami ly, such as a house fire), a hierarchy of needs should be established: survival, safety, security,
food, shelter, health (physical and mental), ori entation of survivors to immediate local ser vices, and
communication with family, friends, and community (National Institute of Mental Health, 2002). In
this crucial time, appropriate interventions include educating survivors about resources; educating
other providers, such as faith-based organizations and social service groups, to screen for increased
psychological effects including use of substances; and use of a trauma response team that assists
clients with their immediate needs. No formal interventions should be attempted at this time, but a
profes sionally trained, empathic listener can offer solace and support (Litz & Gray, 2002). Basic
needs Basic necessities, such as shelter, food, and water, are key to survival and a sense of safety. It
is important to focus on meeting these basic needs and on providing a supportive environ ment.
Clients’ access to prescribed medications may be interrupted after a trauma, particularly a disaster,
so providers should identify clients’ medication needs for preexisting physical and mental disorders,
including methadone or other pharmacological treatment for substance use. For example, after
September 11, 2001, substance abuse treatment program adminis trators in New York had to seek
alternative methadone administration options (Frank, Dewart, Schmeidler, & Demirjian, 2006).
Psychological first aid The psychological first aid provided in the first 48 hours after a disaster is
designed to ensure safety, provide an emotionally support ive environment and activities, identify
those with high-risk reactions, and facilitate com munication, including strong, reassuring lead ership
immediately after the event. The primary helping response of psychological first aid is to provide a
calm, caring, and supportive environment to set the scene for psychological recovery. It is also
essential that all those first responding to a trauma—rescue workers, med ical professionals,
behavioral health workers (including substance abuse counselors), jour nalists, and volunteers—be
familiar with rele vant aspects of traumatic stress. Approaching 140 Part 1, Chapter 6—Trauma-
Specific Services Advice to Counselors: Core Actions in Preparing To Deliver Psychological First Aid •
Contact and engagement • Safety and comfort • Stabilization • Information gathering: Current
needs and concerns • Practical assistance • Connection with social supports • Information on coping
• Linkage with collaborative services Source: National Child Traumatic Stress Net work & NCPTSD,
2012. Advice to Counselors: Evidence Related to Immediate Interventions Evidence related to
immediate interventions suggests that: • Early, brief, focused psychotherapeutic intervention
provided in an individual or group format can reduce distress in be reaved spouses, parents, and
children. • Selected cognitive–behavioral approaches may help reduce the incidence, duration, and
severity of acute stress disorder (ASD), PTSD, and depression in trauma survivors. • A one-session
individual recital of events and expression of emotions evoked by a traumatic event does not
consistently re duce risk of later developing PTSD. In fact, it may increase the risk for adverse out
comes. Perhaps CISD hinders the natural recovery mechanisms that restore pretrau ma functioning
(Bonanno, 2004). • The focus initially should be upon screen ing with follow-up as indicated.
survivors with genuine respect, concern, and knowledge increases the likelihood that the caregiver
can (NCPTSD, 2002): • Answer questions about what survivors may be experiencing. • Normalize
their distress by affirming that what they are experiencing is normal. • Help them learn to use
effective coping strategies. • Help them be aware of possible symptoms that may require additional
assistance. • Provide a positive experience that will in crease their chances of seeking help if they
need it in the future. Clinical experience suggests that care be taken to respect a survivor’s individual
method of coping; some may want information, for ex ample, whereas others do not. Similarly,
some may want to talk about the event, but others won’t. An excellent guide to providing psycho
logical first aid is available online from the Terrorism and Disaster Branch of the National Child
Traumatic Stress Network ([Link] first-aid). Critical incident
stress debriefing Initially developed for work with first re sponders and emergency personnel, critical
incident stress debriefing (CISD; Mitchell & Everly, 2001) is now widely used and encom passes
various group protocols used in a varie ty of settings. This facilitator-led group intervention is for use
soon after a traumatic event with exposed people. The goal is to pro vide psychological closure by
encouraging par ticipants to talk about their experiences and then giving a didactic presentation on
com mon stress reactions and management. The widespread use of CISD has occurred despite the
publication of conflicting results regarding its efficacy. Claims that single session psychological
debriefing can prevent development of chronic negative psychological sequelae are not empirically
supported (van Emmerik, Kamphuis, Hulsbosch, & Emmelkamp, 2002). Some controlled studies
suggest that it may impede natural recovery from trauma (McNally, Bryant, & Ehlers, 2003). Other
research suggests emphasizing screening to determine the need for early in terventions. Mitchell
and Everly (2001) point out that many of the studies showing negative 141 A widely accepted
framework in treating trauma, substance use disorders, and mental illness categorizes therapies as
single (treatment of only one disorder), sequential (treatment of one disorder first, then the other),
or parallel (concurrent treatment of multiple disorders delivered by separate clinicians or in separate
programs that do not necessarily address the interactions between symptoms and disorders).
Trauma-Informed Care in Behavioral Health Services results were not conducted with first respond
ers; that is, CISD may be appropriate for some, but not all, groups. A recent study of 952 U.S.
peacekeepers and CISD by the U.S. Army Research Unit–Europe (Adler et al., 2008) found mixed
results. Interventions Beyond the Initial Response to Trauma In the interest of increasing your overall
famil iarity with relevant approaches, the following sections review several traumatic stress treat
ment approaches that counselors will most likely encounter when collaborating with cli nicians or
agencies that specialize in trauma specific services and treating traumatic stress. Cognitive–
behavioral therapies Most PTSD models involve cognitive behavioral therapy (CBT) that integrates
cog nitive and behavioral theories by incorporating two ideas: first, that cognitions (or thoughts)
mediate between situational demands and one’s attempts to respond to them effectively, and
second, that behavioral change influences acceptance of altered cognitions about oneself or a
situation and establishment of newly learned cognitive–behavioral interaction pat terns. In practice,
CBT uses a wide range of coping strategies. There are many different varieties of CBT. CBT originated
in the 1970s (Beck, Rush, Shaw & Emery, 1979; Ellis & Harper, 1975) and has expanded since then to
address vari ous populations, including people who use substances, people who experience anxiety,
people with PTSD or personality disorders, children and adolescents, individuals involved in the
criminal justice system, and many oth ers. CBT has also been expanded to include various
techniques, coping skills, and ap proaches, such as dialectical behavior therapy (DBT; Linehan, 1993),
Seeking Safety (Najavits, 2002a), and mindfulness (Segal, Williams, & Teasdale, 2002). Traditional
CBT emphasizes symptom reduction or resolution, but recent CBT approaches have also empha sized
the therapeutic relationship, a particular ly important dynamic in trauma treatment ( Jackson,
Nissenson, & Cloitre, 2009). CBT has been applied to the treatment of trauma and has also been
widely and effective ly used in the treatment of substance use. A review of efficacy research on CBT
for PTSD is provided by Rothbaum, Meadows, Resick, and Foy (2000). Najavits and colleagues (2009)
and O’Donnell and Cook (2006) offer an overview of CBT therapies for treating PTSD and substance
abuse. In addition, a free online training resource incorporating CBT for traumatized children within
the communi ty, Trauma-Focused CBT, is available from the Medical University of South Carolina
([Link] Cognitive processing therapy Cognitive processing therapy (CPT) is a
manualized 12-session treatment approach that can be administered in a group or indi vidual setting
(Resick & Schnicke, 1992, 1993). CPT was developed for rape survivors and combines elements of
existing treatments for PTSD, specifically exposure therapy (see the “Exposure Therapy” section later
in this chapter) and cognitive therapy. The exposure therapy component of treatment consists of
142 Advice to Counselors: Relaxation Training, Biofeedback, and Breathing Retraining Strategies
Relaxation training, biofeedback, and breathing retraining strategies may help some clients cope
with anxiety, a core symptom of t raumatic stress. However, no evidence supports the use of
relaxation and biofeedback as effective standalone PTSD treatment techniques (Cahill, Rothbaum,
Resick, & Follete, 2009). Both are sometimes used as complementary strategies to manage anxiety
symptoms elicited by trauma-related stimuli. Breathing retraining uses focused or controlled
breathing to re duce arousal. Breathing retraining and relaxation, along with other interventions
when necessary, can help clients with ASD. An important caution in the use of breath work with
trauma clients is that it can sometimes act as a trigger—for example, given its focus on the body and
its potential to remind them of heavy breathing that occurred during assault. Biofeedback, which
requires specialized equipment, combines stress reduction strategies (e.g., progressive muscle
relaxation, guided image ry) with feedback from biological system measures (e.g., heart rate, hand
temperature) that gauge levels of stress or anxiety reduction. Relaxation training, which requires no
specialized equipment, encourages clients to reduce anxiety responses (including physiological
responses) to trauma-related stimuli; it is often part of more comprehensive PTSD treatments (e.g.,
prolonged exposure and stress inoculation training [SIT]). Part 1, Chapter 6—Trauma-Specific
Services clients writing a detailed account of their trauma, including thoughts, sensations, and
emotions that were experienced during the event. The client then reads the narrative aloud during a
session and at home. The cog nitive therapy aspect of CPT uses six key PTSD themes identified by
McCann and Pearlman (1990): safety, trust, power, control, esteem, and intimacy. The client is
guided to identify cognitive distortions in these areas, such as maladaptive beliefs. Results from
randomized, placebo-controlled trials for the treatment of PTSD related to interpersonal violence
(Resick, 2001; Resick, Nishith, Weaver, Astin, & Feuer, 2002) sup port the use of CPT. CPT and
prolonged exposure therapy models are equally and high ly positive in treating PTSD and depression
in rape survivors; CPT is superior in reducing guilt (Nishith, Resick, & Griffin, 2002; Resick et al., 2002;
Resick, Nishith, & Griffin, 2003). CPT has shown positive out comes with refugees when administered
in the refugees’ native language (Schulz, Marovic Johnson, & Huber, 2006) and with veterans
(Monson et al., 2006). However, CPT has not been studied with high-complexity popula tions such as
individuals with substance de pendence, homelessness, current domestic violence, serious and
persistent mental illness, or suicidality. CPT requires a 3-day training plus consultation (Karlin et al.,
2010). Resick and Schicke (1996) published a CPT treat ment manual, Cognitive Processing Therapy
for Rape Victims: A Treatment Manual. Exposure therapy Exposure therapy for PTSD asks clients to
directly describe and explore trauma-related memories, objects, emotions, or places. In tense
emotions are evoked (e.g., sadness, anxi ety) but eventually decrease, desensitizing clients through
repeated encounters with traumatic material. Careful monitoring of the pace and appropriateness of
exposure-based interventions is necessary to prevent retrauma tization (clients can become
conditioned to fear the trauma-related material even more). Clients must have ample time to
process their memories and integrate cognition and affect, so some sessions can last for 1.5 hours or
more. For simple cases, exposure can work in as few as 9 sessions; more complex cases may require
20 or more sessions (Foa, Hembree, & Rothbaum, 2007). Various techniques can 143 A Brief
Description of EMDR Therapy Treatment involves three main concentrations (past memories,
present disturbances, future actions) and eight phases. Counselors may work with several phases in
one session. Each phase is meant to be revisited either in every session or when appropriate (e.g.,
the closure process is meant to be conducted at the end of every session, in preparation for the
next). • Phase 1: History and Treatment Planning (1-2 sessions) • Phase 2: Preparation • Phase 3:
Assessment and Reprocessing • Phase 4: Desensitization • Phase 5: Installation • Phase 6: Body Scan
• Phase 7: Closure • Phase 8: Reevaluation Source: EMDR Network, 2012. Advice to Counselors:
Steps for Introducing a Breathing Exercise Use the following statements to lead clients through a
breathing exercise: • Place your hands on your stomach. As you inhale, breathe deeply but slowly so
that your hands rise with your stomach. As you exhale slowly, practice breathing so that your hands
drop with your stomach. • Inhale slowly through your nose with your mouth closed; don’t rush or
force in the air. • Exhale slowly through your mouth with your lips in the whistling position. •
Breathe out for twice as long as you breathe in. Trauma-Informed Care in Behavioral Health Services
expose the client to traumatic material. Two of the more common methods are exposure through
imagery and in vivo (“real life”) exposure. The effectiveness of exposure therapy has been firmly
established (Rothbaum et al., 2000); however, adverse reactions to exposure therapy have also been
noted. Some individu als who have experienced trauma exhibit an exacerbation of symptoms during
or following exposure treatments. Even so, the exacerba tion may depend on counselor variables
during administration. Practitioners of exposure ther apy need comprehensive training to master its
techniques (Karlin et al., 2010); a counselor unskilled in the methods of this treatment model can not
only fail to help his or her cli ents, but also cause symptoms to worsen. Exposure therapy is
recommended as a first line treatment option when the prominent trauma symptoms are intrusive
thoughts, flashbacks, or trauma-related fears, panic, and avoidance. However, counselors should
exer cise caution when using exposure with clients who have not maintained stability in manag ing
mental illness symptoms or abstinence from substance use disorders. Studies and rou tine use of
exposure have consistently excluded high-complexity clients such as those with substance
dependence, homelessness, current domestic violence, serious and persistent men tal illness, or
suicidality. The only trial of ex posure therapy with a substance dependence sample found that it did
not outperform standard substance abuse treatment on most variables (Mills et al., 2012).
Prolonged exposure therapy for PTSD is listed in SAMHSA’s NREPP. For reviews of exposure therapy,
also see Najavits (2007a) and Institute of Medicine (2008). In addition to prolonged exposure
therapy, other therapies incorporate exposure and desensitization tech niques, including eye
movement desensitiza tion and reprocessing (EMDR; Shapiro, 2001), cognitive processing, and
systematic desensitization therapies (Wolpe, 1958). Eye movement desensitization and reprocessing
EMDR (Shapiro, 2001) is one of the most widely used therapies for trauma and PTSD. The treatment
protocols of EMDR have evolved into sophisticated paradigms requiring training and, preferably,
clinical supervision. EMDR draws on a variety of theoretical 144 In the substance abuse treatment
field, many clients will see a connection between narrative therapy and the process of telling their
stories in 12 -Step programs, in which reframing life stories of feeling trapped, despairing, and
hopeless leads to stories of strength, joy, and hope. Key storytelling points at a 12 -Step speaker
meeting include describing what an experience was like, what happened, and what it is like now.
Part 1, Chapter 6—Trauma-Specific Services frameworks, including psychoneurology, CBT,
information processing, and nonverbal repre sentation of traumatic memories. The goal of this
therapy is to process the experiences that are causing problems and distress. It is an ef fective
treatment for PTSD (Seidler & Wagner, 2006) and is accepted as an evidence based practice by the
U.S. Department of Veterans Affairs (VA), the Royal College of Psychiatrists, and the International
Society for Traumatic Stress Studies (Najavits, 2007a); numerous reviews support its effectiveness
(e.g., Mills et al., 2012). EMDR values the development of “resource installation” (calming
procedures) and engages in exposure work to desensitize clients to traumatic material, using
external tracking techniques across the visual field to assist in processing distressing materi al.
Training in EMDR, available through the EMDR Institute, is required before counselors use this
treatment. It is listed in SAMHSA’s NREPP (EMDR Network, 2012). Thus far, there is no study
examining the use of EMDR with clients in substance abuse treatment. See Part 3 of this TIP,
available online, to review empirical work on EMDR. Narrative therapy Narrative therapy is an
emerging approach to understanding human growth and change; it is founded on the premise that
individuals are the experts on their own lives and can access their existing intrapsychic and
interpersonal resources to reduce the impact of problems in their lives. Developed for the treatment
of PTSD resulting from political or community violence, narrative therapy is based on CBT principles,
particularly exposure therapy (Neuner, Schauer, Elbert, & Roth, 2002; Neuner, Schauer, Klaschik,
Karunakara, & Elbert, 2004). This approach views psycho therapy not as a scientific practice, but as a
natural extension of healing practices that have been present throughout human history. For a
trauma survivor, the narrative, as it is told and retold, expresses the traumatic expe rience, puts the
trauma in the context of the survivor’s life, and defines the options he or she has for change.
Narrative structure helps clients connect events in their lives, reveals strings of events, explores
alternative expres sions of trauma, evokes explanations for cli ents’ behaviors, and identifies their
knowledge and skills. The use of stories in therapy, with the client as the storyteller, generally helps
lessen suffering (McLeod, 1997; White, 2004). Skills training in affective and interpersonal regulation
Skills training in affective and interpersonal regulation (STAIR) is a two-phase cognitive behavioral
model that adapts therapies devel oped by others into a new package (Cloitre, Koenen, Cohen, &
Han, 2002). Phase 1 con sists of eight weekly sessions of skills training in affect and interpersonal
regulation derived from general CBT and DBT (Linehan, 1993) and adapted to address trauma
involving childhood abuse. Session topics are labeling and identifying feelings, emotion manage
ment, distress tolerance, acceptance of feel ings, identifying trauma-based interpersonal schemas,
identifying conflict between trauma generated feelings and current interpersonal goals, role-plays
on issues of power and con trol, and role-plays on developing flexibility in interpersonal situations.
Phase 2 features eight 145 Trauma-Informed Care in Behavioral Health Services STAIR Steps Phase 1,
tailored to individual clients, is called Skills Training in Affect Regulation and consists of the following
components: • Psychoeducation: Describe the symptoms of PTSD and explain the treatment
rationale. • Training in experiencing and identifying feelings, triggers, and thoughts, as well as
training in mood regulation strategies. • Learning history: Ask the client the following questions—
How did the client deal with traumas past and present? How did the client’s family deal with
feelings? How did the client’s family life affect his or her present difficulty experiencing and
identifying feeling? • Emotion regulation skills: Identify the cognitive, behavioral, and social support
modalities for coping. Use data gathered with self-monitoring forms to identify strengths and
weaknesses in each coping modality. Teach skills such as breathing retraining, self-statements to
reduce fear, and social skill training to improve social support. • Acceptance and tolerance of
negative affect: Motivate clients to face distressing situations relat ed to the trauma that are
important to them. Review negative repercussions of avoidance. Dis cuss tolerating negative affect
as a step toward achieving specific goals. • Schema therapy for improved relationships: Identify
relevant schemas learned in childhood. Sug gest alternative ways of viewing self and others in
current relationships. Use role-playing to teach assertiveness, emphasizing response flexibility based
on relative power in each relationship. Once Phase 1 of STAIR is well learned, clients move to Phase
2, which involves exposure therapy. Source: Mollick & Spett, 2002. sessions of modified prolonged
exposure using a narrative approach. Cloitre and colleagues (2002) assigned women with PTSD
related to childhood abuse ran domly to STAIR or a minimal attention wait list, excluding clients with
current substance dependence as well as other complexities. STAIR participants showed significantly
greater gains in affect regulation, interpersonal skills, and PTSD symptoms than the control
participants. These gains were maintained through follow-up at 3 and 9 months. How ever, it is not
clear from this study whether DBT and exposure were both needed. Phase 1 therapeutic alliance and
negative mood regula tion skills predicted Phase 2 exposure success in reducing PTSD, suggesting the
importance of establishing a strong therapeutic relation ship and emotion regulation skills before
con ducting exposure work with people who have chronic PTSD. 146 Stress inoculation training SIT
was originally developed to manage anxiety (Meichenbaum, 1994; Meichenbaum & Deffenbacher,
1988). Kilpatrick, Veronen, and Resick (1982) modified SIT to treat rape survivors based on the idea
that the anxiety and fear that rape survivors experience during their trauma generalizes to other
objectively safe situations. SIT treatment components include education, skills training (muscle
relaxation training, breathing retraining, role-playing, guided self-talk, assertiveness training, and
thought stopping [i.e., actively and forcefully ending negative thoughts by thinking SIT has been used
to help individuals cope with the aftermath of exposure to stressful events and on a preventative
basis to “inoculate” individuals to future and ongoing stressors (Meichenbaum, 1996). This practice
as a preventive strategy is similar to promoting disease resistance through immunizations. Part 1,
Chapter 6—Trauma-Specific Services Advice to Counselors: SIT Phases SIT is a prevention and
treatment approach that has three overlapping phases. It is often seen as a complementary
approach to other interventions for traumatic stress. Phase 1: Conceptualization and education. This
phase has two main objectives. The initial goal is to develop a collaborative relationship that
supports and encourages the client to confront stressors and learn new coping strategies. The next
objective is to increase the client’s understanding of the nature and impact of his or her stress and
awareness of alternative coping skills. Many cognitive strategies are used to meet these objectives,
including self-monitoring activities, Socratic question ing, identifying strengths and evidence of
resilience, and modeling of coping strategies. Phase 2: Skill acquisition and rehearsal. This phase
focuses on developing coping skills and using coping skills that the individual already possesses. This
process includes practice across settings, so that the individual begins to generalize the use of his or
her skills across situations through rehearsal, rehearsal, and more rehearsal. Phase 3:
Implementation and following through. The main objective is to create more challenging
circumstances that elicit higher stress levels for the client. By gradually increasing the challenge, the
client can practice coping strategies that mimic more realistic circumstances. Through successful
negotiation, the client builds a greater sense of self-efficacy. Common strategies in this phase
include imagery and behavioral rehearsal, modeling, role-playing, and graded in vivo exposure.
Source: Meichenbaum, 2007. “STOP” and then redirecting thoughts in a more positive direction]),
and skills applica tion. The goal is to help clients learn to man age their anxiety and to decrease
avoidant behavior by using effective coping strategies. Randomized controlled clinical trials have
indicated that SIT reduces the severity of PTSD compared with waitlist controls and shows
comparable efficacy to exposure therapy. At follow-up (up to 12 months after treat ment), gains
were maintained (Foa et al., 1999; Foa, Rothbaum, Riggs, & Murdock, 1991). Other therapies
Numerous interventions introduced in the past 20 years focus on traumatic stress. For some
interventions, the evidence is limited, and for other others, it is evolving. One exam ple is the
traumatic incident reduction (TIR) approach. This brief memory-oriented inter vention is designed
for children, adolescents, and adults who have experienced traumatic stress (Valentine & Smith,
2001). Listed in SAMHSA’s NREPP, the intervention is de signed to process specific traumatic
incidents or problematic themes related to the trauma, including specific feelings, emotions, sensa
tions, attitudes, or pain. It involves having cli ents talk through the traumatic incident repeatedly
with the anticipation that changes in affect will occur throughout the repetitions. TIR is a client-
centered approach. Integrated Models for Trauma This section covers models specifically de signed
to treat trauma-related symptoms along with either mental or substance use disorders at the same
time. Integrated treatments help clients work on several presenting problems simultaneously
throughout the treatment, a promising and recommended strategy (Dass Brailsford & Myrick, 2010;
Najavits, 2002b; Nixon & Nearmy, 2011). Thus far, research is limited, but what is available suggests
that integrated treatment models effectively reduce 147 Trauma-Informed Care in Behavioral Health
Services substance abuse, PTSD symptoms, and other mental disorder symptoms. TIP 42, Substance
Abuse Treatment for Persons With Co-Occurring Disorders (Center for Substance Abuse Treat ment,
2005c), offers a detailed description of integrated treatment. In contrast with inte grated models,
other model types include sin gle (treatment of only one disorder), sequential (treatment of one
disorder first, then the other), or parallel (concurrent treat ment of multiple disorders delivered by
sepa rate clinicians or in separate programs that do not necessarily address the interactions be
tween symptoms and disorders). Similar to single models, integrated treatment models are designed
for use in a variety of settings (e.g., outpatient, day treatment, and/or residential substance abuse
and mental health clinics/programs). Most models listed are manual-based treatments that address
trauma-related symptoms, mental disorders, and substance use disorders at the same time.
Additional approaches and further details on the selected approaches can be found at NREPP
([Link] Addiction and Trauma Recovery Integration Model The Addiction
and Trauma Recovery Inte grated Model (ATRIUM; Miller & Guidry, 2001) integrates CBT and
relational treatment through an emphasis on mental, physical, and spiritual health. This 12-week
model for indi viduals and groups blends psychoeducational, process, and expressive activities, as
well as information on the body’s responses to addic tion and traumatic stress and the impact of
trauma and addiction on the mind and spirit. It helps clients explore anxiety, sexuality, self harm,
depression, anger, physical complaints and ailments, sleep difficulties, relationship challenges, and
spiritual disconnection. It was designed primarily for women and focuses on developmental
(childhood) trauma and inter personal violence, but it recognizes that other types of traumatic
events occur. The ATRIUM model consists of three phases of treatment. The first stage, or “outer
circle,” consists of the counselor collecting data from the client about his or her trauma history, of
fering psychoeducation on the nature of trau ma, and helping the client assess personal strengths.
ATRIUM actively discourages the evocation of memories of abuse or other trau ma events in this
phase. The second stage, or “middle circle,” allows clients and counselors to address trauma
symptoms more directly and specifically encourages clients to reach out to and engage with support
resources in the community. The middle circle also emphasiz es learning new information about
trauma and developing additional coping skills. The third stage of the program, the “inner circle,”
focus es on challenging old beliefs that arose as a result of the trauma. For instance, the concept of
“nonprotecting bystander” is used to repre sent the lack of support that the traumatized person
experienced at the time of the trauma. This representation is replaced with the “pro tective
presence” of supportive others today. ATRIUM was used in one of the nine study sites of SAMHSA’s
Women, Co-Occurring Disorders and Violence Study. Across all sites, trauma-specific models
achieved more favora ble outcomes than control sites that did not use trauma-specific models
(Morrissey et al., 2005). There has not yet been a study of ATRIUM per se, however. A manual
describ ing the theory behind this model in greater depth, as well as how to implement it, is pub
lished under the title Addictions and Trauma Recovery: Healing the Body, Mind, and Spirit (Miller &
Guidry, 2001). 148 Part 1, Chapter 6—Trauma-Specific Services Beyond Trauma: A Healing Journey
for Women Beyond Trauma (Covington, 2003) is a curric ulum for women’s services based on theory,
research, and clinical experience. It was devel oped for use in residential, outpatient, and
correctional settings; domestic violence pro grams; and mental health clinics. It uses behavioral
techniques and expressive arts and is based on relational therapy. Although the materials are
designed for trauma treatment, the connection between trauma and substance abuse in women’s
lives is a theme throughout. Beyond Trauma has a psychoeducational com ponent that defines
trauma by way of its pro cess as well as its impact on the inner self (thoughts, feelings, beliefs,
values) and the outer self (behavior and relationships, includ ing parenting). Coping skills are
emphasized; specific exercises develop emotional wellness. Concurrent Treatment of PTSD and
Cocaine Dependence Concurrent Treatment of PTSD and Cocaine Dependence (CTPCD) is a 16-
session, twice weekly individual outpatient psychotherapy model designed to treat women and men
with co-occurring PTSD and cocaine dependence (Coffey, Schumacher, Brimo, & Brady, 2005). CTPCD
combines imagery and in vivo expo sure therapy (in which the client becomes de sensitized to
anxiety-producing stimuli through repeated exposure to them) for the treatment of PTSD with
elements of CBT for substance dependence. To balance the dual needs of abstinence skill building
and prompt trauma treatment, the first five sessions focus on coping skills for cocaine dependence.
Ses sion six transitions into exposure therapy, which begins in earnest in session seven and is
combined with CBT for the treatment of sub stance abuse. CTPCD helps reduce substance use and
PTSD symptoms. The use of any illicit drug, as measured by urine screens, was quite low during the
16-week treatment trial and didn’t escalate during the second half of treatment— when most
exposure sessions occurred. PTSD symptoms dropped significantly over the course of treatment, as
did self-reported de pressive symptoms; however, the dropout rate was high (Coffey, Dansky, &
Brady, 2003). CTPCD was reformulated into Concurrent Prolonged Exposure (COPE; Mills et al.,
2012), which was compared with treatment as usual in a high-complexity clinical sample of
individuals who had PTSD and substance dependence. Both treatment conditions result ed in
improvements in PTSD with no differ ence at 3 months (though COPE showed significantly greater
improvement at 9 months); moreover, the two conditions did not differ in impact on substance use
outcomes, depression, or anxiety. Integrated CBT Integrated CBT is a 14-session individual therapy
model designed for PTSD and sub stance use. It incorporates elements such as psychoeducation,
cognitive restructuring, and breathing retraining (McGovern, Lamber Harris, Alterman, Xie, & Meier,
2011). A ran domized controlled trial showed that both integrated CBT and individual addiction
treatment achieved improvements in substance use and other measures of psychiatric symp tom
severity with no difference between the treatments. Seeking Safety Seeking Safety is an empirically
validated, present-focused treatment model that helps clients attain safety from trauma and
substance abuse (Najavits, 2002a). The Seeking Safety manual (Najavits, 2002b) offers clinician guide
lines and client handouts and is available in 149 Trauma-Informed Care in Behavioral Health Services
several [Link] videos and other implementation materials are available online
([Link] Seeking Safety is flexible; it can be used for groups and indi viduals,
with women and men, in all settings and levels of care, by all clinicians, for all types of trauma and
substance abuse. Seeking Safety covers 25 topics that address cognitive, behavioral, interpersonal,
and case management domains. The topics can be conducted in any order, using as few or as many
as are possible within a client’s course of treatment. Each topic represents a coping skill relevant to
both trauma and substance abuse, such as compassion, taking good care of your self, healing from
anger, coping with triggers, and asking for help. This treatment model builds hope through an
emphasis on ideals and simple, emotionally evocative language and quotations. It attends to clinician
process es and offers concrete strategies that are thought to be essential for clients dealing with
concurrent substance use disorders and histo ries of trauma. More than 20 published studies (which
include pilot studies, randomized controlled trials, and multisite trials representing various investiga
tors and populations) provide the evidence base for this treatment model. For more infor mation,
see SAMHSA’s NREPP Web site ([Link] as well as the “Outcomes” section
of the Seeking Safety Web site ([Link] 06/[Link]). Study samples
included peo ple with chronic, severe trauma symptoms and substance dependence who were
diverse in ethnicity and were treated in a range of set tings (e.g., criminal justice, VA centers, adoles
cent treatment, homelessness services, public sector). Seeking Safety has shown positive outcomes
on trauma symptoms, substance abuse, and other domains (e.g., suicidality, HIV risk, social
functioning, problem-solving, sense of meaning); consistently outperformed treatment as usual; and
achieved high satisfac tion ratings from both clients and clinicians. It has been translated into seven
languages, and a version for blind and/or dyslexic individuals is available. The five key elements of
Seeking Safety are: 1. Safety as the overarching goal (helping clients attain safety in their
relationships, thinking, behavior, and emotions). 2. Integrated treatment (working on trauma and
substance abuse at the same time). 3. A focus on ideals to counteract the loss of ideals in both
trauma and substance abuse. 4. Four content areas: cognitive, behavioral, interpersonal, and case
management. 5. Attention to clinician processes (address ing countertransference, self-care, and
other issues). Substance Dependence PTSD Therapy Substance Dependence PTSD Therapy
(Triffleman, 2000) was designed to help cli ents of both sexes cope with a broad range of traumas. It
combines existing treatments for PTSD and substance abuse into a structured, 40-session (5-month,
twice-weekly) individual therapy that occurs in two phases. Phase I is “Trauma-Informed, Addictions-
Focused Treatment” and focuses on coping skills and cognitive interventions as well as creating a
safe environment. Phase I draws on CBT models, anger management, relaxation training, HIV risk
reduction, and motivational en hancement techniques. Phase II, “Trauma Focused, Addictions-
Informed Treatment,” begins with psychoeducation about PTSD fol lowed by “Anti-Avoidance I,” in
which a modi fied version of stress inoculation training is taught in two to four sessions. Following
this is “Anti-Avoidance II,” lasting 6 to 10 sessions, in which in vivo exposure is used. 150 Part 1,
Chapter 6—Trauma-Specific Services Trauma Affect Regulation: Guide for Education and Therapy
Trauma Affect Regulation: Guide for Educa tion and Therapy (TARGET; Ford & Russo, 2006; Frisman,
Ford, Lin, Mallon, & Chang, 2008) uses emotion and information pro cessing in a present-focused,
strengths-based approach to education and skills training for trauma survivors with severe mental,
substance use, and co-occurring disorders across diverse populations. TARGET helps trauma
survivors understand how trauma changes the brain’s TARGET: The Seven-Step FREEDOM Approach
Focus: Being focused helps a person pay attention and think about what’s happening right now
instead of just reacting based on alarm signals tied to past trauma. This step teaches participants to
use the SOS skill (Slow down, Orient, Self-check) to pay attention to body signals and the immediate
environment and to use a simple scale to measure stress and control levels. Recognize triggers:
Recognizing trauma triggers enables a person to anticipate and reset alarm signals as he or she
learns to distinguish between a real threat and a reminder. This step helps par ticipants identify
personal triggers, take control, and short-circuit their alarm reactions. Emotion self-check: The goal
of this skill is to identify two types of emotions. The first are “alarm” or reactive emotions such as
terror, rage, shame, hopelessness, and guilt. Because these emotions are the most noticeable after
trauma, they are the alarm system’s way of keeping a person primed and ready to fend off further
danger. The second type of emotion, “main” emotions, include posi tive feelings (e.g., happiness,
love, comfort, compassion) and feelings that represent positive striv ings (e.g., hope, interest,
confidence). By balancing both kinds of emotions, a person can reflect and draw on his or her own
values and hopes even when the alarm is activated. Evaluate thoughts: When the brain is in alarm
mode, thinking tends to be rigid, global, and cata strophic. Evaluating thoughts, as with identifying
emotions, is about achieving a healthier balance of positive as well as negative thinking. Through a
two-part process, participants learn to evaluate the situation and their options with a focus on how
they choose to act—moving from reactive thoughts to “main” thoughts. This is a fundamental
change from the PTSD pattern, which causes problems by taking a person straight from alarm signals
to automatic survival reactions. Define goals: Reactive goals tend to be limited to just making it
through the immediate situation or away from the source of danger. These reactive goals are
necessary in true emergencies but don’t reflect a person’s “main” goals of doing worthwhile things
and ultimately achieving a good and meaningful life. This step teaches one how to create “main”
goals that reflect his or her deeper hopes and values. Options: The only options that are available
when the brain’s alarm is turned on and won’t turn off are automatic “flight/fight” or
“freeze/submit” reactive behaviors that are necessary in emergencies but often unhelpful in
ordinary living. This step helps identify positive intentions often hidden by the more extreme
reactive options generated by the alarm system. This opens the possibility for a greater range of
options that take into consideration one’s own needs and goals as well as those of others. Make a
contribution: When the brain’s alarm is turned on and reacting to ordinary stressors as if they were
emergencies, it is very difficult for a person to come away from experiences with a feeling that they
have made a positive difference. This can lead to feelings of alienation, worthlessness, or spiritual
distress. The ultimate goal of TARGET is to empower adults and young people to think clearly
enough to feel in control of their alarm reactions and, as a result, to be able to recognize the
contribution they are making not only to their own lives, but to others’ lives as well. 151 Source:
Advanced Trauma Solutions, 2012. Trauma-Informed Care in Behavioral Health Services normal
stress response into an extreme survival-based alarm response that can lead to PTSD, and it teaches
them a seven-step ap proach to making the PTSD alarm response less distressing and more adaptive
(summa rized by the acronym FREEDOM: Focus, Recognize triggers, Emotion self-check, Eval uate
thoughts, Define goals, Options, and Make a contribution). TARGET can be presented in individual
therapy or gender-specific psychoeducational groups, and it has been adapted for individuals who
are deaf; it has also been translated into Spanish and Dutch. TARGET is a resilience building and
recovery program not limited to individual or group psychotherapy; it is also designed to provide an
educational curriculum and milieu intervention that affects all areas of practice in school,
therapeutic, or correctional programs. TARGET is listed in SAMHSA’s NREPP
([Link] Trauma Recovery and Empowerment Model The trauma recovery
and empowerment mod el (TREM) of therapy (Fallot & Harris, 2002; Harris & Community
Connections Trauma Work Group, 1998) is a manualized group intervention designed for female
trauma survi TREM Program Format vors with severe mental disorders. TREM addresses the
complexity of long-term adapta tion to trauma and attends to a range of diffi culties common among
survivors of sexual and physical abuse. TREM focuses mainly on de veloping specific recovery skills
and current functioning and uses techniques that are effec tive in trauma recovery services. The
model’s content and structure, which cover 33 topics, are informed by the role of gender in
women’s experience of and coping with trauma. TREM can be adapted for shorter-term resi dential
settings and outpatient substance abuse treatment settings, among others. Adaptations of the
model for men and adolescents are available. The model was used in SAMHSA’s Women, Co-
Occurring Disorders and Vio lence Study for three of the nine study sites and in SAMHSA’s Homeless
Families pro gram, and it is listed in SAMHSA’s NREPP. This model has been used with clients in sub
stance abuse treatment; research by Toussaint, VanDeMark, Bornemann, and Graeber (2007) shows
that women in a residential sub stance abuse treatment program showed sig nificantly better
trauma treatment outcomes using TREM than they did in treatment as usual, but no difference in
substance use. Each session includes an experiential exercise to promote group cohesiveness. The 33
sessions are divided into the following general topic areas: • Part I–empowerment introduces
gender identity concepts, interpersonal boundaries, and self esteem. • Part II–trauma recovery
concentrates on sexual, physical, and emotional abuse and their rela tionship to psychiatric
symptoms, substance abuse, and relational patterns and issues. • Part III–advanced trauma recovery
issues addresses additional trauma issues, such as blame and the role of forgiveness. • Part IV–
closing rituals allows participants to assess their progress and encourages them to plan for their
continued healing, either on their own or as part of a community of other survivors. • Part V–
modifications or supplements for special populations provides modifications for sub groups such as
women with serious mental illness, incarcerated women, women who are parents, women who
abuse substances, and male survivors. Source: Mental Health America Centers for Technical
Assistance, 2012. 152 Part 1, Chapter 6—Trauma-Specific Services Triad Women’s Project The Triad
Project was developed as a part of SAMHSA’s Women, Co-Occurring Disorders and Violence Study. It
is a comprehensive, trauma-informed, consumer-responsive inte grated model designed for female
trauma sur vivors with co-occurring substance use and mental disorders who live in semirural areas.
Triad integrates motivational enhancement for substance use disorders, DBT, and intensive case
management techniques for co-occurring mental disorders. This program is a 16-week group
intervention for women that uses inte grated case management services, a curriculum-based
treatment group, and a peer support group (Clark & Fearday, 2003). Emerging Interventions New
interventions are emerging to address traumatic stress symptoms and disorders. The following
sections summarize a few interven tions not highlighted in prior chapters; this is not an exhaustive
list. In addition to specific interventions, technology is beginning to shape the delivery of care and to
increase ac cessibility to tools that complement trauma specific treatments. Numerous applications
are available and evolving. For more information on the role of technology in the delivery of care,
see the planned TIP, Using Technology Based Therapeutic Tools in Behavioral Health Services
(SAMHSA, planned g). Couple and Family Therapy Trauma and traumatic stress affects significant
relationships, including the survivor’s family. Although minimal research has targeted the
effectiveness of family therapy with trauma survivors, it is important to consider the needs of the
individual in the context of their rela tionships. Family and couples therapy may be key to recovery.
Family members may experi ence secondary traumatization silently, lack understanding of traumatic
stress symptoms or treatment, and/or have their own histories of trauma that influence their
willingness to sup port the client in the family or to talk about anything related to trauma and its
effects. Family members can engage in similar pat terns of avoidance and have their own triggers
related to the trauma being addressed at the time. A range of couple and family therapies have
addressed traumatic stress and PTSD, but few studies exist that support or refute their value.
Current couple or family therapies that have some science-based evidence include behavioral family
therapy, behavioral marital therapy, cognitive–behavioral couples treat ment, and lifestyle
management courses (Riggs, Monson, Glynn, & Canterino, 2009). Mindfulness Interventions
Mindfulness is a process of learning to be pre sent in the moment and observing internal experience
(e.g., thoughts, bodily sensations) and external experience (e.g., interactions with others) in a
nonjudgmental way. Mindfulness challenges limiting beliefs that arise from trauma, quells anxiety
about future events, and simply helps one stay grounded in the present. It plays a significant role in
helping individuals who have been traumatized observe their ex periences, increase awareness, and
tolerate uncomfortable emotions and cognitions. To date, mindfulness-based interventions ap pear
to be valuable as an adjunct to trauma specific interventions and in decreasing arous al (Baer, 2003).
It may also help individuals tolerate discomfort during exposure-oriented and trauma processing
interventions. Overall, mindfulness practices can help clients in man aging traumatic stress, coping,
and resilience. In a study of firefighters, mindfulness was associated with fewer PTSD symptoms, de
pressive symptoms, physical symptoms, and alcohol problems when controlling for other variables
(Smith et al., 2011). 153 Trauma-Informed Care in Behavioral Health Services Becoming an Observer
and Learning To Tolerate Discomfort: The Leaf and Stream Metaphor The following exercise, “leaves
floating on a stream,” is a classic. Many clinicians and authors pro vide renditions of this mindfulness
practice. The main objectives are to stand back and observe thoughts rather than get caught up in
them. Simply stated, thoughts are just thoughts. Thoughts come and go like water flowing down a
stream. We don’t need to react to the thoughts; instead, we can just notice them. Conduct the
mindfulness exercise for about 10 minutes, then process afterward. Take time to al low participants
to visualize each sense as they imagine themselves sitting next to the stream. For example, what
does it look like? What do they hear as they sit next to the stream? Don’t rush the exercise. As you
slowly make the statements detailed in the following two paragraphs, take time in between each
statement for participants to be in the exercise without interruption; simply offer gen tle guidance.
Begin to sit quietly, bringing your attention to your breath. If you feel comfortable, close your eyes.
As you focus on breathing in and out, imagine that you are sitting next to a stream. In your imagina
tion, you may clearly see and hear the stream, or you may have difficulty visualizing the stream. Fol
low along with the guided exercise; either way, it will work just as well. Facilitated Questions: Now
begin to notice the thoughts that come into your mind. Some thoughts rush by, while others linger.
Just allow yourself to notice your thoughts. As you begin to notice each thought, imagine putting
those words onto a leaf as it floats by on the stream. Just let the thoughts come, watching them drift
by on the leaves. If your thoughts briefly stop, continue to watch the water flow down the stream.
Eventually, your thoughts will come again. Just let them come, and as they do, place them onto a
leaf. Your attention may wander. Painful feelings may arise. You may feel uncomfortable or start to
think that the exercise is “stupid.” You may hook onto a thought—rehashing it repeatedly. That’s
okay; it’s what our minds do. As soon as you notice your mind wandering or getting stuck, just gently
bring your focus back to your thoughts, and place them onto the leaves. Now, bring your attention
back to your breath for a moment, then open your eyes and become more aware of your
environment. • What was it like for you to observe your thoughts? • Did you get distracted? Stuck? •
Were you able to bring yourself back to the exercise after getting distracted? • In what ways was the
exercise uncomfortable? • In what ways was the exercise comforting? For clients and practitioners
who want to de velop a greater capacity for mindfulness, see Kabat-Zinn’s books Wherever You Go,
There You Are: Mindfulness Meditation In Everyday Life (1994) and Full Catastrophe Living: Using the
Wisdom of Your Body and Mind to Face Stress, Pain, and Illness (1990). For clinical applications of
mindfulness, see Mindfulness Based Cognitive Therapy for Depression: A New Approach to
Preventing Relapse (Segal et al., 2002) and Relapse Prevention: Maintenance 154 Strategies in the
Treatment of Addictive Behav iors (Marlatt & Donovan, 2005). Pharmacological Therapy
Pharmacotherapy for people with mental, sub stance use, and traumatic stress disorders needs to be
carefully managed by physicians who are well versed in the treatment of each condition.
Medications can help manage and control symptoms; however, they are only a part of a
comprehensive treatment plan. There Part 1, Chapter 6—Trauma-Specific Services are no specific
“antitrauma” drugs; rather, cer tain drugs target specific trauma symptoms. Clients receiving
pharmacotherapy need care ful assessment. Some clients with preexisting mental disorders may
need further adjustment in medications due to the physiological effects of traumatic stress. In
addition, sudden with drawal from a pattern of self-administered substances can not only lead to
dangerous lev els of physical distress, but also exacerbate the emergence of more severe PTSD
symptoms. Distress after trauma often lessens over time, which can sometimes make the use of
medica tions unnecessary for some individuals. Some trauma survivors do not develop long-term
psychological problems from their experiences that require medication; others may simply refuse
the initiation of pharmacotherapy or the use of additional medications. Concluding Note Behavioral
health counselors can best serve clients who have experienced trauma by providing integrated
treatment that combines therapeutic models to target presenting symp toms and disorders. Doing
so acknowledges that the disorders interact with each other. Some models have integrated
curricula; others that address trauma alone can be combined with behavioral health techniques with
which the counselor is already familiar. In part, the choice of a treatment model or general approach
will depend on the level of evidence for the model, the counselor’s train ing, identified problems, the
potential for pre vention, and the client’s goals and readiness for treatment. Are improved
relationships with family members a goal? Will the client be satisfied if sleep problems decrease, or
is the goal resolution of broader issues? Are there substance use or substance-related disorders? Is
the goal abstinence? Collaborating with clients to decide on goals, eliciting what they would like
from treatment, and determining what they expect to happen can provide some clues as to what
treatment models or tech niques might be successful in keeping clients engaged in recovery. 155 .
Part 2: An Implementation Guide for Behavioral Health Program Administrators . Trauma-Informed 1
Organizations IN THIS CHAPTER • Show Organizational and Ad ministrative Commitment to TIC • Use
Trauma -Informed Princi ples in Strategic Planning • Review and Update Vision, Mission, and Value
Statements • Assign a Key Staff Member To Facilitate Change • Create a Trauma -Informed Oversight
Committee • Conduct an Organizational Self -Assessment of Trauma Informed Services • Develop an
Implementation Plan • Develop Policies and Proce dures To Ensure Trauma Informed Practices and
To Prevent Retraumatization • Develop a Disaster Plan • Incorporate Universal Routine Screenings •
Apply Culturally Responsive Principles • Use Science -Based Knowledge • Create a Peer -Support Envi
ronment • Obtain Ongoing Feedback and Evaluations • Change the Environment To Increase Safety
• Develop Trauma -Informed Collaborations Part 2 provides a broad overview of how to create and
implement an institutional framework for trauma-informed services in pro gram delivery and staff
development, policies and procedures, ad ministrative practices, and organizational infrastructure in
behavioral health services. Chapter 1, “Trauma-Informed Organi zations,” focuses on specific
organizational strategies that will help develop a trauma-informed culture in behavioral health
settings. Numerous strategies are presented, including organizational com mitment to trauma-
informed care (TIC), trauma-informed organi zational assessment, implementation of universal
screening for trauma, and creation of a peer support environment. Chapter 2, “Building a Trauma-
Informed Workforce,” focuses on organizational activities that foster the development of a trauma
informed workforce, including recruiting, hiring, and retaining trauma-informed staff; providing
training on evidence-based and emerging trauma-informed best practices; developing competen
cies specific to TIC; addressing ethical considerations; providing trauma-informed supervision; and
preventing and treating second ary trauma in behavioral health service providers. The strategies
described in the following sections can help supervi sors and other administrative staff members
create a trauma informed behavioral health environment. As a starting point, the administration
should identify key personnel and consumers to guide the organizational change process and the
organizational as sessment. Administrators and supervisors need to plan for and demonstrate an
ongoing commitment to these strategies, or staff may perceive development activities as comprising
yet another idea or demand from the agency that is short-lived beyond the initial thrust of training.
159 Trauma-Informed Care in Behavioral Health Services TIC Framework in Behavioral Health
Services—Trauma-Informed Organizations Creating a trauma-informed organization is a fluid,
ongoing process; it has no completion date. Consumer demographics change across time, exposure
to specific types of trauma may become more prevalent, and knowledge of best and evidence-based
practices (EBPs) will continue to advance. A trauma-informed organization continues to demonstrate
a commitment to compassionate and effective practices and organizational reassessments, and it
changes to meet the needs of consumers with histories of trauma. It is encouraging that recent
Substance Abuse and Mental Health Services Administration (SAMHSA) data indicates that the
majority of over 10,000 pro grams they surveyed state that they provide trauma-related care
(Capezza & Najavits, 2012). However, there remains a major need to make TIC consistently high-
quality, routine, and pervasive across treatment systems. The following stages form the basis of
creat ing a trauma-informed organization: 1. Commit to creating a trauma-informed agency. 2.
Create an initial infrastructure to initiate, support, and guide changes. 3. Involve key stakeholders,
including con sumers who have histories of trauma. 4. Assess whether and to what extent the
organization’s current policies, procedures, and operations either support TIC or in terfere with the
development of a trauma informed approach. 5. Develop an organizational plan to imple ment and
support the delivery of TIC within the agency. 160 Trauma-Informed Services and Service Systems “A
trauma-informed service system and/or organization is one in which all components of the system
have been reconsidered and evaluated in the light of a basic understanding of the role that violence
and trauma play in the lives of people seeking mental health and addiction services. A ‘trauma
informed’ organizational environment is capable of supporting and sustaining ‘trauma-specific’ ser
vices as they develop. A trauma-informed system recognizes that trauma results in multiple vulnera
bilities and affects many aspects of a survivor’s life over the lifespan, and therefore coordinates and
integrates trauma-related activities and training with other systems of care serving trauma survivors.
A basic understanding of trauma and trauma dynamics…should be held by all staff and should be
used to design systems of services in a manner that accommodates the vulnerabilities of trauma sur
vivors and allows services to be delivered in a way that will avoid retraumatization and facilitate con
sumer participation in treatment. A trauma-informed service system is knowledgeable and
competent to recognize and respond effectively to adults and children traumatically impacted by any
of a range of overwhelming adverse experiences, both interpersonal in nature and caused by natural
events and disasters. There should be written plans and procedures to develop a trauma-informed
service system and/or trauma-informed organizations and facilities with methods to identify and
mon itor progress. Training programs for this purpose should be implemented.” Source: Jennings,
2009, pp. 111–112. Seminal Resource for Administrators As you investigate how best to implement
or improve trauma -informed services within your organization or across systems, review the
influential work, Using Trauma Theory to Design Service Systems: New Directions for Mental Health
Services. (Harris & Fallot, 2001c) Part 2, Chapter 1—Trauma-Informed Organizations 6. Create
collaborations between providers and consumers and among service provid ers and various
community agencies. 7. Put the organizational plan into action. 8. Reassess the implementation of
the plan and its ability to meet the needs of con sumers and to provide consistent TIC on an ongoing
basis. 9. Implement quality improvement measures as needs and problem areas are identified. 10.
Institute practices that support sustainabil ity, such as ongoing training, clinical su pervision,
consumer participation and feedback, and resource allocation. Strategy #1: Show Organizational and
Administrative Commitment to TIC Foremost, administrators need to understand the impact that
trauma can have on people’s lives. The consistent delivery of TIC is only as effective as the
organization’s commitment, which must extend to administrative practices with staff members,
program policies and pro cedures, program design, staffing patterns, use of peer support, staff and
peer training and supervision, organizational assessment and consumer feedback, and resources to
uphold trauma-informed principles and practices. Even short-term change is not sustainable without
the agency’s continual commitment. Typically, desirable organizational change doesn’t occur by
accident. It comes from steadfast leadership, a convincing message that change is necessary and
beneficial for staff and consumers, and resources that support change. Many people naturally resist
change; thus, an organization’s commitment includes a will ingness to discuss with staff members
the im pact and role of trauma in their service setting, patience in planning and implementation, and
161 Trauma-Informed Care in Behavioral Health Services Advice to Administrators: Managing Staff
Reactions to Implementation of New Processes or Ideas A common hurdle for administrators after in
troducing a new process or idea is the staff assumption that it will require more work. Frontline staff
members are often inundated with many responsibilities beyond face-to-face time with clients. In
addition, a common mis perception is that if you begin to address trauma, you will have difficulty
containing it. In addition to administrative buy-in, administra tors must promote rather than simply
announce the implementation of trauma-informed ser vices. Promotion includes educating staff
about the rationale for trauma-informed services, of fering opportunities for discussion and input
from staff and consumers, providing training focused on trauma-informed skills, and so forth. For
example, the San Diego Trauma-Informed Guide Team (2012) created a promotional bro chure on
how TIC can make staff jobs easier: • Focuses on root problem • Is preventative • Shares workload •
Increases support system • Facilitates collaboration • Empowers client • Provides consistency in
agencies/systems • Uses evidence-based best practices TIC may be cost-effective, lead to less
intensive services and less use of services, prevent undue stress for staff members and clients, and
pre vent client crises caused by old policies that could retraumatize trauma survivors. the ability to
tolerate the uncertainty that nat urally accompanies transitions. Strategy #2: Use Trauma Informed
Principles in Strategic Planning Strategic planning provides an opportunity to explore and develop
short- and long-term goals. The planning process often begins with reevaluating the organizations’
values, mission, 162 and vision, yet agencies cannot adequately develop a trauma-informed strategic
plan without obtaining specific information about internal (staff, resources, processes) and exter nal
environmental (referral constellation, changes in health care, funding sources, State and Federal
standards, community needs, con sumer demographics, etc.) factors and influ ences. Data gathered
through staff, consumer, organizational, and community assessments shapes the direction of the
plan, including projected demands, challenges, obstacles, strengths, weaknesses, and resources. At
the conclusion of this planning process, the organ ization will have specific goals, objectives, and
tasks to meet the needs of their stakeholders and to address any anticipated challenges. Ide ally,
strategic planning should define key steps in developing or refining trauma-informed services within
the organization. Strategy #3: Review and Update Vision, Mission, and Value Statements Vision,
mission, and value statements provide a conceptual framework for TIC development and delivery.
They should not be created in isolation; they should reflect voices from the community, populations,
and other stakehold ers that the organization serves. These state ments develop through input,
discussion, and assessment. They are not static; they evolve as needs, populations, or environments
change. Statement Example As behavioral health service providers, we strive to be trauma aware—
to understand the dynamics and impact of trauma on the lives of individuals, families, and
communities. We strive to create a trauma-sensitive culture by demonstrating, through consumer
empower ment, program design, and direct care, an un derstanding of the relationships among
trauma, substance abuse, and mental illness. Advice to Administrators: How To Create Vision, Value,
and Mission Statements Define the organization’s vision, values, and mission to be compatible with
TIC. Emphasize the organ izational culture needed to provide TIC. An outgrowth of that cultural shift
may include an enhanced working environment for employees and consumers that is noncoercive
and reduces conflicts, re straint, and seclusion. Even if the current mission statement is appropriate,
change it anyway to sym bolize intended change within the organization. To define or redefine the
vision, values, and mission: • Involve consumers, all levels of staff, and leadership, including the
director/CEO. • Review: Organizational priorities to identify and manage conflicting priorities.
Resources to assess whether reallocation is necessary for change (e.g., to hire peer support
specialists, to furnish comfort rooms). • Operationalize the vision, values, and mission at the level of
individual departments • Evaluate progress at regular staff meetings to ensure that changing the
culture of care stays on the agenda. Source: New Logic Organizational Learning, 2011. Part 2,
Chapter 1—Trauma-Informed Organizations Strategy #4: Assign a Key Staff Member To Facilitate
Change Prior to the development of an oversight com mittee, a senior staff member with the authori
ty to initiate and implement changes should be assigned to oversee the developmental process. By
assigning a trauma-aware senior staff mem ber who is committed to trauma-informed services, it is
more likely that the organiza tion’s and committee’s goals, objectives, and plans will remain in focus.
This senior staff member is responsible for ongoing develop ment and facilitation of the oversight
commit tee; management of the initial organizational assessment, reassessments, and other
evaluative and feedback processes; and facilitation and oversight of the implementation plan and
sub sequent changes, including policies and proce dures to ensure delivery of TIC. Strategy #5:
Create a Trauma-Informed Oversight Committee The role of the oversight committee includes
providing ongoing input and direction in the initial organizational assessment, strategic plan, plan
implementation, reevaluation and development of trauma-informed policies and procedures, and
future reassessments. The committee monitors progress and uses real time data to forge a clear
pathway to new pro cesses that support TIC. The committee should involve stakeholders from the
commu nity, consumers, specialists, staff members, and administrators. Leadership involvement is
necessary. Stakeholders may be alumni, family members, community-based organizations, and other
institutions that interact with the agency or would benefit from trauma informed services. Initially,
the agency must educate the commit tee on the organization’s mission, values, and vision as well as
the task at hand—developing trauma-informed services. To ease potential conflicts or confusion
about the organization’s structure, the guidelines, expectations, and roles of the committee need to
be communi cated directly to committee members as well as the organization as a whole, including
board members, support and professional staff, su pervisors, and so forth. The committee also needs
to know the extent of their power and the necessary lines of communication before, during, and
after evaluating and implementing changes in the organization. 163 Advice to Administrators: Ten
Steps to Quality Improvement 1. Identify new goals or problems. 2. Gather input from each level of
the organi zation, including consumers and other key stakeholders. 3. Analyze the feedback. 4.
Explore improvement options and the potential barriers associated with each. 5. Select the overall
approach and specific strategies to address barriers (anticipate barriers, and try to address them
before they occur). 6. Develop an implementation plan, and then present the plan to staff members
and other key stakeholders not directly in volved in the quality improvement process. 7. Implement
the plan. 8. Reassess the new plan. 9. Evaluate the results and determine if new goals or additional
problems or issues need to be addressed. 10. Repeat the first nine steps. Trauma-Informed Care in
Behavioral Health Services Including consumers and/or those who have lived through trauma is vital.
They have unique knowledge, experiences, and perspec tives on the impact of treatment design,
deliv ery, policies, and procedures. They offer firsthand information on practices that can potentially
retraumatize clients in behavioral health settings and can suggest preventive, alternative practices
and solutions. Consumer committee members keep staff and adminis trators aware of the goal of
achieving TIC. Strategy #6: Conduct an Organizational Self Assessment of Trauma Informed Services
An organizational self-assessment evaluates the presence and/or the effectiveness of cur rent
trauma-informed practices across each service and level of the organization. This assessment allows
an organization to see how it functions within the context of trauma informed principles and
provides feedback to inform the development or revision of the implementation plan for TIC. In
essence, this assessment process can serve as a blueprint for change and as a benchmark of
compliance with and progress in implementing trauma informed practices across time. Overall, it is a
process of identifying organizational strengths, weaknesses, opportunities, and threats related to the
implementation and maintenance of TIC. Refer to Appendix F for sample organi zational assessment
tools for the organization and the consumer. The self-assessment should obtain feedback from key
stakeholders, particularly consumers, family members, referral sources, community organizations,
and all levels of the organiza tion’s staff, including nonclinical and clinical staff, supervisors, and
administrative person nel. Similar to the universal screening process, an organizational self-
assessment is only as effective as the steps taken after data are gath ered and analyzed. From this
assessment, an implementation plan should be established that highlights the goals, objectives,
steps, timeframe, and personnel responsible in over seeing the specific objective. Assessment
shouldn’t be a once-and-done project. Timely and regularly scheduled organizational assess ments
should follow to assist in quality im provement. For an explanation of more detailed steps to take in
conducting an organi zational self-assessment, see Chapter 4 of the planned Treatment
Improvement Protocol (TIP), Improving Cultural Competence (SAMHSA, planned c). Strategy #7:
Develop an Implementation Plan Implementation plans should evolve from consumer participation,
demographic profiles 164 Part 2, Chapter 1—Trauma-Informed Organizations Advice to
Administrators: Implementation Plan Content 1. 2. 3. Introduction and overview: This includes the
organization’s history, the demographics that char acterize its client base, the rationale for the
implementation plan, and the incorporation of TIC. Focus on identification of strengths, weaknesses,
opportunities, and threats. Provide an overview of goals and objectives. Specific goals and
objectives: Goals and objectives should address: Workforce development strategies for recruiting,
hiring, retaining, training, supervising, and promoting wellness of clinical and nonclinical staff
members to support TIC. Consumer participation and peer support development and
implementation strategies. Policies, procedures, and practices to support TIC and culturally
responsive services, to pro mote safety, and to prevent retraumatization. Specific evidence-based or
best practice adoptions to support TIC. Strategies to amend facility design or environment (plant)
operations to reinforce safety. Fiscal planning to ensure sustainability of the steps initiated in the
organization. Guidelines for implementation: Guidelines should highlight the specific steps, roles,
responsibili ties, and timeframes for each activity to meet TIC objectives. of populations served, data
from organization al self-assessment, and research on promising and evidence-based trauma-
informed practic es. Using the framework proposed in this TIP, Exhibit 2.1-1: TIC Planning Guidelines
the oversight committee is responsible for designing a plan that outlines the purpose, goals,
objectives, timeframes, and personnel responsible for each objective (Exhibit 2.1-1). The following
publications provide samples of organizational guidelines for implementing TIC. • Fallot, R. D. &
Harris, M. (2009). Creating cultures of trauma-informed care (CCTIC): A self assessment and planning
protocol. Washington, DC: Community Connections, 2009. • Guarino, K., Soares, P., Konnath, K.,
Clervil, R., & Bassuk, E. (2009). Trauma-informed organiza tional toolkit. Rockville, MD: Center for
Mental Health Services, Substance Abuse and Mental Health Services Administration; the Daniels
Fund; the National Child Traumatic Stress Network; and the W. K. Kellogg Foundation. • Huckshorn,
K. (2009). Transforming cultures of care toward recovery oriented services: Guidelines toward
creating a trauma informed system of care. In Trauma informed care (TIC) planning guide lines for
use in developing an organizational action plan. Alexandria, VA: National Association of State Mental
Health Program Directors. • Jennings, A. (2009). Criteria for building a trauma-informed mental
health service system. Re trieved on May 21, 2013, from
[Link] • Ohio Legal Rights Service (2007). Trauma-
informed treatment in behavioral health settings. Co lumbus, OH: Ohio Legal Rights Service. •
Prescott, L., Soares, P., Konnath, K., & Bassuk, E. (2008). A long journey home: A guide for creat ing
trauma-informed services for mothers and children experiencing homelessness [draft]. Rock ville,
MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration;
the Daniels Fund; the National Child Traumatic Stress Network; and the W.K. Kellogg Foundation.
The following resource is a systemwide set of guidelines for implementing TIC. • U.S. Department of
Health and Human Services, Health Resources and Services Administration (2006). Model trauma
system: Planning and evaluation. Rockville, MD: Health Resources and Ser vices Administration. 165
Program Curriculum: Roadmap to Seclusion-Free and Restraint-Free Mental Health Services This
curriculum, written from consumer per spectives, provides behavioral health staff with education,
strategies, and hands-on tools to prevent and ultimately eliminate the use of seclusion and restraint.
It includes many handouts for participants and consumers. This training package, available online
([Link] Seclusion-and-Restraint-Free-Mental-Health
Services-CD-/SMA06-4055), is divided into seven modules plus a resources section: • Module 1: The
Personal Experience of Seclusion and Restraint • Module 2: Understanding the Impact of Trauma •
Module 3: Creating Cultural Change • Module 4: Understanding Resilience and Recovery from the
Consumer Perspective • Module 5: Strategies to Prevent Seclusion and Restraint • Module 6:
Sustaining Change Through Consumer and Staff Involvement • Module 7: Review and Action Plan •
Resource Section Source: Center for Mental Health Services (CMHS), SAMHSA, 2005. Trauma-
Informed Care in Behavioral Health Services Strategy #8: Develop Policies and Procedures To Ensure
Trauma Informed Practices and To Prevent Retraumatization In the early stage of evaluating current
services and planning for TIC, the committee needs to assess practices, procedures, and policies that
may have been or could be retraumatizing to any individual, at any level of the organization, from
consumers to administrators. Programs that are not trauma informed are as likely to be unaware of
the impact of trauma on staff as they are to be unaware of its influence on con sumers. In the initial
review, careful scrutiny should be used to eliminate any practice that is potentially harmful,
including seclusion and restraint practices, therapeutic activities that are shaming, treatment
planning without col laboration, any medical inquiry without privacy, and so forth. Policies and
procedures are the building blocks of each agency. They guide the service process and, if followed,
they provide an op portunity for the agency to deliver consistent responses and care. Policies and
procedures must incorporate trauma-informed practices across all domains and standards, such as
ad missions, plant/environmental standards, screening and assessment processes, referrals (to other
services, including hospitalization, or for further evaluations), treatment planning, confidentiality,
discharge, and more. They also need to be updated periodically to incor porate new science and to
meet the changing needs of consumers. By regularly reviewing and adapting administrative and
clinical poli cies and procedures in response to ever changing needs and evidence, the agency can
provide staff members with good guidelines for providing trauma-informed services that are
consistent yet flexible. Strategy #9: Develop a Disaster Plan Facilities are often required to develop
disaster plans, but specific requirements vary from State to State. From the outset, developing a
disaster plan in behavioral health services is essential. Many clients in behavioral health services
have lived with trauma, so proactive steps that reduce the impact of a new trauma may prevent
worsening of symptoms and de crease the risk for more pervasive effects. (See also Technical
Assistance Publication 34, Dis aster Planning Handbook for Behavioral Health Treatment Programs
[SAMHSA, 2013].) 166 Part 2, Chapter 1—Trauma-Informed Organizations Most disaster events
cannot be accurately an ticipated. Even so, behavioral health organiza tions can take steps to reduce
the impact of a disaster event on program functioning and on the lives of clients. Each service or
program should develop a disaster response committee that meets regularly to develop, maintain,
and adapt policies and procedures to respond to disasters affecting the program. Committee
planning efforts may include: 1. Creating a disaster response team of pro gram staff members tasked
with coordi nating program administration and services in a disaster event. 2. Establishing a
communication process for informing staff and clients of the status of program functioning and for
coordinating staff assignments during and shortly after the disaster event. 3. Outlining a process to
inform clients and their families of available services, their lo cation, and contact information for
access ing services to meet clients’ critical needs. 4. Developing plans for service provision during a
disaster event and service imple mentation after the event. 5. Creating special plans for high-risk or
special needs clients who need services during and shortly after the disaster. Ex amples of this are
clients who are home less, in detoxification services or methadone programs, on prescribed psy
chopharmaceuticals, or at risk for suicide. 6. Making plans for maintaining the security of client
records, program records, and fa cilities during and shortly after the event. 7. Coordinating ahead
with other community resources and services to ensure that clients at high risk or with special needs
get the services they require as soon as possible. 8. Prioritizing how services will start back up after a
disaster event. 9. Providing special services after the event to clients at high risk for trauma reactions
and symptoms. 10. Establishing a postdisaster debriefing pro cess to review disaster responses,
services, and outcomes. Some specific disaster events, such as hurri canes, may sometimes offer
opportunities for planning and preparation in advance of the disaster event. This preparation time is
usually just a few days, but it allows programs to make advance preparations and take advance
action to establish lines of communication, stockpile resources, prepare for evacuation of clients,
and protect client and program records. Strategy #10: Incorporate Universal Routine Screenings A
key element of trauma-informed services is the institution of universal routine screening across all
services, regardless of the individual’s path in accessing services (e.g., primary care, hospitalization,
outpatient). Considering the prevalence of trauma among individuals who seek services for mental
and substance use disorders, the implementation of screening is paramount. Without screening,
clients are not identified as trauma survivors. Subsequently, they miss recovery opportunities and
treat ment services that would be more likely to meet their needs, while also running a higher risk of
being retraumatized by unexamined organizational policies, procedures, and prac tices. For more
information on the rationale, processes, and instruments of universal screen ing for trauma, refer to
Part 1, Chapter 4. Strategy #11: Apply Culturally Responsive Principles Providers must be culturally
competent when incorporating evidence-based and best prac tices as well as trauma-informed
treatment 167 Trauma-Informed Care in Behavioral Health Services models within the organization.
Clients’ views of behavioral health differ according to race, ethnicity, and culture (refer to the
planned Treatment Improvement Protocol [TIP], Im proving Cultural Competence [SAMHSA, planned
c]). Likewise, cultures attach different meanings to trauma, and responses to trauma will vary
considerable across cultures (see Part 3, the online literature review, for more in formation). For
example, trauma survivors who come from a collective society or culture, in which the goals of the
group take prece dence over the goals of the individual, may be more focused on the well-being of
their family or the family’s response to the trauma survi vors’ experience. Often, this view runs in op
position to the individualistic perspective of many behavioral health services. Subsequently,
treatment providers who are not culturally competent may interpret collective values as a sign of
resistance or avoidance in dealing with traumatic stress. CMHS (2003) outlines prin ciples of cultural
competence in disaster work applicable across all forms of trauma: 1. Recognize the importance of
culture and respect diversity. Those who value culture and diversity understand their own cul tures,
attitudes, values, and beliefs, and they work to understand the cultures of others. This includes being
able to com municate effectively with those from other cultures, respecting others’ feelings about
personal space, knowing about others’ so cial organization, understanding how time is viewed, and
being aware of others’ be liefs about the effects of their behaviors. 2. Maintain a current prof ile of
the cultural composition of the community. This in cludes describing the community’s popula tion in
terms of race and ethnicity, age, gender, religion, refugee and immigrant status, housing status,
income levels, ru ral/urban balance, unemployment, lan guages spoken, literacy, schools, and
businesses. 3. Recruit workers who are representative of the community or service area. If the work
ers who are available do not match the community, they should have the personal attributes,
knowledge, and skills to develop cultural competence. 4. Provide ongoing cultural competence train
ing to staff. Topics should include cultural values and traditions, family values, lin guistics and
literacy, immigration experi ences and status, help-seeking behaviors, techniques and strategies for
cross-cultural outreach, and the avoidance of stereotypes and labels (DeWolfe & Nordboe, 2000b).
5. Ensure that services are accessible, appro priate, and equitable. In planning disaster work or TIC,
community associations and organizations are invaluable. Gaining their acceptance requires time
and energy. 6. Recognize the role of help-seeking behav iors, traditions, and natural support net
works. Culture includes traditions that dictate whom, or which groups, to seek in times of need; how
to handle suffering and loss; and how healing takes place. These customs and traditions are
respected by a culturally responsive disaster relief program. 7. Involve community leaders and
organiza tions representing diverse cultural groups as “cultural brokers.” Collaborating with
community leaders is an effective means of learning about the community, establishing program
credibility, and ensuring that ser vices are culturally responsive. 8. Ensure that services and
information are culturally and linguistically responsive. Communication with individuals who do not
speak English, who are illiterate in all languages or have limited literacy, and who are deaf or hard of
hearing is essential to service provision. Local radio stations, tel evision outlets, and newspapers that
are multicultural are an excellent venue for educational information after a disaster. 168 For more
detailed information on EBPs, visit the National Registry of Evidence Based Programs and Practices
(NREPP) Web site ([Link] For more specific research -oriented infor mation on
trauma and trauma -specific treatments, refer to the literature review in Part 3 of this TIP, available
online. For an introduction to peer support services, see What Are Peer Recovery Support Services?
(Center for Sub stance Abuse Treatment, 2009e). Part 2, Chapter 1—Trauma-Informed Organizations
Using survivors’ friends or relatives as in terpreters is not recommended, as survi vors may be
uncomfortable discussing personal matters with family members or friends. Asking children to
interpret can place too heavy a responsibility on them and reverses parents’ and children’s roles. 9.
Assess and evaluate the program’s level of cultural responsiveness. Self-assessment and process
evaluation can help keep a program on track. A variety of strategies can be used for collecting data
and com municating findings to stakeholders. Strategy #12: Use Science-Based Knowledge Along
with culturally responsive services, trauma-informed organizations must use science-based
knowledge to guide program development and the implementation of ser vices,policies,procedures,
and [Link] includes the adoption of EBPs (see Part 1, Chapter 6, and Part 3, Section 1, to
review definition, treatments, and resources for EBPs). TIC research is quite new; interpret these lim
ited studies and information cautiously. Chambless and Hollon’s (1998) criteria, which are still the
benchmark for EBPs, are valuable resources for administrators. Look closely at who was included—
and excluded—from treatment studies. Often, the types of severe, chronic, and unstable cases seen
in community settings are excluded from treatment studies. Evidence-based interventions should be
a primary consideration in selecting appropriate treatment models for people with mental ill ness,
substance use disorders, and co-occurring psychological trauma. Nonetheless, other vari ables must
also be contemplated before adopt ing EBPs in an organization, including the cultural
appropriateness of the practice; the strength of its clinical focus on strengths based strategies;
training and competence of clinical staff; the cost of training, materials, and implementation; and
the ease of main taining EBP fidelity amidst staff turnover. Strategy #13: Create a Peer-Support
Environment The main purpose of peer support services is to provide con sumer mentoring, support,
and care coordination for cli ents with histories of mental illness or substance abuse. The goals are
to help others deal with personal and environmental barriers that impede recovery and achieve
wellness. Peer support accom plishes this through many activities, including advocacy, support
during crises and recovery activities, modeling, education, and assistance in accessing available
resources. Peer support programs send a powerful message to staff members, consumers, and the
community— that recovery is possible through support, col laboration, and empowerment. These
pro grams reinforce the trauma-informed premise that organizations need to reflect the popula
tions that they serve and involve consumers in planning, implementing, monitoring, and de livering
recovery services. Notably, peer support services have the poten tial to be considerably flexible to
meet client needs at each stage of recovery. Specifically, peer support services can be incorporated
169 “Peer recovery support services are evi dence based and have been demonstrat ed to promote
positive health outcomes and control the cost of healthcare. These services are offered by a trained
individual with lived experience and recovery from a mental illness, substance use and/or chronic
health conditions. Peer recovery support services minimally include chronic illness self -
management, whole health and wellness promotion and engagement, relapse prevention, life skill
coaching, and insurance and health systems navigation.” (Daniels et al., 2012, p. 22) Advice to
Administrators: Sample Peer Support Staff Tasks • Use active listening skills help peers identi fy areas
of dissatisfaction and benefits of changing beliefs, thoughts, and behavior. • Use problem-solving
skills to help peers identify barriers to recovery and develop plans to meet peer-determined goals. •
Facilitate recovery support groups. • Link clients with community resources. • Work with the
treatment team to advocate for clients and to remove recovery barriers. • Participate in consumer
panels to educate staff about the consumer perspective and about peer support. • Participate in
hospital-wide committees and workgroups Source: New Logic Organizational Learning, 2011.
Trauma-Informed Care in Behavioral Health Services across the continuum of care, starting with
outreach services and extending into long term recovery services. Peer support specialists can
enhance consumer motivation to change, to initiate services, and/or to engage in recov ery
activities. They can play powerful liaison roles by supporting clients entering treatment and
explaining what to expect from services. They can ease the transition into treatment, from one
service to the next, from one mo dality to another (e.g., inpatient group to out patient group), and
beyond formal treatment. Moreover, peer support services create an at mosphere focused on
mutuality rather than pathology. They provide living models of re silience and promote hope—that
recovery is possible and attainable. Administrators should familiarize themselves with how other
organizations have imple mented peer support programs, current curric ula, certifications and
training processes, competencies and ethics, and peer support service State standards or
recommendations, if applicable. The Carter Center’s Summit in 2009, The Pillars of Peer Support
Services, supported in part by SAMHSA and CMHS, highlighted the numerous elements necessary to
develop a strong, vital peer workforce (Daniels et al., 2010). These elements include: • Clear job and
service descriptions. • Job-related competencies and competence based testing processes. • Peer
support certifications. • Ongoing continuing education. • Media and technology access for peer spe
cialists. • Sustainable funding. • Research and evaluation components. • Code of ethics and conduct.
• Competence-based training for supervisors. • Multilevel support and program support teams.
Strategy #14: Obtain Ongoing Feedback and Evaluations Obtain feedback on and evaluations of
organi zational performance on a regular basis. Give consumers a clear avenue for offering feedback
at any time, and make evaluations assessing the organization’s progress toward providing trauma-
informed services standard practice. Without feedback and further evaluation, or ganizations cannot
assess whether they are 170 Creating Sanctuary The sanctuary model is a trauma-based therapeutic
approach that has been used in inpatient, resi dential, therapeutic community, and outpatient
settings with children, adolescents, and adults. It provides a template for changing social service
delivery systems so that they are better equipped to respond to the complex needs of trauma
survivors. Sanctuary is informed by four knowledge areas: “the psychobiology of trauma, the active
creation of nonviolent environments, principles of social learning, and an understanding of the ways
in which complex adaptive systems grow, change, and alter their course” (Bloom et al., 2003, p.
174). The sanctuary model describes a stage-based approach to healing that is referred to as SAGE:
safety, affect modulation, grieving, and emancipation. This model is nonlinear; an individual does not
neces sarily move from one stage to another in a straight path, but progress in one area does affect
pro gress in other areas (Bloom, 1997; Bloom et al., 2003). SAGE is a cognitive–behavioral translation
of the sanctuary model (Bills, 2003). Early in treatment, the focuses are typically on safety and affect
management. Safety encompasses four domains: physical, psychological, social, and moral (Bloom,
1997; see [Link] for further details and a curriculum). Part 2, Chapter 1—
Trauma-Informed Organizations meeting trauma-informed objectives. A rou tine monitoring process
for TIC implementa tion gives the organization additional information necessary to combat new
obsta cles and threats and to understand what works. Regular monitoring equips organizations with
the ability to formulate different strategies to meet objectives as well as to respond to the changing
needs of the population. Ongoing evaluation and consumer feedback are essen tial in improving the
quality of services. Strategy #15: Change the Environment To Increase Safety Practices that generate
emotional and physical safety are necessary. Another aspect of creating safety is reevaluating the
physical facilities and environment to enhance safety and to circum vent preventable
retraumatization. Think how traumatizing it would be if you were a female rape survivor and a night
counselor was con ducting a room check at 2:00 a.m., or a male security guard was walking the
women’s resi dential wing. What would it be like if you were sitting with your back to the door in a
small office during an intake interview, if your history included a physical assault and rob bery? For
most, it would at least increase anxi ety; for others it would be retraumatizing. Trauma-informed
providers must carefully assess environmental safety. Although you are likely to identify some
facility issues that could erode safety for trauma survivors, a safe envi ronment will only be
established if regular feedback is obtained from consumers about their experiences with the
program. Strategy #16: Develop Trauma-Informed Collaborations TIC is about collaboration with
consumers, staff members, key stakeholders, and other agencies. Collaborative relationships provide
opportunities for consumers to access the most appropriate services as needs arise. Rather than
waiting for a crisis or a dire need for a service to investigate available resources, it is far more
efficient and compassionate to estab lish relationships within the agency and with other community
resources before these needs arise. No agency can meet the needs of every client; referral
agreements and/or collaborative arrangements that integrate the delivery of TIC, including support
services (e.g., housing, legal, medical), are important. 171 Building a Trauma 2 Informed Workforce
IN THIS CHAPTER • Introduction • Workforce Recruitment, Hiring, and Retention • Training in TIC •
Trauma -Informed Counselor Competencies • Counselor Responsibilities and Ethics • Clinical
Supervision and Consultation • Secondary Traumatization • Counselor Self -Care Introduction For an
organization to embrace a trauma-informed care (TIC) model fully, it must adopt a trauma-informed
organizational mis sion and commit resources to support it. This entails implementing an agency-
wide strategy for workforce development that is in alignment with the values and principles of TIC
and the organiza tion’s mission statement. Without a fully trained staff, an organiza tion will not be
able to implement the TIC model. However, simply training behavioral health professionals in TIC is
not enough. Counselors will not be able to sustain the kind of focus required to adopt and
implement a trauma-informed philosophy and services without the ongoing support of
administrators and clinical supervisors. An organizational environment of care for the health, well-
being, and safety of, as well as respect for, its staff will enhance the ability of counselors to provide
the best possible trauma-informed behav ioral health services to clients. This culture of care must
permeate the organization from top to bottom. Behavioral health program administrators should
aim to strengthen their workforce; doing so “requires creating environments that support the health
and well being, not only of persons with mental and substance use condi tions, but of the workforce
as well” (Hoge, 2007, p. 58). An organi zational culture of care, safety, and respect demands
activities that foster the development of trauma-informed counselors. This chap ter focuses on key
workforce development activities, such as: • Recruiting, hiring, and retaining trauma-informed staff.
• Training behavioral health service providers on the principles of, and evidence-based and emerging
best practices relevant to, TIC. • Developing and promoting a set of counselor competencies spe cific
to TIC. 173 Trauma-Informed Care in Behavioral Health Services TIC Framework in Behavioral Health
Services—Building a Trauma-Informed Workforce • Delineating the responsibilities of counse lors
and addressing ethical considerations specifically relevant to promoting TIC. • Providing trauma-
informed clinical super vision. • Committing to prevention and treatment of secondary trauma of
behavioral health professionals within the organization. Addressing each of these areas is essential
to building a trauma-informed workforce and an organizational culture that supports TIC. Workforce
Recruitment, Hiring, and Retention An Action Plan for Behavioral Health Workforce Development
(Hoge et al., 2007) emphasizes the importance of organization-wide support and active involvement
in workforce recruit ment, hiring, and retention in behavioral health systems. One of the key findings
of this report is that the work environment itself in many behavioral health settings can be toxic to
the workforce and may hinder the delivery of individualized, respectful, collaborative, and client-
centered care to service recipients. Fac tors such as the downward pressure on organi zations for
higher productivity of counselors increase caseloads and decrease wages of be havioral health staff
members and may create a high-stress environment that contributes to low morale and worker
dissatisfaction. Other factors that often contribute to low retention of qualified counselors in
behavioral health settings include the lack of professional career 174 Who Is a Trauma Champion? “A
champion understands the impact of vio lence and victimization on the lives of people seeking
mental health or addiction services and is a front-line worker who thinks ‘trauma first.’ When trying
to understand a person’s behav ior, the champion will ask, ‘is this related to abuse and violence?’ A
champion will also think about whether his or her own behavior is hurt ful or insensitive to the
needs of a trauma sur vivor. The champion is there to do an identified job—he is a case manager or a
counselor or a residential specialist—but in addition to his or her job, a champion is there to shine
the spot light on trauma issues.” Source: Harris & Fallot, 2001a, p. 8. Part 2, Chapter 2—Building a
Trauma-Informed Workforce ladders, fragile job security, the lack of clinical supervision, and an
inability to influence the organization in which they are working (Hoge et al., 2007). Added to this
mix is the intensity of working with people with the co-occurring conditions of trauma-related
mental and substance use disorders and the risk of secondary traumati zation of counselors. In
creating and sustain ing a trauma-informed workforce, organizations need to foster a work environ
ment that parallels the treatment philosophy of a trauma-informed system of care. Doing so allows
counselors to count on a work envi ronment that values safety, endorses collabora tion in the
making of decisions at all levels, and promotes counselor well-being. Recruitment and Hiring in a
Trauma-Informed System of Care In a 2007 technical report ( Jennings, 2007b), the National Center
for Trauma-Informed Care identified several priorities for organiza tions with regard to recruitment
and hiring trauma-informed staff, including: • Active recruitment of and outreach to pro spective
employees who are trauma informed or have formal education in providing trauma-informed or
trauma specific services in settings such as universi ties, professional organizations, professional
training and conference sites, peer support groups, and consumer advocacy groups. • Hiring
counselors and peer support staff members with educational backgrounds and training in trauma-
informed and/or trauma-specific services and/or lived expe rience of trauma and recovery. •
Providing incentives, bonuses, and promo tions for staff members during recruitment and hiring that
take into consideration prospective employees’ trauma-related ed ucation, training, and job
responsibilities. In addition to hiring behavioral health profes sionals with formal professional
education and training, organizations should also “routinely survey the demographics and other
character istics of the population served and recruit a workforce of similar composition” (Hoge et al.,
2007, p. 297). Essentially, this means ac tively engaging in outreach to consumer advo cacy groups,
recovery-oriented programs, community and faith-based organizations, and former
clients/consumers with the intention of recruiting potential employees whose knowledge and
expertise comes from their lived experience of trauma, resilience, and recovery. Support staff
members, peer support workers, counselors in training, and appren tices can be recruited from this
population and offered incentives, such as tuition reimburse ment, training stipends, and
professional mentoring with the goal of developing a trau ma-informed workforce from within the
de mographic served. Jennings (2007b) calls these staff members “trauma champions” who can
provide needed expertise in a trauma informed organization to promote trauma informed policies,
staff development, and trauma-based services consistent with the mis sion of the organization (p.
135). 175 Trauma-Informed Care in Behavioral Health Services As with hiring behavioral health
professionals who are in recovery from substance use disor ders, the organization should be
transparent and explicit in its recruitment and hiring prac tices of trauma survivors in recovery. The
or ganization can be transparent by advertising the mission statement of the organization as part of
the recruitment process and inviting applicants who are in recovery from trauma to apply. The needs
of behavioral health staff members who are in recovery from both sub stance use and trauma-
related conditions and working in a trauma-informed system of care should be addressed in the
organization’s on going training, clinical supervision, and staff development policies and practices.
Workforce Retention Staff turnover is rampant in behavioral health settings. It is costly to the
organization, and as a result, it is costly to clients. A strong thera peutic relationship with a counselor
is one of the largest factors in an individual’s ability to recover from the overwhelming effects of
trauma. When behavioral health professionals leave an organization prematurely or in crisis as a
result of chronic levels of high stress or secondary traumatization, clients must deal with disruptions
in their relationships with counselors. Some of the organizational factors that contribute to chronic
levels of high stress and often lead to high staff turnover include expecting counselors to maintain
high case loads of clients who have experienced trauma; not providing trauma-informed clinical
super vision and training to counselors; and failing to provide adequate vacation, health insur ance,
and other reasonable benefits that sup port counselors’ well-being. Other factors that may have a
more profound impact on staff retention include failing to acknowledge the reality of secondary
traumatization, promoting the view that counselors’ stress reactions are a personal failure instead of
a normal response to engaging with clients’ traumatic material, and not supporting personal
psychotherapy for counselors (Saakvitne, Pearlman, & Traumat ic Stress Institute/Center for Adult &
Adoles cent Psychotherapy, 1996). Research on promoting counselor retention in behavioral health
settings demonstrates that Advice to Administrators: Preventing Turnover and Increasing Workforce
Retention To prevent behavioral health staff turnover and increase retention of qualified, satisfied,
and highly committed trauma-informed counselors, consider: • Offering competitive wages,
benefits, and performance incentives that take into account educa tion, training, and levels of
responsibility in providing trauma-informed or trauma-specific services. • Creating a safe working
environment that includes both the physical plant and policies and pro cedures to prevent
harassment, stalking, and/or violence in the workplace and to promote re spectful interactions
amongst staff at all levels of the organization. • Establishing an organizational policy that normalizes
secondary trauma as an accepted part of working in behavioral health settings and views the
problem as systemic—not the result of indi vidual pathology or a deficit on the part of the counselor.
• Instituting reasonable, manageable caseloads that mix clients with and without trauma-related
concerns. • Letting staff offer input into clinical and administrative policies that directly affect their
work ex perience. • Providing vacation, health insurance (which includes coverage for
psychotherapy/personal coun seling), and other benefits that promote the well-being of the staff. •
Implementing regular, consistent clinical supervision for all clinical staff members. 176 • Providing
ongoing training in trauma-informed services offered by the organization. Part 2, Chapter 2—
Building a Trauma-Informed Workforce behavioral health staff members are interested in the same
kind of work environment and benefits as employees in many other fields. They include a “living
wage with healthcare benefits; opportunities to grow and advance; clarity in a job role; some
autonomy and input into decisions; manageable workloads; admin istrative support without
crushing administra tive burden; basic orientation and training for assigned responsibilities; a decent
and safe physical work environment; a competent and cohesive team of coworkers; the support of a
supervisor; and rewards for exceptional per formance” (Hoge et al., 2007, p. 18). When an
organization’s administration values its staff by providing competitive salaries and benefits, a safe
working environment, a rea sonable and manageable workload, input into the making of clinical and
administrative poli cy decisions, and performance incentives, it helps behavioral health workers feel
connected to the mission of the organization and become dedicated to its sustainability and growth.
This type of work environment demonstrates both a level of respect for counselors (similar to the
level of respect a trauma-informed or ganization displays toward clients) and an appreciation for the
complexity of their job responsibilities and the stress they face when working with people who have
experienced trauma in their lives. To retain behavioral health professionals working in a trauma
informed setting, wages and performance in centives should be tied not only to education, training,
and work experience, but also to lev els of responsibility in working with clients who have
experienced trauma. Training in TIC Training for all staff members is essential in creating a trauma-
informed organization. It may seem that training should simply focus on new counselors or on
enhancing the skill level of those who have no prior experience in working with trauma, but training
should, in fact, be more systematic across the organiza tion to develop fully sustainable trauma
informed services. All employees, including administrative staff members, should receive an
orientation and basic education about the prevalence of trauma and its impact on the organization’s
clients. To ensure safety and reduction of harm, training should cover dy namics of retraumatization
and how practice can mimic original sexual and physical abuse experiences, trigger trauma
responses, and cause further harm to the person. Training for all employees must also educate them
“about the impacts of culture, race, ethnicity, gender, age, sexual orientation, disability, and socio
economic status on individuals’ experiences of trauma” (Jennings, 2007a, p. 5). All clinical and direct
service staff members, regardless of level of experience, should receive more indepth training in
screening and as sessment of substance use and trauma-related disorders; the relationships among
trauma, substance use disorders, and mental disorders; how to understand difficult client behaviors
through a trauma-informed lens; how to avoid retraumatizing clients in a clinical setting; the
development of personal and professional boundaries unique to clinical work with trau matized
clients; how to identify the signs of secondary traumatization in themselves; and how to develop a
comprehensive personal and professional self-care plan to prevent and/or ameliorate the effects of
secondary traumati zation in the workplace. All clinical staff members who work with traumatized
clients should receive additional training in evidence based and promising practices for the treat
ment of trauma (for information on locating training, see Appendix B.) This might include training
done within the agency by experts in the field or training received by attending ad vanced trauma
trainings. Administrators 177 Case Illustration: Larry Larry is a 28-year-old clinical social worker who
just finished his master’s program in social work and is working in a trauma-informed out patient
program for people with substance use disorders. He is recovering from alcohol use disorder and
previously worked in a residential rehabilitation program as a recovery support counselor. There, his
primary responsibilities were to take residents to Alcoholics Anony mous (AA) meetings, monitor
their participa tion, and confront them about their substance use issues and noncompliance with the
pro gram’s requirement of attendance a t 12-Step meetings. In Larry’s new position as a counselor,
he con fronts a client in his group regarding her dis comfort with attending AA meetings. The client
reports that she feels uncomfortable with the idea that she has to admit that she is pow erless over
alcohol to be accepted by the group of mostly men. She was sexually abused by her stepfather when
she was a child and began drinking heavily and smoking pot when she was 11 years old. The client
reacts angrily to Larry’s intervention. In supervision, Larry discusses his concerns regarding the
client’s resistance to AA and the feedback that he provided to her in group. Beyond focusing
supervision on Larry’s new role as a counselor in a trauma-informed pro gram, the clinical supervisor
recommends that Larry take an interactive, multisession, comput er-assisted training on the 12-Step
facilitation (TSF) model. The TSF model introduces clients to and assists them with engaging in 12-
Step recovery support groups. The agency has the computer-based training available in the office,
and Larry agrees to use follow-up coaching sessions with his supervisor to work on imple mentation
of the approach. The supervisor recognizes that Larry is falling back on his own recovery experience
and the strategies he re lied on in his previous counseling role. He will benefit from further training
and coaching in an evidence-based practice that provides a non aggressive, focused, and structured
way to facilitate participation in recovery support groups with clients who have trauma histories.
Trauma-Informed Care in Behavioral Health Services should provide the time and financial re sources
to clinical staff members for this pro fessional development activity. Jennings (2007a) suggests that,
whenever possible, “trainings should be multi-system, inclusive of staff in mental health and
substance abuse, health care, educational, criminal justice, social services systems and agencies, and
promoting systems integration and coordination” (p. 5). Moreover, criminal justice settings, schools,
military/veteran programs, and other places in which behavioral health services are provided may
benefit from approaches that are sensitive to the special circumstances and cultures of these
environments. For example, in exploring trauma-informed correctional care, Miller and Najavits
(2012, p. 1) observe: Prisons are challenging settings for trauma informed care. Prisons are designed
to house perpetrators, not victims. Inmates arrive shack led and are crammed into overcrowded
hous ing units; lights are on all night, loud speakers blare without warning and privacy is severely
limited. Security staff is focused on maintain ing order and must assume each inmate is po tentially
violent. The correctional environment is full of unavoidable triggers, such as pat downs and strip
searches, frequent discipline from authority figures, and restricted move ment….This is likely to
increase trauma related behaviors and symptoms that can be difficult for prison staff to
manage….Yet, if trauma-informed principles are introduced, all staff can play a major role in
minimizing trig gers, stabilizing offenders, reducing critical in cidents, deescalating situations, and
avoiding restraint, seclusion or other measures that may repeat aspects of past abuse. The Need for
Training Behavioral health service providers working with clients who have mental, substance use,
and trauma-related disorders need to have the best knowledge, skills, and abilities. Substance abuse
counselors, in particular, require addition al training and skill development to be able to extend
trauma-informed services (within the 178 Part 2, Chapter 2—Building a Trauma-Informed Workforce
limits of their professional licensure and scope of practice) to clients who have co-occurring
substance use, trauma-related, or mental disor ders. Many clinical practice issues in traditional
substance abuse treatment are inconsistent with trauma-informed practice, which needs to be
addressed with further training. Similarly, men tal health clinicians often need training in substance
abuse treatment, as they typically do not have backgrounds or experience in that domain.
Moreover, several surveys indicate that clinicians consistently perceive the com bination of trauma
and substance abuse as harder to treat than either one alone (Najavits, Norman, Kivlahan, & Kosten,
2010). It is thus key to emphasize cross-training as part of TIC. Exhibit 2.2-1 addresses these issues
and offers suggestions for additional training. Exhibit 2.2-1: Clinical Practice Issues Relevant to
Counselor Training in Trauma Informed Treatment Settings • Some substance abuse counseling
strategies commonly used to work through clients’ denial and minimization of their substance use
issues may be inappropriate when working with trauma sur vivors (e.g., highly confrontational
models can remind trauma survivors of emotional abuse). Training: The Stages of Change model of
addiction treatment can help counselors shift from the traditional confrontation of denial to
conceptualizing clients’ ambivalence about changing substance use patterns as a normal part of the
precontemplation stage of change. This method is a respectful cognitive–behavioral approach that
helps counselors match counseling strategies to their assessment of where each client is in each
stage of change, with the ultimate goal of helping clients make changes to health risk behaviors.
(Connors, Donovan, & DiClemente, 2001). • The 12-Step concept of powerlessness (Step 1) may
seem unhelpful to trauma survivors for whom the emotional reaction to powerlessness is a major
part of their trauma (particularly for victims of repetitive trauma, such as child abuse or intimate
partner violence). It can be confus ing and counterproductive to dwell on this concept of
powerlessness regarding trauma when the therapeutic objective for trauma-informed counseling
methods should be to help clients empower themselves. For people in recovery, powerlessness is a
paradox, sometimes misunder stood by both counselors and clients, in that the acknowledgment of
powerlessness often cre ates a sense of empowerment. Most clients, with support and respectful
guidance from a counselor, will come to understand that powerlessness (as used in 12-Step
programs) is not an inability to stand up for oneself or express a need, and it does not mean for one
to be powerless in the face of abuse. With this understanding, clients may become more open to
participating in 12-Step groups as a resource for their recovery from substance use disorders. When
clients con tinue to struggle with this concept and decline to participate in 12-Step recovery efforts,
they may benefit from referral to other forms of mutual-help programs or recovery support groups
in which the concept of powerlessness over the substance of abuse is not such a significant issue.
Training: The TSF model can help counselors develop a more supportive and understanding
approach to facilitating clients’ involvement in 12-Step recovery groups (if this is a client generated
recovery goal). “Although based on standard counseling models, TSF differs from them in several
ways. These differences include TSF’s strong emphasis on therapist support, dis couragement of
aggressive ‘confrontation of denial’ and therapist self-disclosure, and highly fo cused and structured
format” (Sholomskas & Carroll, 2006, p. 939). Another well-intentioned, but often misguided,
approach by counselors who have not had for mal or extensive training is “digging” for trauma
memories without a clear therapeutic rationale or understanding of client readiness. In doing so, the
counselor may unintentionally retraumatize the client or produce other harmful effects. In early
intervention, it is sufficient simply to acknowledge and validate the pain and suffering of the client
without uncovering or exploring specific trauma memories. The counselor who is insufficiently
trained in trauma-informed clinical 179 (Continued on the next page.) Trauma-Informed Care in
Behavioral Health Services Exhibit 2.2-1: Clinical Practice Issues Relevant to Counselor Training in
Trauma Informed Treatment Settings (continued) practice may also press agendas that are
ultimately unhelpful, such as insisting that the client forgive an abuser, pursue a legal case against a
perpetrator, or engage in trauma treatment, even when the client may not be ready for such steps.
These efforts are particularly inappropriate for clients in early recovery from substance use
disorders. The first goal in treatment is stabilization Training: The Seeking Safety model of treating
substance abuse and posttraumatic stress disor der (PTSD) can help counselors focus on the primary
goal of stabilization and safety in TIC. This model emphasizes safety as the target goal, humanistic
themes such as honesty and compassion, and making cognitive–behavioral therapy accessible and
interesting to clients who may otherwise be difficult to engage (Najavits, 2002a). • Treatment should
be client-centered; it should acknowledge the client’s right to refuse counsel ing for trauma-related
issues. It is important to discuss the advantages and disadvantages of ex ploring trauma-related
concerns, and then, following an open discussion, to allow clients the right to choose their path. This
discussion should be part of the informed consent process at the start of treatment. Clients also
have the right to change their minds. Training: Motivational interviewing, a client-centered,
nonpathologizing counseling method, can aid clients in resolving ambivalence about and committing
to changing health risk behaviors including substance use, eating disorders, self-injury, avoidant and
aggressive behaviors associ ated with PTSD, suicidality, and medication compliance (Arkowitz, Miller,
Westra, & Rollnick, 2008; Kress & Hoffman, 2008). Training in MI can help counselors remain focused
on the client’s agenda for change, discuss the pros and cons of treatment options, and emphasize
the personal choice and autonomy of clients. In addition to the training needs of substance abuse
counselors, all direct care workers in mental health settings, community-based pro grams, crisis
intervention settings, and crimi nal justice environments should receive training in TIC. Guidelines for
training in assisting trauma-exposed populations are pre sented in Exhibit 2.2-2. Continuing
Education Research on the effectiveness of single-session didactic and/or skill-building workshops
Exhibit 2.2-2: Guidelines for Training in Mental Health Interventions for Trauma Exposed Populations
After a year of collaboration in 2002, the Task Force on International Trauma Training of the
International Society for Traumatic Stress Studies published a consensus-based set of recommen
dations for training. Core curricular elements of the recommended training include: • Competence in
listening. • Recognition of psychosocial and mental problems to promote appropriate assessment. •
Familiarity with established interventions in the client population. • Full understanding of the local
context, including help-seeking expectations, duration of treat ment, attitudes toward intervention,
cost-effectiveness of intervention, and family attitudes and involvement. • Strategies for solving
problems on the individual, family, and community levels. • Treatment approaches for medically
unexplained somatic pain. • Collaboration with existing local resources and change agents (e.g.,
clergy, traditional healers, informal leaders). • Self-care components. Source: Weine et al., 2002. 180
Advice to Administrators: Trauma-Informed Staff Training • Establish training standards for the
evidence-based and promising trauma-informed practice models (such as Seeking Safety) adopted
by your organization. • Bring expert trainers with well-developed curricula in TIC and trauma-specific
practices into your organization. • Select a core group of clinical supervisors and senior counselors to
attend multisession training or certification programs. These clinicians can then train the rest of the
staff. • Use sequenced, longitudinal training experiences instead of single-session seminars or work
shops. • Emphasize interactive and experiential learning activities over purely didactic training. •
Provide ongoing mentoring/coaching to behavioral health professionals in addition to regular clinical
supervision to enhance compliance with the principles and practices of TIC and to foster counselor
mastery of trauma-specific practice models. • Build organization-wide support for the ongoing
integration of new attitudes and counselor skills to sustain constructive, TIC-consistent changes in
practice patterns. • Provide adequate and ongoing training for clinical supervisors in the theory and
practice of clini cal supervision and the principles and practices of TIC. • Include information and
interactive exercises on how counselors can identify, prevent, and ame liorate secondary traumatic
stress (STS) reactions in staff trainings. • Offer cross-training opportunities to enhance knowledge of
trauma-informed processes through out the system. Part 2, Chapter 2—Building a Trauma-Informed
Workforce demonstrates that immediate gains in counse lor knowledge and skills diminish quickly
after the training event (Martino, Canning-Ball, Carroll, & Rounsaville, 2011). Consequently,
organizations may be spending their scarce financial resources on sending counselors to this kind of
training but may not be reaping adequate returns with regard to long-lasting changes in counselor
skills and the develop ment of trauma-informed and trauma-specific counselor competencies. Hoge
et al. (2007) suggest the implementation of training strate gies for behavioral health professionals
that have proven to be effective in improving coun selor skills, attitudes, and practice approaches.
These strategies include: “interactive ap proaches; sequenced, longitudinal learning experiences;
outreach visits, known as academ ic detailing; auditing of practice with feedback to the learner;
reminders; the use of opinion leaders to influence practice; and patient mediated interventions,
such as providing in formation on treatment options to persons in recovery, which in turn influences
the practice patterns of their providers” (p. 124). Trauma-Informed Counselor Competencies Hoge et
al. (2007) identified a number of counselor competencies in behavioral health practices that are
consistent with the skills needed to be effective in a trauma-informed system of care. They include
person-centered planning, culturally competent care, development of therapeutic alliances, shared
responsibility for decisions, collaboratively developed recovery plans, evidence-based practices,
recovery-and resilience-oriented care, interdisciplinary-and team-based practice, and
consumer/client advocacy. In addition, counselor competencies critical to the effective delivery of
services to clients with trauma-related disorders include: • Screening for and assessment of trauma
history and trauma-related disorders, such as mood and anxiety disorders. • Awareness of
differences between trauma informed and trauma-specific services. 181 Trauma-Informed Care in
Behavioral Health Services • Understanding the bidirectional relation ships among substance use
and mental dis orders and trauma. • Engagement in person-centered counseling. • Competence in
delivering trauma-informed and trauma-specific evidence-based inter ventions that lessen the
symptoms associat ed with trauma and improve quality of life for clients. • Awareness of and
commitment to counse lor self-care practices that prevent or lessen the impact of secondary
traumatization on behavioral health workers. Exhibit 2.2-3 provides a checklist of competen cies for
counselors working in trauma-informed behavioral health settings. Administrators and clinical
supervisors can use this checklist to assess behavioral health professionals’ under standing of trauma
awareness and counseling skills and determine the need for additional training and clinical
supervision. Counselor Responsibilities and Ethics Treating all clients in an ethical manner is an
expectation of all healthcare providers. It is of special importance when working with clients who
have trauma-related disorders, as their trust in others may have been severely shaken. Counselors
who work with traumatized indi viduals on a regular basis have special respon sibilities to their
clients because of the nature of this work. Administrators and clinical su pervisors in trauma-
informed organizations should develop policies that clearly define the counselors’ job and should
provide education about the role of counselors in the organiza tion and their responsibilities to
clients. General Principles Regarding Counselor Responsibilities The following are some general
principles governing the responsibilities of counselors who provide behavioral health services for
clients with histories of trauma: • Counselors are responsible for routinely screening clients for
traumatic experiences and trauma-related symptoms (Ouimette & Brown, 2003; see also Treatment
Im provement Protocol [TIP] 42, Substance Abuse Treatment for Persons With Co Occurring
Disorders, Center for Substance Abuse Treatment [CSAT], 2005c). • Counselors should offer clients
with sub stance use and trauma-related disorders continuing mental health services if it is within
their professional license and scope of practice to do so. • Counselors are responsible for referring
clients with substance use disorders and co occurring trauma-related disorders to treatment that
addresses both disorders when the treatment falls outside of the counselor’s professional license
and scope of practice (Ouimette & Brown, 2003). • Counselors should refer clients with sub stance
use disorders and co-occurring trauma-related disorders to concurrent par ticipation in mutual-help
groups if appro priate (Ouimette & Brown, 2003). • Counselors have a responsibility to practice the
principles of confidentiality in all inter actions with clients and to respect clients’ wishes not to give
up their right to privi leged communication. • Counselors are responsible for educating clients about
the limits of confidentiality and what happens to protected health in formation, along with the
client’s privilege, when the client signs a release of infor mation or agrees to assign insurance bene
fits to the provider. • Counselors must inform clients that treat ment for trauma-related disorders is
always voluntary. • Counselors are responsible for being aware of their own secondary trauma and
182 Part 2, Chapter 2—Building a Trauma-Informed Workforce Exhibit 2.2-3: Trauma-Informed
Counselor Competencies Checklist Trauma Awareness ___ Understands the difference between
trauma-informed and trauma-specific services ___ Understands the differences among various kinds
of abuse and trauma, including: physical, emo tional, and sexual abuse; domestic violence;
experiences of war for both combat veterans and survivors of war; natural disasters; and community
violence ___ Understands the different effects that various kinds of trauma have on human
development and the development of psychological and substance use issues ___ Understands how
protective factors, such as strong emotional connections to safe and non judgmental people and
individual resilience, can prevent and ameliorate the negative impact trauma has on both human
development and the development of psychological and substance use issues ___ Understands the
importance of ensuring the physical and emotional safety of clients ___ Understands the importance
of not engaging in behaviors, such as confrontation of substance use or other seemingly unhealthy
client behaviors, that might activate trauma symptoms or acute stress reactions ___ Demonstrates
knowledge of how trauma affects diverse people throughout their lifespans and with different
mental health problems, cognitive and physical disabilities, and substance use is sues ___
Demonstrates knowledge of the impact of trauma on diverse cultures with regard to the mean ings
various cultures attach to trauma and the attitudes they have regarding behavioral health treatment
___ Demonstrates knowledge of the variety of ways clients express stress reactions both
behaviorally (e.g., avoidance, aggression, passivity) and psychologically/emotionally (e.g.,
hyperarousal, avoidance, intrusive memories) Counseling Skills ___ Expedites client-directed choice
and demonstrates a willingness to work within a mutually em powering (as opposed to a
hierarchical) power structure in the therapeutic relationship ___ Maintains clarity of roles and
boundaries in the therapeutic relationship ___ Demonstrates competence in screening and
assessment of trauma history (within the bounds of his or her licensing and scope of practice),
including knowledge of and practice with specific screening tools ___ Shows competence in
screening and assessment of substance use disorders (within the bounds of his or her licensing and
scope of practice), including knowledge of and practice with specific screening tools ___
Demonstrates an ability to identify clients’ strengths, coping resources, and resilience ___ Facilitates
collaborative treatment and recovery planning with an emphasis on personal choice and a focus on
clients’ goals and knowledge of what has previously worked for them ___ Respects clients’ ways of
managing stress reactions while supporting and facilitating taking risks to acquire different coping
skills that are consistent with clients’ values and preferred identity and way of being in the world ___
Demonstrates knowledge and skill in general trauma-informed counseling strategies, including, but
not limited to, grounding techniques that manage dissociative experiences, cognitive– behavioral
tools that focus on both anxiety reduction and distress tolerance, and stress man agement and
relaxation tools that reduce hyperarousal 183 (Continued on the next page.) Exhibit 2.2-3: Trauma-
Informed Counselor Competencies Checklist (continued) ___ Identifies signs of STS reactions and
takes steps to engage in appropriate self-care activities that lessen the impact of these reactions on
clinical work with clients ___ Recognizes when the needs of clients are beyond his or her scope of
practice and/or when cli ents’ trauma material activates persistent secondary trauma or
countertransference reactions that cannot be resolved in clinical supervision; makes appropriate
referrals to other behavioral health professionals Source: Abrahams et al., 2010. Trauma-Informed
Care in Behavioral Health Services countertransference reactions and seeking appropriate help in
responding to these re actions so that they do not interfere with the best possible treatment for
clients. TIC organizations have responsibilities to clients in their care, including: • Protecting client
confidentiality, particularly in relation to clients’ trauma histories. Or ganizations should comply with
the State and Federal laws that protect the confiden tiality of clients being treated for mental and
substance use disorders. • Providing clients with an easy-to-read statement of their rights as
consumers of mental health and substance abuse services, including the right to confidentiality (Ex
hibit 2.2-4). • Providing quality clinical supervision to all counselors and direct-service workers, with
an emphasis on TIC. Organizations should, at minimum, comply with State licensing requirements for
the provision of clinical supervision to behavioral health workers. • Establishing and maintaining
appropriate guidelines and boundaries for client and counselor behavior in the program setting. •
Creating and maintaining a trauma informed treatment environment that respects the clients’ right
to self determination and need to be treated with dignity and respect. • Maintaining a work
environment that rein forces and supports counselor self-care. All behavioral health professionals
are respon sible for abiding by professional standards of care that protect the client. Breaches of
confi dentiality, inappropriate conduct, and other violations of trust can do further harm to cli ents
who already have histories of trauma. Many treatment facilities have a Client Bill of Rights (or a
similar document) that describes the rights and responsibilities of both the counselors and the
participants; it often is part of the orientation and informed consent pro cess when a client enters
treatment. However, simply reading and acknowledging the receipt of a piece of paper is not a
substitute for the dialog that needs to happen in a collaborative therapeutic partnership.
Administrators are responsible for providing clients with easy-to read information describing
counselor respon sibilities and client rights. Clinical supervisors are responsible for helping
counselors engage in a respectful dialog with clients about those rights and responsibilities as part of
a compre hensive informed consent process. Exhibit 2.2-4 is an excerpt from a Client Bill of Rights
that outlines clients’ right to confi dentiality in plain language that is readable and easily understood.
184 Part 2, Chapter 2—Building a Trauma-Informed Workforce Exhibit 2.2-4: Sample Statement of
the Client’s Right to Confidentiality From a Client Bill of Rights Tri-County Mental Health Services is a
trauma-informed mental health and substance abuse treat ment agency in Maine. Below is a
statement regarding clients’ right to confidentiality and staff re sponsibility to protect that privilege;
this statement is provided in a brochure outlining consumer rights that is easily accessible to service
recipients at the agency and online. Confidentiality We will not give out information about you to
anyone without your knowledge and permission. This includes written information from your record
and verbal information from your providers. Addition ally, we will not request any information about
you without your knowledge and permission. A Re lease of Information Form allows you to say what
information can be shared and with whom. You determine the length of time this is valid, up to one
year. Tri-County policies prevent any employee of the agency who does not have a direct need to
know from having access to any information about you. The penalty for violation can include
immediate dismissal. Exceptions to this rule of confidentiality include times when a client is at
immediate risk of harm to self or others, or when ordered by the court. We will make every effort to
notify you in these instances. Source: Tri-County Mental Health Services, 2008, pp. 6-7. Ethics in
Treating Traumatized Clients All behavioral health professionals must con form to the ethical
guidelines established by their profession’s State licensing boards and/or certifying organizations.
State licensing boards for substance abuse counseling, psychiatry, social work, psychology,
professional counsel ing, and other behavioral health professions provide regulatory standards for
ethical prac tice in these professions. These boards also have specific procedures for responding to
complaints regarding the actions of profes sional caregivers. Additionally, national profes sional
societies have standards for ethical practices. Members of these organizations are expected to
practice within the boundaries and scope of these standards. Some of these stand ards are quite
explicit, whereas others are more general; most approach professional ethics not as a rigid set of
rules, but rather, as a process of making ethical decisions. Clinical supervisors are responsible for in
forming counselors of their ethical responsi bilities with regard to their own organization’s policies
and procedures, monitoring supervi sees’ reading and understanding the codes of ethics of
professional organizations and State licensing boards, and promoting counselor understanding of
ethics and how to make de cisions ethically as a regular part of clinical supervision, team meetings,
and counselor training. Administrators can support high ethical standards by creating an
organization wide ethics task group consisting of counse lors, supervisors, and administrators who
meet regularly to review and revise clinical policies in line with State and Federal law and profes
sional codes of ethics. Administrators may also act as a support mechanism for counselors who need
additional consultation regarding potential ethical dilemmas with clients. The Green Cross Academy
of Traumatology pro vides ethical guidelines for the treatment of clients who have experienced
trauma; these guidelines are adapted in Exhibit 2.2-5. 185 Trauma-Informed Care in Behavioral
Health Services Exhibit 2.2-5: Green Cross Academy of Traumatology Ethical Guidelines for the
Treatment of Clients Who Have Been Traumatized Respect for the dignity of clients • Recognize and
value the personal, social, spiritual, and cultural diversity present in society, with out judgment. As a
primary ethical commitment, make every effort to provide interventions with respect for the dignity
of those served. Responsible caring • Take the utmost care to ensure that interventions do no harm.
• Have a commitment to the care of those served until the need for care ends or the responsibility
for care is accepted by another qualified service provider. • Support colleagues in their work and
respond promptly to their requests for help. • Recognize that service to survivors of trauma can
exact a toll in stress on providers. Maintain vigilance for signs in self and colleagues of such stress
effects, and accept that dedication to the service of others imposes an obligation to sufficient self-
care to prevent impaired functioning. • Engage in continuing education in the appropriate areas of
trauma response. Remain current in the field and ensure that interventions meet current standards
of care. Integrity in relationships • Clearly and accurately represent your training, competence, and
credentials. Limit your practice to methods and problems for which you are appropriately trained
and qualified. Readily refer to or consult with colleagues who have appropriate expertise; support
requests for such referrals or consultations from clients. • Maintain a commitment to confidentiality,
ensuring that the rights of confidentiality and privacy are maintained for all clients. • Do not provide
professional services to people with whom you already have either emotional ties or extraneous
relationships of responsibility. The one exception is in the event of an emer gency in which no other
qualified person is available. Responsibility to society Clients’ universal rights • Refrain from entering
other relationships with present or former clients, especially sexual rela tionships or relationships
that normally entail accountability. • Within agencies, ensure that confidentiality is consistent with
organizational policies; explicitly inform individuals of the legal limits of confidentiality. • Be
committed to responding to the needs generated by traumatic events, not only at the indi vidual
level, but also at the level of community and community organizations in ways that are consistent
with your qualifications, training, and competence. • Recognize that professions exist by virtue of
societal charters in expectation of their functioning as socially valuable resources. Seek to educate
government agencies and consumer groups about your expertise, services, and standards; support
efforts by these agencies and groups to ensure social benefit and consumer protection. • If you
become aware of activities of colleagues that may indicate ethical violations or impairment of
functioning, seek first to resolve the matter through direct expression of concern and offers of help
to those colleagues. Failing a satisfactory resolution in this manner, bring the matter to the attention
of the officers of professional societies and of governments with jurisdiction over pro fessional
misconduct. All clients have the right to: • Not be judged for any behaviors they used to cope, either
at the time of the trauma or after the trauma. • Be treated at all times with respect, dignity, and
concern for their well-being. • Refuse treatment, unless failure to receive treatment places them at
risk of harm to self or others. 186 (Continued on the next page.) Part 2, Chapter 2—Building a
Trauma-Informed Workforce Exhibit 2.2-5: Academy of Traumatology Ethical Guidelines for the
Treatment of Clients Who Have Been Traumatized (continued) • Be regarded as collaborators in
their own treatment plans. • Provide their informed consent before receiving any treatment. • Not
be discriminated against based on race, culture, sex, religion, sexual orientation, socioeco nomic
status, disability, or age. • Have promises kept, particularly regarding issues related to the treatment
contract, role of coun selor, and program rules and expectations. Procedures for introducing clients
to treatment Obtain informed consent, providing clients with information on what they can expect
while receiving professional services. In addition to general information provided to all new clients,
clients present ing for treatment who have histories of trauma should also receive information on: •
The possible short-term and long-term effects of trauma treatment on the client and the client’s
relationships with others. • The amount of distress typically experienced with any particular trauma
treatment. • Possible negative effects of a particular trauma treatment. • The possibility of lapses
and relapses when doing trauma work, and the fact that these are a normal and expected part of
healing. Reaching counseling goals through consensus Informing clients about the healing process
Level of functioning Collaborate with clients in the design of a clearly defined contract that
articulates a specific goal in a specific time period or a contract that allows for a more open-ended
process with periodic evalua tions of progress and goals. • Clearly explain to clients the nature of the
healing process, making sure clients understand. • Encourage clients to ask questions about any and
all aspects of treatment and the therapeutic relationship. Provide clients with answers in a manner
they can understand. • Encourage clients to inform you if the material discussed becomes
overwhelming or intolerable. • Inform clients of the necessity of contacting you or emergency
services if they feel suicidal or homicidal, are at risk of self-injury, or have a sense of being out of
touch with reality. • Give clients written contact information about available crisis or emergency
services. • Inform clients about what constitutes growth and recovery and about the fact that some
trauma symptoms may not be fully treatable. • Address unrealistic expectations clients may have
about counseling and/or the recovery process. • Inform clients that they may not be able to function
at the highest level of their ability––or even at their usual level––when working with traumatic
material. • Prepare clients to experience trauma-related symptoms, such as intrusive memories,
dissociative reactions, reexperiencing, avoidance behaviors, hypervigilance, or unusual emotional
reactivity. Source: Green Cross Academy of Traumatology, 2007. Adapted with permission.
Boundaries in therapeutic relationships Maintaining appropriate therapeutic bounda ries is a
primary ethical concern for behavioral health professionals. Counselors working with clients who
have substance use, trauma related, and other mental disorders may feel challenged at times to
maintain boundaries that create a safe therapeutic container. Some clients, especially those with
longstanding disorders, bring a history of client–counselor relationships to counseling. Clients who
have been traumatized may need help understand ing the roles and responsibilities of both the
counselor and the client. Clients with trauma related conditions may also have special needs 187
Advice to Clinical Supervisors: Recognizing Boundary Confusion Clinical supervisors should be aware
of the following counselor behaviors that can indicate boundary confusion with clients: • The
counselor feels reluctant or embarrassed to discuss specific interactions with a client or de tails of
the client’s treatment in supervision or team meetings. • The counselor feels possessive of the
client, advocates with unusual and excessive vehemence for the client, or expresses an
unreasonable sense of overresponsibility for the client. • The counselor becomes defensive and
closed to hearing ideas from the supervisor or the treat ment team members about approaches to
working with a client and/or exploring his or her own emotional reactions to a client. • The clinician
begins or increases personal self-disclosure to the client and is not able to identify legitimate clinical
reasons for the self-disclosure. Trauma-Informed Care in Behavioral Health Services in establishing
appropriate boundaries in the counseling setting; they may be particularly vulnerable and not
understand or appreciate the need for professional boundaries, includ ing not engaging in dual
relationships. For example, some clients might experience a counselor’s boundary around not giving
the client his or her personal phone number for emergency calls as a rejection or abandon ment.
Cultural considerations also influence therapeutic boundaries. Administrators, in collaboration with
clinical supervisors, are responsible for creating poli cies regarding counselor and client boundaries
for various issues (e.g., giving and receiving gifts, counselor personal disclosure, and coun selor roles
and responsibilities when attending the same 12-Step meetings as clients); policies should be specific
to their organization and conform to State and Federal law and behav ioral health professional codes
of ethics. Clini cal supervisors are responsible for training counselors in the informed consent
process and effective ways to discuss boundaries with clients when they enter treatment. Guidelines
for establishing and maintaining boundaries in therapeutic relationships, adapted from the Green
Cross Academy of Traumatology, are given in Exhibit 2.2-6. Clients with trauma histories may be
especial ly vulnerable to counselor behaviors that are inconsistent or that are experienced by the
client as boundary violations. Examples of such behavior include: being late for appoint ments,
ending counseling sessions early, re peatedly and excessively extending the session time, canceling
or “forgetting” appointments multiple times, spending time in the session talking about their own
needs and life experi ences, exploring opportunities for contact out side the therapeutic relationship
(including making arrangements to meet at AA or other 12-Step recovery group meetings), and
enforc ing rules differently for one client than for another. Due to the complex dynamics that can
arise in the treatment of clients with trauma histories, regularly scheduled clinical supervision,
where issues of ethics and boundaries can be dis cussed, is recommended for counselors. For more
information on how clinical supervision can be effectively used, see TIP 52, Clinical Supervision and
the Professional Development of the Substance Abuse Counselor (CSAT, 2009b). Boundary crossing
and boundary violation Although guidelines and codes of ethics are useful tools in helping clinical
supervisors and counselors understand the boundaries between counselors and clients, they are
open to inter pretation and are context-bound. Given these limitations, it is crucial to educate
counselors 188 Part 2, Chapter 2—Building a Trauma-Informed Workforce Exhibit 2.2-6: Boundaries
in Therapeutic Relationships Procedures for Establishing Safety Roles and boundaries Counselor
roles and boundaries should be established at the start of the counseling relationship and reinforced
periodically, particularly at times when the client is experiencing high stress. Ongoing Relationships
and the Issue of Boundaries Dual relationships Dual relationships and inappropriate interactions with
clients are to be avoided. It is important to tell clients at the beginning of counseling that contact
between the counselor and the client can only occur within the boundaries of the professional
relationship. This information is part of the informed consent process. Relationships outside these
boundaries include sexual or romantic relationships, a counselor also serving as a client’s sponsor in
12-Step programs, and any kind of relationship in which the counselor exploits the client for financial
gain. Sexual contact • Never engage in any form of sexual contact with clients. • Do not reward
sexualized behaviors with attention or reactivity. • Directly clarify the boundaries of the therapeutic
relationship, and address the underlying moti vations of persisting sexualized behavior. • Set limits
on a client’s inappropriate behaviors while maintaining an ethos of care. Main• Understand that a
client’s attempt to sexualize a therapeutic relationship may reflect an early history of abuse,
difficulty understanding social norms, or a variety of psychological problems. Boundaries •
Sexualized behavior with the client. • Readdress the absolute inappropriateness of sexual and/or
romantic behavior in a nonlecturing, nonpunitive manner. • If sexual behavior between clients
occurs in a treatment program, counselors should consult with a clinical supervisor. Document the
nature of the contact and how the issue is addressed. • If a counselor has sexual contact with a
client, he or she should take responsibility by ceasing counseling practice, referring clients to other
treatment providers, and notifying legal and pro fessional authorities. If a counselor is at risk for
engaging with a client sexually but has not acted on it, the counselor should immediately consult
with a supervisor, colleague, or psychotherapist. Counselors should use care with self-disclosure or
any behaviors that may be experienced as intru sive by the client, including: • Personal disclosures
made for the counselor’s own gratification. • Excessively intrusive questions or statements. •
Interrupting the client frequently. • Violating the client’s personal space. • Interpersonal touch,
which might activate intrusive memories or dissociative reactions or be ex perienced as a boundary
violation by the client. • Being consistently late for appointments or allowing outside influences
(such as telephone calls) to interrupt the client’s time in a counseling session. Source: Green Cross
Academy of Traumatology, 2007. Adapted with permission. in TIC settings regarding the boundary
issues that may arise for clients who have been trau matized and to give counselors a conceptual
framework for understanding the contextual nature of boundaries. For example, it would be useful
for clinical supervisors to discuss with 189 Trauma-Informed Care in Behavioral Health Services
counselors the distinction between boundary crossings and boundary violations in clinical practice.
Gutheil and Brodsky (2008) define boundary crossing as a departure from the customary norms of
counseling practice in relation to psychological, physical, or social space “that are harmless, are
nonexploitative, and may even support or advance the therapy” (p. 20). Examples of boundary
crossings in clude taking phone calls from a client between sessions if the client is in crisis or telling a
client a story about the counselor’s recovery from trauma (without offering specific per sonal
information or graphic/detailed descrip tion of the trauma) with the intention of offering hope that it
is possible to recover. Gutheil and Brodsky (2008) define boundary violations as boundary crossings
that are un wanted and dangerous and which exploit the client, stating that “some boundary
crossings are inadvisable because of their intent (i.e., they are not done in the service of the
patient’s well-being and growth, involve extra thera peutic gratification for the therapist) and/or
their effect (i.e., they are not likely to benefit Case Illustration: Denise the patient and entail a
significant risk of harming the patient)” (pp. 20–21). An exam ple of a boundary violation would be
when a counselor invites a client to attend the same AA meetings the counselor attends or shares
drinking and drugging “war stories” for the counselor’s own gratification. Two key ele ments in
understanding when a boundary crossing becomes a boundary violation are the intent of the
counselor and the damaging ef fect on the client. Maintaining a standard of practice of
nonexploitation of the client is the primary focus for clinical supervisors and counselors in
determining when boundary crossings become boundary violations. Context is also an important
consideration in determining the acceptability of boundary crossings. For example, it may be
acceptable for a counselor in a partial hospitalization pro gram for serious mental illness to have a
cup of coffee at the kitchen table with a resident, whereas for a counselor in an outpatient men tal
health program, having a cup of coffee with a client at the local coffee shop would be a much more
questionable boundary crossing. Denise is a 40-year-old licensed professional counselor working in
an inpatient eating disorder pro gram. She has had extensive training in trauma and eating disorder
counseling approaches and has been working as a clinician in mental health settings for 15 years.
Denise is usually open to sugges tions from her supervisor and other treatment team members
about specific strategies to use with clients who have trauma histories and eating disorders.
However, in the past week, her supervisor has noticed that she has become defensive in team
meetings and individual supervision when discussing a recently admitted young adult who was
beaten and raped by her boyfriend; subsequently, the cli ent was diagnosed with PTSD and anorexia.
When the clinical supervisor makes note of the change in Denise’s attitude and behavior in team
meetings since this young woman was admitted, initially Denise becomes defensive, saying that the
team just doesn’t understand this young woman and that the client has repeatedly told Denise,
“You’re the only counselor I trust.” The clinical supervisor recognizes that Denise may be
experiencing secondary traumatization and boundary confusion due to working with this young
woman and to the recent increase in the number of clients with co-occurring trauma-related
disorders on her caseload. After further exploration, Denise reveals that her own daughter was
raped at the same age as the young woman and that hear ing her story has activated an STS reaction
in Denise. Her way of coping has been to become overly responsible for and overprotective of the
young woman. With the nonjudgmental support of her supervisor, Denise is able to gain perspective,
recognize that this young woman is not her daughter, and reestablish boundaries with her that are
appropriate to the inpatient treatment setting. 190 Part 2, Chapter 2—Building a Trauma-Informed
Workforce Clinical Supervision and Consultation Organizational change toward a TIC model doesn’t
happen in isolation. Ongoing support, supervision, and consultation are key ingredi ents that
reinforce behavioral health profes sionals’ training in trauma-informed and trauma-specific
counseling methods and en sure compliance with practice standards and consistency over time.
Often, considerable energy and resources are spent on the transi tion to new clinical and
programmatic ap proaches, but without long-range planning to support those changes over time.
The new treatment approach fades quickly, making it hard to recognize and lessening its reliability.
Advice to Clinical Supervisors and Administrators: Adopting an Evidence-Based Model of Clinical
Supervision and Training Just as adopting evidence-based clinical practices in a trauma-informed
organization is important in providing cost-effective and outcome-relevant services to clients,
adopting an evidence-based mod el of clinical supervision and training clinical supervisors in that
model can enhance the quality and effectiveness of clinical supervision for counselors. This will
ultimately enhance client care. One of the most commonly used and researched integrative models
of supervision is the discrimina tion model, originally published by Janine Bernard in 1979 and since
updated (Bernard & Goodyear, 2009). This model is considered a competence-based and social role
model of supervision; it in cludes three areas of focus on counselor competencies (intervention,
conceptualization, and person alization) and three possible supervisor roles (teacher, counselor, and
consultant). Counselor competencies: • Intervention: The supervisor focuses on the supervisee’s
intervention skills and counseling strat egies used with a particular client in a given session. •
Conceptualization: The supervisor focuses on how the supervisee understands what is happen ing in
a session with the client. • Personalization: The supervisor focuses on the personal style of the
counselor and countertrans ference responses (i.e., personal reactions) of the counselor to the
client. Supervisor roles: • Teacher: The supervisor teaches the supervisee specific counseling theory
and skills and guides the supervisee in the use of specific counseling strategies in sessions with
clients. The supervisor as teacher is generally task-oriented. The supervisor is more likely to act as a
teacher with begin ning counselors. • Counselor: The supervisor does not act as the counselor’s
therapist, but helps the counselor reflect on his or her counseling style and personal reactions to
specific clients. The supervisor as counselor is interpersonally sensitive and focuses on the process
and relational aspects of coun seling. • Consultant: The supervisor is more of a guide, offering the
supervisee advice on specific clinical situations. The supervisor as consultant invites the counselor to
identify topics and set the agen da for the supervision. The supervisor is more likely to act as a
consultant with more advanced counselors. This model of supervision may be particularly useful in
working with counselors in TIC settings, be cause the supervisor’s response to the supervisee is
flexible and specific to the supervisee’s needs. In essence, it is a counselor-centered model of
supervision in which the supervisor can meet the most relevant needs of the supervisee in any given
moment. For a review of other theories and methods of clinical supervision, refer to TIP 52, Clinical
Supervision and Professional Development of the Substance Abuse Counselor (CSAT, 2009b). 191
Trauma-Informed Care in Behavioral Health Services Ongoing supervision and consultation sup ports
the organizational message that TIC is the standard of practice. It normalizes second ary
traumatization as a systemic issue (not the individual pathology of the counselor) and reinforces the
need for counselor self-care to prevent and lessen the impact of secondary traumatization. Quality
clinical supervision for direct care staff demonstrates the organiza tion’s commitment to
implementing a fully integrated, trauma-informed system of care. Supervision and Consultation
Historically, there was an administrative belief that counselors who had extensive clinical experience
and training would naturally be the best clinical supervisors. However, research Case Illustration:
Arlene does not support this idea (Falender & Shafranske, 2004). Although a competent clinical
supervisor needs to have an extensive clinical background in the treatment of sub stance use,
trauma-related, and other mental disorders, it is also essential for any counselor moving into a
supervisory role to have exten sive training in the theory and practice of clin ical supervision before
taking on this role. In particular, clinical supervisors in trauma informed behavioral health settings
should be educated in how to perform clinical supervi sion (not just administrative supervision) of
direct service staff and in the importance of providing continuous clinical supervision and support for
staff members working with indi viduals affected by trauma. Clinical Arlene is a 50-year-old licensed
substance abuse counselor who has a personal history of trauma, and she is actively engaged in her
own recovery from trauma. She is an experienced counselor who has several years of training in
trauma-informed and trauma-specific counseling practices. Her clinical supervisor, acting in the role
of consultant, begins the supervision session by inviting her to set the agenda. Arlene brings up a
clinical situation in which she feels stuck with a client who is acting out in her Seeking Safety group
(for more information on Seeking Safety, see Najavits, 2002a). Arlene reports that her client gets up
suddenly and storms out of the group room two or three times during the session. The supervisor,
acting in the role of the counselor and focusing on personaliza tion, asks Arlene to reflect on the
client’s behavior and what feelings are activated in her in response to the client’s anger. Arlene is
able to identify her own experience of hyperarousal and then paralysis as a stress reaction related to
her prior experience of domestic violence in her first marriage. The supervisor, acting in the role of
teacher and focusing on conceptualization, reminds Arlene that her client is experiencing a “fight-or-
flight” response to some experience in the group that reminds her of her own trauma experience.
The supervisor then suggests to Arlene that her own reactions are normal responses to her previous
history of trauma, and that when her client is angry, Arlene is not reexperiencing her own trauma
but is being activated by the client’s traumatic stress reaction to being in group. In this way, the
supervisor highlights the parallel process of the client–counselor’s stress reactions to a perceived
threat based on prior trauma experiences. The supervisor, acting again as a consultant and focusing
on personalization this time, invites Arlene to reflect on the internal and external resources she
might be able to bring to this situation that will help remind her to ground herself so she can lessen
the impact of her stress reactions on her coun seling strategy with this client. Arlene states that she
can create a list of safe people in her life and place this list in her pocket before group. She can use
this list as a touchstone to remind her that she is safe and has learned many recovery skills that can
help her stay grounded, maintain her bounda ries, and deal with her client’s behavior. The clinical
supervisor, acting as a consultant and now focus ing on intervention, asks Arlene if she has some
specific ideas about how she can address the client’s behavior in group. Arlene and the clinical
supervisor spend the remainder of the session discussing different options for addressing the client’s
behavior and helping her feel safer in group. 192 Part 2, Chapter 2—Building a Trauma-Informed
Workforce supervision in a TIC organization should fo cus on the following priorities: • General case
consultation • Specialized consultation in specific and unusual cases • Opportunities to process
clients’ traumatic material • Boundaries in the therapeutic and supervi sory relationship •
Assessment of secondary traumatization • Counselor self-care and stress management • Personal
growth and professional devel opment of the counselor Supervision of counselors working with trau
matized clients should be regularly scheduled, with identified goals and with a supervisor who is
trained and experienced in working with trauma survivors. The styles and types of supervision and
consultation may vary accord ing to the kind of trauma work and its context. For instance, trauma
counseling in a major natural disaster would require a different ap proach to supervision and
consultation than would counseling adults who experienced childhood developmental trauma or
counsel ing clients in an intensive early recovery treatment program using a manualized trauma-
specific counseling protocol. Competence-based clinical supervision is rec ommended for trauma-
informed organiza tions. Competence-based clinical supervision models identify the knowledge and
clinical skills each counselor needs to master, and they use targeted learning strategies and
evaluation procedures, such as direct observation of coun selor sessions with clients, individualized
coaching, and performance-based feedback. Studies on competence-based supervision ap proaches
have demonstrated that these models improve counselor treatment skills and profi ciency (Martino
et al., 2011). Whichever model of clinical supervision an organization adopts, the key to successful
trauma-informed clinical supervision is the recognition that interactions between the su pervisor and
the counselor may parallel those between the counselor and the client. Clinical supervisors need to
recognize counselors’ trauma reactions (whether they are primary or secondary to the work with
survivors of trau ma) and understand that a confrontational or punitive approach will be ineffective
and likely retraumatize counselors. Clinical supervisors should adopt a respectful and collaborative
working relationship with counselors in which role expectations are clearly defined in an informed
consent process similar to that used in the beginning of the counselor–client relationship and in
which exploring the nature of boundaries in both client–counselor and counselor–supervisor
relationships is standard practice. Clear role boundaries, performance expectations, open dialog, and
supervisor transparency can go a long way toward creating a safe and respectful relationship
container for the supervisor and supervisee and set the stage for a mutually enhancing, collaborative
relationship. This respectful, collaborative supervisory relation ship is the main source of training and
profes sional growth for the counselor and for the provision of quality care to people with behav
ioral health disorders. Secondary Traumatization The demands of caregiving exact a price from
behavioral health professionals that cannot be ignored; otherwise, they may become ineffec tive in
their jobs or, worse, emotionally or psychologically impaired. In a study of Mas ter’s level licensed
social workers, 15.2 percent of respondents to a survey reported STS as a result of indirect exposure
to trauma material at a level that meets the diagnostic criteria for PTSD. This rate is almost twice the
rate of PTSD in the general population. The author 193 Advice to Clinical Supervisors: Recognizing
Secondary Traumatization Some counselor behaviors that demonstrate inconsistency to clients may
be outward mani festations of secondary traumatization, and they should be discussed with
counselors through a trauma-informed lens. It is impera tive that clinical supervisors provide a non
judgmental, safe context in which counselors can discuss these behaviors without fear of reprisal or
reprimand. Clinical supervisors should work collaboratively with supervisees to help them
understand their behavior and en gage in self-care activities that lessen the stress that may be
contributing to these behaviors. STS is a trauma related stress reaction and set of symptoms
resulting from exposure to another individual’s traumatic experiences rather than from exposure
directly to a traumatic event. Trauma-Informed Care in Behavioral Health Services concluded that be
havioral health pro fessionals’ experience of STS is a contrib uting factor in staff turnover and one
reason why many behavioral health service professionals leave the field (Bride, 2007). Sec ondary
traumatization of behavioral health workers is a significant organizational issue for clinical
supervisors and administrators in sub stance abuse and mental health treatment pro grams to
address. To prevent or lessen the impact of secondary traumatization on behavioral health profes
sionals, clinical supervisors and administrators need to understand secondary trauma from the
ecological perspective described in Part 1, Chapter 1 of this TIP. The organization itself creates a
social context with risk factors that can increase the likelihood of counselors expe riencing STS
reactions, but it also contains protective factors that can lessen the risk and impact of STS reactions
on staff members. Organizations can lessen the impact of the risk factors associated with working in
trauma-informed organizations by mixing caseloads to contain clients both with and without
trauma-related issues, supporting ongoing counselor training, providing regular clinical supervision,
recognizing counselors’ efforts, and offering an empowering work environment in which counselors
share in the responsibility of making decisions and can offer input into clinical and program policies
that affect their work lives. When organizations support their counselors in their work with clients
who are trauma tized, counselors can be more effective, more productive, and feel greater personal
and pro fessional satisfaction. In addition, counselors develop a sense of allegiance toward the or
ganization, thus decreasing staff turnover. If organizations do not provide this support, counselors
can become demoralized and have fewer emotional and psychological resources to manage the
impact of clients’ traumatic material and outward behavioral expressions of trauma on their own
well-being. Providing counselors with the resources to help them build resilience and prevent feeling
over whelmed should be a high priority for admin istrators and clinical supervisors in TIC
organizations. Risk and Protective Factors Associated With Secondary Traumatization Clinical and
research literature on trauma de scribes a number of factors related to the de velopment of
secondary trauma reactions and psychological distress in behavioral health professionals across a
wide range of practice settings, as well as individual and organiza tional factors that can prevent or
lessen the impact of STS on staff. The risk and protec tive factors model of understanding secondary
trauma is based on the ecological perspective 194 Advice to Clinical Supervisors: Recognizing STS in
Counselors Who Are In Recovery For counselors who are in recovery from a sub stance use or
mental disorder, the develop ment of STS may be a potential relapse concern. As Burke, Carruth, and
Prichard (2006) point out, “a return to drinking or illicit drug use as a strategy for dealing with
second ary trauma reactions would have a profoundly detrimental effect on the recovering counse
lor” (p. 292). So too, secondary trauma may ignite the reappearance of depressive o r anxie ty
symptoms associated with a previous mental disorder. Clinical supervisors can address these risk
factors with counselors and support them in engaging with their own recovery support network
(which might include a peer support group or an individual counselor) to develop a relapse
prevention plan. Part 2, Chapter 2—Building a Trauma-Informed Workforce outlined in Part 1,
Chapter 1 of this TIP. The terms “compassion fatigue,” “vicarious trauma tization,” “secondary
traumatization,” and “burnout” are used in the literature, sometimes interchangeably and
sometimes as distinct constructs. As stated in the terminology por tion of the “How This TIP Is
Organized” sec tion that precedes Part 1, Chapter 1, of this TIP, the term “secondary traumatization”
re fers to traumatic stress reactions and psycho logical distress from exposure to another individual’s
traumatic experiences; this term will be used throughout this section, although the studies cited may
use other terms. Risk factors Individual risk factors that may contribute to the development of STS in
behavioral health professionals include preexisting anxiety or mood disorders; a prior history of
personal trauma; high caseloads of clients with trauma related disorders; being younger in age and
new to the field with little clinical experience or training in treating trauma-related conditions;
unhealthy coping styles, including distancing and detachment from clients and co-workers; and a
lack of tolerance for strong emotions (Newall & MacNeil, 2010). Other negative coping strategies
include substance abuse, oth er addictive behaviors, a lack of recreational activities not related to
work, and a lack of engagement with social support. A recent study of trauma nurses found that low
use of support systems, use of substances, and a lack of hobbies were among the coping strategies
that differed between nurses with and without STS (Von Rueden et al., 2010). Other re searchers
found that clinicians who engaged in negative coping strategies, such as alcohol and illicit drug use,
were more likely to experience intrusive trauma symptoms (Way, Van Deusen, Martin, Applegate, &
Janle, 2004). Numerous organizational factors can contrib ute to the development of STS in
counselors who work with clients with trauma-related disorders. These risk factors include organiza
tional constraints, such as lack of resources for clients, lack of clinical supervision for counse lors,
lack of support from colleagues, and lack of acknowledgment by the organizational cul ture that
secondary traumatization exists and is a normal reaction of counselors to client trauma (Newall &
MacNeil, 2010). In a study of 259 individuals providing mental health counseling services, counselors
who spent more time in session with clients with trauma related disorders reported higher levels of
traumatic stress symptoms (Bober & Regehr, 2006). Counselors may be more at risk for developing
secondary traumatization if the organization does not allow for balancing the distribution of trauma
and nontrauma cases amongst staff members. Protective factors Much of the clinical and research
literature focuses on individual factors that may lessen the impact of STS on behavioral health pro
fessionals, including male gender, being older, having more years of professional experience, 195
Trauma-Informed Care in Behavioral Health Services having specialized training in trauma informed
and trauma-specific counseling practices, lacking a personal trauma history, exhibiting personal
autonomy in the work place, using positive personal coping styles, and possessing resilience or the
ability to find meaning in stressful life events and to rebound from adversity (Sprang, Clark, & Whitt
Woosley, 2007). Some of these factors, like positive personal coping styles and the ability to find
meaning in adversity, can be developed and enhanced through personal growth work,
psychotherapy, engagement with spiritual practices and involvement in the spiritual community, and
stress reduction strategies like mindfulness meditation. A recent multi method study of an 8-week
workplace mind fulness training group for social workers and other social service workers found that
mind fulness meditation increased coping strategies, reduced stress, and enhanced self-care of the
participants; findings suggested that workers were more likely to practice stress manage ment
techniques like mindfulness at their place of work than at home (McGarrigle & Walsh, 2011).
Organizations can support counselors’ individual efforts to enhance posi tive personal coping styles,
find meaning in adversity, and reduce stress by providing time for workers during the workday for
personal self-care activities, like mindfulness meditation and other stress reduction practices. One of
the organizational protective factors identified in the literature that may lessen the negative impact
of secondary traumatization on behavioral health professionals is providing adequate training in
trauma-specific counsel ing strategies, which increases providers’ sense of efficacy in helping clients
with trauma related disorders and reduces the sense of hopelessness that is often a part of the work
(Bober & Regehr 2006). One study found that specialized trauma training enhanced job sat isfaction
and reduced levels of compassion fatigue, suggesting that “knowledge and train ing might provide
some protection against the deleterious effects of trauma exposure” (Sprang et al., 2007, p. 272).
Another protec tive factor that may lessen the chances of de veloping secondary traumatization is
having a diverse caseload of clients. Organizations “must determine ways of distributing work load in
order to limit the traumatic exposure of any one worker. This may not only serve to reduce the
impact of immediate symptoms but may also address the potential longitudinal effects” (Bober &
Regehr, 2006, p. 8). Emotional support from professional col leagues can be a protective factor. A
study of substance abuse counselors working with cli ents who were HIV positive found that work
place support from colleagues and supervisors most effectively prevented burnout (Shoptaw, Stein,
& Rawson, 2000). This support was associated with less emotional fatigue and depersonalization,
along with a sense of great er personal accomplishment. In a study of do mestic violence advocates,
workers who received more support from professional peers were less likely to experience
secondary trau matization (Slattery & Goodman, 2009). In addition, counselor engagement in
relation ally based clinical supervision with a trauma informed supervisor acts as a protective agent.
Slattery and Goodman (2009) note that “for the trauma worker, good supervision can nor malize the
feelings and experiences, provide support and information about the nature and course of the
traumatic reaction, help in the identification of transference and counter transference issues, and
reveal feelings or symptoms associated with the trauma” (p. 1362). Workers who reported
“engaging, au thentic, and empowering relationships with their supervisors” were less likely to
experience STS (p. 1369). Thus, it is not simply the fre quency and regularity of clinical supervision,
196 Part 2, Chapter 2—Building a Trauma-Informed Workforce but also the quality of the
supervision and the quality of the supervisor–counselor relation ship that can lessen the impact of
STS on behavioral health professionals. Engagement with a personal practice of spirit uality that
provides a sense of connection to a larger perspective and meaning in life is an other protective
factor that can lessen the im pact of STS on counselors (Trippany, Kress, & Wilcoxon, 2004).
Although recovering coun selors may look to support groups for connec tion to a spiritual
community, other behavioral health professionals might find support for enhancing spiritual
meaning and connection in church, a meditation group, creative en deavors, or even volunteer work.
The key is for counselors to develop their own unique re sources and practices to enhance a sense of
meaningful spirituality in their lives. Clinical supervisors should be aware of spiritual en gagement as
a protective factor in preventing and lessening the impact of STS and should support clinicians in
including it in their self care plans, but they should take care not to promote or reject any particular
religious belief system or spiritual practice. Another protective factor that may lessen the impact of
workers’ STS is a culture of empow erment in the organization that offers counse lors a sense of
autonomy, a greater ability to participate in making decisions about clinical and organizational
policies, and obtaining support and resources that further their pro fessional development. Slattery
& Goodman (2009) surveyed 148 domestic violence advo cates working in a range of settings. The au
thors found that those workers “who reported a high level of shared power were less likely to report
posttraumatic stress symptoms, despite their own personal abuse history or degree of exposure to
trauma” (p. 1370). To the degree that organizations can provide a cultural con text within which
behavioral health profes sionals have autonomy and feel empowered, they will be able to lessen the
impact of STS on their professional and personal lives. Self efficacy and empowerment are antidotes
to the experience of powerlessness that often accom panies trauma. Strategies for Preventing
Secondary Traumatization The key to prevention of secondary traumati zation for behavioral health
professionals in a trauma-informed organization is to reduce risk and enhance protective factors.
Organiza tional strategies to prevent secondary trauma tization include: • Normalize STS throughout
all levels of the organization as a way to help counselors feel safe and respected, enhancing the like
lihood that they will talk openly about their experiences in team meetings, peer supervi sion, and
clinical supervision. • Implement clinical workload policies and practices that maintain reasonable
stand ards for direct-care hours and emphasize balancing trauma-related and nontrauma related
counselor caseloads. • Increase the availability of opportunities for supportive professional
relationships by promoting activities such as team meetings, peer supervision groups, staff retreats,
and counselor training that focuses on under standing secondary traumatization and self care.
Administrators and clinical supervi sors should provide time at work for coun selors to engage in
these activities. • Provide regular trauma-informed clinical supervision that is relationally based. Su
pervisors should be experienced and trained in trauma-informed and trauma-specific practices and
provide a competence-based model of clinical supervision that promotes counselors’ professional
and personal devel opment. Supervision limited to case consul tation or case management is
insufficient to 197 Exhibit 2.2-7: Counselor Strategies To Prevent Secondary Traumatization
Strategies that counselors can use (with the support and encouragement of supervisors and adminis
trators) to prevent secondary traumatization include: • Peer support: Maintaining adequate social
support, both personally and professionally, helps prevent isolation and helps counselors share the
emotional distress of working with traumatized individuals. • Supervision and consultation:
Professional consultation will help counselors understand second ary traumatization, their own
personal risks, the protective factors that can help them prevent or lessen its impact, and their
countertransference reactions to specific clients. • Training: Ongoing professional training can
improve counselors’ understanding of trauma and enhance a sense of mastery and self-efficacy in
their work. • Personal psychotherapy or counseling: Being in counseling can help counselors become
more self-aware and assist them in managing the psychological and emotional distress that often ac
companies working with clients who have trauma histories in a number of behavioral health set
tings. • Maintaining balance in one’s life: Balancing work and personal life, developing positive
coping styles, and maintaining a healthy lifestyle can enhance resilience and the ability to manage
stress. • Engaging in spiritual activities that provide meaning and perspective: Connection to a spiritu
al community and spiritual practices (such as meditation) can help counselors gain a larger per
spective on trauma and enhance resilience. Trauma-Informed Care in Behavioral Health Services
reduce the risk for secondary traumatiza tion and promote counselor resilience. • Provide
opportunities for behavioral health professionals to enhance their sense of au tonomy and feel
empowered within the organization. Some of these activities in clude soliciting input from
counselors on clinical and administrative policies that af fect their work lives, including how to best
balance caseloads of clients with and with out histories of trauma; inviting represent atives of the
counseling staff to attend selected agency board of directors and/or management team meetings to
offer input on workforce development; and inviting counselors to participate in organizational task
forces that develop trauma-informed services, plan staff retreats, or create mech anisms to discuss
self-care in team meet ings. Administrators and clinical supervisors should assess the organization’s
unique culture and develop avenues for counselor participation in activities that will enhance their
sense of empowerment and efficacy within the organization. Exhibit 2.2-7 highlights some specific
strate gies that individual counselors can engage in to prevent secondary traumatization.
Assessment of Secondary Traumatization Counselors with unacknowledged STS can harm clients,
self, and family and friends by becoming unable to focus on and attend to their needs or those of
others. They may feel helpless or cynical and withdraw from support systems. Exhibit 2.2-8 describes
some emo tional, cognitive, and behavioral signs that may indicate that a counselor is experiencing
secondary traumatization. Clinical supervisors should be familiar with the manifestations of STS in
their counselors and should address signs of STS immediately. Stamm (2009–2012) has developed
and re vised a self-assessment tool, the Professional Quality of Life Scale (ProQOL), that measures
indicators of counselor compassion fatigue and compassion satisfaction. Compas sion fatigue “is best
defined as a syndrome consisting of a combination of the symptoms 198 Part 2, Chapter 2—Building
a Trauma-Informed Workforce Exhibit 2.2-8: Secondary Traumatization Signs The following are some
indicators that counselors may be experiencing secondary traumatization. Psychological distress •
Distressing emotions: grief, depression, anxiety, dread, fear, rage, shame • Intrusive imagery of
client’s traumatic material: nightmares, flooding, flashbacks of client disclo sures • Numbing or
avoidance: avoidance of working with client’s traumatic material • Somatic issues: sleep
disturbances, headaches, gastrointestinal distress, heart palpitations, chronic physiological arousal •
Addictive/compulsive behaviors: substance abuse, compulsive eating, compulsive working •
Impaired functioning: missed or canceled appointments, decreased use of supervision, de creased
ability to engage in self-care, isolation and alienation Cognitive shifts • Chronic suspicion about
others • Heightened sense of vulnerability • Extreme sense of helplessness or exaggerated sense of
control over others or situations • Loss of personal control or freedom • Bitterness or cynicism •
Blaming the victim or seeing everyone as a victim • Feeling victimized by client Relational
disturbances • Decreased intimacy and trust in personal/professional relationships Frame of
reference • Witness or clinician guilt if client reexperiences trauma or reenacts trauma in counseling
• Distancing or detachment from client, which may include labeling clients, pathologizing them,
judging them, canceling appointments, or avoiding exploring traumatic material • Overidentification
with the client, which may include a sense of being paralyzed by one’s own responses to the client’s
traumatic material or becoming overly responsible for the client’s life • Disconnection from one’s
sense of identity • Dramatic change in fundamental beliefs about the world • Loss or distortion of
values or principles • A previous sense of spirituality as comfort or resource decreases or becomes
nonexistent • Loss of faith in something greater • Existential despair and loneliness Sources: Figley,
1995; Newall & MacNeil, 2010; Saakvitne et al., 1996. of secondary traumatic stress and professional
burnout” (Newall & MacNeil, 2010, p. 61). Although secondary traumatization as a reac tion to
exposure to clients’ trauma material is similar to PTSD, burnout is a more general type of
psychological distress related to the pressures of working in high-stress environ ments over time.
Burnout may be a result of secondary traumatization and/or a contrib uting factor in the
development of secondary traumatization. The ProQOL includes STS and burnout scales that have
been validated in research studies (Adams, Figley, & Boscarino, 2008; Newall & MacNeil, 2010). This
tool can be used in individual and group clinical supervision, trainings on self-care, and team
meetings as a way for counselors to check in with themselves on their levels of stress and potential
signs of secondary traumatization. 199 Case Illustration: Gui Gui is a 48-year-old licensed substance
abuse counselor who has worked in a methadone mainte nance clinic for 12 years. He originally
decided to get his degree and become a counselor because he wanted to help people and make a
difference in the world. Over the past 6 months, he has felt fatigued a great deal, gets annoyed
easily with both clients and coworkers, and has developed a cynical attitude about the world and the
p eople who come to the clinic for help. During this time, the clinic has been forced to lay off a
number of counselors due to funding cutbacks. As a result, Gui and the remaining counselors have
had a 20 percent increase in the number of weekly client contact hours required as part of their job
duties. In addition, the level and severity of clients’ trauma-related and other co-occurring disorders,
poverty, joblessness, and homelessness has increased. Gui is a valued employee, and when Gui
discusses his thoughts that he might want to leave the clinic with his clinical supervisor, the
supervisor listens to Gui’s concerns and explores the possibility of having him fill out the ProQOL to
get a pulse on his stress level. Gui agrees and is willing to discuss the results with his supervisor. He is
not surprised to see that he scores above average on the burn out scale of the instrument but is very
surprised to see that he scores below average on the second ary traumatic stress scale and above
average on the compassion satisfaction scale. He begins to feel more hopeful that he still finds
satisfaction in his job and sees that he is resilient in many ways that he did not acknowledge before.
Gui and the clinical supervisor discuss ways that the supervisor and the organization can lessen the
impact of the stress of the work environment on Gui and support the development of a self-care
plan that emphasizes his own ability to rebound from adversity and take charge of his self-care.
Trauma-Informed Care in Behavioral Health Services The compassion satisfaction scale allows
counselors to reflect on their resilience and reminds them of why they choose to work with people
with substance use and trauma-related disorders, despite the fact that this work can lead to
secondary traumatization. The compas sion satisfaction subscale reminds counselors that they are
compassionate, that one of the reasons they are in a helping profession is that they value service to
others, and that helping brings meaning and fulfillment to their lives. Exhibits 2.2-9 through 2.2-11
present the most recent version of the ProQOL. Addressing Secondary Traumatization If a counselor
is experiencing STS, the organi zation should address it immediately. Clinical supervisors can
collaborate with counselors to devise an individualized plan that is accessible, acceptable, and
appropriate for each counselor and that addresses the secondary stress reac tions the counselor is
experiencing, providing specific self-care strategies to counteract the stress. Decisions about
strategies for address ing secondary traumatization should be based on the personal preferences of
the counselor, the opportunity for an immediate intervention following a critical incident, and the
counse lor’s level of awareness regarding his or her experience of STS. Counselors may need to talk
about what they are experiencing, feeling, and thinking. These experiences can be pro cessed in
teams, in consultations with col leagues, and in debriefing meetings to integrate them effectively
(Myers & Wee, 2002). If a critical incident evokes secondary trauma tization among staff––such as a
client suicide, a violent assault in the treatment program, or another serious event––crisis
intervention should be available for workers who would like to participate. Any intervention should
be voluntary and tailored to each worker’s indi vidual needs (e.g., peer, group, or individual
sessions); if possible, these services should be offered continuously instead of just one time. 200 Part
2, Chapter 2—Building a Trauma-Informed Workforce Exhibit 2.2-9: PRoQOL Scale COMPASSION
SATISFACTION AND COMPASSION FATIGUE (PRoQOL) VERSION 5 (2009) When you [help] people you
have direct contact with their lives. As you may have found, your com passion for those you [help]
can affect you in positive and negative ways. Below are some questions about your experiences,
both positive and negative, as a [helper]. Consider each of the following questions about you and
your current work situation. Select the number that honestly reflects how frequently you
experienced these things in the past 30 days. 1=Never 2=Rarely 3=Sometimes 4=Often 5=Very Often
___ 1. I am happy. ___ 2. I am preoccupied with more than one person I [help]. ___ 3. I get
satisfaction from being able to [help] people. ___ 4. I feel connected to others. ___ 5. I jump or am
startled by unexpected sounds. ___ 6. I feel invigorated after working with those I [help]. ___ 7. I
find it difficult to separate my personal life from my life as a [helper]. ___ 8. I am not as productive at
work because I am losing sleep over traumatic experiences of a per son I [help]. ___ 9. I think that I
might have been affected by the traumatic stress of those I [help]. ___ 10. I feel trapped by my job as
a [helper]. ___ 11. Because of my [helping], I have felt “on edge” about various things. ___ 12. I like
my work as a [helper]. ___ 13. I feel depressed because of the traumatic experiences of the people I
[help]. ___ 14. I feel as though I am experiencing the trauma of someone I have [helped]. ___ 15. I
have beliefs that sustain me. ___ 16. I am pleased with how I am able to keep up with [helping]
techniques and protocols. ___ 17. I am the person I always wanted to be. ___ 18. My work makes
me feel satisfied. ___ 19. I feel worn out because of my work as a [helper]. ___ 20. I have happy
thoughts and feelings about those I [help] and how I could help them. ___ 21. I feel overwhelmed
because my case [work] load seems endless. ___ 22. I believe I can make a difference through my
work. ___ 23. I avoid certain activities or situations because they remind me of frightening
experiences of the people I [help]. ___ 24. I am proud of what I can do to [help]. ___ 25. As a result
of my [helping], I have intrusive, frightening thoughts. ___ 26. I feel “bogged down” by the system.
___ 27. I have thoughts that I am a “success” as a [helper]. ___ 28. I can’t recall important parts of
my work with trauma victims. ___ 29. I am a very caring person. ___ 30. I am happy that I chose to
do this work. © B. Hudnall Stamm, 2009–2012. Professional Quality of Life: Compassion Satisfaction
and Fatigue Version 5 (ProQOL). [Link] This test may be freely copied as long as (a)
author is credited, (b) no changes are made, and (c) it is not sold. Those interested in using the test
should visit [Link] to verify that the copy they are using is the most current version
of the test. 201 Source: Stamm, 2012. Used with permission. Trauma-Informed Care in Behavioral
Health Services Exhibit 2.2-10: Your Scores on the ProQOL: Professional Quality of Life Screening
Based on your responses, place your personal scores below. If you have any concerns, you should
discuss them with a physical or mental healthcare professional. Compassion Satisfaction
_____________ Compassion satisfaction is about the pleasure you derive from being able to do your
work well. For example, you may feel like it is a pleasure to help others through your work. You may
feel positively about your colleagues or your ability to contribute to the work setting or even the
greater good of society. Higher scores on this scale represent a greater satisfaction related to your
ability to be an effective caregiver in your job. The average score is 50 (SD 10; alpha scale
reliability .88). About 25% of people score higher than 57 and about 25% of people score below 43. If
you are in the higher range, you probably derive a good deal of professional satisfaction from your
position. If your scores are below 40, you may either find problems with your job, or there may be
some other reason—for example, you might derive your satisfaction from activities other than your
job. Burnout_____________ Most people have an intuitive idea of what burnout is. From the
research perspective, burnout is one of the elements of Compassion Fatigue (CF). It is associated
with feelings of hopelessness and difficulties in dealing with work or in doing your job effectively.
These negative feelings usually have a gradual onset. They can reflect the feeling that your efforts
make no difference, or they can be associated with a very high workload or a non-supportive work
environment. Higher scores on this scale mean that you are at higher risk for burnout. The average
score on the burnout scale is 50 (SD 10; alpha scale reliability .75). About 25% of peo ple score above
57 and about 25% of people score below 43. If your score is below 43, this probably reflects positive
feelings about your ability to be effective in your work. If you score above 57 you may wish to think
about what at work makes you feel like you are not effective in your position. Your score may reflect
your mood; perhaps you were having a “bad day” or are in need of some time off. If the high score
persists or if it is reflective of other worries, it may be a cause for concern. Secondary Traumatic
Stress_____________ The second component of Compassion Fatigue (CF) is secondary traumatic
stress (STS). It is about your work related, secondary exposure to extremely or traumatically stressful
events. Developing problems due to exposure to other’s trauma is somewhat rare but does happen
to many people who care for those who have experienced extremely or traumatically stressful
events. For example, you may repeatedly hear stories about the traumatic things that happen to
other people, commonly called Vicarious Traumatization. If your work puts you directly in the path
of danger, for example, field work in a war or area of civil violence, this is not secondary exposure;
your exposure is primary. However, if you are exposed to others’ traumatic events as a result of your
work, for example, as a therapist or an emergency worker, this is secondary exposure. The
symptoms of STS are usually rapid in onset and associated with a particular event. They may include
being afraid, having difficulty sleeping, having images of the upsetting event pop into your mind, or
avoiding things that remind you of the event. The average score on this scale is 50 (SD 10; alpha
scale reliability .81). About 25% of people score below 43 and about 25% of people score above 57. If
your score is above 57, you may want to take some time to think about what at work may be
frightening to you or if there is some other reason for the elevated score. While higher scores do not
mean that you do have a problem, they are an indi cation that you may want to examine how you
feel about your work and your work environment. You may wish to discuss this with your supervisor,
a colleague, or a healthcare professional. © B. Hudnall Stamm, 2009–2012. Professional Quality of
Life: Compassion Satisfaction and Fatigue Version 5 (ProQOL). [Link] This test may
be freely copied as long as (a) author is credited, (b) no changes are made, and (c) it is not sold.
Those interested in using the test should visit [Link] to verify that the copy they are
using is the most current version of the test. 202 Source: Stamm, 2012. Used with permission. *You
Wrote Change to 1 5 2 4 3 3 4 2 5 1 3. ____ 6. ____ 12. ____ 16. ____ 18. ____ 20. ____ 22. ____ 24.
____ 27. ____ The sum of my Compassion Satisfaction questions is So my score equals And my
Compassion Satisfaction level is 22 or less 43 or less Low Between 23 and 41 Around 50 Average 42
or more 57 or more High 30. ____ Total : _____ *1. ____ = ____ *4. ____ = ____ 8. ____ 10. ____
*15. ____ = ____ *17. ____ = ____ 19. ____ 21. ____ 26. ____ *29. ____ = ____ Total : _____ The
sum of my Burnout questions is So my score equals And my Burnout level is 22 or less 43 or less Low
Between 23 and 41 Around 50 Average 42 or more 57 or more High The sum of my Secondary
Trauma questions is So my score equals And my Secondary Traumatic Stress level is 22 or less 43 or
less Low Between 23 and 41 Around 50 Average 42 or more 57 or more High Exhibit 2.2-11: What Is
My Score and What Does It Mean? In this section, you will score your test so you understand the
interpretation for you. To find your score on each section, total the questions listed on the left and
then find your score in the table on the right of the section. Compassion Satisfaction Scale Copy your
rating on each of these questions on to this table and add them up. When you have added then up
you can find your score on the table to the right. Burnout Scale On the burnout scale you will need
to take an extra step. Starred items are “reverse scored.” If you scored the item 1, write a 5 beside it.
The reason we ask you to reverse the scores is because scientifically the measure works better when
these questions are asked in a positive way though they can tell us more about their negative form.
For example, question 1. “I am happy” tells us more about the effects of helping when you are not
happy so you reverse the score. Secondary Traumatic Stress Scale Just like you did on Compassion
Satisfaction, copy your rating on each of these questions on t o this table and add the[m] up. When
you have added them up you can find your score on the table to the right. 2. ____ 5. ____ 7. ____ 9.
____ 11. ____ 13. ____ 14. ____ 23. ____ 25. ____ 28. ____ Total : _____ © B. Hudnall Stamm,
2009–2012. Professional Quality of Life: Compassion Satisfaction and Fatigue Version 5 (ProQOL).
[Link] This test may be freely copied as long as (a) author is credited, (b) no
changes are made, and (c) it is not sold. Those i nterested in using the test should visit
[Link] to verify that the copy they are using is the most current version of the test.
Source: Stamm, 2012. Used with permission. Part 2, Chapter 2—Building a Trauma-Informed
Workforce 203 Trauma-Informed Care in Behavioral Health Services The objective of debriefing a
critical incident that evokes STS reactions in counselors is to help them dissipate the hyperarousal
associat ed with traumatic stress and prevent long term aftereffects that might eventually lead to
counselor impairment. Because clinical super visors may also be experiencing secondary
traumatization, it is advisable for administra tors to invite an outside trauma consultant into the
organization to provide a safe space for all staff members (including clinical super visors) to address
and process the critical stress incident. For noncrisis situations, secondary traumatization should be
addressed in clinical supervision. Clinical supervisors and counse lors should work collaboratively to
incorporate regular screening and self-assessment of STS into supervision sessions. Advice to Clinical
Supervisors: Advantages and Disadvantages of Using Psychometric Measures Using a psychometric
measure such as the ProQOL has advantages and disadvantages. It is im portant to understand that
all tests measure averages and ranges but do not account for individual circumstances. If you use the
ProQOL in clinical supervision, present it as a self-assessment tool. Let counselors opt out of sharing
their specific results with you and/or your team if it is administered in a group. If counselors choose
to share scores on specific items or scales with you, work collaboratively and re spectfully with them
to explore their own understanding of and meanings attached to their scores. If this tool is not
presented to supervisees in a nonjudgmental, mindful way, counselors may feel as if they have failed
if their scores on the secondary traumatization scale are above average or if their scores on the
compassion satisfaction scale are below average. High scores on the compassion fa tigue and
burnout scales do not mean that counselors don’t care about their clients or that they aren’t
competent clinicians. The scores are simply one way for you and your supervisees to get a sense of
whether they might be at risk for secondary traumatization, what they can do to prevent it, how to
address it, and how you can support them. The potential benefits of using a self-assessment tool like
the ProQOL in clinical supervision are that it can help counselors: • Assess their risk levels. • Reflect
on their emotional reactions and behaviors and identify possible triggers for secondary
traumatization. • Examine alternative coping strategies that may prevent secondary traumatization.
• Understand their own perceptions of themselves and their job satisfaction, affirming what they
already know about their risk of secondary traumatization and their compassion satisfaction. •
Reflect on different factors that might contribute to unexpected low or high scores, such as the day
of the week, the intensity of the workload, whether they have just come back from the weekend or
a vacation, and so forth. • Increase self-awareness and self-knowledge, because scores on specific
items or scales bring to consciousness what is often outside of awareness. • Realize how resilient
they are emotionally, mentally, physically, and spiritually. • Become aware of and open up
conversations about self-care and self-care activities and re sources, such as supportive coworkers,
team members, and social networks outside of work. If used regularly, self-assessment tools can
help counselors and clinical supervisors monitor STS lev els, indicate significant positive and negative
changes, and suggest action toward self-care in specif ic areas. Clinical supervisors should fill out the
ProQOL and review results with their own supervisors, a peer supervisor, or a colleague before
administering it to supervisees. Doing so enables supervisors to gauge their own reactions to the
self-assessment and anticipate potential reactions from supervisees. 204 Part 2, Chapter 2—Building
a Trauma-Informed Workforce Advice to Clinical Supervisors: Is it Supervision or Psychotherapy?
Although there are some aspects of clinical supervision that can be therapeutic and parallel the
therapeutic and emotional support that occurs between the counselor and the client, clinical
supervision is not therapy. As a result, it is important for clinical supervisors to maintain appropriate
boundaries with supervisees when addressing their STS reactions at work. When does the process in
supervision cross over into the realm of practicing therapy with a supervisee? One clear indicator is if
the super visor begins to explore the personal history of the counselor and reflects directly on that
his tory instead of bringing it back to how the counselor’s history influences his or her work with a
particular client or with clients with trauma histories in general. Clinical supervisors should focus
only on counselor issues that may be directly affecting their clinical functioning with clients. If
personal issues arise in clinical supervision, counselors should be encouraged to address them in
their own counseling or psychotherapy. When STS issues arise, the clinical supervisor should work
with counselors to review and revise their self-care plans to determine what strategies are working
and whether additional support, like individual psychotherapy or counseling, may be warranted.
Exhibit 2.2-12 outlines some guidelines for clinical supervisors in addressing secondary trauma in
behavioral health professionals work ing with clients who have substance use, men tal, and trauma-
related disorders. Counselor Self-Care In light of the intensity of therapeutic work with clients with
co-occurring substance use, mental, and trauma-related disorders and the vulnerability of
counselors to secondary trau matization, a comprehensive, individualized self-care plan is highly
recommended. Balance is the key to the development of a self-care Exhibit 2.2-12: Clinical
Supervisor Guidelines for Addressing Secondary Traumatization 1. 2. 3. 4. 5. 6. Engage counselors in
regular screen ing/self-assessment of counselors’ experi ence of STS. Address signs of STS with
counselors in clinical supervision. Work collaboratively with counselors to develop a comprehensive
self-care plan and evaluate its effectiveness on a regular basis. Provide counselors a safe and
nonjudg mental environment within which to pro cess STS in individual and group supervision or
team meetings. Provide counselors with a safe and non judgmental place within which to debrief
critical stress incidents at work; bring in an outside consultant if needed. Support and encourage
counselors to en gage in individual counseling or psycho therapy, when needed, to explore personal
issues that may be contributing to secondary traumatization at work. plan—a balance between
home and work, a balance between focusing on self and others, and a balance between rest and
activity (Saakvitne, Perlman, & Traumatic Stress Institute/ Center for Adult & Adolescent
Psychotherapy 1996). Counselor self-care is also about balancing vulnerability, which al lows
counselors to be present and available when clients address intensely painful content, with
reasonable efforts to preserve their sense of integrity in situations that may threaten the counselors’
faith or worldview (Burke et al., 2006). A comprehensive self-care plan should include activities that
nourish the physical, psychological/mental, emotional/relational, and spiritual aspects of counselors’
lives. The literature on counselor self-care advocates for individual, team, and organizational strat
egies that support behavioral health profes sionals working with clients who have 205 Case
Illustration: Carla Carla is a 38-year-old case manager working in an integrated mental health and
substance abuse agency. She provides in-home case management services to home-bound clients
with chronic health and/or severe mental health and substance abuse problems. Many of her clients
have PTSD and chronic, debilitating pain. Both her parents had alcohol use disorders, and as a result,
Carla became the caretaker in her family. She loves her job; however, she often works 50 to 60 hours
per week and has difficulty leaving her work at work. She often dreams about her clients and wakes
up early, feeling anxious. She some times has traumatic nightmares, even though she was never
physically or sexually abused, and she has never experienced the trauma of violence or a natural
disaster. She drinks five cups of coffee and three to four diet sodas every day and grabs burgers and
sweets for snacks while she drives from one client to the next. She has gained 20 pounds in the past
year and has few friends outside of her coworkers. She has not taken a vacation in more than 2
years. She belongs to the Catholic church down the street, but she has stopped going because she
says she is too busy and exhausted by the time Sunday rolls around. The agency brings in a trainer
who meets with the case management department and guides the staff through a self-assessment of
their current self-care practices and the development of a compre hensive self-care plan. During the
training, Carla acknowledges that she has let her work take over the rest of her life and needs to
make some changes to bring her back into balance. She writes out her self-care plan, which includes
cutting back on the caffeine, calling a friend she knows from church to go to a movie, going to Mass
on Sunday, dusting off her treadmill, and planning a short vacation to the beach. She also decides
that she will discuss her plan with her supervisor and begin to ask around for a counselor for herself
to talk about her anxiety and her nightmares. In the next supervi sion session, Carla’s supervisor
reviews her self-care plan with her and helps Carla evaluate the effec tiveness of her self-care
strategies. Her supervisor also begins to make plans for how to cover Carla’s cases when she takes
her vacation. Trauma-Informed Care in Behavioral Health Services substance use and trauma-related
disorders. Counselors are responsible for developing comprehensive self-care plans and committing
to their plans, but clinical supervisors and ad ministrators are responsible for promoting counselor
self-care, supporting implementa tion of counselor self-care plans, and modeling self-care. Counselor
self-care is an ethical im perative; just as the entire trauma-informed organization must commit to
other ethical issues with regard to the delivery of services to clients with substance use, mental, and
trauma related disorders, it must also commit to the self-care of staff members who are at risk for
secondary traumatization as an ethical con cern. Saakvitne and colleagues (1996) suggest that when
administrators support counselor self-care, it is not only cost-effective in that it reduces the negative
effects of secondary traumatization on counselors (and their cli ents), but also promotes “hope-
sustaining be haviors” in counselors, making them more motivated and open to learning, and
thereby improving job performance and client care. A Comprehensive Self-Care Plan A self-care plan
should include a self assessment of current coping skills and strategies and the development of a
holistic, comprehensive self-care plan that addresses the following four domains: 1. Physical self-
care 2. Psychological self-care (includes cogni tive/mental aspects) 3. Emotional self-care (includes
relational aspects) 4. Spiritual self-care Activities that may help behavioral health workers find
balance and cope with the stress 206 Part 2, Chapter 2—Building a Trauma-Informed Workforce
Advice to Clinical Supervisors: Spirituality The word “spiritual” in this context is used broadly to
denote finding a sense of meaning and purpose in life and/or a connection to something greater
than the self. Spiritual mean ings and faith experiences are highly individual and can be found within
and outside of specific religious contexts. Engaging in spiritual practices, creative endeav ors, and
group/community activities can foster a sense of meaning and connection that can coun teract the
harmful effects of loss of meaning, loss of faith in life, and cognitive shifts in worldview that can be
part of secondary trau matization. Counselors whose clients have trau ma-related disorders
experience fewer disturbances in cognitive schemas regarding worldview and less hopelessness
when they engage in spiritually oriented activities, such as meditation, mindfulness practices, being
in na ture, journaling, volunteer work, attending church, and finding a spiritual community (Burke et
al., 2006). Clinical supervisors can encourage counselors to explore their own spirituality and
spiritual resources by staying open and attuned to the multidimensional nature of spiritual mean ing
of supervisees and refraining from imposing any particular set of religious or spiritual beliefs on
them. A strong sense of spiritual connection can enhance counselors’ resilience and ability to cope
with the sometimes overwhelming effects of clients’ trauma material and trauma-related behavior
(including suicidality) on counselors’ faith in life and sense of meaning and purpose. of working with
clients with trauma-related disorders include talking with colleagues about difficult clinical
situations, attending work shops, participating in social activities with family and friends, exercising,
limiting client sessions, balancing caseloads to include clients with and without trauma histories,
making sure to take vacations, taking breaks during the workday, listening to music, walking in
nature, and seeking emotional support in both their personal and professional lives (Saakvitne et al.,
1996). In addition, regular clinical su pervision and personal psychotherapy or coun Modeling Self-
Care “Implementing interventions was not always easy, and one of the more difficult coping strat
egies to apply had to do with staff working long hours. Many of the staff working at the support
center also had full-time jobs working for the Army. In addition, many staff chose to volunteer at the
Family Assistance Center and worked 16 to 18-hour days. When we spoke with them about the
importance of their own self-care, many barriers emerged: guilt over not working, worries about
others being disappointed in them, fear of failure with respect to being una ble to provide what the
families might need, and a ‘strong need to be there.’ Talking with people about taking a break or
time off proved problematic in that many of them insisted that time off was not needed, despite
signs of fa tigue, difficulty concentrating, and decreased productivity. Additionally, time off was not
modeled. Management, not wanting to fail the families, continued to work long hours, despite our
requests to do otherwise. Generally, indi viduals could see and understand the reasoning behind
such endeavors. Actually making the commitment to do so, however, appeared to be an entirely
different matter. In fact, our own team, although we kept reasonable hours (8 to 10 per day), did not
take a day off in 27 days. Requiring time off as part of membership of a Disaster Response Team
might be one way to solve this problem.” —Member of a Disaster Response Team at the Pentagon
after September 11 Source: Walser, 2004, pp. 4–5. seling can be positive coping strategies for
lessening the impact of STS on counselors. Still, each counselor is unique, and a self-care approach
that is helpful to one counselor may not be helpful to another. Exhibits 2.2-13 and 2.2-14 offer tools
for self-reflection to help counselors discover which specific self-care activities might best suit them.
The worksheet can be used privately by counselors or by clini cal supervisors as an exercise in
individual su pervision, group supervision, team meetings, or trainings on counselor self-care. 207
Trauma-Informed Care in Behavioral Health Services Exhibit 2.2-13: Comprehensive Self-Care Plan
Worksheet Name: Date: Personal Professional/Workspace Physical Psychological/Mental
Emotional/Relational Spiritual © P. Burke, 2006. This worksheet may be freely copied as long as (a)
author is credited, (b) no changes are made, and (c) it is not sold. Permission to reprint has been
granted by the author, Patricia A. Burke. Source: Burke, 2006. Used with permission. Review the
questions in Exhibit 2.2-14, and then write down specific self-care strategies in the form (given in
Exhibit 2.2-13) that you’re confident you will practice in both personal and professional realms. The
Comprehensive Self-Care Worksheet is a tool to help counselors (and clinical supervi sors) develop
awareness of their current coping strategies and where in the four domains they need to increase
their engagement in self-care activities. Once completed, clinical supervisors should periodically
review the plan with their supervisees for effectiveness in preventing and/or ameliorating secondary
traumatization and then make adjustments as needed. Essential Components of Self-Care Saakvitne
and colleagues (1996) describe three essential components, the “ABCs,” of self-care that effectively
address the negative impact of secondary traumatization on counselors: 208 1. Awareness of one’s
needs, limits, feelings, and internal/external resources. Awareness involves mindful/nonjudgmental
attention to one’s physical, psychological, emotional, and spiritual needs. Such attention re quires
quiet time and space that supports self-reflection. 2. Balance of activities at work, between work and
play, between activity and rest, and between focusing on self and focusing on others. Balance
provides stability and helps counselors be more grounded when stress levels are high. 3. Connection
to oneself, to others, and to something greater than the self. Connec tion decreases isolation,
increases hope, diffuses stress, and helps counselors share the burden of responsibility for client
care. It provides an anchor that enhances coun selors’ ability to witness tremendous suf fering
without getting caught up in it. Part 2, Chapter 2—Building a Trauma-Informed Workforce Exhibit
2.2-14: Comprehensive Self-Care Plan Worksheet Instructions Use the following questions to help
you engage in a self-reflective process and develop your com prehensive self-care plan. Be specific
and include strategies that are accessible, acceptable, and appropriate to your unique
circumstances. Remember to evaluate and revise your plan regularly. Physical What are non-
chemical things that help my body relax? What supports my body to be healthy?
Psychological/Mental What helps my mind relax? What helps me see a bigger perspective? What
helps me break down big tasks into smaller steps? What helps me counteract negative self-talk?
What helps me challenge negative beliefs? What helps me build my theoretical understanding of
trauma and addictions? What helps me enhance my counseling/helping skills in working with
traumatized clients? What helps me become more self-reflective? Emotional/Relational Spiritual
What helps me feel grounded and able to tolerate strong feelings? What helps me express my
feelings in a healthy way? Who helps me cope in positive ways and how do they help? What helps
me feel connected to others? Who are at least three people I feel safe talking with about my
reactions/feelings about clients? How can I connect with those people on a regular basis? What
helps me find meaning in life? What helps me feel hopeful? What sustains me during difficult times?
What connects me to something greater? © P. Burke, 2006. This worksheet may be freely copied as
long as (a) author is credited, (b) no changes are made, and (c) it is not sold. Permission to reprint
has been granted by the author, Patricia A. Burke. Source: Burke, 2006. Used with permission.
Clinical supervisors can help counselors re view their self-care plans through the ABCs by reflecting
on these questions: 1. Has the counselor accurately identified his or her needs, limits, feelings, and
internal and external resources in the four domains (physical, psychological/mental, emotion
al/relational, spiritual)? 2. Has the counselor described self-care ac tivities that provide a balance
between 3. work and leisure, activity and rest, and a focus on self and others? Has the counselor
identified self-care ac tivities that enhance connection to self, others, and something greater than
self (or a larger perspective on life)? Supervisors should make their own self-care plans and review
them periodically with their clinical supervisors, a peer supervisor, or a colleague. 209 Trauma-
Informed Care in Behavioral Health Services Commitment to Self-Care One of the major obstacles to
self-care is giv ing in to the endless demands of others, both at work and at home. It is therefore
essential for counselors with the support of clinical su pervisors to become “guardians of [their]
boundaries and limits” (Saakvitne et al., 1996, p 136). Creating a daily schedule that includes breaks
for rest, exercise, connection with coworkers, and other self-care activities can support counselors in
recognizing that they are valuable individuals who are worthy of taking the time to nourish and
nurture themselves, thus increasing commitment to self-care. An Exhibit 2.2-15: The Ethics of Self-
Care other way to support counselors in commit ting to self-care is for supervisors and admin
istrators to model self-care in their own professional and personal lives. Understanding that
counselor self-care is not simply a luxury or a selfish activity, but rather, an ethical imperative
(Exhibit 2.2-15) can foster counselors’ sense of connection to their own values and accountability to
the people they serve as competent and compassionate caregivers. Clinical supervisors and adminis
trators can reinforce this sense of accountabil ity while supporting counselors by providing a caring,
trauma-informed work environment The Green Cross Academy of Traumatology was originally
established to serve a need in Oklahoma City following the April 19, 1995, bombing of the Alfred P.
Murrah Federal Building. Below are adapted examples of the Academy’s code of ethics with regard
to worker self-care. Ethical Principles of Self-Care in Practice These principles declare that it is
unethical not to attend to your self-care as a practitioner, because sufficient self-care prevents
harming those we serve. Standards of self-care guidelines: • Respect for the dignity and worth of
self: A violation lowers your integrity and trust. • Responsibility of self-care: Ultimately it is your
responsibility to take care of yourself—and no situation or person can justify neglecting this duty. •
Self-care and duty to perform: There must be a recognition that the duty to perform as a helper
cannot be fulfilled if there is not, at the same time, a duty to self-care. Standards of humane practice
of self-care: Commitment to self-care: • Universal right to wellness: Every helper, regardless of her
or his role or employer, has a right to wellness associated with self-care. • Physical rest and
nourishment: Every helper deserves restful sleep and physical separation from work that sustains
them in their work role. • Emotional rest and nourishment: Every helper deserves emotional and
spiritual renewal both in and outside the work context. • Sustenance modulation: Every helper must
utilize self-restraint with regard to what and how much they consume (e.g., food, drink, drugs,
stimulation) since improper consumption can com promise their competence as a helper. • Make a
formal, tangible commitment: Written, public, specific, measurable promises of self-care. • Set
deadlines and goals: The self-care plan should set deadlines and goals connected to specific activities
of self-care. • Generate strategies that work and follow them: Such a plan must be attainable and
followed with great commitment and monitored by advocates of your self-care. Source: Green Cross
Academy of Traumatology, 2010. Adapted with permission. 210 Part 2, Chapter 2—Building a
Trauma-Informed Workforce that acknowledges and normalizes secondary traumatization and by
offering reasonable re sources that make it possible for counselors to do their work and take care of
themselves at the same time. Preventing secondary traumati zation and lessening its impact on
counselors once it occurs is not only cost-effective with regard to decreasing staff turnover and
poten tial discontinuity of services to clients; it is also the ethical responsibility of a trauma informed
organization. 211 . Appendix B—Trauma Resource List Introduction As it would be difficult to include
every or ganization focused on trauma, the list of re sources in this appendix is not exhaustive;
consequently, this list does not include books or other materials concerning the vast nature of this
topic, but rather, it concentrates solely on online resources accessible to the public for free or as
part of an organization member ship. The inclusion of selected resources does not necessarily signify
endorsement by the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S.
Department of Health and Human Services (HHS). Following these resources for adults is a list of
resources focused on children and adolescents and a list of training opportunities. Technology and
Trauma: Using the Web To Treat PTSD The role of the Internet in helping those who are experiencing
posttraumatic stress disorder (PTSD) has expanded rapidly; there are numerous Web sites with
toolkits and research publications for clini cians who treat clients with PTSD, as well as Web sites
aimed at providing information and support for these individuals. The U.S. military has contributed
to the field in developing these avenues— specifically, with interactive Web applications for use on
home computers and smartphones. • PTSD Coach is a smartphone application from the U.S.
Department of Veterans Affairs (VA) to help people experiencing PTSD learn about and manage their
symptoms ([Link] • [Link] is a Web
site developed by the Defense Centers of Excellence project led by the National Center for
Telehealth & Technology, with interactive workshops about PTSD, traumatic brain injury (TBI),
anxiety, and depression, aimed at returning veterans ([Link] • T2 Virtual
PTSD Experience, also developed by the National Center for Telehealth & Technology, is an
application to be used within the popular online game Second Life as an interactive way of
simulating how PTSD can be acquired within a combat environment, how PTSD may present itself to
the person experiencing it, and how to seek effective treatment ([Link]
Resources for Adults Academy of Cognitive Therapy [Link] 260 South Broad
Street 18th Floor Philadelphia, PA 19102 Phone: 267-350-7683 Email: info@[Link] The
Academy of Cognitive Therapy, a non profit organization, supports continuing edu cation and
research in cognitive therapy, provides a valuable resource in cognitive ther apy for professionals
and the public at large, 247 Trauma-Informed Care in Behavioral Health Services and actively works
toward the identification and certification of clinicians skilled in cognitive therapy. Certification is
awarded to those individuals who, based on an objective evaluation, have demonstrated an
advanced level of expertise in cognitive therapy. The Academy includes physicians, psychologists,
social workers, and other mental health pro fessionals from around the world. The Academy formed
a Trauma Task Force after September 11, 2001, to disseminate infor mation (available on their Web
site) to help people around the world receive the best help possible following trauma. Addiction
Technology Transfer Center Network [Link] 5100 Rockhill Road
Kansas City, MO 64110 Phone: 816-235-6888 Email: networkoffice@[Link] The Addiction
Technology Transfer Center (ATTC) Network serves as a resource for stu dents and professionals to
identify international distance education opportunities for the sub stance abuse treatment field and
as a free mar keting venue for ATTC-approved sponsors of distance education [Link] ATTC
Web site provides trauma-related resources that in clude case studies, information on working with
returning veterans who have been exposed to trauma, and links to various publications on PTSD and
secondary traumatic stress. Agency for Healthcare Research and Quality
[Link] 540 Gaither Road Suite 2000 Rockville, MD 20850
Phone: 301-427-1104 The Agency for Healthcare Research and Quality (AHRQ) is the research arm of
HHS, specializing in patient safety and quality im provement, outcomes and effectiveness of care,
clinical practice and technology assessment, and healthcare organization and delivery sys tems.
AHRQ also provides funding and tech nical assistance to health research and research training
programs at many universities and institutions. AHRQ’s Web site provides links to research
publications on PTSD and to oth er government publications and toolkits deal ing with trauma-
informed care. The American Academy of Experts in Traumatic Stress [Link] 203
Deer Road Ronkonkoma, NY 11779 Phone: 631-543-2217 Email: info@[Link] The American
Academy of Experts in Trau matic Stress is a multidisciplinary network of professionals who are
committed to the ad vancement of intervention for survivors of trauma. The Academy aims to
identify exper tise among professionals and across disci plines and to provide meaningful standards
for those who work regularly with survivors. The Academy is committed to fostering a greater
appreciation of the effects of common traumatic experiences (e.g., chronic illness, accidents,
domestic violence, loss) in addition to large-scale disasters and catastrophes. The group’s aim is to
help all victims to become survivors and, ultimately, to thrive. American Red Cross Disaster Services
[Link] do/disaster-relief American Red Cross National Headquarters
2025 E Street, NW 248 Appendix B—Trauma Resource List Washington, DC 20006 Phone: 202-303-
4498 Red Cross disaster relief focuses on meeting people’s immediate emergency disaster-caused
needs. When a disaster threatens or strikes, the Red Cross provides shelter, food, and health and
mental health services to address basic human needs. In addition to these ser vices, the core of Red
Cross disaster relief is the assistance given to individuals and families affected by disaster to enable
them to resume their normal daily activities independently. Training opportunities are also provided.
Anxiety and Depression Association of America [Link] 8701 Georgia Avenue #412
Silver Spring, MD 20910 Phone: 240-485-1001 The Anxiety and Depression Association of America
(ADAA) is the only national, non profit membership organization dedicated to informing the public,
healthcare professionals, and legislators that anxiety disorders are real, serious, and treatable. ADAA
promotes the early diagnosis, treatment, and cure of anxiety disorders and is committed to
improving the lives of the people who have them. The ADAA Web site provides information about
the symptoms of PTSD and how it can be treated, in addition to offering a PTSD self screening tool.
Association for Behavioral and Cognitive Therapies [Link] 305 7th Avenue 16th Floor
New York, NY 10001 Phone: 212-647-1890 Fax: 212-647-1865 The Association for Behavioral and
Cognitive Therapies is a professional, interdisciplinary organization concerned with the application of
behavioral and cognitive science to under standing human behavior, developing inter ventions to
enhance the human condition, and promoting the appropriate use of these inter ventions. The
association’s Web site includes resources for the public and for professionals on trauma and
disaster-related problems, a clinical referral directory, and other resources and training
opportunities in behavioral therapy. Association of Traumatic Stress Specialists [Link]
88 Pompton Avenue Verona, NJ 07044 Phone: 973-559-9200 Email: Admin@[Link] The
Association of Traumatic Stress Specialists is an international membership organization that offers
three distinct board certifications to qualified individuals who pro vide services, intervention,
response, and/or treatment in the field of traumatic stress. The Association is dedicated to
improving the quality of life of all individuals throughout the world who have been affected by
traumatic events. Membership represents those who serve survivors of natural disasters, terrorist
attacks, injuries and deaths related to serving in the line of duty or to school and workplace violence;
veterans; refugees; victims of crime; Holocaust survivors; those affected and ex ploited by political
persecution; and others who have experienced traumatic stress injuries. Center for Anxiety and
Related Disorders [Link] 648 Beacon Street 6th Floor 249 Trauma-Informed Care
in Behavioral Health Services Boston, MA 02215 Phone: 617-353-9610 The Center for Anxiety and
Related Disor ders (CARD) at Boston University is a clinical and research center dedicated to
advancing knowledge and providing care for anxiety, mood, eating, sleep, and related disorders.
CARD’s Web site offers information regard ing PTSD and research publications on trau ma and
anxiety, in addition to linking to toolkits from the National Child Traumatic Stress Network’s
Adolescent Traumatic Stress and Substance Abuse Program. Center for the Study of Traumatic Stress
[Link] Uniformed Services University of the Health Sciences Department of
Psychiatry 4301 Jones Bridge Road Bethesda, MD 20814-4799 Phone: 301-295-2470 Fax: 301-319-
6965 The Center for the Study of Traumatic Stress (CSTS) is a federally funded organization
established by the Military Health System in 1987 to address Department of Defense con cerns
regarding health risks and concerns re sulting from the traumatic impact of the use of weapons of
mass destruction in combat, acts of terrorism and hostage events, combat and peacekeeping
operations, natural disasters, and assaults or accidents occurring in both uni formed and civilian
communities. CSTS pri marily serves members of the armed forces, along with their children and
families. Center for Culture, Trauma and Mental Health Disparities
[Link] UCLA Semel Institute of Neuroscience & Biobehavioral Sciences
760 Westwood Plaza Los Angeles, CA 90024 Phone: 310-794-9929 The Collaborative Center for
Trauma and Mental Health Disparities at the University of California Los Angeles is a multiethnic and
multidisciplinary group that focuses on con ducting research and providing training that pertains to
trauma in minority populations. Council of State Governments Justice Center—Mental Health
[Link] health 100 Wall Street 20th Floor New York, NY
10005 Phone: 212-482-2320 Fax: 212-482-2344 Email: consensusproject@[Link] The Consensus
Project is part of the Council of State Governments Justice Center and partners with other
organizations, such as SAMHSA’s GAINS Center, working to im prove outcomes for people, including
juveniles, with mental illnesses involved with the crimi nal justice system. The Consensus Project of
fers a webinar on trauma services in the criminal justice system and on child trauma and juvenile
justice, as well as a local programs database. Dart Center for Journalism and Trauma
[Link] Columbia University Graduate School of Journalism 2950 Broadway New
York, NY 10027 Phone: 212-854-8056 The Dart Center is dedicated to improving media coverage of
trauma, conflict, and 250 Appendix B—Trauma Resource List tragedy. The Center also addresses the
conse quences of such coverage for those working in journalism and provides training and educa
tion via seminars, newsroom briefings and consultation on trauma issues, in addition to training for
journalism educators and other trainers. The Dart Center Web site offers fact sheets, publications,
and DVDs on request for use by journalists, educators, and clinicians. David Baldwin’s Trauma
Information Pages [Link] Phone: 541-686-2598 Email: dvb@trauma-
[Link] This Web site focuses primarily on emotional trauma and traumatic stress, including PTSD
and dissociation, whether following individual traumatic experience(s) or a large-scale disas ter. The
site’s purpose is to provide infor mation for clinicians and researchers in the traumatic stress field.
Specifically, the focus is on both clinical and research aspects of trauma responses and their
resolution. Disaster Technical Assistance Center [Link] 9300 Lee Highway
Fairfax, VA 22031 Phone: 800-308-3515 Fax: 703-225-2338 SAMHSA has created the Disaster
Technical Assistance Center (DTAC) to help States prepare for and respond to a wide range of
potential catastrophes—both natural and human-caused disasters. DTAC primarily serves individuals
and communities who are recovering from natural and human-caused disasters. It works in
conjunction with the Federal Emergency Management Agency (FEMA) and SAMHSA’s Emergency
Mental Health and Traumatic Stress Services Branch, using strengths-based, outreach-oriented prin
ciples conducted in nontraditional settings, as a supplement to programs already in place on a local
level. EMDR Institute, Inc. [Link] P.O. Box 750 Watsonville, CA 9507 Phone: 831-
761-1040 Fax: 831-761-1204 Email: inst@[Link] Eye Movement Desensitization and Repro
cessing (EMDR) is an information-processing therapy that uses an eight-phase approach. (See the
description in Part 1, Chapter 6.) The Web site presents background and descriptive information
about this approach to treatment and lists training opportunities, references, and networking
groups. The Federal Emergency Management Agency [Link] 500 C Street SW
Washington, DC 20472 Phone: 202-646-2500 The Federal Emergency Management Agency, a
formerly independent agency that became part of the Department of Homeland Security in March
2003, is tasked with responding to, planning for, recovering from, and mitigating against disasters.
FEMA can trace its begin nings to the Congressional Act of 1803. This Act, generally considered the
first piece of disaster legislation, provided assistance to a New Hampshire town following an
extensive fire. In the century that followed, ad hoc legis lation was passed more than 100 times in re
sponse to hurricanes, earthquakes, floods, and other natural disasters. 251 Trauma-Informed Care in
Behavioral Health Services The International Critical Incident Stress Foundation, Inc.
[Link] 3290 Pine Orchard Lane Suite 106 Ellicott City, MD 21042 Phone: 410-750-9600
Fax: 410-750-9601 Email: info@[Link] The International Critical Incident Stress Foundation, Inc., is
a nonprofit, open membership foundation dedicated to the pre vention and mitigation of disabling
stress through the provision of education, training, and support services for all emergency services
professions; continuing education and training in emergency mental health services for psy
chologists, psychiatrists, social workers, and licensed professional counselors; and consulta tion in
the establishment of crisis and disaster response programs for varied organizations and communities
worldwide. International Society for the Study of Trauma and Dissociation [Link] 8400
Westpark Drive Second Floor McLean, VA 22102 Phone: 703-610-9037 Fax: 703-610-0234 Email:
info@[Link] The Society is a nonprofit professional associ ation organized for the purposes of
infor mation sharing and international networking of clinicians and researchers; providing profes
sional and public education; promoting re search and theory about dissociation; and promoting
research and training in the identi fication, treatment, and prevention of dissocia tive disorders. The
Society offers courses in its Dissociative Disorders Psychotherapy Training Program. The
International Society for Traumatic Stress Studies [Link] 111 Deer Lake Road Suite 100
Deerfield, IL 60015 Phone: 847-480-9028 Fax: 847-480-9282 The International Society for Traumatic
Stress Studies (ISTSS) was founded in 1985 for pro fessionals to share information about the ef fects
of trauma. ISTSS is dedicated to the discovery and dissemination of knowledge about policy,
program, and service initiatives that seek to reduce traumatic stressors and their immediate and
long-term consequences. ISTSS provides a forum for the sharing of research, clinical strategies,
public policy con cerns, and theoretical formulations on trauma in the United States and around the
world. National Alliance on Mental Illness [Link] 3803 N. Fairfax Dr. Suite 100
Arlington, VA 22203 Phone: 703-524-7600 Fax: 703-524-9094 The National Alliance on Mental Illness
(NAMI) is a nonprofit advocacy group found ed in 1979 to raise awareness and provide es sential and
free education, advocacy, and support group programs for people living with mental illness and their
loved ones. NAMI operates at the local, State, and national levels, with each level of the
organizations providing education, information, support, and advocacy for those with mental illness
and their support system. NAMI has developed a Trauma Toolkit and includes a series of lectures for
mental health professionals about trauma. 252 Appendix B—Trauma Resource List National
Association of State Alcohol and Drug Abuse Directors, Inc. [Link] 1025
Connecticut Ave NW Suite 605 Washington, DC 20036 Phone: 202-293-0090 Fax: 202-293-1250
Email: dcoffice@[Link] The National Association of State Alcohol and Drug Abuse Directors,
Inc. (NASADAD) is a private, not-for-profit educational, scien tific, and informational organization.
NASADAD’s basic purpose is to foster and support the development of effective alcohol and drug
abuse prevention and treatment pro grams throughout every State. NASADAD offers a policy brief
with regards to trauma and substance use/abuse in the wake of natural or human-made disasters.
National Association of State Mental Health Program Directors [Link] 66 Canal
Center Plaza Suite 302 Alexandria, VA 22314 Phone: 703-739-9333 Fax: 703-548-9517 The National
Association of State Mental Health Program Directors (NASMHPD; pro nounced “NASH-pid”) is a
nonprofit organiza tion dedicated to serving the needs of the Nation’s public mental health system
through policy development, information dissemination, and technical assistance. NASMHPD repre
sents the $23 billion public mental health service delivery system. As a private, not-for profit 501(c)
(3) membership organization, NASMHPD helps set the agenda and deter mine the direction of State
mental health agency interests across the country, historically including State mental health
planning, service delivery, and [Link] principal pro grams operated, funded, and/or
regulated by NASMHPD members serve people who have serious mental illnesses, developmental
disabili ties, and/or substance use disorders. NASMPHD has launched a Technical Assistance
Coordinating Center in response to the Alternatives to Restraint and Seclusion State Infrastructure
Grant Project, an initiative of SAMHSA’s Center for Mental Health Services, designed to promote the
implementa tion and evaluation of best practice approaches to preventing and reducing the use of
seclusion and restraint in mental health settings. National Center for Injury Prevention and Control
[Link] 1600 Clifton Road Atlanta, GA 30333 Phone: 800-232-4636 Email:
cdcinfo@[Link] The National Center for Injury Prevention and Control (NCIPC) was established by
the Centers for Disease Control and Prevention in 1992. Through research, surveillance, imple
mentation of evidence-based strategies, ca pacity building, and communication activities, NCIPC
works to reduce morbidity, disability, mortality, and costs associated with injuries and violence.
NCIPC is the lead U.S. Federal agency for nonoccupational injury prevention. National Center for
PTSD [Link] 810 Vermont Avenue NW Washington, DC 20420 Phone: 802-296-
6300 Email: ncptsd@[Link] The National Center for PTSD (NCPTSD) was created within the
Department of 253 Trauma-Informed Care in Behavioral Health Services Veterans Affairs in 1989 in
response to a Congressional mandate to address the needs of veterans with military-related PTSD.
Its mission is to advance the clinical care and so cial welfare of America’s veterans through re search,
education, and training in the science, diagnosis, and treatment of PTSD and stress related disorders.
Its Web site is provided as an educational resource concerning PTSD and other enduring
consequences of traumatic stress. The NCPTSD Web site has infor mation about instruments to
measure trauma exposure, risk and resilience factors for PTSD, self-report instruments, and
interview sched ules. Training opportunities are listed at
[Link] [Link]. National Center for Telehealth and
Technology [Link] 9933C West Hayes Street Joint Base Lewis-McChord, WA
98431 Phone: 253-968-1914 Fax: 253-968-4192 Email: AskUs@[Link] The National Center for
Telehealth and Technology is a Federal agency founded by the Department of Defense as part of the
Military Health System. It primarily serves veterans and active-duty military personnel who are
experiencing adverse health effects due to TBI and PTSD, as well as military children who are coping
with their parents’ deployment, through the use of technology (e.g., mobile phone applications,
deployable telehealth centers). National Center for Trauma Informed Care
[Link] 66 Canal Center Plaza Suite 302 Alexandria, VA 22314 Phone: 866-
254-4819 Fax: 703-548-9517 Email: NCTIC@[Link] The National Center for Trauma-Informed
Care (NCTIC) is a Federal center established by SAMHSA in 2005 to offer consultation, technical
assistance, education, outreach, and resources to support trauma-informed care in publicly-funded
systems and programs. NCTIC primarily serves those who are al ready receiving services from the
behavioral health system and is focused on helping be havioral health services and programs to be
come more aware of the impact of trauma among consumers, to adapt services to incor porate
trauma-informed practices, and to help raise awareness of practices or processes that are more
likely to retraumatize consumers. National Center for Victims of Crime
[Link] 2000 M Street NW Suite 480 Washington, DC 20036 Phone: 202-467-
8700 Fax: 202-467-8701 Email: webmaster@[Link] The National Center for Victims of Crime
(NCVC) is a nonprofit organization funded partially by Federal grants from the Depart ment of
Justice. It was founded in 1985 and originally known as the Sunny Von Bulow National Victim
Advocacy Center. NCVC is a resource center for those affected by violent crimes and also provides
training and educa tion for behavioral health service providers. National Center on Domestic
Violence, Trauma & Mental Health [Link] Phone: 312-726-
7020 Fax: 312-726-7022 254 Appendix B—Trauma Resource List The National Center on Domestic
Violence, Trauma & Mental Health was established in 2005 through a grant from the Family Vio
lence Prevention and Services Program, HHS. The Center’s mission is to promote accessible,
culturally relevant, and trauma-informed re sponses to domestic violence and other life time trauma
so that survivors and their children can access the resources that are es sential to their safety and
well-being; this is achieved by providing training and online re sources to mental health and
substance abuse treatment providers and developing policies to improve system responses to
domestic violence survivors and their children. National Center on Elder Abuse
[Link] University of California–Irvine Program in Geriatric Medicine 101 The City
Drive South, 200 Building Orange, CA 92868 Phone: 855-500-3537 Email: ncea-info@[Link]
The National Center on Elder Abuse (NCEA), part of the U.S. Administration on Aging, serves as a
national resource center dedicated to the prevention of elder mistreat ment. NCEA provides
information to both mental health professionals and the general public and also provides technical
assistance and training to States and community-based organizations. National Center on Family
Homelessness [Link] 200 Reservoir Street Suite 200 Needham, MA
02494 Phone: 617-964-3834 Fax: 617-244-1758 Email: info@[Link] The National
Center on Family Homelessness (NCFH) was founded in 1988 and is a non profit organization that
conducts research and creates public awareness about the special needs of families experiencing
homelessness. NCFH primarily serves veterans who are homeless and their families and young moth
ers who are homeless with their children. NCFH has developed a Trauma-Informed Organizational
Toolkit for Homeless Services. National Coalition Against Domestic Violence [Link] 1
Broadway Suite B210 Denver, CO 80203 Phone: 303-839-1852 Fax: 303-831-9251 Email:
mainoffice@[Link] The National Coalition Against Domestic Violence (NCADV) is an advocacy
group founded in 1978 and acts as a national infor mation and referral center for the general pub lic,
media, survivors of domestic violence and their children, and allied and member agencies and
organizations. NCADV also works to influence legislation that would provide pro tection for survivors
of domestic violence and their families and provide funding to shelters, healthcare centers, and
other organizations. National Council for Behavioral Health [Link] 1701
K Street NW Suite 400 Washington, DC 20006 Phone: 202-684-7457 Email: communica
tions@[Link] The National Council for Behavioral Health is a national community
behavioral health 255 Trauma-Informed Care in Behavioral Health Services advocacy organization,
formed in 1970, to conduct Federal advocacy activities, represent ing the industry on Capitol Hill and
before Federal agencies. It also offers a national con sulting service program, various publications,
and an annual training conference. The Na tional Council Magazine, 2011, Issue 2, focus es on
trauma-informed behavioral health services. The National Council has offered a Learning Community
for Adoption of Trauma-Informed Practices, funded by SAMHSA. National Institute on Drug Abuse
[Link] National Institute on Drug Abuse National Institutes of Health 6001 Executive
Boulevard Room 5213, MSC 9561 Bethesda, MD 20892-9561 Phone: 301-443-1124 Email:
information@[Link] The National Institute on Drug Abuse’s (NIDA) mission is to lead the
Nation in bringing the power of science to bear on drug abuse and addiction. NIDA’s goal is to ensure
that science, not ideology or anecdote, forms the foundation for all of the Nation’s drug abuse
reduction efforts. NIDA was established in 1974, and in October 1992 it became part of the National
Institutes of Health (NIH), HHS. The Institute is organized into divisions and offices, each of which
plays an important role in programs of drug abuse research. NIDA has an ongoing research program
on women’s health and sex/gender differences, including the gathering of information on trauma
and substance abuse. National Institute of Mental Health [Link] National
Institute of Mental Health Science Writing, Press, and Dissemination Branch 6001 Executive
Boulevard Room 8184, MSC 9663 Bethesda, MD 20892-9663 Phone: 301-443-4513 Fax: 301-443-
4279 Email: nimhinfo@[Link] The National Institute of Mental Health (NIMH) is one of the 27
component insti tutes of NIH, the Federal Government’s prin cipal biomedical and behavioral
research agency that is part of HHS. NIMH’s mission is to reduce the burden of mental illness and
behavioral disorders through research on mind, brain, and behavior. This public health mandate
demands that NIMH use science to achieve better understanding, treatment, and eventually,
prevention of these disabling con ditions that affect millions of Americans. NIMH offers publications
and podcasts relat ed to traumatic events and PTSD. National Registry for Evidence Based Programs
and Practices [Link] Phone: 866-436-7377 Email: nrepp@[Link]
SAMHSA’s National Registry for Evidence Based Programs and Practices (NREPP) is a searchable
online registry of more than 300 interventions supporting mental health pro motion, substance
abuse prevention, and men tal health and substance abuse treatment. NREPP offers several
interventions that ad dress trauma and PTSD. National Sexual Violence Resource Center
[Link] 123 North Enola Drive Enola, PA 17025 Phone: 717-909-0710 Fax: 717-909-
0714 256 Appendix B—Trauma Resource List The National Sexual Violence Resource Cen ter (NSVRC)
was founded by the Pennsylva nia Coalition Against Rape in 2000 and is partially federally funded by
grants from the Centers for Disease Control and Prevention. NSVRC advocates for changes in Federal
and State legislation to further the goal of ending sexual violence in all communities, in addition to
collecting and disseminating a wide range of resources on sexual violence, including sta tistics,
research, position statements, statutes, training curricula, prevention initiatives and program
information. NSVRC does not pro vide direct services to survivors of sexual vio lence but acts as a
resource to support these services. National Trauma Consortium
[Link] 520 Ralph Street Sarasota, FL 34242 Phone: 941-312-
9795 The National Trauma Consortium (NTC) is a clearinghouse for information about trauma and
emerging best practices in trauma treat ment and services and, in addition, offers training and
consultation services. NTC also provides resources in the form of down loadable publications and
links to other organ izations related to mental health and trauma. National Voluntary Organizations
Active in Disasters [Link] 1501 Lee Highway Suite 170 Arlington, VA 22209-1109
Phone: 703-778-5088 Fax: 703-778-5091 Email: info@[Link] National Voluntary Organizations
Active in Disasters (NVOAD) coordinates planning efforts by many voluntary organizations re
sponding to disaster. Member organizations provide more effective service and less dupli cation by
getting together before disasters strike. Once disasters occur, NVOAD or an affiliated State VOAD
encourages members and other voluntary agencies to convene on site. This cooperative effort has
proven to be the most effective way for a wide variety of volunteers and organizations to work
together in a crisis. NVOAD’s principles are coopera tion, coordination, communication, education,
mitigation, convening mechanisms, and out reach. Office for Victims of Crime Training and Technical
Assistance Center [Link] 9300 Lee Highway Fairfax, VA 22031-6050 Phone: 866-
682-8822 TTY: 866-682-8880 Fax: 703-279-4673 Email: TTAC@[Link] The Office for Victims of
Crime Training and Technical Assistance Center provides com prehensive, quality technical
assistance and training resources to victims’ service providers and allied professionals. Its mission is
to sup port the development of the field by increasing the Nation’s capacity to provide crime victims
with skilled, capable, and sensitive assistance. Its core functions are needs assessment, ca pacity
building, evaluation, and reporting. Rape, Abuse & Incest National Network [Link]
1220 L Street NW Suite 505 Washington, DC 20005 Phone: 202-544-1034 Email: info@[Link] 257
Trauma-Informed Care in Behavioral Health Services The Rape, Abuse & Incest National Network
(RAINN) is a nonprofit organization, found ed in 1994, that is partially funded by a grant from the
Office for Victims of Crime, Office of Justice Programs, U.S. Department of Jus tice. RAINN provides
support for survivors of sexual assault via a telephone hotline and an online hotline and works with
the Department of Defense (DoD) to provide a hotline for members of the DoD community who
have experienced sexual assault. SAMHSA’s Tribal Training and Technical Assistance Center
[Link] 201 Corporate Drive Suite 800 Landover, MD 20785 Phone: 240-
650-0257 Email: TA-Request@[Link] SAMHSA’s Tribal Training and Technical Assistance
Center (Tribal TTAC) is commit ted to providing comprehensive broad, fo cused, and/or intensive
training and technical assistance to federally recognized Tribes and other American Indian and
Alaska Native communities seeking to address and prevent mental and substance use disorders and
suicide while promoting mental health. The goal of the Tribal TTAC is to use a culturally relevant,
evidence-based, holistic approach to support Native communities in their self determination efforts
through infrastructure development, capacity building, and program planning and implementation.
Sanctuary Model [Link] Phone: 888-538-3124 The goals of the Sanctuary
Model include increasing the perceived sense of communi ty/cohesiveness; the degree of social
immunity to the spread of violence; the capacity for so cial learning; the making of decisions demo
cratically and the sharing of responsibility in solving problems and resolving conflicts; the ability to
deal with complexity; opportunities for all clients and staff members to experience a truly safe and
connected community; oppor tunities for troubled clients to have corrective emotional, relational,
and environmental expe riences; and recovery, healing, and growth. Seeking Safety
[Link] Treatment Innovations 28 Westbourne Road Newton Centre, MA
02459 Phone: 617-299-1610 Fax: 617-701-1295 Email: info@[Link] This Web site
provides information about Seeking Safety, a psychotherapeutic interven tion for treating trauma,
PTSD, and substance abuse. Seeking Safety is a present-focused therapy to help people attain safety
from both PTSD and substance abuse. The treatment is also available as a book, which provides both
client handouts and guidance for clinicians. The site includes topics included in the treat ment
program, sample materials, relevant em pirical studies, and supplementary articles. Sidran Institute
[Link] P.O. Box 436 Brooklandville, MD 21022-0436 Phone: 410-825-8888 Fax: 410-
560-0134 Email: info@[Link] The Sidran Institute is a nationally focused nonprofit organization
devoted to helping people who have experienced traumatic life events through education and
advocacy. The Institute’s education and advocacy focuses on: 258 Appendix B—Trauma Resource
List • The early recognition and treatment of trauma-related stress in children. • The understanding
of trauma and its long term effect on adults. • The strategies in engaging in mutual-help recovery for
trauma survivors. • The clinical methods and practices leading in aiding trauma victims. • The
development of public policy initia tives responsive to the needs of adult and child survivors of
traumatic events. Substance Abuse and Mental Health Services Administration
[Link] 1 Choke Cherry Lane Rockville, MD 20857 Phone: 877-726-4727 Fax: 240-
221-4292 Email: SAMHSAInfo@[Link] SAMHSA is the Federal agency within HHS charged
with improving the quality and avail ability of prevention, treatment, and rehabili tative services to
reduce illness, death, disability, and cost to society resulting from substance abuse and mental
illness. The Emergency Mental Health and Traumatic Stress Services Branch, a branch of SAMHSA’s
Center for Mental Health Ser vices, works with FEMA to provide crisis counseling training and
technical assistance to State and local mental health professionals. SAMHSA offers several
publications regard ing trauma and PTSD, as well as a publica tion focusing on creating a seclusion-
free and restraint-free environment. Traumatic Stress Institute
[Link] Klingberg Family Centers 370 Linwood Street New Britain,
CT 06052 Phone: 860-224-9113 The Traumatic Stress Institute (TSI) works to increase understanding
of the psychological impact of trauma and to help victims of vio lence restore meaning and
wholeness to their lives. In meeting these goals, TSI is involved in clinical service, professional
training, commu nity education, and research. TSI offers foren sic assessment and expert testimony,
professional education, training opportunities, and publications. TSI developed the “Risking
Connections” trauma treatment program and provides training in the use of this model. Tulane
University Traumatology Institute [Link]
Home/traumatologyinstitute Tulane School of Social Work 6823 St. Charles Ave., Building 9 New
Orleans, LA 70118 Phone: 800-631-8234 Email: figley@[Link] The Traumatology Institute,
founded in 1996, brings together health and mental health pro fessionals from a wide array of
disciplines from throughout the United States and around the world to develop cutting-edge re
search, treatment approaches, and training programs in the field of traumatology. The Institute
facilitates the development of knowledge about the traumatization experi ence of victims, survivors,
and the profession als who serve them. The Traumatology Institute conducts research, education,
and service activities toward reducing the deleteri ous effects of trauma on individuals, families,
communities, and entire societies. Veterans Affairs PTSD Support Services
[Link] P.O. Box 5574 Woodland Park, CO 80866 Email:
russ@[Link] 259 Trauma-Informed Care in Behavioral Health Services The Department of
Veterans Affairs Medical Centers provide a network of more than 100 specialized programs for
veterans with PTSD, working closely in conjunction with the Veter ans Web Site
([Link] operated by VA’s Readjustment Counseling Service. Each specialized
PTSD program of fers veterans education, evaluation, and treat ment conducted by mental health
professionals from a variety of disciplines (such as psychiatry, psychology, social work, counseling,
and nursing). See also: National Center for PTSD. White Bison Wellbriety Training Institute
[Link] 701 N. 20th Street Colorado Springs, CO 80904 Phone: 877-871-1495
Email: info@[Link] White Bison is an American Indian nonprofit charitable organization that
focuses on offer ing sobriety, recovery, addictions prevention, and wellness/Wellbriety learning
resources to the Native American community nationwide. White Bison’s Wellbriety Training Institute
provides training, tools, and resources for his torical and intergenerational trauma to train ers and
mental health professionals. Resources for Children and Adolescents The following section provides
resources that address the needs of children and adolescents who are affected by traumatic stress.
American Academy of Child & Adolescent Psychiatry [Link] 3615 Wisconsin Avenue
NW Washington, DC 20016-3007 Phone: 202-966-7300 Fax: 202-966-2891 The American Academy of
Child & Adoles cent Psychiatry (AACAP) is a national profes sional medical association dedicated to
treating and improving the quality of life for children, adolescents, and families affected by mental,
behavioral, and developmental disor ders. AACAP distributes information to promote an
understanding of mental illnesses and remove the shame associated with them, to advance efforts in
prevention of mental illnesses, and to ensure proper treatment and access to services for children
and adolescents. American Professional Society on the Abuse of Children [Link] 350
Poplar Avenue Elmhurst, IL 60126 Phone: 630-941-1235 Fax: 630-359-4274 E-mail: apsac@[Link]
The mission of the American Professional Society on the Abuse of Children (APSAC) is to enhance the
ability of professionals to re spond to children and families affected by abuse and violence. Among
other initiatives, APSAC provides education and other sources of information to professionals who
work in the child maltreatment and related fields. Anna Institute [Link]
21 Ocean Street Rockland, ME 04841 Email: afj@[Link] The Anna Institute was founded in memory
of artist Anna Caroline Jennings; it focuses on educating both the public and mental health
professionals about the effects of sexual abuse and trauma on children. The Anna Institute’s Web
site provides articles on incorporating 260 Appendix B—Trauma Resource List trauma-informed care
into existing behavioral health models, presentations on childhood trauma and retraumatization,
and handouts for teachers at primary and secondary schools. Caring for Every Child’s Mental Health
Campaign [Link] P.O. Box 2345 Rockville, MD 20847-2345 Email: nmhic-
info@[Link] SAMHSA’s Caring for Every Child’s Mental Health communications campaign is
a national public information and education operation. Its goals are to increase public awareness
about the importance of protecting the mental health of young people; foster the recognition that
many children have mental health problems; and encourage caregivers to seek early, appropriate
treatment and services. It also strives to reduce discrimination associated with mental health
problems. The campaign is a technical assis tance program that is part of the Comprehen sive
Community Mental Health Services Program for Children and Their Families. Child Study Center
[Link] One Park Avenue 7th Floor New York, NY 10016 Phone: 212-263-6622
Email: webmaster@[Link] The New York University Child Study Center Web site offers
information to parents of chil dren and adolescents with learning, behavior al, and emotional
disorders, including PTSD and substance use disorders. An online news letter is available. Its research
initiatives ad vance understanding of the causes and treatments of child mental disorders, and these
findings are integrated into clinical care to provide state-of-the-art service. Child Trauma Academy
[Link] 5161 San Felipe Suite 320 Houston, TX 77056 Phone: 866-943-9779
Email: cta@[Link] The mission of the Child Trauma Academy is to help improve the lives of
traumatized and maltreated children. Through education, ser vice delivery, and program
consultation, the academy seeks to advance systems that edu cate, nurture, protect, and enrich
these chil dren. Child Trauma Institute [Link] P.O. Box 544 Greenfield, MA
01302-0544 Phone: 413-774-2340 Email: cti@[Link] The Child Trauma Institute provides
training, consultation, information, and resources for those who work with trauma-exposed chil
dren, adolescents, and adults. The Web site has information for parents, publications for par ents
and professionals, and links to other child trauma Web sites. Child Welfare Information Gateway
[Link] Children’s Bureau/ACYF 1250 Maryland Avenue SW Eighth Floor
Washington, DC 20024 Phone: 800-394-3366 Email: info@[Link] The Child Welfare
Information Gateway (CWIG) is a service of the Children’s Bureau in the Administration for Children
and Fami lies, part of HHS, which provides information 261 Trauma-Informed Care in Behavioral
Health Services to child welfare and mental health profession als about programs, research, laws and
policies, training approaches, and statistics regarding child welfare, child abuse and neglect, and
adoption. CWIG offers educators’ toolkits for preventing and responding to child abuse and neglect,
a function to search State statutes about child abuse and neglect, and logic model builder toolkits for
program administrators. Child Welfare League of America [Link] 1726 M Street NW
Suite 500 Washington DC, 20036 Phone: 202-688-4200 Fax: 202-833-1689 Through its member child
welfare agencies, the Child Welfare League of America devel ops and disseminates practice
standards as benchmarks for high-quality services that pro tect children and youth; promotes high-
quality services through training, consultation, confer ences, and publications; formulates and pro
motes public policies that contribute to the well-being of children and youth; ensures that all child
welfare services are provided in a manner that demonstrates respect for cultural and ethnic
diversity; and promotes open ex change of data, resources, and ideas within and across systems that
serve children, youth, and families. Eunice Kennedy Shriver National Institute of Child Health and
Human Development [Link] 31 Center Drive Building 31,
Room 2A32 Bethesda, MD 20892-2425 Phone: 800-370-2943 Established in 1962, NIH’s National
Institute of Child Health and Human Development (NICHD) focuses on human development
processes from conception to later years. The Institute implements, conducts, and supports
laboratory research, clinical trials, epidemio logical research, and other studies that explore health
processes and the impact of disabilities, diseases, and variations on the lives of individ uals. NICHD
sponsors training for scientists and healthcare providers to promote the goals of the Institute.
National Center for Children Exposed to Violence [Link] Yale Child Study Center 230
South Frontage Road P.O. Box 207900 New Haven, CT 06520-7900 Phone: 877-496-2238 Email:
[Link]@[Link] The National Center for Children Exposed to Violence (NCCEV) seeks to
increase the ca pacity of individuals and communities to re duce the incidence and impact of
violence on children and families; to train and support the professionals who provide intervention
and treatment; and to increase professional and public awareness of the effects of violence on
children, families, communities, and society. The Center’s Web site is a rich source of in formation.
NCCEV is supported by grants from the Office of Juvenile Justice and Delin quency Prevention, the
Department of Justice, SAMHSA, and the Department of Education. National Center on Substance
Abuse and Child Welfare [Link] P.O. Box 2345 Rockville, MD 20847-2345
Phone: 866-493-2758 Email: ncsacw@[Link] 262 Appendix B—Trauma Resource List The
National Center on Substance Abuse and Child Welfare (NCSACW) is an initiative of HHS and is jointly
funded by SAMHSA’s Center for Substance Abuse Treatment and the Administration on Children,
Youth and Families, Children’s Bureau’s Office on Child Abuse and Neglect. NCSACW seeks to de
velop and implement a comprehensive pro gram of information gathering and dissemination, to
provide technical assistance, and to develop knowledge that promotes ef fective practical,
organizational, and systemic changes at the local, State, and national levels. Its Web site includes
PowerPoint presenta tions, online tutorials and training, technical assistance presentations, and
additional print resources. National Child Traumatic Stress Network [Link] NCTSN
—University of California, Los Angeles 11150 W. Olympic Boulevard Suite 650 Los Angeles, CA 90064
Phone: 310-235-2633 Fax: 310-235-2612 The National Child Traumatic Stress Network (NCTSN),
currently comprising 54 treatment centers nationwide, is funded by SAMHSA’s Center for Mental
Health Services through the Donald J. Cohen National Child Traumatic Stress Initiative and
coordinated by Duke Uni versity and the University of California, Los Angeles. The purpose of this
congressionally mandated initiative is to improve the quality, effectiveness, provision, and
availability of therapeutic services delivered to all children and adolescents experiencing traumatic
events. NCTSN works with SAMHSA to raise pub lic awareness of the effects of traumatic stress on
children and families, and with other sys tems of care (including the health, mental health,
education, law enforcement, child wel fare, juvenile justice, and military family ser vice systems) to
ensure that there is a comprehensive trauma-informed continuum of accessible care. Additionally,
NCTSN offers a list of evidence-based and promising practices. National Institute for Trauma and
Loss in Children [Link] children 42855 Garfield Road Suite 111
Clinton Township, MI 48038 Phone: 877-306-5256 Fax: 586-263-4915 Email: TLC@[Link]
The National Institute for Trauma and Loss in Children provides school professionals, cri sis
intervention teams, medical and mental health professionals, child care professionals, and clinicians
with trauma education, training, consultation, referral services, and trauma specific intervention
programs and resource materials needed to help those traumatized by violent or nonviolent trauma-
inducing incidents. National Native Children’s Trauma Center
[Link] _Trauma_Center Institute for Educational Research
and Service McGill Hall 026 The University of Montana Missoula, MT 59812-6376 Phone: 406-243-
5344 Fax: 406-243-2197 Email: iers@[Link] The National Native Children’s Trauma Center
(NNCTC) is a federally funded organization created by SAMHSA and affiliated with the National Child
Traumatic Stress Network. It 263 Trauma-Informed Care in Behavioral Health Services is run by the
University of Montana. NNCTC offers trauma interventions and trainings to address trauma in
American Indian/Alaska Native children, primarily through clinicians, Tribal programs, school
systems, and commu nity agencies. Training Opportunities The following resources highlight various
training and credentialing opportunities for behavioral health professionals interested in gaining
more education in treating and providing services to those affected by trauma. It is not an
exhaustive list, but provides a start ing place for service providers looking for fur ther training. The
Web site of the ISTSS has posted a direc tory of trauma-related academic and training opportunities
([Link] [Link]). It includes links to the institutions providing the
[Link] Asso ciation for Traumatic Stress Specialists ([Link] offers three levels
of recognition for education and experience: • Certified Trauma Specialist (CTS)— designed for
counselors, clinicians, and treatment specialists who provide interven tion services or individual,
group, and/or family [Link] certification re quires 240 hours of education and training in
trauma treatment, plus 2,000 hours of trauma counseling and intervention experience. • Certified
Trauma Responder (CTR)— designed for those who provide immediate trauma interventions. It
requires a mini mum of 40 hours of experience on a crisis or critical incident response team, an asso
ciate degree or a high school diploma with successful completion of disaster or critical incident stress
debriefing training, and 72 hours of crisis response training. • Certified Trauma Services Specialist
(CTSS)—designed for those who provide immediate trauma intervention, crisis sup port, advocacy,
or victim assistance. It re quires 1 year of experience in a trauma related field, plus specific training.
Some colleges and universities, such as the International Trauma Studies Program at New York
University and the Center for Anxiety and Related Disorders at Boston University, provide specialty
trauma training for mental health practitioners. The University of Mis souri at St. Louis offers
specialized training in trauma therapy or research at its Center for Trauma Recovery to students in
its Clinical Psychology graduate program. The Center for the Treatment and Study of Anxiety at the
University of Pennsylvania provides training for health [Link] Department of Counseling
at the University of Nevada, Las Vegas offers a graduate and undergraduate course on Trauma and
Addiction; graduate students can receive training in trauma and addictions as part of the Advanced
Graduate Certificate in Addiction Studies. The Medical University of South Carolina offers Web based
courses in trauma-focused cognitive behavioral therapy (TF-CBT) and in using TF-CBT for childhood
traumatic grief. Many universities have faculty members with exper tise in trauma and trauma-
related subjects, so that training can be accessed through many graduate programs. The Addiction
Technology Transfer Center (ATTC) Network, a resource established in 1993 by the SAMHSA’s Center
for Substance Abuse Treatment, is a network of 14 inde pendent regional centers with a national
office. One of its programs provides long-distance education for clinicians on various topics. Among
hundreds of self-paced, self-directed, and supervised courses available online
([Link] 264 Appendix B—Trauma Resource List [Link])
are Substance Abuse Treatment for Trauma Survivors, Substance Abuse Treat ment for Persons with
Child Abuse and Ne glect Issues, Chemical Dependency and Posttraumatic Stress Disorder, Clinical
Self Care for Addiction Counselors and Clinical Supervisors, Eye Movement Desensitization and
Reprocessing, Battered Women and Ad dictions, and Posttraumatic Stress Disorder. ATTC training
and educational opportunities are based on empirical research and are in tended to bring science to
service. Undoubted ly, more distance-learning courses in this specialized area of interest will be
developed as professional attention to co-occurring disor ders increases. SAMHSA’s Center for
Mental Health Ser vices provides training for FEMA-approved crisis counseling programs using
Stafford Act funding. These funding resources are available to select agencies designated to provide
crisis counseling in the wake of a Presidential Disas ter Declaration. Other funding for trauma
training may be found through special pro grams of funding for target groups, such as those who
provide mental health services and case management for victims of crime (e.g., Office for Victims of
Crime in the U.S. De partment of Justice; see p. 257). The American Red Cross provides limited
disaster mental health training. The focus of this training is to orient licensed mental health
professionals to the Red Cross Disaster ser vices system and their roles as volunteers. The National
Center for Post-Traumatic Stress Disorder was originally created in 1989 within the U.S. Department
of Veterans Af fairs (VA) to address the needs of veterans with military-connected PTSD. Its focus has
since broadened to include trauma in general. The Center provides a variety of training op
portunities for both VA and non-VA mental health personnel, including a PTSD 101 course developed
specifically for clinicians who provide services to clients who have expe rienced trauma (see
[Link] professional/[Link]). Seeking Safety offers training in trauma, PTSD, and
co-occurring disorders to mental health professionals on all levels, from counse lors to nurses to
administrators. The EMDR International Association (EMDRIA) pro vides training to clinicians for
certification in EMDR via a curriculum including instruction, supervised practicum, and consultation;
EMDRIA additionally provides basic training in the field, separate from the certification process.
EMDR training is also provided by the EMDR Humanitarian Assistance Pro gram, a nonprofit
organization with a training-focused model to assist clinicians in treating trauma. ISTSS was founded
in 1985 to bring attention to the study, assessment, and treatment of traumatized people
([Link] ISTSS is a professional society and provides face-to-face training during its
annual meet ing, especially through the preconference insti tutes. The ISTSS Web site offers
numerous video and audio trainings for continuing edu cation credits. ISTSS and the Figley Institute
([Link] have estab lished best practice standards. The American Academy
of Experts in Traumatic Stress pro vides training and certification in several dif ferent areas
([Link] Similarly, the International Society for the Study of Dis sociation
([Link] specializes in promoting therapies for dissociative disorders. In 2002, the
Green Cross Academy of Trau matology ([Link] estab lished a Commission on
Accreditation of Traumatology Education Programs to increase and maintain the high standards in
the educa tion and training of traumatologists. 265 Appendix C—Historical Account of Trauma
Historically, symptoms of traumatic stress have been recorded in both military and civil ian
populations (Lasiuk & Hegadoren, 2006). Early accounts described the effect of battle conditions on
soldiers; “soldier’s heart” and “nostalgia” were the terms for traumatic stress reactions used during
the American Civil War. As warfare techniques and strategies changed, so did the depiction of
soldiers’ traumatic stress reactions. The advent of heavy explosives in World War I led to the attribu
tion of symptoms to “shell shock,” giving a more physiological description of the effects from
explosions (Benedek & Ursano, 2009). On the civilian side, the industrial revolution gave rise to
larger and more dramatic catastro phes, including industrial and railway acci dents. These, as well as
other disasters, are noted in occupational health histories, news papers, and contemporary
literature. Even with a more physical explanation of traumatic stress (i.e., shell shock), a prevailing
attitude remained that the traumatic stress response was due to a character flaw. For in stance, a
soldier’s pain at that time was often seen as a symptom of homesickness. In spite of the efforts of
Charcot, Janet, and Freud, who described the psychogenic origin of symptoms as a response to
psychological trauma (Lasiuk & Hegadoren, 2006), World War II military recruits were screened in at
tempt to identify those “who were afflicted with moral weakness,” which would prevent them from
entering military service. At the same time, there were new treatment innovations for war-related
trauma during World War II. One approach treated soldiers in the field for what was then called
“battle fatigue” by allowing some time for rest before returning to battle. During the Korean and
Vietnam wars, approaches began to focus more on the use of talk therapy. It was not until the post-
Vietnam era that interest in de veloping treatment alternatives started to take hold. During this
time, the U.S. Department of Veterans Affairs (then called the Veterans Administration) developed
group therapy for posttraumatic stress disorder (PTSD). Beyond being cost-effective, the technique
was well suited to the symptoms of the veterans and fostered socialization and reintegration
(Greene et al., 2004). The publication of the American Psychiatric Association’s (APA’s) Diagnostic
and Statistical Manual of Mental Disorders, Third Edition (DSM-III), in 1980 marked the introduction
of PTSD as a diagnosis, inspired by symptoms presented by veterans of the Vietnam War (Benedek &
Ursano, 2009). The diagnosis in this iteration required the identification of a specific stressor—a
catastrophic stressor that was outside the range of usual human experi ence (APA, 1980)—and
classified PTSD as 267 Trauma-Informed Care in Behavioral Health Services Historical Approaches to
Trauma Healing and Recovery First Generation of Approaches to Trauma Healing and Recovery The
first generation approaches to trauma healing and recovery focused on individual and clinical
interventions to address the symptoms of PTSD and moved toward integration of trauma effects into
ongoing life activities. The rapidly developing recognition of additional groups with violence and
trauma histories—beyond those with war and captivity experiences (e.g., survivors of natural
disasters and terrorism, refugees and immigrants fleeing homeland violence and persecution)—
presented issues and needs that incited a second generation of approaches to trauma healing and
recovery. Second Generation of Approaches to Trauma Healing and Recovery The second generation
approaches focused on psychosocial education and empowerment models designed to tap into self-
healing forces to energize personal and social movement. These approaches often are based on
group and peer support models, and provide both support and education on the management of
trauma and its affects. These approaches are not designed to replace clinical or alternative
therapies; rather, they provide a social context for care. Concurrent to the development of
psychosocial educational empowerment approaches, we also learned that if the approaches are not
implemented in organizations or programs that are trauma informed, they will not take root and
may lose effectiveness. Trauma-Informed Care: A New Paradigm for Public Health Services Trauma-
informed care is a new paradigm for organizing public mental health and human services. Trauma-
informed care changes the opening question for those seeking services from “What is wrong with
you?” (patient or consumer) to “What has happened to you?” (survivor). Trauma informed care is
initiated by assumption that every person seeking services is a trauma survivor who designs his or
her own path to healing, facilitated by support and mentoring from the service provider. In a
trauma-informed environment, survivors are empowered to proactively set goals and to manage
progress toward those goals. For most existing organizations or programs, that requires movement
from a traditional “top down” hierarchical clinical model to a psychosocial empowerment partner
ship that embraces all possible tools and paths to healing. In a pluralistic public health system with
many levels and types of services and treatment, this is coming to be accepted as a “sine qua non,”
or “without which not,” for humane, dignified, cost-effective, genuinely person-centered support
and assistance in moving forward. Source: Salasin, 2011, p. 18. an anxiety disorder (Lasiuk &
Hegadoren, 2006). Beginning with this definition, the body of research grew, and the scope of appli
cation began to broaden, but not without con siderable debate on what constituted a trauma. The
social revolution that began in the 1960s, combined with the women’s movement and the call for
more attention to diverse and dis enfranchised groups, set the stage for an in crease in the
acknowledgement and treatment of victims of interpersonal violence and crime 268 related trauma
(Figley, 2002). The introduc tion of rape trauma syndrome as a condition highlighted the
psychological consequences of sexual assault and the subsequent lack of sup port from society and
the social services sys tem (Kramer & Green, 1997). Subsequently, research began to focus more on
interpersonal violence, thus leading to the identification of risk factors and treatment approaches
unique to this form of violence and trauma (Olff, Langeland, Drajer, & Gersons, 2007). Appendix C—
Historical Account of Trauma With input from international and national mental health organizations
and research, the DSM-IV further modified the definition of trauma to include a broader
interpretation of the identified stressor (Andreasen, 2010). DSM-5 has maintained the modified
defini tion of trauma, but the criterion requires being explicit as to whether qualifying traumatic
events were experienced directly, witnessed, or experienced indirectly (APA, 2013b). Paralleling the
change in DSM criteria, cognitive–behavioral therapy for traumatic stress was developed along with
other skills based approaches (Greene et al., 2004). Researchers, such as Foa, Resick, D’Zurilla, and
Michenbaum, added to the body of knowledge and gave clinicians a variety of tools; these
approaches continue to develop and show efficacy even today. There was also renewed interest in
the long- and short-term effects of childhood sexual abuse and domestic violence. Interest in
documenting the effects of trauma expanded further, including trau matic brain injury, significant
orthopedic inju ries, and multiple traumas (Starr et al., 2004). So too, the consumer movement in
health care began. Consumers insisted on patient rights, humane treatment, and involvement in the
treatment process; as a result, the paternalistic approach to health care began to change. As
consumers set the initial stage and Federal agencies (e.g., the Substance Abuse and Men tal Health
Services Administration and its centers) and national organizations promoted the need for trauma-
informed policies and care, national studies began to demonstrate the prevalence of traumatic
experiences. Re search including the Adverse Childhood Experiences and the Women, Co-Occurring,
and Violence studies clearly demonstrated the pervasive long-term impact of trauma, rein forcing
the call for trauma-informed policies and care. (For more information on the devel opment of
trauma-informed care, see Harris and Fallot, 2001b, as well as Jennings, 2004.) 269 Appendix D—
Screening and Assessment Instruments This appendix provides a selected sample of available tools
for screening and assessment of trau matic events and trauma-related symptoms. This is not an
exhaustive list, nor does this list focus on screening instruments that capture a broader range of
symptoms related to trauma (such as sleep hygiene and dissociation) or other features important in
providing trauma-informed care (e.g., resilience level, coping skill style, resource availability). For
more information on a broad range of available instruments, refer back to Part 1, Chapter 4. Many of
the instruments listed below use criteria found in the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision (DSM-IV-TR; APA, 2000), but with the release of the DSM-5
(APA, 2013a), instruments will evolve, and new versions will be available under the same contact
infor mation. Screening and Assessment Measures • Clinician Administered PTSD Scale (CAPS) •
Davidson Trauma Scale (DTS) • Distressing Event Questionnaire (DEQ) • Evaluation of Lifetime
Stressors (ELS) • Impacts of Event Scale Revised (IES-R) • Mississippi Scale for Combat-Related PTSD
(M-PTSD) • Penn Inventory for Posttraumatic Stress Disorder • Posttraumatic Diagnostic Scale (PDS)
• PTSD Symptom Scale-Interview (PSS-I) • PTSD Symptom Scale: Self-Report Version (MPSS-SR)