Through a Trauma Lens

Transforming Health and Behavioral Health Systems

Vivian Barnett Brown

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781317233992
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Through a Trauma Lens aims to understand and highlight successful examples of health, mental health, substance abuse treatment, and other service delivery systems that have implemented an integrated trauma-informed service model. This innovative volume draws on the author's first-hand experience working alongside a number of local and state organizations as well as a nationwide survey of notable trauma-informed models. Structured around illustrative case studies, chapters that correspond to stage of adoption, and strategies for cultivating staff support, this valuable new resource include examples and strategies to be applied in any treatment or service setting.

Part I

Introduction

I would like you to meet Mary, a 25-year-old African American woman from South Central Los Angeles. She has used heroin in the past, but most recently has been using crack cocaine numerous times each day. She is homeless and has one child, a 2-year-old boy. She was living with her son’s father, who introduced her to drug use and beat her throughout the time they were together. In order to feed herself and her son and be able to maintain her drug use, she now participates in sex work.

Outreach workers found Mary in a park, bleeding from wounds inflicted by her former partner and trying to comfort her frightened son. The outreach workers fed her and her son and spoke to Mary about getting help. She was interested in getting off the streets and protecting herself and her child, but she was not sure about any drug treatment program, especially if it meant having her son taken away. The outreach workers called the residential treatment program (the Women’s Center) run by their agency and scheduled an appointment for Mary that afternoon. After driving her to the emergency room to ensure that her wounds were taken care of immediately, the outreach workers took her and her son to her intake appointment.

Because the outreach workers had some basic information about Mary and knew she needed some assistance immediately, she did not have to go through a phone screening or any waiting period before she could be seen at the treatment program. At the Women’s Center, the psychiatric social worker doing the intake screening detected signs of a thought disorder in Mary. After exploring Mary’s history, the social worker found that she had been hospitalized for mental illness on a number of occasions since her adolescence. She also had received psychiatric medications, which she always failed to continue taking after returning home from the hospital because of the side effects.

Because the Women’s Center is designed as a comprehensive, trauma-informed treatment program for women with substance use disorders, mental illness, trauma (including domestic violence), and health problems (including HIV/AIDS), Mary was not only welcomed, but ensured that all her needs would be addressed. The medical staff met with her and her son to get a full medical history and do a basic examination, and the consulting psychiatrist spoke with her about taking medications.

When Mary realized that she and her son could both be in the residential treatment program, she relaxed and said that now she felt her son would be safe. When asked by the nurse practitioner if she was ready to move in that day, Mary said, “Yes.” A “mentor mom” (a senior resident) then greeted her and her son, took them to her room, and then took them on a tour of the facility. Mary and her son were then given a meal and introduced to the Children’s Center Coordinator. Mary’s son was just in time for afternoon nap, so he stayed in the Children’s Center.

Next, Mary was introduced by the mentor mom to the leader of the Orientation Group, a group for all newcomers to the program. In the group, Mary learned about all the components of the treatment program and the procedures and schedules (including phases of the program). She had time to share what she wants to receive from the program and express what she fears about being in treatment.

The next day, when Mary was participating in a more comprehensive assessment with the social worker, she was asked about the domestic violence she had experienced and then about any other experiences in her life that might have been traumatic. Mary revealed that she had been sexually abused as a child by a family friend who lived in the projects.

After meeting her primary counselor, an initial treatment plan was constructed with Mary’s input. It included an ongoing psychiatric consultation, a trauma-specific intervention group, a substance use educational group, and a Mommy and Me group. For her son, there would be the Children’s Center and the Early Head Start program. The counselor went over the plan with Mary and asked her if it seemed to cover what she might want in the program. Mary was also told that, over the period of time of her stay in treatment, she would have a number of opportunities to see her schedule changed.

Now, let me introduce you to Joe, a 24-year-old war veteran, who served in Afghanistan. Joe came to the outpatient treatment program for assistance with his alcohol and methamphetamine problems. During his intake appointment, it became clear that he was also struggling with flashbacks, hypervigilance, and anger toward his wife. When asked why he did not go to the VA program, he responded that the waiting list was too long and that he didn’t trust the VA to really help him. When he was asked if he had ever been seen by the VA or a military health care provider, he said that he was seen once and was told about some therapy for his symptoms, but that he “didn’t like the sounds of it” (it was exposure therapy¹ for trauma) and didn’t return for care.

When the medical staff in the outpatient program, including the consulting psychiatrist, met with Joe, they recommended to him that his medical records be obtained in order to: (1) understand his whole medical history; (2) see if he had been evaluated for traumatic brain injury (TBI); and (3) find out if he had been prescribed any medications. Joe was then introduced to the staff of the outpatient program, who explained all the program components, including family treatment (if he wanted it), vocational training, etc. He and his primary counselor went over his initial treatment plan.

Mary and Joe are like patients/clients that our health care, mental health, and substance abuse treatment systems encounter every day. As you read their stories, you might well have thought about how they would have been treated in your system and how difficult it can be to take care of patients and clients with a history of trauma. You may have noticed that they have overlapping and complex problems that preclude simple solutions from traditional systems of mental health, substance abuse, and medical treatment. Their problems can be overwhelming, not only for them, but for their providers. They need more services—and better-integrated services—to help them enter care and follow recommendations. Their priorities for themselves may differ from the ones we have for them. And, perhaps hardest of all, they don’t trust us because they have been harmed and are fearful.

I ask you, as you begin reading this book, to think of it as undertaking a “journey through the trauma lens.” I ask you to come with me on a walk through the health care system, the mental health system, and the substance abuse treatment system. I ask you to look through a trauma lens as we take that walk together and to keep Mary and Joe in mind. If you look at the individuals who cross our thresholds, trauma is everywhere. It pervades their histories and their lives. However, most of our systems have not come to terms with this, and the result is high numbers of dropouts from treatment, poorer outcomes, and higher costs. At the same time, the reactions and challenges of trauma-affected patients frustrate and exhaust their providers, who want to help them and who sometimes cannot see the reasons why their most sincere and dedicated efforts to do that are not enough to keep patients coming back or to do what they need to do to get better. This book is about the “exceptions”: organizations that have transformed their programs, services, staff, and approaches to care to become trauma-informed.

The first part of the book (Chapters 1 to 5) introduces a trauma perspective, i.e., that trauma is ubiquitous and that it takes a toll and adds burdens to both patients and providers. It discusses why trauma needs to be addressed by each of our systems and introduces some of the adaptations that can help systems of care provide effective, equitable, and cost-effective services to the large numbers of patients and clients who have been affected by trauma.

Part II of the book (Chapters 6 to 8) describes, in depth, exemplary trauma-informed programs and allows us to hear the perspectives of their directors in their own words. Those who designed and implemented them discuss the core components of these programs, as well as the barriers and facilitators they experienced in adopting trauma-informed practice.

In the third part of the book (Chapters 9 to 10), I discuss the core components and specific recommended practice changes for each system (health care, mental health, substance abuse treatment) in order for them to become trauma-informed. Finally, I describe how the programs interviewed have demonstrated their successes through research.

Part IV (Chapter 11) describes steps already taken by other systems—including child welfare, education, criminal justice, and the military—to become trauma- informed.

I believe that, as the role of traumatic life experiences in our patients’ developing and overcoming health and behavioral problems/conditions becomes increasingly clear, trauma-informed practice will become “standard practice.” I also believe that this will lead to enhanced patient-provider relationships, improved outcomes, better provider morale, and lower costs. I hope this book adds to the important changes happening in our health and behavioral health systems. Improvement depends on our collective wisdom. It is not easy to give up the culture in which we were trained, but, if we decide to make it happen and learn from each other about how to make it happen, it will happen.

Note

1Exposure therapy for PTSD involves having the client describe and explore trauma-related memories and emotions; intense emotions are evoked, with the intention of desensitizing the client through repeated exposure. However, some patients may show an exacerbation of symptoms.

Chapter 1

Trauma as a Core Component of Care

Dramatic changes are taking place in our health care and behavioral health care systems. Attention to issues related to comorbidity, health care reform, and fragmentation of care have led to greater awareness of the urgent need for integrated care. Defined simply, integrated care is the working together of medical and behavioral health providers so that both providers and patients experience one seamless treatment plan, with several steps for the array of problems the patient brings, implemented by one treatment team (Blount 1998). Integrated care models are the best laboratories for the development and refinement of services for complex problems.

In Western medicine, we have perpetuated the dichotomy of mind and body in our biomedical model, in our organization of services (separate health, mental health, and substance use disorders systems), and in our practice. This has led to both fragmentation and duplication of effort. We need to do better with and for patients who have co-occurring mental and physical problems, particularly patients who have experienced trauma.¹ As will be discussed below and in later chapters, there is now increasing recognition that traumatic experiences are pervasive in the lives of our patients and clients. Because of this, trauma-sensitive and trauma-informed care must be a core component of integrated systems; it is an important link that has been missing in much of our work. As providers, agencies, and entire systems look at the best strategies for providing collaborative, patient-centered care, implementing trauma-informed practice is another important step toward transformation. In fact, I believe that we cannot and will not truly attain the aims of enhancing our patients’ experience of care, improving the health of our diverse population, and reducing costs of care unless we adopt a trauma-informed approach. Trauma should be seen as the expectation, not the exception.

In fact, research during the past two decades has demonstrated that a large percentage of children and adults in our human service systems have experienced trauma at some point(s) in their lives. As defined by the Substance Abuse and Mental Health Services Administration, trauma is: “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being” (SAMHSA 2014, p. 9). Estimates of lifetime exposure to traumatic events in the general population in the U.S. ranges from 60 to 70 percent (Kessler et al. 1995). Overall, 20 to 30 percent of those exposed to trauma will develop posttraumatic stress disorder (PTSD). The more one is exposed to trauma, in terms of severity and duration, the higher the likelihood of a PTSD diagnosis (e.g., veterans’ exposure to heavy levels of combat and trauma). However, millions of individuals who are experiencing PTSD and other sequelae of trauma go unrecognized and untreated.

The traumatic event may be re-experienced in one or more of the following ways: recurrent and intrusive recollections of the event or the feeling as if the event was recurring; avoidance of stimuli associated with the trauma and detachment from others; dissociative symptoms; symptoms of increased arousal (e.g., bursts of anger); physical symptoms (e.g., pain). Comorbid disorders such as depression may be the survivor’s primary reason for coming into treatment, while the history of trauma is easily overlooked. Because of shame, memory difficulties, fear of ongoing danger (domestic violence), and mistrust of the provider, the patient may not disclose any issue related to his/her trauma experiences.

As will be discussed in more detail in later chapters, studies have shown that violence and trauma can cause neurological damage, lead to adoption of risky behaviors, and result in a wide variety of health and behavioral health problems. This increases the demands on all health care and human services and costs the U.S. billions of dollars annually. The growing science base regarding trauma and PTSD is important as providers, legislators, and policymakers increasingly push for higher quality, increased accountability, and better outcomes. As our understanding has grown about the scope of and possible causal pathways for trauma-related syndromes, new trauma-specific services/interventions and trauma-informed approaches and practices have been developed and tested. Trauma-informed systems and services take into account knowledge about trauma—its prevalence, impacts, and interpersonal dynamics—and incorporate this knowledge thoroughly in all aspects of service delivery.

Trauma, Comorbidity, and Health Reform

As national health reform is implemented, the health care system is stepping up its efforts to improve quality and reduce costs. Since a small percentage of the population account for most of the health care spending (Stanton 2005), achieving these goals may require focusing on the subgroups most at risk of high costs and poor quality of care. Priority populations include children, aging adults, chronically ill patients, and those with comorbidity. In an important monograph funded by the Robert Wood Johnson Foundation entitled The Synthesis Project: Mental Disorders and Medical Comorbidity, comorbidity is defined as “the co-occurrence of mental and physical disorders in the same person, regardless of the chronological order in which they occurred or the causal pathway linking them” (Goodell, Druss, and Walker 2011, p. 2). At the present time, an increasing proportion of health care resources are directed toward an expanding group of patients with complex conditions and comorbidities.

In fact, most primary care visits by adults involve more than one health problem or disease. Based upon epidemiological data from the 2001–2003 National Comorbidity Survey Replication (NCS-R) (Algeria et al. 2003), 34 million American adults (17% of the adult population) had comorbid mental health and medical conditions within a 12-month period. In addition, more than 68 percent of adults with a diagnosed mental health disorder reported having at least one medical disorder, and 29 percent of those adults with a medical disorder had a comorbid mental health disorder (Kessler et al. 2004).

When primary care has traditionally sought to coordinate care for patients with multiple morbidities, incentives have been used mainly to improve outcomes in specific diseases, rather than to manage comorbidity. The effects of comorbidity are excluded from most medical practice guidelines. For example, a physician following clinical guidelines could prescribe up to 12 medications for a patient with osteoporosis, diabetes, hypertension, and COPD. It should be noted that this same patient could be taking medications for behavior health issues, such as depression, anxiety, and/or severe mental illness.

At the systems level, fragmentation and separation (silos) among medical, mental health, and substance abuse systems result in patients with co-occurring conditions receiving care from multiple uncoordinated practices (Druss and Esenwein 2006). Fragmentation and separation is often made worse by the prese...