by ATI PROTOCOL · Cited by 2 — Your feedback will help SAMHSA develop future products. “modest” thresholds through a series of carefully controlled single-case studies. An evidence-.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment1 Choke Cherry Road Rockville, MD 20857A TREATMENT IMPROVEMENT PROTOCOL Trauma-Informed Care in Behavioral Health Services TIP 57

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Trauma -Informed Care in Behavioral Health Services Acknowledgments This publication was produced under contract number s 270 -99- 7072, 270 -04- 7049, and 09-0307 by the Knowledge Application Program (KAP), a Joint Venture of The CDM Group, Inc., and JBS International, Inc., for the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. De partment of Health and Human Services (HHS). Andrea Kopstein, Ph.D., M.P.H., Karl D. White, Ed.D., and Christina Currier served as the Contracting Officer™s Representative s. Disclaimer The views, opinions , and content expressed herein are the views of the consensus panel members and do not necessarily reflect the official position of SAMHSA or HHS. No official support of or endorsement by SAMHSA or HHS for these opinions or for the instruments or resources described ar e intended or should be inferred. The guidelines presented should not be considered substitutes for individualized client care and treatment decisions. Public Domain Notice All materials appearing in this volume except those taken directly from copyrighte d sources are in the public domain and may be reproduced or copied without permission from SAMHSA or the authors. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, HHS. Electronic Access and Copies of Publication This publication may be ordered or downloaded from SAMHSA™s Publications Ordering Web page at Or, please call SAMHSA at 1 -877-S AMHSA -7 (1-877- 4727) (English and Español). Recommended Citation Substance Abuse and Mental Health Services Administration. Trauma -Informed Care in Behavioral Health Services . Treatment Improvement Protocol (TIP) Series 57 . HHS Publication No. (SMA) 13-4801 . Rockville, MD: Substance Abuse and Mental Health Services Administration, 201 4. Originating Office Quality Improvement and Workforce Development Branch, Division of Services Improvement, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857. HHS Publication No. (SMA) 1-48First Printed 2014 ii

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.. . 61˛ Sequen ce of Traum a Reactions 60˛ Commo n Experiences and Responses to Trauma Subthreshold Trauma -Related Symptoms 75˛ Specific Trauma -Related Psychological Disorders . 77˛ Other Trauma -Relat ed and Co -Occurring Disorders . 85˛ Contents˜ Consensus Panel . vii˜ KAP Expert Panel and Federal Government Participants ix˜ What Is a TIP? ..xi˜ Foreword .. xiii˜ How This TIP Is Organized .. xv˜ Terminology ..xvi˛ PART 1 : A PRACTICAL GUIDE FOR THE PROVISION OF BEHAVIORAL˜ HEALTH SERVICES .. 1˜ Chapter 1 ŠTrauma -Informed Care : A Sociocultural Perspective 3˜ Scope of the TIP 4˛Intended Audience 4˛ Before You Begin .. 4˛Structure of the TIP . 6˛ What Is Trauma? 7˛ Trauma Matters in Behavioral Health Services . 7˛ Trauma -Informed Intervention and Treatment Principle s 11˛As You Proceed 32˛ Chapter 2ŠTrauma Awareness .33˜ Types of Trauma .. 33˛Characteristics of Trauma .. 46˛ Individual and Sociocultural Features .. 52˛ Chapter 3ŠUnderstanding the Impact of Trauma .59˜ iii

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Strategy #8: Develop Policies and Procedures To Ensure Trauma -Informed Pra ctices and ˛ To Prevent Retraumatization 166˛ Concluding No te .. 110˛ Trauma -Informed Care in Behavioral Health Services Chapter 4 ŠScreening and Assessment ..91˜ .. 99˛Screening and Assessment . 92˛Barriers and Challenges to Trauma -Informed Screening and Assessment Cross -Cultural Screening and Assessment . 103˛Choosing Instruments 104˛Trauma -Informed Screening and Assessment .. 106˛Chapter 5 ŠClinical Issu es Across Services 111˜ Trauma -Informed Prevention and Treatment Objectives .. 111˛Treatment Issues .. 127˛ Making Referrals to Trauma -Specific Services . 135˛ Chapter 6 ŠTrauma -Specific Services .137˜ Introduction 137˛ Trauma -Specific Treatment Models .. 139˛Integrated Models for Trauma .. 147˛Emerging Interventions 153˛Concluding Note .. 155˛ PART 2 : AN IMPLEMENTATION GUIDE FOR BEHAVIORAL HEALTH˜ PROGRAM ADMINISTRATORS 157˜ Chapter 1 ŠTrauma -Informed Organizations .159˜ Strategy #1: Show Organizational and Administrative Commitment to TIC . 161˛Strategy #2: Use Trauma -Informed Principles in Strategic Planning .. 162˛Strategy #3: Review and Update Vision, Mission, andValue Statements ..162˛Strategy #4: Assign a Key Staff Member To Facilitate Change .. 163˛Strategy #5: Create a Trauma -Informed Oversight Committee . 163˛Strategy #6: Conduct an Organizational Self -Assessment of Trauma -Informed Services 164˛Strategy #7: Develop an Implementation Plan . 164˛Strategy #9: Dev elop a Disaster Plan . 166˛Strategy #10: Incorporate Universal Routine Screenings 167˛Strategy #11: Apply Culturally Responsive Principles . 167˛Strategy #12: Use Science -Based Knowledge 169˛Strategy #13: Create a Peer -Support Environment 169˛Strategy #14: Obtain Ongoing Feedback and Evaluations 170˛Strategy #15: Change the Environment To Increase Safety .. 171˛Strategy #16: Develop Trauma -Informed Collaborations .. 171˛ Chapter 2 ŠBuilding a Trauma -Informed Workforce 173˜ Introduction 173˛ Workforce Recruitment, Hiring, and Retention ..174˛ iv

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Trauma -Informed Care in Behavioral Health Services Exhibit 2.1 -1: T IC Planning Guidelines . 165˛Exhibit 2.2 -1: Clinical Practice Issues Relevant to Counselor Training in Trauma -˛Informed Treatment Settings 179˛Exhibit 2.2 -2: Guidelines for Training in Mental Health Interventions for Trauma 183˛ Exposed Populations . 180˛Exhibit 2.2 -3: Trauma -Informed Counselor Competencies Checklist Exhibit 2.2 -4: Sample Statement of the Client™s Right to Confidentiality From a˛ Client Bill of Rights .. 185˛Exhibit 2.2 -5: Green Cross Academy of Traumatology Ethical Guidelines for the ˛ Treatment of Clients Who Have Been Traumatized .. 186˛ Exhibit 2.2 -6: Boundaries in Therapeutic Relationships . 189˛Exhib it 2.2 -7: Counselor Strategies T o Prevent Secondary Traumatization . 198˛Exhibit 2.2 -8: Secondary Traumatization Signs .. 199˛Exhibit 2.2 -9: ProQOL Scale 201˛Exhibit 2.2 -10: Your Scores on the ProQOL: Professional Quality of Life Screening 202˛Exhibit 2.2 -11: What Is My Score and What Does It Mean? . 203˛Exhibit 2.2 -12: Clinical Supervisor Guidelines for Addressing Secondary Traumatization . 205˛Exhibit 2.2 -13: Comprehensive Self -Care Plan Worksheet .. 208˛Exhibit 2.2 -14: Comprehensive Self -Care Plan Worksheet Instructions 209˛Exhibit 2.2 -15: The Ethics of Self -Care .. 210˛ vi

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Consensus Panel Note: Each panelist™s information reflects his or her affiliation at the time of the Consensus Panel meeting and may not reflect that person™s most current affiliation. Chair Lisa M. Najavits, Ph.D. Co-Chair Linda B. Cottler, Ph.D., M.P.H. Professor of Epidemiology in Psychiatry Department of Psychiatry Washington University ŒSt. Louis St. Louis, MO Workgroup Leaders Stephanie S. Covington, Ph.D., LCSW, MFCC Co-Director Center for Gender and Justice Institute for Relational Development La Jolla, CA Margaret Cramer, Ph.D. Clinical Psychologist/Clinical Instructor Harvard Medical School Boston, MA Anne M. H erron, M.S. Director Treatment Programming New York State Office of Alcoholism and Substance Abuse Services Albany , NY Denise Hien, Ph.D. Research Scholar Social Intervention Group School of Social Work Columbia University New York , NY Dee S. Owens, M.P.A. Director Alcohol -Drug Information Indiana University Bloomington, IN Panelists Charlotte Chapman, M.S., LPC, CAC Training Director Division of Addiction Psychiatry Mid -Atlantic Addiction Technology Transfer Center Virginia Commonwealth University Richmond, VA vii

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Trauma -Informed Care in Behavioral Health Services Scott F. Coffey, Ph.D. Associate Professor Department of Psychiatry and Human Behavior University of Mississippi Medical Center Jackson, MS Renee M. Cunningha m-Williams, M.S.W., M.P.E., Ph.D. Research Assistant/Professor of Social Work Department of Psychiatry Washington University St. Louis, MO Chad D. Emrick, Ph.D. Administrative Director Substance Abuse Treatment Program Denver VA Medical Center (116A1) Denver, CO Charles R. Figley, Ph.D. Professor Director of the Traumatology Institute Florida State University Tallahassee, FL Larry M. Gentilello, M.D., FACS Professor and Chairman Division of Burn, Trauma, and Critical Care University of Texas Southwest ern Medical School Dallas, TX Robert Grant, Ph.D. Trauma Consultant Oakland, CA Anthony (Tony) Taiwai Ng, M.D. Disaster Psychiatrist Washington, DC Pallavi Nishith, Ph.D. Associate Research Professor Center for Trauma Department of Psychology University of Missouri ŒSt. Louis St. Louis, MO Joseph B. Stone, Ph.D., CACIII, ICADC Program Manager and Clinical Supervisor Confederated Tribes of Grand Ronde Behavioral Health Program Grand Ronde, OR Michael Villanueva, Ph.D. Research Professor Center on Alcoholism, Substance Abuse, and Addiction Albuquerque, NM viii

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. KAP Expert Panel and Federal˜ Government Participants˜ Barry S. Brown, Ph.D. Adjunct Professor University of North Carolina ŒWilmington Carolina Beach, NC Jacqueline Butler, M.S.W., LISW, LPCC, CCDC III, CJS Professor of Clinical Psychiatry College of Medicine University of Cincinnati Cincinnati, OH Deion Cash Executive Director Community Treatment and Correction Center, Inc. Canton, OH Debra A. Claymore, M.Ed.Adm. Owner/Chief Executive Officer WC Consulting, LLC Loveland, CO Carlo C. DiClemente, Ph.D. Chair Department of Psychology University of Maryland ŒBaltimore County Baltimore, MD Catherine E. Dube, Ed.D. Independent Consultant Brown University Providence, RI Jerry P. Flanzer, D.S.W., LCSW, CAC Chief, Services Division of Clinical and Services Research National Institute on Drug Abuse Bethesda, MD Michael Galer, D.B.A. Independent Consultant Westminster, MA Renata J. Henry, M.Ed. Director Division of Alcoholism, Drug Abuse and Mental Health Delaware Department of Health and Social Services New Castle, DE Joel Hochberg, M.A. President Asher & Partners Los Angeles, CA ix

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