ANOTHER Trendy Initiative?!? -Integrating Trauma-Informed and Co-Occurring Capable Care

1. ANOTHER Trendy Initiative?!? -Integrating Trauma-Informed and Co-Occurring Capable Care Cary Hopkins Eyles, MA, CAPSamantha A. Farro, PhDColleen Clark, PhD Annual Conference August 25, 2011 Orlando, Florida

2. Agenda • The Centrality of Trauma • What is Trauma-Informed Care? • Assessing Readiness for Trauma-Informed Care • Integrating Care for Co-occurring Disorders and Trauma Issues • Making it all Work for the Client

3. Introduction • Clients seeking substance abuse and mental health treatment often have history of trauma. • History of trauma complicates treatment. • Integrated care is more cost effective and demonstrates more positive outcomes of treatment

4. Prevalence Childhood Sexual Abuse

5. ACE Study

6. ACE Score vs. Adult Alcoholism Family Care Version: Understanding Trauma & Trauma-Informed Care

8. Integration How mental health, substance abuse, violence work together

9. Trauma ♀ Substance Abuse

10. Trauma and Substance Abuse • Following traumatic event – substance abuse as “self-medication” “self-soothing” • Substance abuse leading to high risk situations or poor judgment increasing chances of victimization

11. Trauma ♀ Mental illness, Emotional disorders

12. Trauma and Mental Illness • Violence and abuse, especially over a long term, abuse by multiple perpetrators and/or extremely violence abuse is associated with the development of many disorders. • Some responses to abuse – SIV, flashbacks, result in involuntary hospitalization, seclusion , restraints and possible retraumatization • People with mental illnesses are more likely to be victims of violence

13. Substance abuse ♀ Mental illness, Emotional disorders

14. Problem • Integrated treatment is complex to assess and difficult to implement. • Current empirical approaches require a great deal of time and resources

15. Potential Solution Consumer Perspective Staff Perspective Description: Assesses staff perspective about residential treatment’s level of trauma informed care on six dimensions Method: Semi-structured interviews of staff are qualitatively coded using an anchored rating scale Sample: Agency’s staff leaders in residential treatment Description: Examines prevalence of childhood trauma and perceptions of service integration and choice at DACCO’s residential treatment Method: Survey data is statistically analyzed to examine mean differences, correlations, and frequencies. Sample: Female and male clients in residential treatment

16. Current Approach • Adverse Childhood Experiences Scale • Consumer Perceptions of Care Scale • Community Readiness Model Interviews

17. Current Approach • Adverse Childhood Experiences • Measures the extent of exposure from the study’s sample to different types of childhood trauma.

18. Current Approach • Consumer Perceptions of Care • Measures client’s perceptions of and satisfaction with services for substance abuse, mental health, and trauma related disorders.

19. Current Approach • Community Readiness Model • Guide for assessing readiness and capacity to successfully develop and implement a program on a community/organizational level • Theoretically based on stages of change

20. Stages of Change: Brief Overview • Developed by Prochaska and DiClemente • Change is a process and each person progresses at their own rate through this process • Decisions must come ultimately from inside, an internal locus of control, as long-term stable change cannot be externally imposed • The stages describe an individual's attitude toward behavior change • Precontemplation • Contemplation • Preparation • Action • Maintenance • Relapse

21. Stages of Change • Assess where the person or system is in the change process to determine the appropriate intervention • Once you assess where you are in the process then you can what steps you need to take next to get to your goal • This research will help us determine our readiness as a division and then each of us will need to personally decide how ready we are to focus on trauma with our population

22. ACE Results

23. ACE Results

24. ACE Results

25. CPC Results

26. CPC Results

27. Spectrum of Readiness

28. CRM Results • Community Efforts • 7 Stabilization • Community Knowledge of the Efforts • 6 Initiation • Leadership • 6 Initiation • Community Climate • 7 Stabilization • Community Knowledge About the Issue • 5 Preparation • Resources for Efforts • 5 Preparation

29. CRM Results • Community Efforts and Community Climate • Level 7 - Stabilization • One or two efforts are running, supported by administrators/community decision-makers • Programs and activities are viewed as stable • Staff are trained and experienced • No in-depth evaluation of effectiveness as of yet • Climate supports activities

30. CRM Results • Level 7 – Stabilization Goal and Strategies • Goal: Stabilize efforts or establish programs • Plan events to maintain support for TIC efforts • Introduce evaluation results through multiple media sources • Review efforts/activity progress on a quarterly basis • Maintain business and outside organizational support for the effort/activity • Increase and further develop media exposure to reach community, use evaluation data

31. CRM Results • Community Knowledge of the Efforts and Leadership • Level 6 – Initiation • Information is available to justify the efforts • Activity and action is underway but still viewed as a new effort • Staff are being trained • Great enthusiasm in leaders, as limitations and issues have yet to be met • Improved attitude in community members is reflected by continued modest support

32. CRM Results • Level 6 – Initiation Goal and Strategies • Goal: Provide Community Specific Information • If local data sources are non-existent or unreliable, plan how to begin accurate local data collection • Inform other community providers and leaders through multidisciplinary meetings, administrative meetings, in-service trainings, etc. and talk about the progress of your efforts • Network with existing resources to enhance your efforts • Sponsor or co-sponsor larger community events • Plan publicity efforts associated with start up of activity, program, or efforts • Begin discussion about basic evaluation efforts

33. CRM Results • Community Knowledge About the Issue and Resources for Efforts • Level 5 – Preparation • Planning is going on and focuses on details • General information about problem and pros and cons of efforts • Leadership is active and energetic • Resources (people, money, time, etc) are actively being sought • Community climate offers modest support

34. CRM Results • Level 5 – Preparation Goal and Strategies • Goal: Gather pertinent information • Organize and present local statistics, local efforts, and survey information to the community through agency newsletters, emails, etc. (Compile the facts: locals statistics, local stories, emotional cost, consequences to the division, future impact, financial costs, etc) • Begin searching for potential funding for resources through state federal and foundation sources • Network within your agency to foster support for initiatives

35. Some History • Co-occurring initiative has been strong for 10 years at DACCO • Have made significant changes in terms of having services available to clients on-site, assessing for comorbidity, making clients’ mental health concerns part of the treatment planning and clinical chart, etc • Realization that trauma is at the root of many of the clients’ disorders (both SA and MH)

36. COD and TIC principles Integrating Care

37. Outline • Co-Occurring Disorders • Definition • CCISC (Minkoff & Cline) Model • Trauma-Informed Care • Components of Trauma Informed Care • System changes • Fully Integration Care • Combining Mental Health, Substance Abuse, and Trauma Treatment

38. Co-Occurring Disorders • People who are diagnosed with both mental health and substance abuse disorders and are, therefore, living with symptoms of both. • Often struggle to cope with past trauma, medical problems, social concerns (i.e., involvement in the child welfare system), criminal justice/legal problems.

39. Comprehensive, Continuous, Integrated System of Care Model(CCISC) • Designed to improve access and implementation of treatment for clients in a holistic manner

40. CCISC principles • Welcoming • Accessible • Integrated • Continuous • Comprehensive • Consumer / Family Oriented

41. CCISC Principles • Dual diagnosis is an expectation, not an exception • Empathic, hopeful, integrated treatment relationships are one of the most important contributors to treatment success in any setting; provision of continuous integrated treatment relationships is an evidence based best practice for individuals with the most severe combinations of psychiatric and substance difficulties

42. CCISC Principles • All COD clients are not the same (quadrant model) • Case management and care must be balanced with empathic detachment, expectation, contracting, consequences, and contingent learning for each client, and in each service setting

43. CCISC Principles, con’t • When psychiatric and substance disorders coexist, both disorders should be considered primary, and integrated dual (or multiple) primary diagnosis-specific treatment is recommended. • “Disease and recovery model” (Minkoff) • No single correct intervention for persons with COD (quadrants, diagnoses, level of functioning, stage of change, etc)… • Clinical outcomes for persons with COD must also be individualized, based on similar parameters for individualizing treatment interventions

44. CCISC • Change to occur throughout the system of care • Tries to use the existing resources or the most efficient use of existing resources • Use of evidence-based practices and consensus-based best practices • Integrated treatment

45. CCISC • Co-morbidity • Integrated treatment • Acknowledgement that readiness varies (which fits best with what modalities?) • Continuous relationships with providers • Both dx are primary • Chronic, relapsing illnesses

46. Service Provider Recommendations • Create a Committee or sub-committee in your organization to discuss issues of co-occurring disorders • Leadership and Change Agents need to prioritize • Review the following areas: • Admission • Are you currently excluding clients who have substance abuse (if a MH agency) or mental health (if a SA agency) • Do you have standard methods of screening for both disorders? • Records • Are both diagnoses documented? • Do staff include treatment plan objectives for both?

47. Service Provider Recommendations • Treatment Quality Enhancements • Manualized groups discuss the integration of SA and MH. • Use of the stages of change in a systematic way. • Program employs drug testing procedures, routinely or as indicated • Program participants have access to self-help groups onsite or are regularly transported to groups that specifically address COD (e.g., Dual Recovery / Double Trouble)

48. Service Provider Recommendations • Staff Structure • Program staff includes persons onsite that have expertise / professional backgrounds in mental health and substance use disorders • Human resource policies and written training expectations focus on the acquisition of skills related to the treatment of persons with co-occurring disorders • Program Administration • Program Mission Statement specifically welcomes persons with active co-occurring disorders • MIS / data entry systems are employed that identify and track services delivered to persons with COD

49. Trauma Informed Care

50. Trauma-Informed Care For an organization to be trauma-informed, “all staff…from the receptionist to the direct care workers to the board of directors, must understand how violence impacts the lives of people being served, so that every interaction is consistent with the recovery process and reduces the possibility of re-traumatization (Elliot, 2005, pg 462).”