Assignment: Posttraumatic Stress Disorder

Succinctly, in 1–2 pages, address the following:

• Briefly explain the neurobiological basis for PTSD illness.
• Discuss the DSM-5 diagnostic criteria for PTSD and relate these criteria to the symptomology presented in the case study. Does the video case presentation provide sufficient information to derive a PTSD diagnosis? Justify your reasoning. Do you agree with the other diagnoses in the case presentation? Why or why not?
• Discuss one other psychotherapy treatment option for the client in this case study. Explain whether your treatment option is considered a “gold standard treatment” from a clinical practice guideline perspective, and why using gold standard, evidence-based treatments from clinical practice guidelines is important for psychiatric-mental health nurse practitioners. Assignment: Posttraumatic Stress Disorder

Support your Assignment with specific examples from this week’s media and at least three peer-reviewed, evidence-based sources. Explain why each of your supporting sources is considered scholarly. Attach the PDFs of your sources.

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Learning Resources

 

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425596

https://www.apa.org/ptsd-guideline

https://video.alexanderstreet.com/watch/ptsd-and-veterans-a-conversation-with-dr-frank-ochberg

 

U.S. Department of Veterans Affairs Public Access Author manuscript Harv Rev Psychiatry. Author manuscript; available in PMC 2015 August 20. Published in final edited form as: Harv Rev Psychiatry. 2015 ; 23(1): 51–58. doi:10.1097/HRP.0000000000000035.

Preclinical Perspectives on Posttraumatic Stress Disorder Criteria in DSM-5 Susannah Tye, PhD, Elizabeth Van Voorhees, PhD, Chunling Hu, MD, PhD, and Timothy Lineberry, MD Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN (Drs. Tye, Hu, and Lineberry); Schools of Psychiatry and Medicine, Deakin University, Geelong, VIC, Australia (Dr. Tye); Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC (Dr. Van Voorhees); Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC (Dr. Van Voorhees); Durham Veterans Affairs Medical Center, Durham, NC (Dr. Van Voorhees); Aurora Health Care, Green Bay, WI (Dr. Lineberry) Assignment: Posttraumatic Stress Disorder

Abstract Posttraumatic stress disorder (PTSD) now sits within the newly created “Trauma- and StressorRelated Disorders” section of the Diagnostic and Statistical Manual of Mental Disorders (fifth edition; DSM-5). Through the refinement and expansion of diagnostic criteria, the DSM-5 version better clarifies the broad and pervasive effects of trauma on functioning, as well as the impact of development on trauma reactions. Aggressive and dissociative symptoms are more thoroughly characterized, reflecting increasing evidence that reactions to trauma often reach beyond the domains of fear and anxiety (these latter domains were emphasized in DSM-IV). These revised criteria are supported by decades of preclinical and clinical research quantifying traumatic stress– induced changes in neurobiological and behavioral function. Several features of the DSM-5 PTSD criteria are similarly and consistently represented in preclinical animal models and humans following exposure to extreme stress. In rodent models, for example, increases in anxiety-like, helplessness, or aggressive behavior, along with disruptions in circadian/neurovegetative function, are typically induced by severe, inescapable, and uncontrollable stress. These abnormalities are prominent features of PTSD and can help us in understanding the pathophysiology of this and other stress-associated psychiatric disorders. In this article we examine some of the changes to the diagnostic criteria of PTSD in the context of trauma-related neurobiological dysfunction, and discuss implications for how preclinical data can be useful in current and future clinical conceptualizations of trauma and trauma-related psychiatric disorders. Keywords animal models; DSM-5; plasticity; posttraumatic stress disorder; stress; trauma Correspondence: Susannah Tye, PhD, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN 55905. tye.susannah@mayo.edu. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. The views presented here do not necessarily reflect those of the US Department of Veterans Affairs or the US government. U.S. Department of Veterans Affairs Public Access Author manuscript Harv Rev Psychiatry. Author manuscript; available in PMC 2015 August 20. Published in final edited form as: Harv Rev Psychiatry. 2015 ; 23(1): 51–58. doi:10.1097/HRP.0000000000000035. VA Author Manuscript VA Author Manuscript VA Author Manuscript The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes important changes to the diagnostic criteria for posttraumatic stress disorder (PTSD). Although many of the symptoms remain consistent with DSM-IV-TR, the disorder has been moved to a new section entitled “Trauma- and Stressor-Related Disorders,” and the changes to the diagnostic criteria and their descriptions have expanded the section from just over one page to four pages. Much of the additional information is included under a subsection, “Posttraumatic Stress Disorder for Children 6 Years and Younger,” reflecting the greater attention to developmental differences in the manifestation of trauma symptomatology. Other key changes include: (1) removal of the requirement that the individual responded with fear, helplessness, or horror at the time of the trauma, (2) renaming the “re-experiencing” cluster symptoms as “intrusion” symptoms, (3) separating “avoidance” and “numbing” symptoms into two separate clusters, (4) subsuming “numbing” symptoms under a newly developed symptom cluster, “negative alterations in cognitions and mood,” (5) elaborating upon the “irritability or outbursts of anger” symptom to highlight the occurrence of verbal and physical aggression, (6) adding a specifier for a dissociative subtype. These modifications represent at least two important changes in the conceptualization of how individuals respond to overwhelming trauma. First, the development of a separate category for trauma- and stressor-related disorders takes an important step toward acknowledging that trauma often has broad and pervasive effects on functioning beyond what can be adequately captured in a single diagnosis Assignment: Posttraumatic Stress Disorder. Coupled with the greater emphasis on aggressive and dissociative symptoms within the diagnosis of PTSD, the presence of this new section reflects a deeper understanding that reactions to trauma can be pervasive and diverse, and that they often reach beyond our previous conceptualization of them as being limited to the domains of fear and anxiety, which DSM-IV emphasized.1–16 Second, the inclusion of reactive attachment disorder and disinhibited social engagement disorder in the trauma- and stressor-related disorders section, coupled with the elaboration of the description of trauma symptoms in children within the PTSD criteria, begins to integrate the decades of preclinical and clinical research demonstrating the profound impact that developmental timing of trauma exposure has on trauma reactions, both at the time of initial exposure and in response to stress and trauma experienced later in life.17–31 In this article we examine changes to the diagnostic criteria of PTSD in the context of animal models of trauma-related neurobiological dysfunction, and discuss implications for how preclinical data can be useful in current and future clinical conceptualizations of trauma and traumarelated psychiatric disorders. HOW CAN PRECLINICAL RESEARCH INFORM THE REFINEMENT OF DIAGNOSTIC CRITERIA FOR PTSD? Preclinical models that complement clinical research can greatly enhance our understanding of the neurobiological underpinnings of neuropsychiatric traits. While animal studies are limited in their capacity to model human psychiatric phenomena, consideration of preclinical data of the demonstrated effects of stress on neurobiology and behavior can help us to better understand human responses to severe stress or trauma.32 To confer this Tye et al. Page 2 Harv Rev Psychiatry. Author manuscript; available in PMC 2015 August 20. VA Author Manuscript VA Author Manuscript VA Author Manuscript complementary and evidence-based insight, animal models of complex disorders such as PTSD must demonstrate a satisfactory degree of reliability together with face, construct, and predictive validity. That is, behavioral responses must be observable and measurable, emulate clinical symptomatology, and be corrected with pharmacological treatments that alleviate similar indications in patients with the disorder.33 Preclinical models considered to phenotypically resemble clinical cases of PTSD in humans are characterized by long-lasting adaptations in stress and conditioned-fear responses, together with a generalized sensitization to stimuli following intense stress exposure.34 In rodent models, simulation of a traumatic event can be induced via exposure to inescapable electric shocks, aggressive social confrontation, predator scent, or a short, varied sequence of stressors.33,34 Animals exposed to such trauma typically demonstrate sensitized responses to novel stressful stimuli across neuroendocrine, cardiovascular, gastrointestinal, and immune systems for weeks to months after the exposure.34 Increased sensitivity to pain, dysregulation of circadian biorhythms, greater depression-like behavior, and heightened fear and defensive reactivity are also observed.35 Insights into the sensitizing effects of trauma exposure on systems involved in both physiological and affective stress regulation in animal models have provided the foundation for examining mechanisms of comorbidity of PTSD and a host of physical and psychiatric disorders, including cardiovascular and metabolic disease,36,37 disrupted immune functioning,38 chronic pain,39–42 and depression.31 Cortisol and noradrenaline, adrenaline, and a host of other stress-mediated physiological sequelae work in concert to coordinate cellular responses in both the peripheral and central nervous systems, thereby facilitating an individual’s behavioral response to an immediate threat.43–52 These physiological cascades concurrently modulate synaptic plasticity and epigenetic mechanisms governing future cellular responses to stress.53 These adaptations enable individuals to rapidly recall memories and biological responses, facilitating their avoidance of, or coping with, similar threats in the future. From this perspective, the psychophysiological symptoms of PTSD reflect augmentation of biologically engineered adaptations in behavioral coping (e.g., hyperarousal, aggressive defense, avoidance, and persistent negative alterations in cognitions and mood).54 Neurobiological adaptations—mediated by hyperactivation of both the hypothalamicpituitary-adrenal axis and sympathetic nervous system during severe stress—attune neural systems, primed to facilitate cognitive and behavioral responses, to future threats.55 These adaptations include augmenting memory consolidation at the cellular and systems level to prime an individual’s future fight, flight, or freeze response when faced with similar threats. Rapid recall of memories, both psychologically and physiologically, are critical to this adaptive response. PTSD symptomatology is not per se a disruption of this system but is, instead, reflective of an inherently efficient and enduring memory storage and retrieval system Assignment: Posttraumatic Stress Disorder.From an evolutionary perspective, therefore, symptoms of PTSD, including intrusive memories of the traumatic event, avoidance of reminders of it, emotional numbing or dysregulation, hyperarousal, and exaggerated active versus passive coping, can be considered natural adaptations to extreme stress that fail to subside once the threat is removed. The enduring nature of these stress-mediated neuroadaptations, which are thought to underlie symptom persistence in vulnerable individuals, has led to suggestions that PTSD Tye et al. Page 3 Harv Rev Psychiatry. Author manuscript; available in PMC 2015 August 20. VA Author Manuscript VA Author Manuscript VA Author Manuscript is a “forgetting” disorder, such that PTSD patients lose the ability to forget the trauma.32 Consequently, when they encounter trauma-associated cues, vivid memories of the traumatic event are reexperienced together with associated emotional states and physiological stress responses. Preclinical research suggests mechanisms mediating PTSD and other trauma- and stressorrelated psychopathology are founded in a functionally adaptive stress response system evolved to rapidly and effectively store fear-related memories and facilitate the rapid recall of situationally relevant physiological and psychological reactions.56–58 Once an individual previously exposed to trauma is in a safer environmental context, the situationally adaptive response is to attenuate recall of trauma-related memories and associated system-wide physiological reactions. In PTSD, however, the all-too-effective recall of memories formed during exposure to extreme stress, together with the rapid coordination of physiological and behavioral responses, can be disabling later, when the individual is no longer facing the impending threat. Building upon the understanding of mechanisms afforded by animal models, clinical studies have begun to demonstrate parallels between deficits in attention, learning, and memory observed in humans with PTSD and alterations in brain systems and structures identified in animals as underlying these processes.10,34,59–61 Redefining PTSD as a “Trauma- and Stressor-Related Disorder” has helped to refine clinical criteria for diagnosis, better aligning the diagnosis with our understanding of the neurobiological mechanisms of stress reactivity and stress-mediated psychopathology. REDEFINING PTSD AS A “TRAUMA- AND STRESSOR-RELATED DISORDER” It has been argued for some time that the unique neurobiological adaptations to traumatic stress in PTSD validate its inclusion in a distinct diagnostic entity.56,62,63 This perspective has been extended by the creation in the DSM-5 of a separate category for “Trauma- and Stressor-Related Disorders,” and the relocation of PTSD from “Anxiety Disorders” into this new section. These changes appear to reflect the growing appreciation that the characteristic symptom persistence of PTSD and other trauma- and stress-related disorders reflect allostatic overload to neurobiological stress-response systems21,64,65 and the subsequent failure of re-adaptation to a safe environment at a neurophysiological level.66 As discussed above, the cascading changes to neurobiological systems as a result of chronic or severe stress may manifest in changes to psychological and physiological functioning that reach far beyond symptoms of fear and anxiety. Indeed, behavioral neuroscience research across species suggests that when environmental stressors are too demanding and the individual is unable to effectively cope, poor health and psychopathology across multiple domains can result.67 The creation of a DSM-5 section specifically for disorders reflecting trauma- and stressrelated psychopathology also may reflect an acknowledgment of the variability in the expression of post-traumatic reactions. That overwhelming stress can induce significant and enduring changes in cognitions, feelings, and behavior56,68–72 remains the fundamental construct of PTSD and the other stress-related disorders in DSM-5. However, the greater consideration of stress-related adaptations in the specific diagnostic criteria for PTSD in Tye et al. Page 4 Harv Rev Psychiatry. Author manuscript; available in PMC 2015 August 20. VA Author Manuscript VA Author Manuscript VA Author Manuscript DSM-5 seems to reflect an increased awareness of the enduring impact of severe stress on mood and coping systems. The way in which an animal copes with stress is often colloquially referred to as the fight, flight, or freeze response, and reflects well-characterized confrontational and avoidant behavioral responses. In DSM-IV-TR, the role of the fear response in PTSD was acknowledged by its placement among the anxiety disorders. This emphasis on the role of fear and anxiety in PTSD has led to the development of effective therapies for PTSD that have built upon exposure and cognitive-behavior therapy for other anxiety disorders,73,74 but it has also limited the development of therapies to address other trauma- and stress-related responses such as aggression or sleep disturbance.75,76 Nonconfrontational behavioral responses to stress, such as the flight response or freeze response, are a means through which an individual can withdraw and avoid the threat, thereby both conserving energy and avoiding aggressive conflicts.77 Many of the symptoms of PTSD in both DSM-IV-TR and DSM-5 reflect such withdrawal from, or “depressive” responses to, stress, although this emphasis is more pronounced in the DSM-5 criteria. By contrast, confrontational responses to stress, though well represented by aggressive and territorial posturing (particularly in animals),78 have been conspicuously absent from previous DSM formulations of PTSD. The elaboration of the DSM-IV symptom “irritability or outbursts of anger” to the DSM-5 symptom “irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects” takes an important step toward addressing this omission.79,80 A more thorough consideration of such confrontational responses as they apply to anger and aggression in PTSD may facilitate the development of treatments that more effectively target the profound impact that these “externalizing” behaviors81 have on interpersonal, occupational, and health-related outcomes.2,5,7,75,79,80,82–85 STRESS SENSITIZATION AND TRAUMA-RELATED PSYCHOPATHOLOGY All of the coping behaviors described above are triggered and regulated by stress and are fundamental features of PTSD pathophysiology. Indeed, a wealth of neurobiological data demonstrates that exposure to stress (or stress hormones) serves to modify the expression of these behaviors through alteration of hypothalamic-pituitary-adrenal axis feedback and monoamine neurotransmission.86,87 The enduring nature of stress-induced neurobiological adaptations in PTSD represents a critical feature of this disorder.86 Behavioral coping is mediated, in part, through genetics and fine-tuned by exposure to stress, particularly in early life. Adaptations that occur within the neuroendocrine systems are also modified by prior stress exposure and serve to regulate neural systems mediating mood and coping. Such adaptations may be influenced by the developmental timing, chronicity, and characteristic of the trauma(s). For example, long-term childhood maltreatment by primary caregivers may result in neural, endocrine, cognitive, and behavioral alterations that are distinct from those occurring in response to a single, prolonged stressor in adulthood, such as exposure to combat.10,21,23–26,28,88,89 Preclinical models provide a valuable tool for elucidating the influence of gene × environment × development factors in the pathogenesis and symptomatic expression of PTSD.90–93 Tye et al. Page 5 Harv Rev Psychiatry. Author manuscript; available in PMC 2015 August 20. VA Author Manuscript VA Author Manuscript VA Author Manuscript Animal models of PTSD have contributed significant insight into the neurobiological mechanisms mediating fear conditioning, extinction learning, retention of extinction learning, and behavioral and neuroendocrine sensitization involved in the development or maintenance of PTSD.94,95 Such studies have demonstrated that exposure to stress, particularly early in life, can result in enduring changes in neuroendocrine regulation and also in neurobiological reorganization within the mesocorticolimbic system.96 While important similarities can be identified across multiple stress-sensitive disorders, a core and unique feature of PTSD is to be unable to forget trauma memories, and to experience, and be unable to inhibit, exaggerated physiological stress responses to associated stimuli.32 Classical associative fear conditioning, used extensively to model the traumatic memory features of PTSD in animals,97 has shown that disruption of “for-getting” (extinction learning) is characterized by exaggerated amygdala responses together with deficits in frontal cortical and hippocampal function.98 These functional and structural changes directly mediate memory recall and behavioral coping in the face of future stress and negatively affect the effectiveness of pharmacotherapies.96 Amygdala hyperactivity promotes acquisition of fear associations and responses (both freezing in reaction to similar stimuli and aggressive behaviors when socially challenged), whereas deficits in frontal and hippocampal function prevent both the suppression of attentional responses to trauma-related stimuli and the behavioral adaptation to safe contexts.98 These anatomical regions are thought to be particularly sensitive to the impact of severe stress via the direct actions of glucocorticoids and their facilitation of glutamatemediated, long-term synaptic plasticity.99–101 Relevantly, functional and structural differences have been observed in both the amygdala and hippocampus in both children and adults with PTSD.17,20,59,102–105 Preexisting risks for PTSD, including depression and early life stress, may prime these regional responses to stress, in part via differential methylation of glucocorticoid response genes.53,106 Together with previously incurred structural and functional vulnerabilities, such insults may further serve to augment trauma-induced neuroadaptations. Although the relationship between genes, environment, and development in the etiology of PTSD is inherently complex, animal models provide a valuable means of elucidating pathophysiological mechanisms, identifying key biomarkers of vulnerability, and testing novel therapeutics. PREVENTION AND TREATMENT IMPLICATIONS Research into the neurobiology of susceptibility and resilience to development of PTSD in preclinical animal models provides novel avenues for treatment and prevention.43,107–109 Psychotherapy is a critical first-line treatment for PTSD,110 and the mechanistic understanding of the effects of stress and trauma on functioning (based upon animal models) has been fundamental to the development and testing of these nonpharmacological interventions Assignment: Posttraumatic Stress Disorder. For example, animal research on the impact of trauma on learning and memory has been used to develop trauma-focused therapies for PTSD such as cognitive processing therapy and prolonged exposure therapy.73,74,111 Likewise, animal research has illuminated the neurobiological substrates of PTSD, opening the door for research examining the effects of psychotherapy on relevant neurobiological systems.59,112–114 Tye et al. Page 6 Harv Rev Psychiatry. Author manuscript; available in PMC 2015 August 20. VA Author Manuscript VA Author Manuscript VA Author Manuscript Moving forward, the more we understand the neurobiological mechanisms of stress and their implications for plasticity and treatment response, the broader our scope for treatment options becomes for both behavioral and somatic treatments. For example, pharmacotherapies that block the formation of trauma-related memories may help to prevent PTSD if given acutely and immediately post-trauma. Illustrating this point, morphine used acutely in early resuscitation and trauma care in US service members has been associated with a reduced risk of developing PTSD.115 Conversely, drugs that functionally induce an adaptive state in otherwise resistant neural circuits affected by trauma will potentially facilitate recovery and efficacy of psychotherapeutic approaches, as demonstrated in treatment-resistant depression.116 To date, the selective serotonin reuptake inhibitor class of antidepressants has most commonly been used in managing PTSD.117,118 Possible treatments that directly modulate mechanisms implicated in synaptic plasticity include D-cycloserine, a broad-spectrum antibiotic and partial N-methyl-D-aspartate receptor agonist;119–122 dehydroepiandrosterone, a precursor to male and female sex hormones (androgens and estrogens);123–125 and neuropeptides such as corticotropin-releasing hormone and neuropeptide-Y.126 Each of these compounds serves to regulate neuroendocrine and behavioral responses to stress and, through direct actions on mechanisms mediating synaptic plasticity, has promise as a therapeutic intervention for PTSD. CONCLUSIONS Broadly, the changes to the conceptualization of PTSD reflected in DSM-5 mirror the field’s ever deeper understanding of the long-term consequences of stress and trauma, and of the biological mechanisms underlying these changes, as derived from research using animal models over the past several decades. The critical role that trauma plays in cascading neurobiological changes underlying psychopathology, the importance of developmental timing in shaping posttraumatic outcomes, and the heterogeneity of emotional and behavioral dysfunction associated with exposure to severe trauma have all been elegantly interwoven into the new diagnostic criteria. Much work remains to be done, however, to integrate the knowledge we have gained from animal models into our diagnostic guidelines. Based on the above discussion, we conclude with some considerations for collaborative efforts between preclinical and clinical researchers. It is our hope that these collaborations will continue to lead us toward increasingly refined and nuanced formulations of the psychiatric effects of trauma in future versions of the DSM. The new DSM-5 structure separating out trauma- and stressor-related disorders potentially lays the groundwork for incorporating into the DSM framework both the impact of chronic trauma on personality development and the association of trauma with the onset of other psychiatric syndromes. We recommend that in examining the implications of animal models for defining human responses to trauma, researchers and theorists continue to emphasize a developmental perspective on PTSD. Animal models demonstrate that early trauma exposure affects responsivity to later stressful events. Continuing to focus primarily on the effects of a single index event is, in light of the evidence, misguided. At the very least, this myopic view wastes valuable resources by discounting the vast literature suggesting that early experiences Tye et al. Page 7 Harv Rev Psychiatry. Author manuscript; available in PMC 2015 August 20. VA Author Manuscript VA Author Manuscript VA Author Manuscript shape neurobiological systems in ways that contribute formatively to the development of PTSD and other forms of psychopathology. More critically, however, such a narrow perspective inappropriately localizes the genesis of dysfunctional behavioral responses in PTSD to the individual without effectively acknowledging the influence of both genes and environment on neurodevelopmental processes that prime an individual to effectively store and recall trauma- and stress-related memories. This narrow perspective not only creates obstacles to the development of effective interventions but also risks exacerbating traumarelated alterations in cognition and mood by implicitly blaming the individual for problems having a strong biological basis, such as persistent negative emotional states and aggressive behavior. With creation of the “Trauma- and Stressor-Related Disorders” section, we are now better placed to conceptualize PTSD as one clinical manifestation of an underlying neurobiological adaptation to stress. In addition to aiding our understanding of the basic neurobiology of PTSD, preclinical studies can help determine the influence of genetic, environmental, and developmental factors in mediating an individual’s vulnerability to develop PTSD. Preclinical studies can also help to identify the mechanisms through which these mediating factors can be therapeutically disrupted, thereby providing opportunities both to identify novel drug targets and therapeutic interventions and to enhance our capacity to personalize treatments based on the unique phenotypic expression of PTSD. Importantly, as we better appreciate the mechanisms through which an inherently efficient stress response facilitates the hard wiring of fear memories and behavioral coping responses at the core of PTSD pathophysiology, we take an important step toward destigmatizing this devastating illness. Acknowledgments Supported, in part, by US Department of Veterans Affairs Rehabilitation Research and Development Program Career Development Award 1K2RX001298-01-A2 (Dr. Van Voorhees). Assignment: Posttraumatic Stress Disorder

REFERENCES

1. Andrews B, Brewin CR, Rose S, Kirk M. Predicting PTSD symptoms in victims of violent crime: the role of shame, anger, and childhood abuse. J Abnorm Psychol. 2000; 109:69–73. [PubMed: 10740937] 2. Barazzone N, Davey GC. Anger potentiates the reporting of threatening interpretations: an experimental study. J Anxiety Disord. 2009; 23:489–95. [PubMed: 19070989] 3. Beckham JC, Vrana SR, Barefoot JC, Feldman ME, Fairbank J, Moore SD. Magnitude and duration of cardiovascular responses to anger in Vietnam veterans with and without posttraumatic stress disorder. J Consult Clin Psychol. 2002; 70:228–34. [PubMed: 11860049] 4. Chemtob CM, Novaco RW, Hamada RS, Gross DM, Smith G. Anger regulation deficits in combatrelated posttraumatic stress disorder. J Trauma Stress. 1997; 10:17–36. [PubMed: 9018675] 5. Evans S, Giosan C, Patt I, Spielman L, Difede J. Anger and its association to distress and social/ occupational functioning in symptomatic disaster relief workers responding to the September 11, 2001, World Trade Center disaster. J Trauma Stress. 2006; 19:147–52. [PubMed: 16568457] 6. Feeny NC, Zoellner LA, Foa EB. Anger, dissociation, and posttraumatic stress disorder among female assault victims. J Trauma Stress. 2000; 13:89–100. [PubMed: 10761176] 7. Hellmuth JC, Stappenbeck CA, Hoerster KD, Jakupcak M. Modeling PTSD symptom clusters, alcohol misuse, anger, and depression as they relate to aggression and suicidality in returning U.S. veterans. J Trauma Stress. 2012; 25:527–34. [PubMed: 23073972] Assignment: Posttraumatic Stress Disorder

Wheeler, K. (Ed.). (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (3rd ed.). Springer Publishing.

• Chapter 3, “Assessment and Diagnosis” (Previously read in Week 2)
• Chapter 7, “Eye Movement Desensitization and Reprocessing Therapy”
• Chapter 11, “Trauma Resiliency Model Therapy”
• Chapter 15, “Trauma-Informed Medication Management”
• Chapter 17, “Stabilization for Trauma and Dissociation”
• Chapter 18, “Dialectical Behavior Therapy for Complex Trauma”

 

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SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach Prepared by SAMHSA’s Trauma and Justice Strategic Initiative July 2014

Introduction Trauma is a widespread, harmful and costly public supports and intervention, people can overcome health problem. It occurs as a result of violence, traumatic experiences.6,7,8,9 However, most people go abuse, neglect, loss, disaster, war and other without these services and supports. Unaddressed emotionally harmful experiences. Trauma has no trauma significantly increases the risk of mental boundaries with regard to age, gender, socioeconomic and substance use disorders and chronic physical status, race, ethnicity, geography or sexual orientation. diseases.1,10,11 It is an almost universal experience of people with mental and substance use disorders. The need to address trauma is increasingly viewed as an important component of effective behavioral health service delivery. Additionally, it has become evident that addressing trauma requires a multi-pronged, multi-agency public health approach inclusive of public education and awareness, prevention and early identification, and effective trauma-specific assessment and treatment. In order to maximize the impact of these efforts, they need to be provided in an organizational or community context that is trauma-informed, that is, based on the knowledge and understanding of trauma and its far-reaching implications. The effects of traumatic events place a heavy burden on individuals, families and communities and create challenges for public institutions and service systems. Although many people who experience a traumatic event will go on with their lives without lasting negative effects, others will have more difficulty and experience traumatic stress reactions. Emerging research has documented the relationships among exposure to traumatic events, impaired neurodevelopmental and immune systems responses and subsequent health risk behaviors resulting in chronic physical or behavioral health disorders.1,2,3,4,5 Research has also indicated that with appropriate With appropriate supports and intervention, people can overcome traumatic experiences. Individuals with experiences of trauma are found in multiple service sectors, not just in behavioral health. Studies of people in the juvenile and criminal justice system reveal high rates of mental and substance use disorders and personal histories of trauma.12,13 Children and families in the child welfare system similarly experience high rates of trauma and associated behavioral health problems.5,14 Young people bring their experiences of trauma into the school systems, often interfering with their school success. And many patients in primary care similarly have significant trauma histories which has an impact on their health and their responsiveness to health interventions.15,16,17 In addition, the public institutions and service systems that are intended to provide services and supports to individuals are often themselves trauma-inducing. The use of coercive practices, such as seclusion and restraints, in the behavioral health system; the abrupt removal of a child from an abusing family in the child welfare system; the use of invasive procedures in the medical system; the harsh disciplinary practices in educational/school systems; or intimidating practices in the criminal justice system can be re-traumatizing for individuals who already enter these systems with significant histories of trauma. These program or system practices and policies often interfere with achieving the desired outcomes in these systems. The need to address trauma is increasingly viewed as an important component of effective behavioral health service delivery. page 3 Thus, the pervasive and harmful impact of traumatic experienced by these individuals and how to mitigate events on individuals, families and communities and the re-traumatizing effect of many of our public the unintended but similarly widespread re-traumatizing institutions and service settings was not an integral of individuals within our public institutions and part of the work of these systems. Now, however, service systems, makes it necessary to rethink there is an increasing focus on the impact of trauma doing “business as usual.” In public institutions and and how service systems may help to resolve or service systems, there is increasing recognition that exacerbate trauma-related issues.  Assignment: Posttraumatic Stress Disorder.These systems are many of the individuals have extensive histories of beginning to revisit how they conduct their “business” trauma that, left unaddressed, can get in the way of under the framework of a trauma-informed approach. achieving good health and well-being. For example, a child who suffers from maltreatment or neglect in the home may not be able to concentrate on school work and be successful in school; a women victimized by domestic violence may have trouble performing in the work setting; a jail inmate repeatedly exposed to violence on the street may have difficulty refraining from retaliatory violence and re-offending; a sexually abused homeless youth may engage in self-injury and high risk behaviors to cope with the effects of sexual abuse; and, a veteran may use substances to mask the traumatic memories of combat. The experiences of these individuals are compelling and, unfortunately, all too common. Yet, until recently, gaining a better understanding of how to address the trauma There is an increasing focus on the impact of trauma and how service systems may help to resolve or exacerbate trauma-related issues. These systems are beginning to revisit how they conduct their business under the framework of a trauma-informed approach. Purpose and Approach: Developing a Framework for Trauma and a Trauma-Informed Approach PURPOSE The purpose of this paper is to develop a working concept of trauma and a trauma-informed approach and to develop a shared understanding of these concepts that would be acceptable and appropriate across an array of service systems and stakeholder groups. SAMHSA puts forth a framework for the behavioral health specialty sectors, that can be adapted to other sectors such as child welfare, education, criminal and juvenile justice, primary health care, the military and other settings that have the potential to ease or exacerbate an individual’s capacity to cope with traumatic experiences. In fact, many people with behavioral health problems receive treatment and services in these non-specialty behavioral health systems. SAMHSA intends this framework be relevant to its federal partners and their state and local system counterparts and to practitioners, researchers, and trauma survivors, families and communities. The desired goal is to build a framework that helps systems “talk” to each other, to understand better the connections between trauma and behavioral health issues, and to guide systems to become trauma-informed. APPROACH SAMHSA approached this task by integrating three significant threads of work: trauma focused research work; practice-generated knowledge about trauma interventions; and the lessons articulated by survivors page 4 of traumatic experiences who have had involvement in multiple service sectors. It was expected that this blending of the research, practice and survivor knowledge would generate a framework for improving the capacity of our service systems and public institutions to better address the trauma-related issues of their constituents. To begin this work, SAMHSA conducted an environmental scan of trauma definitions and models of trauma informed care. SAMHSA convened a group of national experts who had done extensive work in this area. This included trauma survivors who had been recipients of care in multiple service system; practitioners from an array of fields, who had experience in trauma treatment; researchers whose work focused on trauma and the development of trauma-specific interventions; and policymakers in the field of behavioral health. From this meeting, SAMHSA developed a working document summarizing the discussions among these experts. The document was then vetted among federal agencies that conduct work in the field of trauma. Simultaneously, it was placed on a SAMHSA website for public comment. Federal agency experts provided rich comments and suggestions; the public comment site drew just over 2,000 respondents and 20,000 comments or endorsements of others’ comments. SAMHSA reviewed all of these comments, made revisions to the document and developed the framework and guidance presented in this paper. The key questions addressed in this paper are: • What do we mean by trauma? • What do we mean by a trauma-informed approach? • What are the key principles of a traumainformed approach? • What is the suggested guidance for implementing a trauma-informed approach? • How do we understand trauma in the context of community? SAMHSA’s approach to this task has been an attempt to integrate knowledge developed through research and clinical practice with the voices of trauma survivors. This also included experts funded through SAMHSA’s trauma-focused grants and initiatives, such as SAMHSA’s National Child Traumatic Stress Initiative, SAMHSA’s National Center for Trauma Informed Care, and data and lessons learned from other grant programs that did not have a primary focus on trauma but included significant attention to trauma, such as SAMHSA’s: Jail Diversion Trauma Recovery grant program; Children’s Mental Health Initiative; Women, Children and Family Substance Abuse Treatment Program; and Offender Reentry and Adult Treatment Drug Court Programs. page 5 Background: Trauma — Where We Are and How We Got Here The concept of traumatic stress emerged in the Simultaneously, an emerging trauma survivors field of mental health at least four decades ago. movement has provided another perspective on the Over the last 20 years, SAMHSA has been a leader understanding of traumatic experiences. Trauma in recognizing the need to address trauma as a survivors, that is, people with lived experience fundamental obligation for public mental health and of trauma, have powerfully and systematically substance abuse service delivery and has supported documented their paths to recovery.26 Traumatic the development and promulgation of trauma-informed experiences complicate a child’s or an adult’s systems of care. In 1994, SAMHSA convened the capacity to make sense of their lives and to create Dare to Vision Conference, an event designed to meaningful consistent relationships in their families bring trauma to the foreground and the first national and communities. conference in which women trauma survivors talked about their experiences and ways in which standard practices in hospitals re-traumatized and often, triggered memories of previous abuse. In 1998, SAMHSA funded the Women, Co-Occurring Disorders and Violence Study to generate knowledge on the development and evaluation of integrated services approaches for women with co-occurring mental and substance use disorders who also had histories of physical and or sexual abuse. In 2001, SAMHSA funded the National Child Traumatic Stress Initiative to increase understanding of child trauma and develop effective interventions for children exposed to different types of traumatic events. The American Psychiatric Association (APA) played an important role in defining trauma. Diagnostic criteria for traumatic stress disorders have been debated through several iterations of the Diagnostic and Statistical Manual of Mental Disorders (DSM) with a new category of Trauma- and Stressor-Related Disorders, across the life-span, included in the recently released DSM-V (APA, 2013). Measures and inventories of trauma exposure, with both clinical and research applications, have proliferated since the 1970’s.18,19,20,21 National trauma research and practice centers have conducted significant work in the past few decades, further refining the concept of trauma, and developing effective trauma assessments and treatments.22,23,24,25 With the advances in neuroscience, a biopsychosocial approach to traumatic experiences has begun to delineate the mechanisms in which neurobiology, psychological processes, and social attachment interact and contribute to mental and substance use disorders across the life-span.3,25 Trauma survivors have powerfully and systematically documented their paths to recovery. The convergence of the trauma survivor’s perspective with research and clinical work has underscored the central role of traumatic experiences in the lives of people with mental and substance use conditions. The connection between trauma and these conditions offers a potential explanatory model for what has happened to individuals, both children and adults, who come to the attention of the behavioral health and other service systems.25,27 People with traumatic experiences, however, do not show up only in behavioral health systems. Responses to these experiences often manifest in behaviors or conditions that result in involvement with the child welfare and the criminal and juvenile justice system or in difficulties in the education, employment or primary care system Assignment: Posttraumatic Stress Disorder. Recently, there has also been a focus on individuals in the military and increasing rates of posttraumatic stress disorders.28,29,30,31 page 6 With the growing understanding of the pervasiveness of traumatic experience and responses, a growing number of clinical interventions for trauma responses have been developed. Federal research agencies, academic institutions and practice-research partnerships have generated empirically-supported interventions. In SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP) alone there are over 15 interventions focusing on the treatment or screening for trauma. These interventions have been integrated into the behavioral health treatment care delivery system; however, from the voice of trauma survivors, it has become clear that these clinical interventions are not enough. Building on lessons learned from SAMHSA’s Women, Co-Occurring Disorders and Violence Study; SAMHSA’s National Child Traumatic Stress Network; and SAMHSA’s National Center for Trauma-Informed Care and Alternatives to Seclusion and Restraints, among other developments in the field, it became clear that the organizational climate and conditions in which services are provided played a significant role in maximizing the outcomes of interventions and contributing to the healing and recovery of the people being served. SAMHSA’s National Center for Trauma-Informed Care has continued to advance this effort, starting first in the behavioral health sector, but increasingly responding to technical assistance requests for organizational change in the criminal justice, education, and primary care sectors. FEDERAL, STATE AND LOCAL LEVEL TRAUMA-FOCUSED ACTIVITIES The increased understanding of the pervasiveness of trauma and its connections to physical and behavioral health and well-being, have propelled a growing number of organizations and service systems to explore ways to make their services more responsive to people who have experienced trauma. This has been happening in state and local systems and federal agencies. States are elevating a focus on trauma. For example, Oregon Health Authority is looking at different types of trauma across the age span and different population groups. Maine’s “Thrive Initiative” incorporates a trauma-informed care focus in their children’s systems of care. New York is introducing a trauma-informed initiative in the juvenile justice system. Missouri is exploring a trauma-informed approach for their adult mental health system. In Massachusetts, the Child Trauma Project is focused on taking trauma-informed care statewide in child welfare practice. In Connecticut the Child Health and Development Institute with the state Department of Children and Families is building a trauma-informed system of care throughout the state through policy and workforce development. SAMHSA has supported the further development of trauma-informed approaches through its Mental Health Transformation Grant program directed to State and local governments. Increasing examples of local level efforts are being documented. For example, the City of Tarpon Springs in Florida has taken significant steps in becoming a trauma-informed community. The city made it its mission to promote a widespread awareness of the costly effects of personal adversity upon the wellbeing of the community. The Family Policy Council in Washington State convened groups to focus on the impact of adverse childhood experiences on the health and well-being of its local communities and tribal communities. Philadelphia held a summit to further its understanding of the impact of trauma and violence on the psychological and physical health of its communities. SAMHSA continues its support of grant programs that specifically address trauma. At the federal level, SAMHSA continues its support of grant programs that specifically address trauma and technical assistance centers that focus on prevention, treatment and recovery from trauma. page 7 Other federal agencies have increased their focus primary care on how to address trauma issues in on trauma. The Administration on Children Youth health care for women. The Department of Labor is and Families (ACYF) has focused on the complex examining trauma and the workplace through a federal trauma of children in the child welfare system and interagency workgroup. The Department of Defense is how screening and assessing for severity of trauma honing in on prevention of sexual violence and trauma and linkage with trauma treatments can contribute in the military. to improved well-being for these youth. In a joint As multiple federal agencies representing varied effort among ACYF, SAMHSA and the Centers for sectors have recognized the impact of traumatic Medicare and Medicaid Services (CMS), the three experiences on the children, adults, and families agencies developed and issued through the CMS they serve, they have requested collaboration with State Directors’ mechanism, a letter to all State Child SAMHSA in addressing these issues. The widespread Welfare Administrators, Mental Health Commissioners, recognition of the impact of trauma and the burgeoning Single State Agency Directors for Substance Abuse interest in developing capacity to respond through and State Medicaid Directors discussing trauma, trauma-informed approaches compelled SAMHSA its impact on children, screening, assessment and to revisit its conceptual framework and approach treatment interventions and strategies for paying to trauma, as well as its applicability not only to for such care. The Office of Juvenile Justice and behavioral health but also to other related fields. Delinquency Prevention has specific recommendations to address trauma in their Children Exposed to Violence Initiative. The Office of Women’s Health has developed a curriculum to train providers in SAMHSA’s Concept of Trauma Decades of work in the field of trauma have generated multiple definitions of trauma. Combing through this work, SAMHSA developed an inventory of trauma definitions and recognized that there were subtle nuances and differences in these definitions. Desiring a concept that could be shared among its constituencies — practitioners, researchers, and trauma survivors, SAMHSA turned to its expert panel to help craft a concept that would be relevant to public health agencies and service systems. SAMHSA aims to provide a viable framework that can be used to support people receiving services, communities, and stakeholders in the work they do. A review of the existing definitions and discussions of the expert panel generated the following concept: Individual trauma results from 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. page 8 THE THREE “E’S” OF TRAUMA: EVENT(S), EXPERIENCE OF EVENT(S), AND EFFECT shattering a person’s trust and leaving them feeling alone. Often, abuse of children and domestic violence Events are accompanied by threats that lead to silencing and and circumstances may include the actual fear of reaching out for help. or extreme threat of physical or psychological harm (i.e. natural disasters, violence, etc.) or severe, How the event is experienced may be linked to a life-threatening neglect for a child that imperils healthy range of factors including the individual’s cultural development. These events and circumstances may beliefs (e.g., the subjugation of women and the occur as a single occurrence or repeatedly over experience of domestic violence), availability of time. This element of SAMHSA’s concept of trauma social supports (e.g., whether isolated or embedded is represented in the fifth version of the Diagnostic in a supportive family or community structure), or to and Statistical Manual of Mental Disorders (DSM-5), the developmental stage of the individual (i.e., an which requires all conditions classified as “trauma and individual may understand and experience events stressor-related disorders” to include exposure to a differently at age five, fifteen, or fifty).1 traumatic or stressful event as a diagnostic criterion. The long-lasting adverse effects of the event are a The individual’s experience of these events or critical component of trauma. These adverse effects circumstances helps to determine whether it may occur immediately or may have a delayed onset. is a traumatic event. A particular event may be The duration of the effects can be short to long term. experienced as traumatic for one individual and not In some situations, the individual may not recognize for another (e.g., a child removed from an abusive the connection between the traumatic events and home experiences this differently than their sibling; the effects. Examples of adverse effects include an one refugee may experience fleeing one’s country individual’s inability to cope with the normal stresses differently from another refugee; one military and strains of daily living; to trust and benefit from veteran may experience deployment to a war zone relationships; to manage cognitive processes, such as traumatic while another veteran is not similarly as memory, attention, thinking; to regulate behavior; affected). How the individual labels, assigns meaning or to control the expression of emotions. In addition to, and is disrupted physically and psychologically to these more visible effects, there may be an altering by an event will contribute to whether or not it is of one’s neurobiological make-up and ongoing experienced as traumatic. Traumatic events by their health and well-being. Advances in neuroscience very nature set up a power differential where one and an increased understanding of the interaction entity (whether an individual, an event, or a force of of neurobiological and environmental factors have nature) has power over another. They elicit a profound documented the effects of such threatening events.1,3 question of “why me?” The individual’s experience of Traumatic effects, which may range from hyperthese events or circumstances is shaped in the context vigilance or a constant state of arousal, to numbing of this powerlessness and questioning. Feelings of or avoidance, can eventually wear a person down, humiliation, guilt, shame, betrayal, or silencing often physically, mentally, and emotionally. Survivors of shape the experience of the event. When a person trauma have also highlighted the impact of these experiences physical or sexual abuse, it is often events on spiritual beliefs and the capacity to make accompanied by a sense of humiliation, which can meaning of these experiences. lead the person to feel as though they are bad or dirty, leading to a sense of self blame, shame and guilt. In cases of war or natural disasters, those who survived the traumatic event may blame themselves for surviving when others did not. Abuse by a trusted caregiver frequently gives rise to feelings of betrayal, page 9 SAMHSA’s Trauma-Informed Approach: Key Assumptions and Principles Trauma researchers, practitioners and survivors have recognized that the understanding of trauma and trauma-specific interventions is not sufficient to optimize outcomes for trauma survivors nor to influence how service systems conduct their business. The context in which trauma is addressed or treatments deployed contributes to the outcomes for the trauma survivors, the people receiving services, and the individuals staffing the systems. Referred to variably as “trauma-informed care” or “traumainformed approach” this framework is regarded as essential to the context of care.22,32,33 SAMHSA’s concept of a trauma-informed approach is grounded in a set of four assumptions and six key principles. A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization. A trauma informed approach is distinct from traumaspecific services or trauma systems. A trauma informed approach is inclusive of trauma-specific interventions, whether assessment, treatment or recovery supports, yet it also incorporates key trauma principles into the organizational culture. Referred to variably as “traumainformed care” or “trauma-informed approach” this framework is regarded as essential to the context of care. THE FOUR “R’S: KEY ASSUMPTIONS IN A TRAUMA-INFORMED APPROACH In a trauma-informed approach, all people at all levels of the organization or system have a basic realization about trauma and understand how trauma can affect families, groups, organizations, and communities as well as individuals. People’s experience and behavior are understood in the context of coping strategies designed to survive adversity and overwhelming circumstances, whether these occurred in the past (i.e., a client dealing with prior child abuse), whether they are currently manifesting (i.e., a staff member living with domestic violence in the home), or whether they are related to the emotional distress that results in hearing about the firsthand experiences of another (i.e., secondary traumatic stress experienced by a direct care professional).There is an understanding that trauma plays a role in mental and substance use disorders and should be systematically addressed in prevention, treatment, and recovery settings. Similarly, there is a realization that trauma is not confined to the behavioral health specialty service sector, but is integral to other systems (e.g., child welfare, criminal justice, primary health care, peer–run and community organizations) and is often a barrier to effective outcomes in those systems as well. People in the organization or system are also able to recognize the signs of trauma. These signs may be gender, age, or setting-specific and may be manifest by individuals seeking or providing services in these settings. Trauma screening and assessment assist in the recognition of trauma, as do workforce development, employee assistance, and supervision practices Assignment: Posttraumatic Stress Disorder. page 10 The program, organization, or system responds by applying the principles of a trauma-informed approach to all areas of functioning. The program, organization, or system integrates an understanding that the experience of traumatic events impacts all people involved, whether directly or indirectly. Staff in every part of the organization, from the person who greets clients at the door to the executives and the governance board, have changed their language, behaviors and policies to take into consideration the experiences of trauma among children and adult users of the services and among staff providing the services. This is accomplished through staff training, a budget that supports this ongoing training, and leadership that realizes the role of trauma in the lives of their staff and the people they serve. The organization has practitioners trained in evidence-based trauma practices. Policies of the organization, such as mission statements, staff handbooks and manuals promote a culture based on beliefs about resilience, recovery, and healing from trauma. For instance, the agency’s mission may include an intentional statement on the organization’s commitment to promote trauma recovery; agency policies demonstrate a commitment to incorporating perspectives of people served through the establishment of client advisory boards or inclusion of people who have received services on the agency’s board of directors; or agency training includes resources for mentoring supervisors on helping staff address secondary traumatic stress. The organization is committed to providing a physically and psychologically safe environment. Leadership ensures that staff work in an environment that promotes trust, fairness and transparency. The program’s, organization’s, or system’s response involves a universal precautions approach in which one expects the presence of trauma in lives of individuals being served, ensuring not to replicate it. A trauma-informed approach seeks to resist re-traumatization of clients as well as staff. Organizations often inadvertently create stressful or toxic environments that interfere with the recovery of clients, the well-being of staff and the fulfillment of the organizational mission.27 Staff who work within a trauma-informed environment are taught to recognize how organizational practices may trigger painful memories and re-traumatize clients with trauma histories. For example, they recognize that using restraints on a person who has been sexually abused or placing a child who has been neglected and abandoned in a seclusion room may be re-traumatizing and interfere with healing and recovery. SIX KEY PRINCIPLES OF A TRAUMAINFORMED APPROACH A trauma-informed approach reflects adherence to six key principles rather than a prescribed set of practices or procedures. These principles may be generalizable across multiple types of settings, although terminology and application may be setting- or sector-specific. SIX KEY PRINCIPLES OF A TRAUMA-INFORMED APPROACH 1. Safety 2. Trustworthiness and Transparency 3. Peer Support 4. Collaboration and Mutuality 5. Empowerment, Voice and Choice 6. Cultural, Historical, and Gender Issues From SAMHSA’s perspective, it is critical to promote the linkage to recovery and resilience for those individuals and families impacted by trauma. Consistent with SAMHSA’s definition of recovery, services and supports that are trauma-informed build on the best evidence available and consumer and family engagement, empowerment, and collaboration. page 11 The six key principles fundamental to a trauma-informed approach include:24,36 1. Safety: Throughout the organization, staff and the 5. Empowerment, Voice and Choice: Throughout people they serve, whether children or adults, feel the organization and among the clients served, physically and psychologically safe; the physical individuals’ strengths and experiences are setting is safe and interpersonal interactions recognized and built upon. The organization promote a sense of safety. Understanding safety as fosters a belief in the primacy of the people served, defined by those served is a high priority. in resilience, and in the ability of individuals, organizations, and communities to heal and promote recovery from trauma. The organization 2. Trustworthiness and Transparency: understands that the experience of trauma may Organizational operations and decisions are be a unifying aspect in the lives of those who run conducted with transparency with the goal of the organization, who provide the services, and/ building and maintaining trust with clients and family or who come to the organization for assistance members, among staff, and others involved in the and support. As such, operations, workforce organization. development and services are organized to foster empowerment for staff and clients alike. 3. Peer Support: Peer support and mutual self-help Organizations understand the importance of power are key vehicles for establishing safety and hope, differentials and ways in which clients, historically, building trust, enhancing collaboration, and utilizing have been diminished in voice and choice and their stories and lived experience to promote are often recipients of coercive treatment. Clients recovery and healing. The term “Peers” refers to are supported in shared decision-making, choice, individuals with lived experiences of trauma, or in and goal setting to determine the plan of action the case of children this may be family members of they need to heal and move forward. They are children who have experienced traumatic events supported in cultivating self-advocacy skills. Staff and are key caregivers in their recovery. Peers have are facilitators of recovery rather than controllers also been referred to as “trauma survivors.” of recovery.34 Staff are empowered to do their work as well as possible by adequate organizational support. This is a parallel process as staff need to 4. Collaboration and Mutuality: Importance is feel safe, as much as people receiving services. placed on partnering and the leveling of power differences between staff and clients and among organizational staff from clerical and housekeeping 6. Cultural, Historical, and Gender Issues: personnel, to professional staff to administrators, The organization actively moves past cultural demonstrating that healing happens in relationships stereotypes and biases (e.g. based on race, and in the meaningful sharing of power and ethnicity, sexual orientation, age, religion, genderdecision-making. The organization recognizes that identity, geography, etc.); offers, access to gender everyone has a role to play in a trauma-informed responsive services; leverages the healing value approach. As one expert stated: “one does not have of traditional cultural connections; incorporates to be a therapist to be therapeutic.”12 policies, protocols, and processes that are responsive to the racial, ethnic and cultural needs of individuals served; and recognizes and addresses historical trauma. page 12 Guidance for Implementing a Trauma-Informed Approach Developing a trauma-informed approach requires change at multiples levels of an organization and systematic alignment with the six key principles described above. The guidance provided here builds upon the work of Harris and Fallot and in conjunction with the key principles, provides a starting point for developing an organizational trauma-informed approach.20 While it is recognized that not all public institutions and service sectors attend to trauma as an aspect of how they conduct business, understanding the role of trauma and a trauma-informed approach may help them meet their goals and objectives. Organizations, across service-sectors and systems, are encouraged to examine how a trauma-informed approach will benefit all stakeholders; to conduct a trauma-informed organizational assessment and change process; and to involve clients and staff at all levels in the organizational development process. The guidance for implementing a trauma-informed approach is presented in the ten domains described below. This is not provided as a “checklist” or a prescriptive step-by-step process. These are the domains of organizational change that have appeared both in the organizational change management literature and among models for establishing trauma-informed care.35,36,37,38 What makes it unique to establishing a trauma-informed organizational approach is the cross-walk with the key principles and trauma-specific content. TEN IMPLEMENTATION DOMAINS 1. Governance and Leadership 2. Policy 3. Physical Environment 4. Engagement and Involvement 5. Cross Sector Collaboration 6. Screening, Assessment, Treatment Services 7. Training and Workforce Development 8. Progress Monitoring and Quality Assurance 9. Financing 10. Evaluation page 13 GOVERNANCE AND LEADERSHIP: The leadership CROSS SECTOR COLLABORATION: Collaboration and governance of the organization support and invest across sectors is built on a shared understanding of in implementing and sustaining a trauma-informed trauma and principles of a trauma-informed approach. approach; there is an identified point of responsibility While a trauma focus may not be the stated mission of within the organization to lead and oversee this work; various service sectors, understanding how awareness and there is inclusion of the peer voice. A champion of trauma can help or hinder achievement of an of this approach is often needed to initiate a system organization’s mission is a critical aspect of building change process. collaborations. People with significant trauma histories often present with a complexity of needs, crossing POLICY: There are written policies and protocols various service sectors. Even if a mental health establishing a trauma-informed approach as clinician is trauma-informed, a referral to a traumaan essential part of the organizational mission. insensitive program could then undermine the Organizational procedures and cross agency progress of the individual. protocols, including working with community-based agencies, reflect trauma-informed principles. This SCREENING, ASSESSMENT, AND TREATMENT approach must be “hard-wired” into practices and SERVICES: Practitioners use and are trained in procedures of the organization, not solely relying interventions based on the best available empirical on training workshops or a well-intentioned leader. evidence and science, are culturally appropriate, and reflect principles of a trauma-informed approach. PHYSICAL ENVIRONMENT OF THE Trauma screening and assessment are an essential ORGANIZATION: The organization ensures that the part of the work. Trauma-specific interventions are physical environment promotes a sense of safety acceptable, effective, and available for individuals and collaboration. Staff working in the organization and families seeking services. When trauma-specific and individuals being served must experience the services are not available within the organization, setting as safe, inviting, and not a risk to their physical there is a trusted, effective referral system in place or psychological safety. The physical setting also that facilitates connecting individuals with appropriate supports the collaborative aspect of a trauma informed trauma treatment. approach through openness, transparency, and shared spaces. TRAINING AND WORKFORCE DEVELOPMENT: On-going training on trauma and peer-support are ENGAGEMENT AND INVOLVEMENT OF PEOPLE essential. The organization’s human resource system IN RECOVERY, TRAUMA SURVIVORS, PEOPLE incorporates trauma-informed principles in hiring, RECEIVING SERVICES, AND FAMILY MEMBERS supervision, staff evaluation; procedures are in place RECEIVING SERVICES: These groups have to support staff with trauma histories and/or those significant involvement, voice, and meaningful experiencing significant secondary traumatic stress choice at all levels and in all areas of organizational or vicarious trauma, resulting from exposure to and functioning (e.g., program design, implementation, working with individuals with complex trauma. service delivery, quality assurance, cultural competence, access to trauma-informed peer PROGRESS MONITORING AND QUALITY support, workforce development, and evaluation.) ASSURANCE: There is ongoing assessment, This is a key value and aspect of a trauma-informed tracking, and monitoring of trauma-informed principles approach that differentiates it from the usual and effective use of evidence-based trauma specific approaches to services and care. screening, assessments and treatment. page 14 FINANCING: Financing structures are designed to key principles of a trauma-informed approach. Many support a trauma-informed approach which includes of these questions and concepts were adapted from resources for: staff training on trauma, key principles the work of Fallot and Harris, Henry, Black-Pond, of a trauma-informed approach; development of Richardson, & Vandervort, Hummer and Dollard, and appropriate and safe facilities; establishment of Penney and Cave.39, 40, 41,42 peer-support; provision of evidence-supported trauma While the language in the chart may seem more screening, assessment, treatment, and recovery familiar to behavioral health settings, organizations supports; and development of trauma-informed cross- across systems are encouraged to adapt the sample agency collaborations. questions to best fit the needs of the agency, staff, EVALUATION: Measures and evaluation designs used and individuals being served. For example, a to evaluate service or program implementation and juvenile justice agency may want to ask how it would effectiveness reflect an understanding of trauma and incorporate the principle of safety when examining appropriate trauma-oriented research instruments. its physical environment. A primary care setting may explore how it can use empowerment, voice, and To further guide implementation, the chart on the next choice when developing policies and procedures to page provides sample questions in each of the ten provide trauma-informed services (e.g. explaining step domains to stimulate change-focused discussion. by step a potentially invasive procedure to a patient at The questions address examples of the work to be an OBGYN office). done in any particular domain yet also reflect the six SAMPLE QUESTIONS TO CONSIDER WHEN IMPLEMENTING A TRAUMA-INFORMED APPROACH KEY PRINCIPLES Safety Trustworthiness Peer Support Collaboration Empowerment, Cultural, and and Mutuality Voice, and Historical, and Transparency Choice Gender Issues 10 IMPLEMENTATION Governance and Leadership DOMAINS • How does agency leadership communicate its support and guidance for implementing a trauma-informed approach? • How do the agency’s mission statement and/or written policies and procedures include a commitment to providing trauma-informed services and supports? • How do leadership and governance structures demonstrate support for the voice and participation of people using their services who have trauma histories? Policy • • • • • How do the agency’s written policies and procedures include a focus on trauma and issues of safety and confidentiality? How do the agency’s written policies and procedures recognize the pervasiveness of trauma in the lives of people using services, and express a commitment to reducing re-traumatization and promoting well-being and recovery? How do the agency’s staffing policies demonstrate a commitment to staff training on providing services and supports that are culturally relevant and trauma-informed as part of staff orientation and in-service training? How do human resources policies attend to the impact of working with people who have experienced trauma? What policies and procedures are in place for including trauma survivors/people receiving services and peer supports in meaningful and significant roles in agency planning, governance, policy-making, services, and evaluation? page 15 SAMPLE QUESTIONS TO CONSIDER WHEN IMPLEMENTING A TRAUMA-INFORMED APPROACH (continued) 10 IMPLEMENTA Physical Environment TION DOMAINS continued • How does the physical environment promote a sense of safety, calming, and de-escalation for clients and staff? • In what ways do staff members recognize and address aspects of the physical environment that may be re-traumatizing, and work with people on developing strategies to deal with this? • How has the agency provided space that both staff and people receiving services can use to practice self-care? • How has the agency developed mechanisms to address gender-related physical and emotional safety concerns (e.g., gender-specific spaces and activities). Engagement • How do people with lived experience have the opportunity to provide feedback to the and organization on quality improvement processes for better engagement and services? Involvement • • • • How do staff members keep people fully informed of rules, procedures, activities, and schedules, while being mindful that people who are frightened or overwhelmed may have a difficulty processing information? How is transparency and trust among staff and clients promoted? What strategies are used to reduce the sense of power differentials among staff and clients? How do staff members help people to identify strategies that contribute to feeling comforted and empowered? Cross Sector • Is there a system of communication in place with other partner agencies working with the Collaboration • • • individual receiving services for making trauma-informed decisions? Are collaborative partners trauma-informed? How does the organization identify community providers and referral agencies that have experience delivering evidence-based trauma services? What mechanisms are in place to promote cross-sector training on trauma and traumainformed approaches? Screening, • Is an individual’s own definition of emotional safety included in treatment plans? Assessment, • Is timely trauma-informed screening and assessment available and accessible to individuals Treatment receiving services? Services • • • • • Does the organization have the capacity to provide trauma-specific treatment or refer to appropriate trauma-specific services? How are peer supports integrated into the service delivery approach? How does the agency address gender-based needs in the context of trauma screening, assessment, and treatment? For instance, are gender-specific trauma services and supports available for both men and women? Do staff members talk with people about the range of trauma reactions and work to minimize feelings of fear or shame and to increase self-understanding? How are these trauma-specific practices incorporated into the organization’s ongoing operations? page 16 SAMPLE QUESTIONS TO CONSIDER WHEN IMPLEMENTING A TRAUMA-INFORMED APPROACH (continued) 10 IMPLEMENTATION DOMAINS continued Training and Workforce Development • How does the agency address the emotional stress that can arise when working with individuals who have had traumatic experiences? • How does the agency support training and workforce development for staff to understand and increase their trauma knowledge and interventions? • How does the organization ensure that all staff (direct care, supervisors, front desk and reception, support staff, housekeeping and maintenance) receive basic training on trauma, its impact, and strategies for trauma-informed approaches across the agency and across personnel functions? • How does workforce development/staff training address the ways identity, culture, community, and oppression can affect a person’s experience of trauma, access to supports and resources, and opportunities for safety? • How does on-going workforce development/staff training provide staff supports in developing the knowledge and skills to work sensitively and effectively with trauma survivors. • What types of training and resources are provided to staff and supervisors on incorporating trauma-informed practice and supervision in their work? • What workforce development strategies are in place to assist staff in working with peer supports and recognizing the value of peer support as integral to the organization’s workforce? Progress • Is there a system in place that monitors the agency’s progress in being trauma-informed? Monitoring • Does the agency solicit feedback from both staff and individuals receiving services? and Quality • What strategies and processes does the agency use to evaluate whether staff members feel Assurance safe and valued at the agency? • How does the agency incorporate attention to culture and trauma in agency operations and quality improvement processes? • What mechanisms are in place for information collected to be incorporated into the agency’s quality assurance processes and how well do those mechanisms address creating accessible, culturally relevant, trauma-informed services and supports? Financing • How does the agency’s budget include funding support for ongoing training on trauma and trauma-informed approaches for leadership and staff development? • What funding exists for cross-sector training on trauma and trauma-informed approaches? • What funding exists for peer specialists? • How does the budget support provision of a safe physical environment? Evaluation • How does the agency conduct a trauma-informed organizational assessment or have measures or indicators that show their level of trauma-informed approach? • How does the perspective of people who have experienced trauma inform the agency performance beyond consumer satisfaction survey? • What processes are in place to solicit feedback from people who use services and ensure anonymity and confidentiality? • What measures or indicators are used to assess the organizational progress in becoming trauma-informed? page 17 Next Steps: Trauma in the Context of Community Delving into the work on community trauma is beyond the scope of this document and will be done in the next phase of this work. However, recognizing that many individuals cope with their trauma in the safe or not-so safe space of their communities, it is important to know how communities can support or impede the healing process. Trauma does not occur in a vacuum. Individual trauma occurs in a context of community, whether the community is defined geographically as in neighborhoods; virtually as in a shared identity, ethnicity, or experience; or organizationally, as in a place of work, learning, or worship. How a community responds to individual trauma sets the foundation for the impact of the traumatic event, experience, and effect. Communities that provide a context of understanding and self-determination may facilitate the healing and recovery process for the individual. Alternatively, communities that avoid, overlook, or misunderstand the impact of trauma may often be re-traumatizing and interfere with the healing process. Individuals can be re-traumatized by the very people whose intent is to be helpful. This is one way to understand trauma in the context of a community. A second and equally important perspective on trauma and communities is the understanding that communities as a whole can also experience trauma. Just as with the trauma of an individual or family, a community may be subjected to a communitythreatening event, have a shared experience of the event, and have an adverse, prolonged effect. Whether the result of a natural disaster (e.g., a flood, a hurricane or an earthquake) or an event or circumstances inflicted by one group on another (e.g., usurping homelands, forced relocation, servitude, or mass incarceration, ongoing exposure to violence in the community), the resulting trauma is often transmitted from one generation to the next in a pattern often referred to as historical, community, or intergenerational trauma. Communities can collectively react to trauma in ways that are very similar to the ways in which individuals respond. They can become hyper-vigilant, fearful, or they can be re-traumatized, triggered by circumstances resembling earlier trauma. Trauma can be built into cultural norms and passed from generation to generation. Communities are often profoundly shaped by their trauma histories. Making sense of the trauma experience and telling the story of what happened using the language and framework of the community is an important step toward healing community trauma. Many people who experience trauma readily overcome it and continue on with their lives; some become stronger and more resilient; for others, the trauma is overwhelming and their lives get derailed. Some may get help in formal support systems; however, the vast majority will not. The manner in which individuals and families can mobilize the resources and support of their communities and the degree to which the community has the capacity, knowledge, and skills to understand and respond to the adverse effects of trauma has significant implications for the well-being of the people in their community. Conclusion As the concept of a trauma-informed approach has become a central focus in multiple service sectors, SAMHSA desires to promote a shared understanding of this concept. The working definitions, key principles, and guidance presented in this document represent a beginning step toward clarifying the meaning of this concept. This document builds upon the extensive work of researchers, practitioners, policymakers, and people with lived experience in the field. A standard, unified working concept will serve to advance the understanding of trauma and a trauma-informed approach for public institutions and service sectors. page 18 Assignment: Posttraumatic Stress Disorder.

 

Endnotes

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