A TREATMENT IMPROVEMENT PROTOCOL 

Trauma-Informed Care in 

Behavioral Health Services 

TIP 57 
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

1 Choke Cherry Road

Rockville, MD 20857

A TREATMENT IMPROVEMENT PROTOCOL 

Trauma-Informed Care in 


Behavioral Health Services
 

TIP 57 
Trauma-Informed Care in Behavioral Health Services 

Acknowledgments 

This publication was produced under contract numbers 270-99-7072, 270-04-7049, and 270­

09-0307 by the Knowledge Application Program (KAP), a Joint Venture of The CDM Group,

Inc., and JBS International, Inc., for the Substance Abuse and Mental Health Services 

Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). Andrea

Kopstein, Ph.D., M.P.H., Karl D. White, Ed.D., and Christina Currier served as the 

Contracting Officer’s Representatives. 

Disclaimer 

The views, opinions, and content expressed herein are the views of the consensus panel members 

and do not necessarily reflect the official position of SAMHSA or HHS. No official support of

or endorsement by SAMHSA or HHS for these opinions or for the instruments or resources 

described are intended or should be inferred. The guidelines presented should not be considered

substitutes for individualized client care and treatment decisions. 

Public Domain Notice 

All materials appearing in this volume except those taken directly from copyrighted sources are

in the public domain and may be reproduced or copied without permission from SAMHSA or

the authors. Citation of the source is appreciated. However, this publication may not be 

reproduced or distributed for a fee without the specific, written authorization of the Office of 

Communications, SAMHSA, HHS. 

Electronic Access and Copies of Publication 

This publication may be ordered or downloaded from SAMHSA’s Publications Ordering Web

page at http://store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726­

4727) (English and Español). 

Recommended Citation 

Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in 

Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication

No. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 2014. 

Originating Office 

Quality Improvement and Workforce Development Branch, Division of Services Improvement,

Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services 

Administration, 1 Choke Cherry Road, Rockville, MD 20857. 

HHS Publication No. (SMA) 14-4816 

First Printed 2014 

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.................................................................... 

............................................................................... 

61


Sequence of Trauma Reactions................................................................................................ 60


Common Experiences and Responses to Trauma

Subthreshold Trauma-Related Symptoms 75


Specific Trauma-Related Psychological Disorders................................................................... 77


Other Trauma-Related and Co-Occurring Disorders............................................................. 85
 

Contents
 

Consensus Panel............................................................................................................. vii
 

KAP Expert Panel and Federal Government Participants ...................................................ix
 

What Is a TIP? .................................................................................................................xi
 

Foreword....................................................................................................................... xiii
 

How This TIP Is Organized ............................................................................................ xv
 

Terminology.............................................................................................................................xvi
 

PART 1: A PRACTICAL GUIDE FOR THE PROVISION OF BEHAVIORAL
 

HEALTH SERVICES ..................................................................................................... 1
 

Chapter 1—Trauma-Informed Care: A Sociocultural Perspective ....................................... 3
 

Scope of the TIP........................................................................................................................ 4


Intended Audience..................................................................................................................... 4
 

Before You Begin ....................................................................................................................... 4


Structure of the TIP................................................................................................................... 6
 

What Is Trauma?........................................................................................................................ 7
 

Trauma Matters in Behavioral Health Services......................................................................... 7
 

Trauma-Informed Intervention and Treatment Principles...................................................... 11


As You Proceed ........................................................................................................................ 32
 

Chapter 2—Trauma Awareness ........................................................................................33
 

Types of Trauma....................................................................................................................... 33


Characteristics of Trauma ........................................................................................................ 46
 

Individual and Sociocultural Features...................................................................................... 52
 

Chapter 3—Understanding the Impact of Trauma .............................................................59
 

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Strategy #8: Develop Policies and Procedures To Ensure Trauma-Informed Practices and 
 

To Prevent Retraumatization............................................................................................. 166
 

Concluding Note.................................................................................................................... 110
 

Trauma-Informed Care in Behavioral Health Services 

Chapter 4—Screening and Assessment .............................................................................91
 

............................. 99


Screening and Assessment ....................................................................................................... 92


Barriers and Challenges to Trauma-Informed Screening and Assessment 

Cross-Cultural Screening and Assessment............................................................................ 103


Choosing Instruments............................................................................................................ 104


Trauma-Informed Screening and Assessment....................................................................... 106


Chapter 5—Clinical Issues Across Services.....................................................................111
 

Trauma-Informed Prevention and Treatment Objectives ..................................................... 111


Treatment Issues .................................................................................................................... 127
 

Making Referrals to Trauma-Specific Services...................................................................... 135
 

Chapter 6—Trauma-Specific Services ............................................................................137
 

Introduction ........................................................................................................................... 137
 

Trauma-Specific Treatment Models ...................................................................................... 139


Integrated Models for Trauma............................................................................................... 147


Emerging Interventions......................................................................................................... 153


Concluding Note.................................................................................................................... 155
 

PART 2: AN IMPLEMENTATION GUIDE FOR BEHAVIORAL HEALTH
 

PROGRAM ADMINISTRATORS..............................................................................157
 

Chapter 1—Trauma-Informed Organizations ................................................................159
 

Strategy #1: Show Organizational and Administrative Commitment to TIC...................... 161


Strategy #2: Use Trauma-Informed Principles in Strategic Planning ................................... 162


Strategy #3: Review and Update Vision, Mission, and Value Statements............................. 162


Strategy #4: Assign a Key Staff Member To Facilitate Change ............................................ 163


Strategy #5: Create a Trauma-Informed Oversight Committee ........................................... 163


Strategy #6: Conduct an Organizational Self-Assessment of Trauma-Informed Services ... 164


Strategy #7: Develop an Implementation Plan...................................................................... 164


Strategy #9: Develop a Disaster Plan..................................................................................... 166


Strategy #10: Incorporate Universal Routine Screenings ...................................................... 167


Strategy #11: Apply Culturally Responsive Principles .......................................................... 167


Strategy #12: Use Science-Based Knowledge........................................................................ 169


Strategy #13: Create a Peer-Support Environment............................................................... 169


Strategy #14: Obtain Ongoing Feedback and Evaluations ................................................... 170


Strategy #15: Change the Environment To Increase Safety.................................................. 171


Strategy #16: Develop Trauma-Informed Collaborations..................................................... 171
 

Chapter 2—Building a Trauma-Informed Workforce ......................................................173
 

Introduction ........................................................................................................................... 173
 

Workforce Recruitment, Hiring, and Retention.................................................................... 174
 

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Contents 

......................................................................... 181


Training in TIC ..................................................................................................................... 177


Trauma-Informed Counselor Competencies

Counselor Responsibilities and Ethics................................................................................... 182


Clinical Supervision and Consultation .................................................................................. 191


Secondary Traumatization ..................................................................................................... 193


Counselor Self-Care............................................................................................................... 205
 

APPENDICES.............................................................................................................215
 

Appendix A—Bibliography ............................................................................................215
 

Appendix B—Trauma Resource List...............................................................................247
 

Appendix C—Historical Account of Trauma...................................................................267
 

Appendix D—Screening and Assessment Instruments ....................................................271
 

Appendix E—Consumer Materials.................................................................................285
 

Appendix F—Organizational Assessment for Trauma-Informed Care..............................287
 

Appendix G—Resource Panel ........................................................................................289
 

Appendix H—Field Reviewers .......................................................................................293
 

Appendix I—Cultural Competence and Diversity Network Participants ..........................299
 

Appendix J—Acknowledgments.....................................................................................300
 

EXHIBITS
 

Exhibit 1.1-1: TIC Framework in Behavioral Health Services—Sociocultural Perspective ..... 6


Exhibit 1.1-2: A Social-Ecological Model for Understanding Trauma and Its Effects.......... 15


Exhibit 1.1-3: Understanding the Levels Within the Social-Ecological Model of


Trauma and Its Effects......................................................................................................... 16
 

Exhibit 1.1-4: Cross-Cutting Factors of Culture..................................................................... 26


Exhibit 1.2-1: Trauma Examples ............................................................................................. 35


Exhibit 1.3-1: Immediate and Delayed Reactions to Trauma ................................................. 62


Exhibit 1.3-2: Cognitive Triad of Traumatic Stress................................................................. 67


Exhibit 1.3-3: DSM-5 Diagnostic Criteria for ASD .............................................................. 78


Exhibit 1.3-4: DSM-5 Diagnostic Criteria for PTSD............................................................ 82


Exhibit 1.3-5: ICD-10 Diagnostic Criteria for PTSD ........................................................... 85


Exhibit 1.3-6: Important Treatment Facts About PTSD and Substance Use Disorders........ 89


Exhibit 1.4-1: Grounding Techniques ..................................................................................... 98


Exhibit 1.4-2: Key Areas of Trauma Screening and Assessment........................................... 105


Exhibit 1.4-3: SLE Screening................................................................................................ 107


Exhibit 1.4-4: STaT: Intimate Partner Violence Screening Tool .......................................... 108


Exhibit 1.4-5: PC-PTSD Screen........................................................................................... 108
 

Exhibit 1.4-6: The SPAN ...................................................................................................... 108
 

Exhibit 1.4-7: The PTSD Checklist...................................................................................... 109
 

Exhibit 1.4-8: Resilience Scales ............................................................................................. 110
 

Exhibit 1.5-1: OBSERVATIONS: A Coping Strategy......................................................... 119
 

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Trauma-Informed Care in Behavioral Health Services 

Exhibit 2.1-1: TIC Planning Guidelines............................................................................... 165


Exhibit 2.2-1: Clinical Practice Issues Relevant to Counselor Training in Trauma-


Informed Treatment Settings............................................................................................. 179


Exhibit 2.2-2: Guidelines for Training in Mental Health Interventions for Trauma­

................................. 183


Exposed Populations.......................................................................................................... 180


Exhibit 2.2-3: Trauma-Informed Counselor Competencies Checklist 

Exhibit 2.2-4: Sample Statement of the Client’s Right to Confidentiality From a


Client Bill of Rights........................................................................................................... 185


Exhibit 2.2-5: Green Cross Academy of Traumatology Ethical Guidelines for the 


Treatment of Clients Who Have Been Traumatized ........................................................ 186
 

Exhibit 2.2-6: Boundaries in Therapeutic Relationships....................................................... 189


Exhibit 2.2-7: Counselor Strategies To Prevent Secondary Traumatization ......................... 198


Exhibit 2.2-8: Secondary Traumatization Signs .................................................................... 199


Exhibit 2.2-9: ProQOL Scale ................................................................................................ 201


Exhibit 2.2-10: Your Scores on the ProQOL: Professional Quality of Life Screening......... 202


Exhibit 2.2-11: What Is My Score and What Does It Mean?.............................................. 203


Exhibit 2.2-12: Clinical Supervisor Guidelines for Addressing Secondary Traumatization....... 205


Exhibit 2.2-13: Comprehensive Self-Care Plan Worksheet.................................................. 208


Exhibit 2.2-14: Comprehensive Self-Care Plan Worksheet Instructions.............................. 209


Exhibit 2.2-15: The Ethics of Self-Care................................................................................ 210
 

vi 
 

 

 

 

 

 

 

 

Consensus Panel 

Note: Each panelist’s information reflects his or her affiliation at the time of the Consensus 

Panel meeting and may not reflect that person’s most current affiliation. 

Chair 

Lisa M. Najavits, Ph.D.

Research Psychologist

Veterans Affairs Boston Healthcare System

Professor of Psychiatry

Boston University School of Medicine

Boston, MA

Co-Chair 

Linda B. Cottler, Ph.D., M.P.H.

Professor of Epidemiology in Psychiatry

Department of Psychiatry

Washington University–St. Louis

St. Louis, MO 

Workgroup Leaders 

Stephanie S. Covington, Ph.D., LCSW,

MFCC 

Co-Director 

Center for Gender and Justice 

Institute for Relational Development

La Jolla, CA 

Margaret Cramer, Ph.D.

Clinical Psychologist/Clinical Instructor

Harvard Medical School 

Boston, MA 

Anne M. Herron, M.S.

Director 

Treatment Programming

New York State Office of Alcoholism and 

Substance Abuse Services 

Albany, NY 

Denise Hien, Ph.D.

Research Scholar 

Social Intervention Group

School of Social Work 

Columbia University

New York, NY 

Dee S. Owens, M.P.A.

Director 

Alcohol-Drug Information

Indiana University

Bloomington, IN 

Panelists 

Charlotte Chapman, M.S., LPC, CAC

Training Director

Division of Addiction Psychiatry

Mid-Atlantic Addiction Technology Transfer 

Center 

Virginia Commonwealth University 

Richmond, VA 

vii 
 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

Scott F. Coffey, Ph.D.

Associate Professor 

Department of Psychiatry and Human

Behavior 

University of Mississippi Medical Center

Jackson, MS 

Renee M. Cunningham-Williams, M.S.W.,

M.P.E., Ph.D.

Research Assistant/Professor of Social Work

Department of Psychiatry

Washington University 

St. Louis, MO 

Chad D. Emrick, Ph.D.

Administrative Director 

Substance Abuse Treatment Program

Denver VA Medical Center (116A1)

Denver, CO 

Charles R. Figley, Ph.D.

Professor 

Director of the Traumatology Institute

Florida State University

Tallahassee, FL 

Larry M. Gentilello, M.D., FACS

Professor and Chairman 

Division of Burn, Trauma, and Critical Care

University of Texas Southwestern Medical

School 

Dallas, TX 

Robert Grant, Ph.D.

Trauma Consultant 

Oakland, CA 

Anthony (Tony) Taiwai Ng, M.D.

Disaster Psychiatrist

Washington, DC 

Pallavi Nishith, Ph.D.

Associate Research Professor 

Center for Trauma 

Department of Psychology

University of Missouri–St. Louis

St. Louis, MO 

Joseph B. Stone, Ph.D., CACIII, ICADC

Program Manager and Clinical Supervisor

Confederated Tribes of Grand Ronde 

Behavioral Health Program

Grand Ronde, OR 

Michael Villanueva, Ph.D.

Research Professor 

Center on Alcoholism, Substance Abuse, and

Addiction 

Albuquerque, NM 

viii 
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KAP Expert Panel and Federal
 

Government Participants
 

Barry S. Brown, Ph.D.

Adjunct Professor

University of North Carolina–Wilmington

Carolina Beach, NC 

Jacqueline Butler, M.S.W., LISW, LPCC,

CCDC III, CJS

Professor of Clinical Psychiatry

College of Medicine

University of Cincinnati

Cincinnati, OH 

Deion Cash 

Executive Director 

Community Treatment and Correction

Center, Inc.

Canton, OH 

Debra A. Claymore, M.Ed.Adm.

Owner/Chief Executive Officer

WC Consulting, LLC

Loveland, CO 

Carlo C. DiClemente, Ph.D.

Chair 

Department of Psychology

University of Maryland–Baltimore County

Baltimore, MD 

Catherine E. Dube, Ed.D.

Independent Consultant

Brown University

Providence, RI 

Jerry P. Flanzer, D.S.W., LCSW, CAC

Chief, Services

Division of Clinical and Services Research 

National Institute on Drug Abuse

Bethesda, MD 

Michael Galer, D.B.A.

Independent Consultant

Westminster, MA 

Renata J. Henry, M.Ed.

Director 

Division of Alcoholism, Drug Abuse and

Mental Health 

Delaware Department of Health and Social 

Services 

New Castle, DE 

Joel Hochberg, M.A.

President 

Asher & Partners 

Los Angeles, CA 

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Trauma-Informed Care in Behavioral Health Services 

Jack Hollis, Ph.D.

Associate Director, Center for Health

Research 

Kaiser Permanente 

Portland, OR 

Mary Beth Johnson, M.S.W.

Director 

Addiction Technology Transfer Center

University of Missouri–Kansas City

Kansas City, MO 

Eduardo Lopez

Executive Producer 

EVS Communications 

Washington, DC 

Holly A. Massett, Ph.D.

Academy for Educational Development

Washington, DC 

Diane Miller 

Chief 

Scientific Communications Branch 

National Institute on Alcohol Abuse and 

Alcoholism 

Bethesda, MD 

Harry B. Montoya, M.A.

President/Chief Executive Officer

Hands Across Cultures 

Española, NM 

Richard K. Ries, M.D.

Director/Professor

Outpatient Mental Health Services

Dual Disorder Programs

Seattle, WA 

Gloria M. Rodriguez, D.S.W.

Research Scientist 

Division of Addiction Services 

New Jersey Department of Health and

Senior Services 

Trenton, NJ 

Everett Rogers, Ph.D.

Center for Communications Programs

Johns Hopkins University

Baltimore, MD 

Jean R. Slutsky, P.A., M.S.P.H.

Senior Health Policy Analyst

Agency for Healthcare Research & Quality

Rockville, MD 

Nedra Klein Weinreich, M.S.

President 

Weinreich Communications 

Canoga Park, CA 

Clarissa Wittenberg

Director 

Office of Communications and Public 

Liaison 

National Institute of Mental Health 

Bethesda, MD 

Consulting Members of the KAP 

Expert Panel 

Paul Purnell, M.A

Social Solutions, LLC

Potomac, MD 

Scott Ratzan, M.D., M.P.A., M.A.

Academy for Educational Development

Washington, DC 

Thomas W. Valente, Ph.D.

Director 

Master of Public Health Program

Department of Preventive Medicine

School of Medicine 

University of Southern California

Los Angeles, CA 

Patricia A. Wright, Ed.D.

Independent Consultant

Baltimore, MD 

x 
. 

 

What Is a TIP? 

Treatment Improvement Protocols (TIPs) are developed by the Substance Abuse and Mental 

Health Services Administration (SAMHSA) within the U.S. Department of Health and Human

Services (HHS). Each TIP involves the development of topic-specific best practice guidelines for 

the prevention and treatment of substance use and mental disorders. TIPs draw on the experience 

and knowledge of clinical, research, and administrative experts of various forms of treatment and

prevention. TIPs are distributed to facilities and individuals across the country. Published TIPs 

can be accessed via the Internet at http://store.samhsa.gov. 

Although each consensus-based TIP strives to include an evidence base for the practices it recommends, SAMHSA recognizes that behavioral health is continually evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey 

“front-line” information quickly but responsibly. If research supports a particular approach, citations are provided. 

xi 
 
. 

 

Foreword
 

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency 

within the U.S. Department of Health and Human Services that leads public health efforts to

advance the behavioral health of the nation. SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities. 

The Treatment Improvement Protocol (TIP) series fulfills SAMHSA’s mission to improve prevention and treatment of substance use and mental disorders by providing best practices guidance 

to clinicians, program administrators, and payers.TIPs are the result of careful consideration of

all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program administrators, and patient advocates debates and discusses their particular area of expertise until they 

reach a consensus on best practices. This panel’s work is then reviewed and critiqued by field 

reviewers. 

The talent, dedication, and hard work that TIP panelists and reviewers bring to this highly participatory process have helped bridge the gap between the promise of research and the needs of

practicing clinicians and administrators to serve, in the most scientifically sound and effective

ways, people in need of behavioral health services. We are grateful to all who have joined with us 

to contribute to advances in the behavioral health field. 

Pamela S. Hyde, J.D.

Administrator 

Substance Abuse and Mental Health Services Administration 

H. Westley Clark, M.D., J.D.,

M.P.H., CAS, FASAM

Director 

Frances M. Harding

Director 

Center for Substance Abuse 

Paolo del Vecchio, M.S.W. 

Director 

Center for Mental Health 

Center for Substance Abuse Prevention Services 

Treatment Substance Abuse and Mental Substance Abuse and Mental 

Substance Abuse and Mental Health Services Administration Health Services Administration 

Health Services Administration 

xiii 

 

 

 

 

 

How This TIP Is Organized 

This Treatment Improvement Protocol (TIP) is divided into three parts:

• Part 1: A Practical Guide for the Provision of Behavioral Health Services 

• Part 2: An Implementation Guide for Behavioral Health Program Administrators 

• Part 3: A Review of the Literature 

Part 1 is for behavioral health service providers and consists of six chapters. Recurring themes 

include the variety of ways that substance abuse, mental health, and trauma interact; the importance of context and culture in a person’s response to trauma; trauma-informed screening and

assessment tools, techniques, strategies, and approaches that help behavioral health professionals 

assist clients in recovery from mental and substance use disorders who have also been affected by 

acute or chronic traumas; and the significance of adhering to a strengths-based perspective that 

acknowledges the resilience within individual clients, providers, and communities. 

Chapter 1 lays the groundwork and rationale for the implementation and provision of traumainformed services. It provides an overview of specific trauma-informed intervention and treatment principles that guide clinicians, other behavioral health workers, and administrators in

becoming trauma informed and in creating a trauma-informed organization and workforce.

Chapter 2 provides an overview of traumatic experiences. It covers types of trauma; distinguishes 

among traumas that affect individuals, groups, and communities; describes trauma characteristics;

and addresses the socioecological and cultural factors that influence the impact of trauma. Chapter 3 broadly focuses on understanding the impact of trauma, trauma-related stress reactions and

associated symptoms, and common mental health and substance use disorders associated with

trauma. Chapter 4 provides an introduction to screening and assessment as they relate to trauma

and is devoted to screening and assessment processes and tools that are useful in evaluating

trauma exposure, its effects, and client intervention and treatment needs. Chapter 5 covers clinical issues that counselors and other behavioral health professionals may need to know and address when treating clients who have histories of trauma. Chapter 6 presents information on

specific treatment models for trauma, distinguishing integrated models (which address substance

use disorders, mental disorders, and trauma simultaneously) from those that treat trauma alone. 

Advice to Counselors and/or Administrators boxes in Part 1 provide practical information for

providers. Case illustrations, exhibits, and text boxes further illustrate information in the text by 

offering practical examples. 

Part 2 provides an overview of programmatic and administrative practices that will help behavioral health program administrators increase the capacity of their organizations to deliver 

xv 
 

 

 

Trauma-Informed Care in Behavioral Health Services 

trauma-informed services. Chapter 1 examines the essential ingredients, challenges, and processes 

in creating and implementing trauma-informed services within an organization. Chapter 2

focuses on key development activities that support staff members, including trauma-informed 

training and supervision, ethics, and boundaries pertinent to responding to traumatic stress,

secondary trauma, and counselor self-care. 

Advice to Administrators and/or Supervisors boxes in Part 2 highlight more detailed information

that supports the organizational implementation of trauma-informed care (TIC). In addition,

case illustrations, organizational activities, and text boxes reinforce the material presented within

this section. 

Part 3 is a literature review on TIC and behavioral health services and is intended for use by clinical supervisors, interested providers, and administrators. Part 3 has three sections: an analysis of

the literature, links to select abstracts of the references most central to the topic, and a general 

bibliography of the available literature. To facilitate ongoing updates (performed periodically for

up to 3 years from first publication), the literature review is only available online at the Substance 

Abuse and Mental Health Services Administration (SAMHSA) Publications Ordering Web

page (http://store.samhsa.gov). 

Terminology 

Behavioral health: Throughout the TIP, the term “behavioral health” is used. Behavioral health

refers to a state of mental/emotional being and/or choices and actions that affect wellness. Behavioral health problems include substance abuse or misuse, alcohol and drug addiction, serious 

psychological distress, suicide, and mental and substance use disorders. This includes a range of

problems from unhealthy stress to diagnosable and treatable diseases like serious mental illness 

and substance use disorders, which are often chronic in nature but from which people can and do

recover. The term is also used in this TIP to describe the service systems encompassing the promotion of emotional health, the prevention of mental and substance use disorders, substance use 

and related problems, treatments and services for mental and substance use disorders, and recovery support. Because behavioral health conditions, taken together, are the leading causes of disability burden in North America, efforts to improve their prevention and treatment will benefit

society as a whole. Efforts to reduce the impact of mental and substance use disorders on America’s communities, such as those described in this TIP, will help achieve nationwide improvements 

in health. 

Client/consumer: In this TIP, the term “client” means anyone who seeks or receives mental 

health or substance abuse services. The term “consumer” stands in place of “client” in content

areas that address consumer participation and determination. It is not the intent of this document to ignore the relevance and historical origin of the term “consumer” among individuals who

have received, been subject to, or are seeking mental health services. Instead, we choose the word

“client,” given that this terminology is also commonly used in substance abuse treatment services.

Note: This TIP also uses the term “participant(s)” instead of “client(s)” for individuals, families, or

communities seeking or receiving prevention services. 

Complex trauma: This manual adopts the National Child Traumatic Stress Network (NCTSN) 

definition of complex trauma. The term refers to the pervasive impact, including developmental 

xvi 
 

 

 

How This TIP Is Organized 

consequences, of exposure to multiple or prolonged traumatic events. According to the NCTSN

Web site (http://www.nctsn.org/trauma-types), complex trauma typically involves exposure to

sequential or simultaneous occurrences of maltreatment, “including psychological maltreatment,

neglect, physical and sexual abuse, and domestic violence.... Exposure to these initial traumatic

experiences—and the resulting emotional dysregulation and the loss of safety, direction, and the 

ability to detect or respond to danger cues—often sets off a chain of events leading to subsequent

or repeated trauma exposure in adolescence and adulthood” (NCTSN, 2013). 

Co-occurring disorders: When an individual has one or more mental disorders as well as one or 

more substance use disorders (including substance abuse), the term “co-occurring” applies.

Although people may have a number of health conditions that co-occur, including physical problems, the term “co-occurring disorders,” in this TIP, refers to substance use and mental disorders. 

Cultural responsiveness and cultural competence: This TIP uses these terms interchangeably,

with “responsiveness” applied to services and systems and “competence” applied to people, to refer

to “a set of behaviors, attitudes, and policies that...enable a system, agency, or group of professionals to work effectively in cross-cultural situations” (Cross, Bazron, Dennis, & Isaacs, 1989, p.

13). Culturally responsive behavioral health services and culturally competent providers “honor

and respect the beliefs, languages, interpersonal styles, and behaviors of individuals and families 

receiving services.... [C]ultural competence is a dynamic, ongoing developmental process that 

requires a long-term commitment and is achieved over time” (U.S. Department of Health and

Human Services, 2003, p. 12). 

Evidence-based practices: There are many different uses of the term “evidence-based practices.”

One of the most widely accepted is that of Chambless and Hollon (1998), who say that for a

treatment to be considered evidence based, it must show evidence of positive outcomes based on

peer-reviewed randomized controlled trials or other equivalent strong methodology. A treatment

is labeled “strong” if criteria are met for what Chambless and Hollon term “well-established”

treatments. To attain this level, rigorous treatment outcome studies conducted by independent

investigators (not just the treatment developer) are necessary. Research support is labeled “modest” when treatments attain criteria for what Chambless and Hollon call “probably efficacious 

treatments.”To meet this standard, one well-designed study or two or more adequately designed

studies must support a treatment’s efficacy. In addition, it is possible to meet the “strong” and

“modest” thresholds through a series of carefully controlled single-case studies. An evidencebased practice derived from sound, science-based theories incorporates detailed and empirically 

supported procedures and implementation guidelines, including parameters of applications (such

as for populations), inclusionary and exclusionary criteria for participation, and target

interventions. 

Promising practices: Even though current clinical wisdom, theories, and professional and expert

consensus may support certain practices, these practices may lack support from studies that are 

scientifically rigorous in research design and statistical analysis; available studies may be limited

in number or sample size, or they may not be applicable to the current setting or population. This 

TIP refers to such practices as “promising.” 

xvii 
 

 

Trauma-Informed Care in Behavioral Health Services 

Recovery: This term denotes a process of change through which individuals improve their

health and wellness, live a self-directed life, and strive to reach their full potential. Major dimensions that support a life in recovery, as defined by SAMHSA, include:

•	 Health: overcoming or managing one’s disease(s) as well as living in a physically and emotionally healthy way. 

•	 Home: a stable and safe place to live. 

•	 Purpose: meaningful daily activities, such as a job, school, volunteerism, family caretaking, or

creative endeavors, and the independence, income, and resources to participate in society. 

•	 Community: relationships and social networks that provide support, friendship, love, and hope. 

Resilience: This term refers to the ability to bounce back or rise above adversity as an individual,

family, community, or provider. Well beyond individual characteristics of hardiness, resilience

includes the process of using available resources to negotiate hardship and/or the consequences of

adverse events. This TIP applies the term “resilience” and its processes to individuals across the 

life span. 

Retraumatization: In its more literal translation, “retraumatization” means the occurrence of

traumatic stress reactions and symptoms after exposure to multiple events (Duckworth &

Follette, 2011). This is a significant issue for trauma survivors, both because they are at increased

risk for higher rates of retraumatization, and because people who are traumatized multiple times 

often have more serious and chronic trauma-related symptoms than those with single traumas. In

this manual, the term not only refers to the effect of being exposed to multiple events, but also

implies the process of reexperiencing traumatic stress as a result of a current situation that mirrors or replicates in some way the prior traumatic experiences (e.g., specific smells or other sensory input; interactions with others; responses to one’s surroundings or interpersonal context, such 

as feeling emotionally or physically trapped). 

Secondary trauma: Literature often uses the terms “secondary trauma,”“compassion fatigue,”

and “vicarious traumatization” interchangeably. Although compassion fatigue and secondary 

trauma refer to similar physical, psychological, and cognitive changes and symptoms that behavioral health workers may encounter when they work specifically with clients who have histories 

of trauma, vicarious trauma usually refers more explicitly to specific cognitive changes, such as in

worldview and sense of self (Newell & MacNeil, 2010). This publication uses “secondary trauma”

to describe trauma-related stress reactions and symptoms resulting from exposure to another

individual’s traumatic experiences, rather than from exposure directly to a traumatic event. Secondary trauma can occur among behavioral health service providers across all behavioral health

settings and among all professionals who provide services to those who have experienced trauma

(e.g., healthcare providers, peer counselors, first responders, clergy, intake workers). 

Substance abuse: Throughout the TIP, the term “substance abuse” has been used to refer to both

substance abuse and substance dependence. This term was chosen partly because behavioral 

health professionals commonly use the term substance abuse to describe any excessive use of addictive substances. In this TIP, the term refers to the use of alcohol as well as other substances of

abuse. Readers should attend to the context in which the term occurs to determine what possible 

range of meanings it covers; in most cases, it will refer to all varieties of substance-related 

xviii 
 

 

How This TIP Is Organized 

disorders as found in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition 

(American Psychiatric Association, 2013a). 

Trauma: In this text, the term “trauma” refers to experiences that cause intense physical and psychological stress reactions. It can refer to “a single event, multiple events, or a set of circumstances 

that is experienced by an individual as physically and emotionally harmful or threatening and

that has lasting adverse effects on the individual’s physical, social, emotional, or spiritual wellbeing” (SAMHSA, 2012, p. 2). Although many individuals report a single specific traumatic

event, others, especially those seeking mental health or substance abuse services, have been exposed to multiple or chronic traumatic events. See the “What Is Trauma” section in Part 1, Chapter 1, for a more indepth definition and discussion of trauma. 

Trauma-informed: A trauma-informed approach to the delivery of behavioral health services 

includes an understanding of trauma and an awareness of the impact it can have across settings,

services, and populations. It involves viewing trauma through an ecological and cultural lens and

recognizing that context plays a significant role in how individuals perceive and process traumatic

events, whether acute or chronic. In May 2012, SAMHSA convened a group of national experts 

who identified three key elements of a trauma-informed approach: “(1) realizing the prevalence 

of trauma; (2) recognizing how trauma affects all individuals involved with the program, organization, or system, including its own workforce; and (3) responding by putting this knowledge into

practice” (SAMHSA, 2012, p 4). 

Trauma-informed care: TIC is a strengths-based service delivery approach “that is grounded in

an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities 

for survivors to rebuild a sense of control and empowerment” (Hopper, Bassuk, & Olivet, 2010, p.

82). It also involves vigilance in anticipating and avoiding institutional processes and individual 

practices that are likely to retraumatize individuals who already have histories of trauma, and it

upholds the importance of consumer participation in the development, delivery, and evaluation of

services. 

Trauma-specific treatment services: These services are evidence-based and promising practices

that facilitate recovery from trauma. The term “trauma-specific services” refers to prevention,

intervention, or treatment services that address traumatic stress as well as any co-occurring disorders (including substance use and mental disorders) that developed during or after trauma. 

Trauma survivor: This phrase can refer to anyone who has experienced trauma or has had a

traumatic stress reaction. Knowing that the use of language and words can set the tone for recovery or contribute to further retraumatization, it is the intent of this manual to put forth a message 

of hope by avoiding the term “victim” and instead using the term “survivor” when appropriate. 

xix 

Part 1: A Practical Guide for
 

the Provision of Behavioral
 

Health Services
 

 

 

 

IN THIS CHAPTER 

• Scope of the TIP

• Intended Audience

• Before You Begin

• Structure of the TIP

• What Is Trauma?

• Trauma Matters in

Behavioral Health

Services

• Trauma -Informed

Intervention and

Treatment Principles

• As You Proceed

Trauma-Informed Care: 1 A Sociocultural 


Perspective
 

Many individuals who seek treatment in behavioral health settings 

have histories of trauma, but they often don’t recognize the significant effects of trauma in their lives; either they don’t draw connections between their trauma histories and their presenting problems,

or they avoid the topic altogether. Likewise, treatment providers 

may not ask questions that elicit a client’s history of trauma, may 

feel unprepared to address trauma-related issues proactively, or may 

struggle to address traumatic stress effectively within the constraints of their treatment program, the program’s clinical orientation, or their agency’s directives. 

By recognizing that traumatic experiences and their sequelae tie 

closely into behavioral health problems, front-line professionals 

and community-based programs can begin to build a traumainformed environment across the continuum of care. Key steps 

include meeting client needs in a safe, collaborative, and compassionate manner; preventing treatment practices that retraumatize 

people with histories of trauma who are seeking help or receiving

services; building on the strengths and resilience of clients in the 

context of their environments and communities; and endorsing

trauma-informed principles in agencies through support, consultation, and supervision of staff. 

This Treatment Improvement Protocol (TIP) begins by introducing

the scope, purpose, and organization of the topic and describing its

intended audience. Along with defining trauma and traumainformed care (TIC), the first chapter discusses the rationale for

addressing trauma in behavioral health services and reviews traumainformed intervention and treatment principles.These principles 

serve as the TIP’s conceptual framework. 

3 
 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

Scope of the TIP 

Many individuals experience trauma during

their lifetimes. Although many people exposed

to trauma demonstrate few or no lingering

symptoms, those individuals who have experienced repeated, chronic, or multiple traumas 

are more likely to exhibit pronounced symptoms and consequences, including substance 

abuse, mental illness, and health problems.

Subsequently, trauma can significantly affect

how an individual engages in major life areas 

as well as treatment. 

This TIP provides evidence-based and best

practice information for behavioral health

service providers and administrators who want

to work more effectively with people who have 

been exposed to acute and chronic traumas 

and/or are at risk of developing traumatic

stress reactions. Using key trauma-informed

principles, this TIP addresses trauma-related

prevention, intervention, and treatment issues 

and strategies in behavioral health services.

The content is adaptable across behavioral 

health settings that service individuals, families, and communities—placing emphasis on

the importance of coordinating as well as integrating services. 

Intended Audience 

This TIP is for behavioral health service providers, prevention specialists, and program 

administrators—the professionals directly responsible for providing care to trauma survivors across behavioral health settings,

including substance abuse and mental health

services. This TIP also targets primary care

professionals, including physicians; teams 

working with clients and communities who

have experienced trauma; service providers in

the criminal justice system; and researchers 

with an interest in this topic. 

Before You Begin 

This TIP endorses a trauma-informed model 

of care; this model emphasizes the need for

behavioral health practitioners and organizations to recognize the prevalence and pervasive 

impact of trauma on the lives of the people 

they serve and develop trauma-sensitive or

trauma-responsive services. This TIP provides 

key information to help behavioral health 

practitioners and program administrators become trauma aware and informed, improve 

screening and assessment processes, and implement science-informed intervention strategies across settings and modalities in

behavioral health services. Whether provided 

by an agency or an individual provider, traumainformed services may or may not include 

trauma-specific services or trauma specialists 

(individuals who have advanced training and

education to provide specific treatment interventions to address traumatic stress reactions).

Nonetheless,TIC anticipates the role that 

trauma can play across the continuum of care—

establishing integrated and/or collaborative

processes to address the needs of traumatized

individuals and communities proactively. 

Individuals who have experienced trauma are 

at an elevated risk for substance use disorders,

including abuse and dependence; mental 

health problems (e.g., depression and anxiety 

symptoms or disorders, impairment in relational/social and other major life areas, other

distressing symptoms); and physical disorders 

and conditions, such as sleep disorders. This 

TIP focuses on specific types of prevention

(Institute of Medicine et al., 2009): selective 

prevention, which targets people who are at 

risk for developing social, psychological, or

other conditions as a result of trauma or who 

are at greater risk for experiencing trauma due 

to behavioral health disorders or conditions;

and indicated prevention, which targets people

who display early signs of trauma-related 

4 
 

 

 

 

 

 

Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective 

symptoms. This TIP identifies interventions,

including trauma-informed and traumaspecific strategies, and perceives treatment as a

means of prevention—building on resilience, 

developing safety and skills to negotiate the 

impact of trauma, and addressing mental and 

substance use disorders to enhance recovery. 

This TIP’s target population is adults. Beyond

the context of family, this publication does not 

examine or address youth and adolescent

responses to trauma, youth-tailored traumainformed strategies, or trauma-specific interventions for youth or adolescents, because the 

developmental and contextual issues of these 

populations require specialized interventions.

Providers who work with young clients who

have experienced trauma should refer to the

resource list in Appendix B. This TIP covers

TIC, trauma characteristics, the impact of

traumatic experiences, assessment, and interventions for persons who have had traumatic

experiences. Considering the vast knowledge 

base and specificity of individual, repeated,

and chronic forms of trauma, this TIP does 

not provide a comprehensive overview of the 

unique characteristics of each type of trauma

(e.g., sexual abuse, torture, war-related trauma, 

murder). Instead, this TIP provides an overview supported by examples. For more information on several specific types of trauma,

please refer to TIP 36, Substance Abuse 

Treatment for Persons With Child Abuse and 

Neglect Issues (Center for Substance Abuse 

Treatment [CSAT], 2000b), TIP 25,

Substance Abuse Treatment and Domestic 

Violence (CSAT, 1997b), TIP 51, Substance 

Abuse Treatment: Addressing the Specific Needs 

of Women (CSAT, 2009d), and the planned 

TIP, Reintegration-Related Behavioral Health

Issues in Veterans and Military Families 

(Substance Abuse and Mental Health

Services Administration [SAMHSA], 

planned f). 

This TIP, Trauma-Informed Care in Behavioral 

Health Services, is guided by SAMHSA’s Strategic Initiatives described in Leading Change: 

A Plan for SAMHSA’s Roles and Actions 2011– 

2014 (SAMHSA, 2011b). Specific to Strategic Initiative #2, Trauma and Justice, this TIP 

addresses several goals, objectives, and actions 

outlined in this initiative by providing behavioral health practitioners, supervisors, and administrators with an introduction to culturally 

responsive TIC. 

Specifically, the TIP presents fundamental 

concepts that behavioral health service providers can use to: 

•	 Become trauma aware and knowledgeable 

about the impact and consequences of

traumatic experiences for individuals, families, and communities. 

•	 Evaluate and initiate use of appropriate

trauma-related screening and assessment

tools. 

•	 Implement interventions from a collaborative, strengths-based approach, appreciating

the resilience of trauma survivors. 

•	 Learn the core principles and practices that

reflect TIC. 

•	 Anticipate the need for specific traumainformed treatment planning strategies that

support the individual’s recovery. 

•	 Decrease the inadvertent retraumatization 

that can occur from implementing standard

organizational policies, procedures, and interventions with individuals, including clients and staff, who have experienced

trauma or are exposed to secondary trauma. 

•	 Evaluate and build a trauma-informed organization and workforce. 

The consensus panelists, as well as other contributors to this TIP, have all had experience as

substance abuse and mental health counselors,

prevention and peer specialists, supervisors,

clinical directors, researchers, or administrators 

working with individuals, families, and 

5 
 

 

Trauma-Informed Care in Behavioral Health Services 

communities who have experienced trauma.

The material presented in this TIP uses the 

wealth of their experience in addition to the

available published resources and research

relevant to this topic. Throughout the consensus process, the panel members were mindful 

of the strengths and resilience inherent in individuals, families, and communities affected

by trauma and the challenges providers face in 

addressing trauma and implementing TIC. 

Structure of the TIP 

Using a TIC framework (Exhibit 1.1-1), this

TIP provides information on key aspects of

trauma, including what it is; its consequences;

screening and assessment; effective 

prevention, intervention, and treatment approaches; trauma recovery; the impact of 

trauma on service providers; programmatic

and administrative practices; and trauma resources. 

Note: To produce a user-friendly but informed document, the first two parts of the

TIP include minimal citations. If you are interested in the citations associated with topics 

covered in Parts 1 and 2, please consult the 

review of the literature provided in Part 3

(available online at http://store.samhsa.gov). 

Parts 1 and 2 are easily read and digested on 

their own, but it is highly recommended that 

you read the literature review as well. 

Exhibit 1.1-1: TIC Framework in Behavioral Health Services—Sociocultural 

Perspective 

6 
 

 

See Appendix C to 

read about the history 

of trauma and trauma 

interventions. 

Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective 

What Is Trauma? 

According to SAMHSA’s Trauma and Justice 

Strategic Initiative, “trauma results from an

event, series of events, or set of circumstances 

that is experienced by an individual as physically or emotionally harmful or threatening

and that has lasting adverse effects on the individual’s functioning and physical, social,

emotional, or spiritual well-being” 

(SAMHSA, 2012, p. 2). Trauma can affect

people of every race, ethnicity, age, sexual orientation, gender, psychosocial background, and

geographic region. A traumatic experience can

be a single event, a series of events, and/or a

chronic condition (e.g., childhood neglect,

domestic violence). Traumas can affect individuals, families, groups, communities, specific

cultures, and generations. It generally overwhelms an individual’s or community’s resources to cope, and it often ignites the “fight,

flight, or freeze” reaction at the time of the

event(s). It frequently produces a sense of fear,

vulnerability, and helplessness. 

Often, traumatic 

events are unexpected. Individuals 

may experience 

the traumatic 

event directly, witness an event, feel threatened, or hear about an event that affects 

someone they know. Events may be humanmade, such as a mechanical error that causes a 

disaster, war, terrorism, sexual abuse, or violence, or they can be the products of nature 

(e.g., flooding, hurricanes, tornadoes). Trauma 

can occur at any age or developmental stage,

and often, events that occur outside expected

life stages are perceived as traumatic (e.g., a

child dying before a parent, cancer as a teen,

personal illness, job loss before retirement). 

It is not just the event itself that determines

whether something is traumatic, but also the 

individual’s experience of the event. Two people may be exposed to the same event or series 

of events but experience and interpret these 

events in vastly different ways. Various 

biopsychosocial and cultural factors influence 

an individual’s immediate response and longterm reactions to trauma. For most, regardless 

of the severity of the trauma, the immediate or

enduring effects of trauma are met with resilience—the ability to rise above the circumstances or to meet the challenges with

fortitude. 

For some people, reactions to a traumatic

event are temporary, whereas others have prolonged reactions that move from acute symptoms to more severe, prolonged, or enduring

mental health consequences (e.g., posttraumatic stress and other anxiety disorders, substance use and mood disorders) and medical 

problems (e.g., arthritis, headaches, chronic

pain). Others do not meet established criteria

for posttraumatic stress or other mental disorders but encounter significant trauma-related

symptoms or culturally expressed symptoms of

trauma (e.g., somatization, in which psychological stress is expressed through physical 

concerns). For that reason, even if an individual does not meet diagnostic criteria for

trauma-related disorders, it is important to

recognize that trauma may still affect his or 

her life in significant ways. For more information on traumatic events, trauma characteristics, traumatic stress reactions, and factors 

that heighten or decrease the impact of trauma, see Part 1, Chapter 2, “Trauma Awareness,” and Part 1, Chapter 3, “Understanding

the Impact of Trauma.” 

Trauma Matters in 

Behavioral Health Services 

The past decade has seen an increased focus 

on the ways in which trauma, psychological 

distress, quality of life, health, mental illness, 

7 
 

 

 

Two Influential Studies That Set the Stage for the Development of TIC 

The Adverse Childhood Experiences Study (Centers for Disease Control and Prevention, 2013) was 

a large epidemiological study involving more than 17,000 individuals from United States; it analyzed 

the long-term effects of childhood and adolescent traumatic experiences on adult health risks, mental 

health, healthcare costs, and life expectancy. 

The Women, Co-Occurring Disorders and Violence Study (SAMHSA, 2007) was a large multisite 

study focused on the role of interpersonal and other traumatic stressors among women; the interrelatedness of trauma, violence, and co-occurring substance use and mental disorders; and the incorporation of trauma-informed and trauma-specific principles, models, and services. 

Trauma-Informed Care in Behavioral Health Services 

and substance abuse are linked. With the attacks of September 11, 2001, and other acts of 

terror, the wars in Iraq and Afghanistan, disastrous hurricanes on the Gulf Coast, and sexual 

abuse scandals, trauma has moved to the forefront of national consciousness. 

Trauma was once considered an abnormal 

experience. However, the first National

Comorbidity Study established how prevalent

traumas were in the lives of the general population of the United States. In the study, 61

percent of men and 51 percent of women reported experiencing at least one trauma in

their lifetime, with witnessing a trauma, being

involved in a natural disaster, and/or experiencing a life-threatening accident ranking as

the most common events (Kessler et al., 1999).

In Wave 2 of the National Epidemiologic

Survey on Alcohol and Related Conditions,

71.6 percent of the sample reported witnessing

trauma, 30.7 percent experienced a trauma

that resulted in injury, and 17.3 percent experienced psychological trauma (El-Gabalawy,

2012). For a thorough review of the impact of

trauma on quality of life and health and

among individuals with mental and substance 

use disorders, refer to Part 3 of this TIP, the 

online literature review. 

Rationale for TIC 

Integrating TIC into behavioral health services provides many benefits not only for clients, but also for their families and

communities, for behavioral health service 

organizations, and for staff. Trauma-informed

services bring to the forefront the belief that 

trauma can pervasively affect an individual’s 

well-being, including physical and mental 

health. For behavioral health service providers,

trauma-informed practice offers many opportunities. It reinforces the importance of acquiring trauma-specific knowledge and skills 

to meet the specific needs of clients; of recognizing that individuals may be affected by 

trauma regardless of its acknowledgment; of 

understanding that trauma likely affects many 

clients who are seeking behavioral health services; and of acknowledging that organizations

and providers can retraumatize clients through

standard or unexamined policies and practices.

TIC stresses the importance of addressing the 

client individually rather than applying general treatment approaches. 

TIC provides clients more opportunities to

engage in services that reflect a compassionate 

perspective of their presenting problems. TIC

can potentially provide a greater sense of safety for clients who have histories of trauma and

a platform for preventing more serious consequences of traumatic stress (Fallot & Harris,

2001). Although many individuals may not

identify the need to connect with their histories, trauma-informed services offer clients a

chance to explore the impact of trauma, their

strengths and creative adaptations in managing traumatic histories, their resilience, and the

relationships among trauma, substance use,

and psychological symptoms. 

8 
 

 

 

Advice to Counselors: The Importance of TIC 

The history of trauma raises various clinical issues. Many counselors do not have extensive training in 

treating trauma or offering trauma-informed services and may be uncertain of how to respond to 

clients’ trauma-related reactions or symptoms. Some counselors have experienced traumas themselves that may be triggered by clients’ reports of trauma. Others are interested in helping clients 

with trauma but may unwittingly cause harm by moving too deeply or quickly into trauma material or 

by discounting or disregarding a client’s report of trauma. Counselors must be aware of traumarelated symptoms and disorders and how they affect clients in behavioral health treatment. 

Counselors with primary treatment responsibilities should also have an understanding of how to recognize trauma-related reactions, how to incorporate treatment interventions for trauma-related 

symptoms into clients’ treatment plans, how to help clients build a safety net to prevent further 

trauma, how to conduct psychoeducational interventions, and when to make treatment referrals for 

further evaluations or trauma-specific treatment services. All treatment staff should recognize that 

traumatic stress symptoms or trauma-related disorders should not preclude an individual from mental 

health or substance abuse treatment and that all co-occurring disorders need to be addressed on 

some level in the treatment plan and setting. For example, helping a client in substance abuse treatment gain control over trauma-related symptoms can greatly improve the client’s chances of substance abuse recovery and lower the possibility of relapse (Farley, Golding, Young, Mulligan, & 

Minkoff, 2004; Ouimette, Ahrens, Moos, & Finney, 1998). In addition, assisting a client in achieving 

abstinence builds a platform upon which recovery from traumatic stress can proceed. 

Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective 

Implementing trauma-informed services can

improve screening and assessment processes,

treatment planning, and placement while also

decreasing the risk for retraumatization. The

implementation may enhance communication

between the client and treatment provider,

thus decreasing risks associated with misunderstanding the client’s reactions and presenting problems or underestimating the need for

appropriate referrals for evaluation or traumaspecific treatment. Organizational investment

in developing or improving trauma-informed

services may also translate to cost effectiveness, in that services are more appropriately 

matched to clients from the outset. TIC is an 

essential ingredient in organizational risk 

management; it ensures the implementation of

decisions that will optimize therapeutic outcomes and minimize adverse effects on the 

client and, ultimately, the organization. A key 

principle is the engagement of community,

clients, and staff. Clients and staff are more 

apt to be empowered, invested, and satisfied if

they are involved in the ongoing development

and delivery of trauma-informed services. 

An organization also benefits from work development practices through planning for,

attracting, and retaining a diverse workforce of 

individuals who are knowledgeable about

trauma and its impact. Developing a traumainformed organization involves hiring and

promotional practices that attract and retain

individuals who are educated and trained in 

trauma-informed practices on all levels of the 

organization, including board as well as peer

support appointments. Trauma-informed organizations are invested in their staff and

adopt similar trauma-informed principles,

including establishing and providing ongoing

support to promote TIC in practice and in 

addressing secondary trauma and implementing processes that reinforce the safety of the

staff. Even though investing in a traumainformed workforce does not necessarily guarantee trauma-informed practices, it is more 

likely that services will evolve more proficiently to meet client, staff, and community 

needs. 

9 
 

 

 

Trauma-Informed Care in Behavioral Health Services 

Trauma and Substance Use 

Disorders 

Many people who have substance use disorders have experienced trauma as children or

adults (Koenen, Stellman, Sommer, &

Stellman, 2008; Ompad et al., 2005). Substance abuse is known to predispose people to

higher rates of traumas, such as dangerous 

situations and accidents, while under the influence (Stewart & Conrod, 2003; Zinzow, 

Resnick, Amstadter, McCauley, Ruggiero, &

Kilpatrick, 2010) and as a result of the lifestyle 

associated with substance abuse (Reynolds et

al., 2005). In addition, people who abuse substances and have experienced trauma have

worse treatment outcomes than those without 

histories of trauma (Driessen et al., 2008;

Najavits et al., 2007). Thus, the process of recovery is more difficult, and the counselor’s 

role is more challenging, when clients have 

histories of trauma. A person presenting with

both trauma and substance abuse issues can 

have a variety of other difficult life problems 

that commonly accompany these disorders,

such as other psychological symptoms or mental disorders, poverty, homelessness, increased

risk of HIV and other infections, and lack of

social support (Mills, Teesson, Ross, & Peters,

2006; Najavits, Weiss, & Shaw, 1997). Many

individuals who seek treatment for substance 

use disorders have histories of one or more 

traumas. More than half of women seeking

substance abuse treatment report one or more 

lifetime traumas (Farley, Golding, Young,

Mulligan, & Minkoff, 2004; Najavits et al.,

1997), and a significant number of clients in

inpatient treatment also have subclinical

traumatic stress symptoms or posttraumatic

stress disorder (PTSD; Falck, Wang, Siegal, & 

Carlson, 2004; Grant et al., 2004; Reynolds et

al., 2005). 

Trauma and Mental Disorders 

People who are receiving treatment for severe 

mental disorders are more likely to have histories of trauma, including childhood physical

and sexual abuse, serious accidents, homelessness, involuntary psychiatric hospitalizations,

drug overdoses, interpersonal violence, and

other forms of violence. Many clients with

severe mental disorders meet criteria for 

PTSD; others with serious mental illness who

have histories of trauma present with psychological symptoms or mental disorders that are

commonly associated with a history of trauma, 

including anxiety symptoms and disorders, 

mood disorders (e.g., major depression, dysthymia, bipolar disorder; Mueser et al., 2004),

impulse control disorders, and substance use 

disorders (Kessler, Chiu, Demler, & Walters,

2005). 

Traumatic stress increases the risk for mental 

illness, and findings suggest that traumatic

stress increases the symptom severity of mental illness (Spitzer, Vogel, Barnow, Freyberger

& Grabe, 2007). These findings propose that

traumatic stress plays a significant role in perpetuating and exacerbating mental illness and

suggest that trauma often precedes the development of mental disorders. As with trauma

and substance use disorders, there is a bidirectional relationship; mental illness increases the 

risk of experiencing trauma, and trauma increases the risk of developing psychological

symptoms and mental disorders. For a more 

comprehensive review of the interactions 

among traumatic stress, mental illness, and

substance use disorders, refer to Part 3 of this

TIP, the online literature review. 

10 
 

 

 

Advice to Counselors: Implementing Trauma-Informed Services 

Recognizing that trauma affects a majority of clients served within public health systems, the National 

Center for Trauma-Informed Care (NCTIC) has sought to establish a comprehensive framework to 

guide systems of care in the development of trauma-informed services. If a system or program is to 

support the needs of trauma survivors, it must take a systematic approach that offers trauma-specific 

diagnostic and treatment services, as well as a trauma-informed environment that is able to sustain 

such services, while fostering positive outcomes for the clients it serves. NCTIC also offers technical 

assistance in the implementation of trauma-informed services. For specific administrative information 

on TIC implementation, refer to Part 2, Chapters 1 and 2, of this TIP. 

“A program, organization, or system that 

is trauma -informed realizes the widespread 

impact of trauma and under -stands poten -

tial paths for healing; recognizes the signs 

and symptoms of trauma in staff, clients, 

and others involved with the system; and 

responds by fully integrating knowledge 

about trauma into policies, procedures, 

practices, and settings.” 

(SAMHSA, 2012, p. 4) 

Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective 

Trauma-Informed 

Intervention and 

Treatment Principles 

TIC is an intervention and organizational

approach that focuses on how trauma may 

affect an individual’s life and his or her response to behavioral health services from prevention through treatment. There are many 

definitions of TIC and various models for 

incorporating it across organizations, but a 

“trauma-informed approach incorporates three

key elements: (1) realizing the prevalence of 

trauma; (2) recognizing how trauma affects all 

individuals involved with the program, organization, or system, including its own workforce;

and (3) responding by putting this knowledge 

into practice” (SAMHSA, 2012, p. 4). 

TIC begins with the first contact a person has

with an agency; it requires all staff members 

(e.g., receptionists, intake personnel, direct

care staff, supervisors, administrators, peer

supports, board members) to recognize that 

the individual’s experience of trauma can

greatly influence his or her receptivity to and

engagement with services, interactions with

staff and clients, and responsiveness to program guidelines, practices, and interventions.

TIC includes program policies, procedures,

and practices to protect the vulnerabilities of

those who have experienced trauma and those

who provide trauma-related services. TIC is 

created through a supportive environment and

by redesigning organizational practices, with 

consumer participation, to prevent practices

that could be retraumatizing (Harris & Fallot,

2001c; Hopper et al., 2010). The ethical principle, “first, do no harm,” resonates strongly in 

the application of TIC. 

TIC involves a commitment to building competence among staff and establishing programmatic standards and clinical guidelines

that support the delivery of trauma-sensitive 

services. It encompasses recruiting, hiring, and

retaining competent staff; involving consumers, trauma survivors, and peer support specialists in the planning, implementation, and

evaluation of trauma-informed services; developing collaborations across service systems to

streamline referral processes, thereby securing

trauma-specific services when appropriate; and

building a continuity of TIC as consumers 

move from one system or service to the next.

TIC involves reevaluating each service delivery component through a trauma-aware lens. 

The principles described in the following subsections serve as the TIP’s conceptual 

11 
 

 

 

 

 

 

“Trauma -informed care embraces a perspective that highlights adaptation over 

symptoms and resilience over pathology.” 

(Elliot, Bjelajac, Fallot, Markoff, & Reed, 

2005, p. 467) 

Trauma-Informed Care in Behavioral Health Services 

framework. These principles comprise a compilation of resources, including research, theoretical papers, commentaries, and lessons 

learned from treatment facilities. Key elements

are outlined for each principle in providing

services to clients affected by trauma and to

populations most likely to incur trauma.

Although these principles are useful across all 

prevention and intervention services, settings,

and populations, they are of the utmost importance in working with people who have 

had traumatic experiences. 

Promote Trauma Awareness and 

Understanding 

Foremost, a behavioral health service provider

must recognize the prevalence of trauma and

its possible role in an individual’s emotional,

behavioral, cognitive, spiritual, and/or physical

development, presentation, and well-being. 

Being vigilant about the prevalence and potential consequences of traumatic events 

among clients allows counselors to tailor their

presentation styles, theoretical approaches, and

intervention strategies from the outset to plan

for and be responsive to clients’ specific needs.

Although not every client has a history of

trauma, those who have substance use and

mental disorders are more likely to have experienced trauma. Being trauma aware does not

mean that you must assume everyone has a

history of trauma, but rather that you anticipate the possibility from your initial contact

and interactions, intake processes, and screening and assessment procedures. 

Even the most standard behavioral health 

practices can retraumatize an individual exposed to prior traumatic experiences if the 

provider implements them without recognizing or considering that they may do harm. For

example, a counselor might develop a treatment plan recommending that a female client—who has been court mandated to 

substance abuse treatment and was raped as an

adult—attend group therapy, but without considering the implications, for her, of the fact

that the only available group at the facility is

all male and has had a low historical rate of 

female participation. Trauma awareness is an

essential strategy for preventing this type of

retraumatization; it reinforces the need for

providers to reevaluate their usual practices. 

Becoming trauma aware does not stop with

the recognition that trauma can affect clients;

instead, it encompasses a broader awareness 

that traumatic experiences as well as the impact of an individual’s trauma can extend to 

significant others, family members, first responders and other medical professionals, behavioral health workers, broader social 

networks, and even entire communities. Family members frequently experience the traumatic stress reactions of the individual family 

member who was traumatized (e.g., angry 

outbursts, nightmares, avoidant behavior, other

symptoms of anxiety, overreactions or underreactions to stressful events). These repetitive 

experiences can increase the risk of secondary 

trauma and symptoms of mental illness among

the family, heighten the risk for externalizing

and internalizing behavior among children

(e.g., bullying others, problems in social relationships, health-damaging behaviors), increase children’s risk for developing

posttraumatic stress later in life, and lead to a 

greater propensity for traumatic stress reactions across generations of the family. Hence,

prevention and intervention services can provide education and age-appropriate programming tailored to develop coping skills and

support systems. 

12 
 

 

 

 

Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective 

So too, behavioral health service providers can 

be influenced by exposure to trauma-related

affect and content when working with clients.

A trauma-aware workplace supports supervision and program practices that educate all 

direct service staff members on secondary 

trauma, encourages the processing of traumarelated content through participation in peersupported activities and clinical supervision,

and provides them with professional development opportunities to learn about and engage

in effective coping strategies that help prevent 

secondary trauma or trauma-related symptoms. It is important to generate trauma

awareness in agencies through education

across services and among all staff members 

who have any direct or indirect contact with

clients (including receptionists or intake and

admission personnel who engage clients for

the first time within the agency). Agencies can

maintain a trauma-aware environment 

through ongoing staff training, continued supervisory and administrative support, collaborative (i.e., involving consumer participation)

trauma-responsive program design and implementation, and organizational policies and

practices that reflect accommodation and flexibility in attending to the needs of clients affected by trauma. 

Recognize That Trauma-Related 

Symptoms and Behaviors 

Originate From Adapting to 

Traumatic Experiences 

A trauma-informed perspective views traumarelated symptoms and behaviors as an individual’s best and most resilient attempt to manage, cope with, and rise above his or her 

experience of trauma. Some individuals’ means 

of adapting and coping have produced little

difficulty; the coping and adaptive strategies of 

others have worked in the past but are not

working as well now. Some people have difficulties in one area of life but have effectively 

negotiated and functioned in other areas. 

Individuals who have survived trauma vary 

widely in how they experience and express 

traumatic stress reactions.Traumatic stress 

reactions vary in severity; they are often measured by the level of impairment or distress that

clients report and are determined by the multiple factors that characterize the trauma itself,

individual history and characteristics, developmental factors, sociocultural attributes, and

available resources. The characteristics of the 

trauma and the subsequent traumatic stress 

reactions can dramatically influence how individuals respond to the environment, relationships, interventions, and treatment services,

and those same characteristics can also shape 

the assumptions that clients/consumers make 

about their world (e.g., their view of others,

sense of safety), their future (e.g., hopefulness,

fear of a foreshortened future), and themselves 

(e.g., feeling resilient, feeling incompetent in

regulating emotions). The breadth of these 

effects may be observable or subtle. 

Once you become aware of the significance of

traumatic experiences in clients’ lives and 

begin to view their presentation as adaptive,

your identification and classification of their

presenting symptoms and behaviors can shift

from a “pathology” mindset (i.e., defining clients strictly from a diagnostic label, implying

that something is wrong with them) to one of

resilience—a mindset that views clients’ presenting difficulties, behaviors, and emotions as 

responses to surviving trauma. In essence, you 

will come to view traumatic stress reactions as 

normal reactions to abnormal situations. In 

embracing the belief that trauma-related reactions are adaptive, you can begin relationships

with clients from a hopeful, strengths-based

stance that builds upon the belief that their

responses to traumatic experiences reflect

creativity, self-preservation, and determination. 

13 
 

 

Trauma-Informed Care in Behavioral Health Services 

This will help build mutual and collaborative 

therapeutic relationships, help clients identify 

what has worked and has not worked in their 

attempts to deal with the aftermath of trauma

from a nonjudgmental stance, and develop

intervention and coping strategies that are

more likely to fit their strengths and resources.

This view of trauma prevents further retraumatization by not defining traumatic stress

reactions as pathological or as symptoms of

pathology. 

View Trauma in the Context of 

Individuals’ Environments 

Many factors contribute to a person’s response 

to trauma, whether it is an individual, group,

or community-based trauma. Individual attributes, developmental factors (including protective and risk factors), life history, type of

trauma, specific characteristics of the trauma,

amount and length of trauma exposure, cultural meaning of traumatic events, number of

losses associated with the trauma, available 

resources (internal and external, such as coping

skills and family support), and community 

reactions are a few of the determinants that 

influence a person’s responses to trauma across 

time. Refer to the “View Trauma Through a 

Sociocultural Lens” section later in this chapter for more specific information highlighting

the importance of culture in understanding

and treating the effects of trauma. 

Trauma cannot be viewed narrowly; instead, it

needs to be seen through a broader lens—a 

contextual lens integrating biopsychosocial,

interpersonal, community, and societal (the 

degree of individualistic or collective cultural 

values) characteristics that are evident preceding and during the trauma, in the immediate

and sustained response to the event(s), and in

the short- and long-term effects of the traumatic event(s), which may include housing

availability, community response, adherence to 

or maintenance of family routines and structure, and level of family support. 

To more adequately understand trauma, you 

must also consider the contexts in which it 

occurred. Understanding trauma from this 

angle helps expand the focus beyond individual characteristics and effects to a broader systemic perspective that acknowledges the 

influences of social interactions, communities,

governments, cultures, and so forth, while also

examining the possible interactions among

those various influences. Bronfenbrenner’s 

(1979) and Bronfenbrenner and Ceci’s (1994) 

work on ecological models sparked the development of other contextual models. In recent

years, the social-ecological framework has 

been adopted in understanding trauma, in

implementing health promotion and other

prevention strategies, and in developing treatment interventions (Centers for Disease Control and Prevention, 2009). Here are the three 

main beliefs of a social-ecological approach

(Stokols, 1996):

•	 Environmental factors greatly influence 

emotional, physical, and social well-being. 

•	 A fundamental determinant of health versus illness is the degree of fit between individuals’ biological, behavioral, and

sociocultural needs and the resources available to them. 

•	 Prevention, intervention, and treatment

approaches integrate a combination of

strategies targeting individual, interpersonal, and community systems. 

This TIP uses a social-ecological model to

explore trauma and its effects (Exhibit 1.1-2).

The focus of this model is not only on negative attributes (risk factors) across each level,

but also on positive ingredients (protective 

factors) that protect against or lessen the impact of trauma. This model also guides the 

inclusion of certain targeted interventions in

this text, including selective and indicated 

14 
Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective 

Exhibit 1.1-2: A Social-Ecological Model for Understanding Trauma and Its Effects 

prevention activities. In addition, culture, developmental processes (including the developmental stage or characteristics of the 

individual and/or community), and the specific

era when the trauma(s) occurred can significantly influence how a trauma is perceived and

processed, how an individual or community 

engages in help-seeking, and the degree of

accessibility, acceptability, and availability of

individual and community resources. 

Depending on the developmental stage and/or 

processes in play, children, adolescents, and

adults will perceive, interpret, and cope with

traumatic experiences differently. For example,

a child may view a news story depicting a 

traumatic event on television and believe that 

the trauma is recurring every time they see the 

scene replayed. Similarly, the era in which one 

lives and the timing of the trauma can greatly 

influence an individual or community response. Take, for example, a pregnant woman

who is abusing drugs and is wary of receiving

medical treatment after being beaten in a domestic dispute. She may fear losing her children or being arrested for child neglect. Even

though a number of States have adopted policies focused on the importance of treatment

for pregnant women who are abusing drugs 

and of the accessibility of prenatal care, other

States have approached this issue from a criminality standpoint (e.g., with child welfare and

criminal laws) in the past few decades. Thus, 

the traumatic event’s timing is a significant 

15 
 

 

 

Trauma-Informed Care in Behavioral Health Services 

component in understanding the context of

trauma and trauma-related responses. 

The social-ecological model depicted in Exhibit 1.1-2 provides a systemic framework for

looking at individuals, families, and communities affected by trauma in general; it highlights

the bidirectional influence that multiple contexts can have on the provision of behavioral

health services to people who have experienced trauma (see thin arrow). Each ring represents a different system (refer to Exhibit 

1.1-3 for examples of specific factors within

each system). The innermost ring represents 

the individual and his or her biopsychosocial

characteristics. The “Interpersonal” circle embodies all immediate relationships including

family, friends, peers, and others. The “Community/Organizational” band represents social 

support networks, workplaces, neighborhoods,

and institutions that directly influence the

individual and his/her relationships. The “Societal” circle signifies the largest system—State 

and Federal policies and laws, such as economic and healthcare policies, social norms,

governmental systems, and political ideologies.

The outermost ring, “Period of Time in History,” reflects the significance of the period of

time during which the event occurred; it influences each other level represented in the circle.

For example, making a comparison of society’s 

attitudes and responses to veterans’ homecomings across different wars and conflicts 

through time shows that homecoming environments can have either a protective or a 

negative effect on healing from the psychological and physical wounds of war, depending on

the era in question. The thicker arrows in the 

figure represent the key influences of culture,

developmental characteristics, and the type 

and characteristics of the trauma. All told, the

context of traumatic events can significantly 

influence both initial and sustained responses 

to trauma; treatment needs; selection of prevention, intervention, and other treatment 

Exhibit 1.1-3: Understanding the Levels Within the Social-Ecological Model of Trauma and Its Effects 

Individual 

Factors 

Interpersonal 

Factors 

Community and 

Organizational 

Factors 

Societal 

Factors 

Cultural and 

Developmental Factors 

Period of 

Time in 

History 

Age, biophysical state, mental health 

status, temperament and 

other personality traits, education, gender, 

coping styles, 

socioeconomic 

status 

Family, peer, 

and significant 

other interaction patterns, 

parent/family 

mental health, 

parents’ history of trauma, 

social network 

Neighborhood 

quality, school 

system and/or 

work environment, behavioral 

health system 

quality and accessibility, faithbased settings, 

transportation 

availability, community socioeconomic status, 

community employment rates 

Laws, 

State and 

Federal 

economic 

and social 

policies, 

media, 

societal 

norms, 

judicial 

system 

Collective or 

individualistic 

cultural 

norms, ethnicity, cultural 

subsystem 

norms, cognitive and maturational 

development 

Societal attitudes related 

to military 

service members’ homecomings, 

changes in 

diagnostic 

understanding 

between DSMIII-R* and 

DSM-5** 

*Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (American Psychiatric 

Association [APA], 1987) 

**Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (APA, 2013a) 

16 
 

 

Marisol is a 28-year-old Latina woman working as a barista at a local coffee shop. One evening, she 

was driving home in the rain when a drunk driver crossed into her lane and hit her head on. Marisol 

remained conscious as she waited to be freed from the car and was then transported to the hospital. 

She sustained fractures to both legs. Her recovery involved two surgeries and nearly 6 months of 

rehabilitation, including initial hospitalization and outpatient physical therapy. 

She described her friends and family as very supportive, saying that they often foresaw what she 

needed before she had to ask. She added that she had an incredible sense of gratitude for her employer and coworkers, who had taken turns visiting and driving her to appointments. Although she 

was able to return to work after 9 months, Marisol continued experiencing considerable distress 

about her inability to sleep well, which started just after the accident. Marisol describes repetitive 

dreams and memories of waiting to be transported to the hospital after the crash. The other driver 

was charged with driving under the influence (DUI), and it was reported that he had been convicted 

two other times for a DUI misdemeanor. 

Answering the following questions will help you see how the different levels of influence affect the 

impact and outcome of the traumatic event Marisol experienced, as well as her responses to that 

event: 

1. Based on the limited information provided in this illustration, how might Marisol’s personality 

affect the responses of her family and friends, her coworkers, and the larger community? 

2. In what ways could Marisol’s ethnic and cultural background influence her recovery? 

3. What societal factors could play a role in the car crash itself and the outcomes for Marisol and 

the other driver? 

Explore the influence of the period of time in history during which the scenario occurs—compare the 

possible outcomes for both Marisol and the other driver if the crash occurred 40 years ago versus in 

the present day. 

Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective 

strategies; and ways of providing hope and

promoting recovery. 

Minimize the Risk of 

Retraumatization or Replicating 

Prior Trauma Dynamics 

Trauma-informed treatment providers 

acknowledge that clients who have histories of

trauma may be more likely to experience particular treatment procedures and practices as 

negative, reminiscent of specific characteristics

of past trauma or abuse, or retraumatizing—

feeling as if the past trauma is reoccurring or

as if the treatment experience is as dangerous 

and unsafe as past traumas. For instance, clients may express feelings of powerlessness or

being trapped if they are not actively involved

in treatment decisions; if treatment processes 

or providers mirror specific behavior from the 

clients’ past experiences with trauma, they may 

voice distress or respond in the same way as 

they did to the original trauma. Among the 

potentially retraumatizing elements of treatment are seclusion or “time-out” practices that

isolate individuals, mislabeling client symptoms as personality or other mental disorders 

rather than as traumatic stress reactions, interactions that command authority, treatment 

assignments that could humiliate clients (such

as asking a client to wear a sign in group that

reflects one of their treatment issues, even if

the assignment centers on positive attributes 

of the client), confronting clients as resistant,

or presenting treatment as conditional upon

conformity to the provider’s beliefs and definitions of issues. 

Clients’ experiences are unique to the specific

traumas they have faced and the surrounding 

17 
How often have you heard “We aren’t equipped to handle trauma” or “We don’t have time to deal 

with reactions that surface if traumatic experiences are discussed in treatment” from counselors and 

administrators in behavioral health services? For agencies, staff members, and clients, these statements present many difficulties and unwanted outcomes. For a client, such comments may replicate 

his or her earlier encounters with others (including family, friends, and previous behavioral health 

professionals) who had difficulty acknowledging or talking about traumatic experiences with him or 

her. A hands-off approach to trauma can also reinforce the client’s own desire to avoid such discussions. Even when agencies and staff are motivated in these sentiments by a good intention—to contain clients’ feelings of being overwhelmed—such a perspective sends strong messages to clients 

that their experiences are not important, that they are not capable of handling their traumaassociated feelings, and that dealing with traumatic experiences is simply too dangerous. Statements 

like these imply that recovery is not possible and provide no structured outlet to address memories 

of trauma or traumatic stress reactions. 

Nevertheless, determining how and when to address traumatic stress in behavioral health services 

can be a real dilemma, especially if there are no trauma-specific philosophical, programmatic, or 

procedural processes in place. For example, it is difficult to provide an appropriate forum for a client 

to address past traumas if no forethought has been given to developing interagency and intraagency collaborations for trauma-specific services. By anticipating the need for trauma-informed 

services and planning ahead to provide appropriate services to people who are affected by trauma, 

behavioral health service providers and program administrators can begin to develop informed intervention strategies that send a powerful, positive message: 

• Both clients and providers can competently manage traumatic experiences and reactions. 

• Providers are interested in hearing clients’ stories and attending to their experiences. 

• Recovery is possible. 

Trauma-Informed Care in Behavioral Health Services 

circumstances before, during, and after that 

trauma, so remember that even seemingly safe 

and standard treatment policies and procedures, including physical plant operations (e.g.,

maintenance, grounds, fire and safety procedures), may feel quite the contrary for a client

if one or more of those elements is reminiscent 

of his or her experience of trauma in some 

way. Examples include having limited privacy 

or personal space, being interviewed in a room 

that feels too isolating or confining, undergoing physical examination by a medical professional of the same sex as the client’s previous 

perpetrator of abuse, attending a group session

in which another client expresses anger appropriately in a role play, or being directed not to

talk about distressing experiences as a means 

of deescalating traumatic stress reactions. 

Although some treatment policies or procedures are more obviously likely to solicit distress than others, all standard practices should 

be evaluated for their potential to retraumatize 

a client; this cannot be done without knowing

the specific features of the individual’s history 

of trauma. Consider, for instance, a treatment

program that serves meals including entrees 

that combine more than one food group. Your

client enters this program and refuses to eat

most of the time; he expresses anger toward

dietary staff and claims that food choices are

limited. You may initially perceive your client’s refusal to eat or to avoid certain foods as 

an eating disorder or a behavioral problem.

However, a trauma-aware perspective might

change your assumptions; consider that this 

client experienced neglect and abuse surrounding food throughout childhood (his

mother forced him to eat meals prepared by 

combining anything in the refrigerator and

cooking them together). 

18 
 

 

From the first time you provide outpatient counseling to Mike, you explain that he can call an agency 

number that will put him in direct contact with someone who can provide further assistance or support if he has emotional difficulty after the session or after agency hours. However, when he attempts 

to call one night, no one is available despite what you’ve described. Instead, Mike is directed by an 

operator to either use his local emergency room if he perceives his situation to be a crisis or to wait 

for someone on call to contact him. The inconsistency between what you told him in the session and 

what actually happens when he calls makes Mike feel unsafe and vulnerable. 

Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective 

As a treatment provider, you cannot consistently predict what may or may not be upsetting or retraumatizing to clients. Therefore, it

is important to maintain vigilance and an attitude of curiosity with clients, inquiring about

the concerns that they express and/or present

in treatment. Remember that certain behaviors 

or emotional expressions can reflect what has 

happened to them in the past. 

Foremost, a trauma-informed approach begins

with taking practical steps to reexamine treatment strategies, program procedures, and organizational polices that could solicit distress 

or mirror common characteristics of traumatic 

experiences (loss of control, being trapped, or

feeling disempowered). To better anticipate 

the interplay between various treatment elements and the more idiosyncratic aspects of a

particular client’s trauma history, you can: 

•	 Work with the client to learn the cues he or 

she associates with past trauma. 

•	 Obtain a good history. 

•	 Maintain a supportive, empathetic, and

collaborative relationship. 

•	 Encourage ongoing dialog. 

•	 Provide a clear message of availability and

accessibility throughout treatment. 

In sum, trauma-informed providers anticipate

and respond to potential practices that may be

perceived or experienced as retraumatizing to

clients; they are able to forge new ways to respond to specific situations that trigger a

trauma-related response, and they can provide 

clients with alternative ways of engaging in a 

particularly problematic element of treatment. 

Create a Safe Environment 

The need to create a safe environment is not 

new to providers; it involves an agency-wide 

effort supported by effective policies and procedures. However, creating safety within a

trauma-informed framework far exceeds the 

standard expectations of physical plant safety 

(e.g., facility, environmental, and space-related

concerns), security (of staff members, clients,

and personal property), policies and procedures (including those specific to seclusion

and restraint), emergency management and

disaster planning, and adherence to client

rights. Providers must be responsive and adapt

the environment to establish and support clients’ sense of physical and emotional safety. 

Beyond anticipating that various environmental stimuli within a program may generate 

strong emotions and reactions in a trauma 

survivor (e.g., triggers such as lighting, access

to exits, seating arrangements, emotionality 

within a group, or visual or auditory stimuli)

and implementing strategies to help clients 

cope with triggers that evoke their experiences 

with trauma, other key elements in establishing a safe environment include consistency in

client interactions and treatment processes,

following through with what has been reviewed or agreed upon in sessions or meetings,

and dependability. Mike’s case illustration depicts ways in which the absence of these key 

elements could erode a client’s sense of safety 

during the treatment process. 

Neither providers nor service processes are 

always perfect. Sometimes, providers 

19 
 

 

 

 

 

 

Case Illustration: Jane 

Jane, a newly hired female counselor, had a nephew who took his own life. The program that hired 

her was short of workers at the time; therefore, Jane did not have an opportunity to engage sufficiently in orientation outside of reviewing the policies and procedure manual. In an attempt to present well to her new employer and supervisor, she readily accepted client assignments without 

considering her recent loss. By not immersing herself in the program’s perspective and policies on 

staff well-being, ethical and clinical considerations in client assignments, and how and when to seek 

supervision, Jane failed to engage in the practices, heavily supported by the agency, that promoted 

safety for herself and her clients. Subsequently, she felt emotionally overwhelmed at work and would 

often abruptly request psychiatric evaluation for clients who expressed any feelings of hopelessness 

out of sheer panic that they would attempt suicide. 

Trauma-Informed Care in Behavioral Health Services 

unintentionally relay information inaccurately

or inconsistently to clients or other staff members; other times, clients mishear something, 

or extenuating circumstances prevent providers from responding as promised. Creating

safety is not about getting it right all the time;

it’s about how consistently and forthrightly 

you handle situations with a client when circumstances provoke feelings of being vulnerable or unsafe. Honest and compassionate 

communication that conveys a sense of handling the situation together generates safety. It

is equally important that safety extends beyond the client. Counselors and other behavioral health staff members, including peer

support specialists, need to be able to count on

the agency to be responsive to and maintain

their safety within the environment as well. By 

incorporating an organizational ethos that

recognizes the importance of practices that 

promote physical safety and emotional wellbeing, behavioral health staff members may be

more likely to seek support and supervision

when needed and to comply with clinical and 

programmatic practices that minimize risks

for themselves and their clients. 

Beyond an attitudinal promotion of safety,

organizational leaders need to consider and 

create avenues of professional development

and assistance that will give their staff the

means to seek support and process distressing

circumstances or events that occur within the 

agency or among their clientele, such as case 

consultation and supervision, formal or informal processes to debrief service providers 

about difficult clinical issues, and referral processes for client psychological evaluations and

employee assistance for staff. Organizational

practices are only effective if supported by 

unswerving trauma awareness, training, and

education among staff. Jane’s case illustration 

shows the impact of a minor but necessary 

postponement in staff orientation for a new

hire—not an unusual circumstance in behavioral health programs that have heavy caseloads and high staff turnover. 

Identify Recovery From Trauma as 

a Primary Goal 

Often, people who initiate or are receiving

mental health or substance abuse services don’t 

identify their experiences with trauma as a 

significant factor in their current challenges or

problems. In part, this is because people who

have been exposed to trauma, whether once or

repeatedly, are generally reluctant to revisit it.

They may already feel stuck in repetitive 

memories or experiences, which may add to

their existing belief that any intervention will

make matters worse or, at least, no better. For

some clients, any introduction to their traumarelated memories or minor cues reminiscent of 

the trauma will cause them to experience 

strong, quick-to-surface emotions, supporting

their belief that addressing trauma is dangerous and that they won’t be able to handle the 

20 
 

 

Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective 

emotions or thoughts that result from attempting to do so. Others readily view their

experiences of trauma as being in the past; as a 

result, they engage in distraction, dissociation,

and/or avoidance (as well as adaptation) due to

a belief that trauma has little impact on their

current lives and presenting problems. Even

individuals who are quite aware of the impact

that trauma has had on their lives may still 

struggle to translate or connect how these 

events continue to shape their choices, behaviors, and emotions. Many survivors draw no

connection between trauma and their mental 

health or substance abuse problems, which

makes it more difficult for them to see the 

value of trauma-informed or trauma-specific 

interventions, such as creating safety, engaging

in psychoeducation, enhancing coping skills,

and so forth. 

As a trauma-informed provider, it is important

that you help clients bridge the gap between

their mental health and substance-related issues and the traumatic experiences they may 

have had. All too often, trauma occurs before 

substance use and mental disorders develop;

then, such disorders and their associated 

symptoms and consequences create opportunities for additional traumatic events to occur. If 

individuals engage in mental health and substance abuse treatment without addressing the 

role that trauma has played in their lives, they 

are less likely to experience recovery in the 

long run. For example, a person with a history 

of trauma is more likely to have anxiety and

depressive symptoms, use substances to selfmedicate, and/or relapse after exposure to

trauma-related cues. Thus, collaboration within and between behavioral health agencies is 

necessary to make integrated, timely, traumaspecific interventions available from the beginning to clients/consumers who engage in

substance abuse and mental health services. 

Support Control, Choice, and 

Autonomy 

Not every client who has experienced trauma

and is engaged in behavioral health services 

wants, or sees the need for, trauma-informed

or trauma-specific treatment. Clients may 

think that they’ve already dealt with their

trauma adequately, or they may believe that 

the effects of past trauma cause minimal distress for them. Other clients may voice the 

same sentiments, but without conviction—

instead using avoidant behavior to deter distressing symptoms or reactions. Still others 

may struggle to see the role of trauma in their

presenting challenges, not connecting their

past traumatic experiences with other, more 

current difficulties (e.g., using substances to

self-medicate strong emotions). Simply the 

idea of acknowledging trauma-related experiences and/or stress reactions may be too

frightening or overwhelming for some clients,

and others may fear that their reactions will be 

dismissed. On the other hand, some individuals want so much to dispense with their traumatic experiences and reactions that they 

hurriedly and repeatedly disclose their experiences before establishing a sufficiently safe 

environment or learning effective coping strategies to offset distress and other effects of retraumatization. 

As these examples show, not everyone affected 

by trauma will approach trauma-informed

services or recognize the impact of trauma in

their lives in the same manner. This can be 

challenging to behavioral health service providers who are knowledgeable about the impact of trauma and who perceive the 

importance of addressing trauma and its effects with clients. As with knowing that different clients may be at different levels of

awareness or stages of change in substance 

abuse treatment services, you should

acknowledge that people affected by trauma 

21 
 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

present an array of reactions, various levels of

trauma awareness, and different degrees of

urgency in their need to address trauma. 

Appreciating clients’ perception of their presenting problems and viewing their responses 

to the impact of trauma as adaptive—even

when you believe their methods of dealing

with trauma to be detrimental—are equally 

important elements of TIC. By taking the

time to engage with clients and understand 

the ways they have perceived, adjusted to, and

responded to traumatic experiences, providers 

are more likely to project the message that

clients possess valuable personal expertise and

knowledge about their own presenting problems. This shifts the viewpoint from “Providers know best” to the more collaborative 

“Together, we can find solutions.” 

How often have you heard from clients that

they don’t believe they can handle symptoms 

that emerge from reexperiencing traumatic

cues or memories? Have you ever heard clients 

state that they can’t trust themselves or their 

reactions, or that they never know when they 

are going to be triggered or how they are going to react? How confident would you feel 

about yourself if, at any time, a loud noise 

could initiate an immediate attempt to hide,

duck, or dive behind something? Traumatic

experiences have traditionally been described

as exposure to events that cause intense fear,

helplessness, horror, or feelings of loss of control. Participation in behavioral health services

should not mirror these aspects of traumatic

experience. Working collaboratively to facilitate clients’ sense of control and to maximize 

clients’ autonomy and choices throughout the

treatment process, including treatment planning, is crucial in trauma-informed services. 

For some individuals, gaining a sense of control and empowerment, along with understanding traumatic stress reactions, may be 

pivotal ingredients for recovery. By creating 

opportunities for empowerment, counselors 

and other behavioral health service providers

help reinforce, clients’ sense of competence, 

which is often eroded by trauma and prolonged traumatic stress reactions. Keep in

mind that treatment strategies and procedures 

that prioritize client choice and control need

not focus solely on major life decisions or

treatment planning; you can apply such approaches to common tasks and everyday interactions between staff and consumers. Try

asking your clients some of the following

questions (which are only a sample of the 

types of questions that could be useful):

•	 What information would be helpful for us 

to know about what happened to you? 

•	 Where/when would you like us to call you? 

•	 How would you like to be addressed? 

•	 Of the services I’ve described, which seem

to match your present concerns and needs? 

•	 From your experience, what responses from 

others appear to work best when you feel 

overwhelmed by your emotions? 

Likewise, organizations need to reinforce the 

importance of staff autonomy, choice, and

sense of control. What resources can staff 

members access, and what choices are available to them, in processing emotionally charged

content or events in treatment? How often do 

administrators and supervisors seek out feedback on how to handle problematic situations

(e.g., staff rotations for vacations, case consultations, changes in scheduling)? Think about

the parallel between administration and staff

members versus staff members and clients; 

often, the same philosophy, attitudes, and

behaviors conveyed to staff members by administrative practices are mirrored in staff–

client interactions. Simply stated, if staff

members do not feel empowered, it will be a

challenge for them to value the need for client

empowerment. (For more information on

administrative and workforce development

issues, refer to Part 2, Chapters 1 and 2.) 

22 
 

members cannot make decisions pertaining to

interventions or involvement in community 

services autocratically; instead, they should

develop trauma-informed, individualized care

plans and/or treatment plans collaboratively

with the client and, when appropriate, with 

family and caregivers. The nonauthoritarian

approach that characterizes TIC views clients 

Mina initially sought counseling after her husband was admitted to an intensive outpatient drug and 

alcohol program. She was self-referred for low-grade depression, resentment toward her spouse, 

and codependency. When asked to define “codependency” and how the term applied to her, she 

responded that she always felt guilty and responsible for everyone in her family and for events that 

occurred even when she had little or no control over them. 

After the intake and screening process, she expressed interest in attending group sessions that focused primarily on family issues and substance abuse, wherein her presenting concerns could be 

explored. In addition to describing dynamics and issues relating to substance abuse and its impact 

on her marriage, she referred to her low mood as frozen grief. During treatment, she reluctantly 

began to talk about an event that she described as life changing: the loss of her father. The story 

began to unfold in group; her father, who had been 62 years old, was driving her to visit a cousin. 

During the ride, he had a heart attack and drove off the road. As the car came to stop in a field, she 

remembered calling 911 and beginning cardiopulmonary resuscitation while waiting for the ambulance. She rode with the paramedics to the hospital, watching them work to save her father’s life; 

however, he was pronounced dead soon after arrival. 

She always felt that she never really said goodbye to her father. In group, she was asked what she 

would need to do or say to feel as if she had revisited that opportunity. She responded in quite a 

unique way, saying, “I can’t really answer this question; the lighting isn’t right for me to talk about 

my dad.” The counselor encouraged her to adjust the lighting so that it felt “right” to her. Being 

invited to do so turned out to be pivotal in her ability to address her loss and to say goodbye to her 

father on her terms. She spent nearly 10 minutes moving the dimmer switch for the lighting as others in the group patiently waited for her to return to her chair. She then began to talk about what 

happened during the evening of her father’s death, their relationship, the events leading up to that 

evening, what she had wanted to say to him at the hospital, and the things that she had been wanting to share with him since his death. 

Weeks later, as the group was coming to a close, each member spoke about the most important 

experiences, tools, and insights that he or she had taken from participating. Mina disclosed that the 

group helped her establish boundaries and coping strategies within her marriage, but said that the 

event that made the most difference for her had been having the ability to adjust the lighting in the 

room. She explained that this had allowed her to control something over which she had been powerless during her father’s death. To her, the lighting had seemed to stand out more than other details at the scene of the accident, during the ambulance ride, and at the hospital. She felt that the 

personal experience of losing her father and needing to be with him in the emergency room was 

marred by the obtrusiveness of staff, procedures, machines, and especially, the harsh lighting. She 

reflected that she now saw the lighting as a representation of this tragic event and the lack of privacy she had experienced when trying to say goodbye to her father. Mina stated that this moment in 

group had been the greatest gift: “...to be able to say my goodbyes the way I wanted... I was given 

an opportunity to have some control over a tragic event where I couldn’t control the outcome no 

matter how hard I tried.” 

Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective 

Create Collaborative 

Relationships and Participation 

Opportunities 

This trauma-informed principle encompasses 

three main tenets. First, ensure that the 

provider–client relationship is collaborative,

regardless of setting or service. Agency staff 

23 
 

 

 

Trauma-Informed Care in Behavioral Health Services 

as the experts in their own lives and current

struggles, thereby emphasizing that clients and

providers can learn from each other. 

The second tenet is to build collaboration 

beyond the provider–client relationship. 

Building ongoing relationships across the service system, provider networks, and the local 

community enhances TIC continuity as clients move from one level of service to the next 

or when they are involved in multiple services 

at one time. It also allows you to learn about

resources available to your clients in the service system or community and to connect with

providers who have more advanced training in

trauma-specific interventions and services. 

The third tenet emphasizes the need to ensure client/consumer representation and

participation in behavioral health program

development, planning, and evaluation as

well as in the professional development of

behavioral health workers. To achieve trauma-informed competence in an organization

or across systems, clients need to play an active 

role; this starts with providing program feedback. However, consumer involvement should

not end there; rather, it should be encouraged

throughout the implementation of traumainformed services. So too, clients, potential 

clients, their families, and the community 

should be invited to participate in forming any

behavioral health organization’s plans to improve trauma-informed competence, provide 

TIC, and design relevant treatment services 

and organizational policies and procedures. 

Trauma-informed principles and practices

generated without the input of people affected

by trauma are difficult to apply effectively.

Likewise, staff trainings and presentations

should include individuals who have felt the 

impact of trauma. Their participation reaches

past the purely cognitive aspects of such education to offer a personal perspective on the 

strengths and resilience of people who have 

experienced trauma. The involvement of

trauma survivors in behavioral health education lends a human face to subject matter that

is all too easily made cerebral by some staff

members in an attempt to avoid the emotionality of the topic. 

Consumer participation also means giving

clients/consumers the chance to obtain State

training and certification, as well as employment in behavioral health settings as peer specialists. Programs that incorporate peer

support services reinforce a powerful message—that provider–consumer partnership is 

important, and that consumers are valued.

Peer support specialists are self-identified individuals who have progressed in their own 

recovery from alcohol dependence, drug addiction, and/or a mental disorder and work 

within behavioral health programs or at peer

support centers to assist others with similar

disorders and/or life experiences. Tasks and

responsibilities may include leading a peer

support group; modeling effective coping,

help-seeking, and self-care strategies; helping

clients practice new skills or monitor progress;

promoting positive self-image to combat clients’ potentially negative feelings about themselves and the discrimination they may

perceive in the program or community; handling case management tasks; advocating for

program changes; and representing a voice of

hope that views recovery as possible. 

Familiarize the Client With 

Trauma-Informed Services 

Without thinking too much about it, you

probably know the purpose of an intake process, the correct way to complete a screening

device, the meaning of a lot of the jargon specific to behavioral health, and your program’s 

expectations for client participation; in fact, 

maybe you’re already involved in facilitating

these processes in behavioral health services 

every day, and they’ve become almost 

24 
 

 

 

Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective 

automatic for you. This can make it easy to

forget that nearly everything clients and their

families encounter in seeking behavioral

health assistance is new to them. Thus, introducing clients to program services, activities,

and interventions in a manner that expects

them to be unfamiliar with these processes is 

essential, regardless of their clinical and treatment history. Beyond addressing the unfamiliarity of services, educating clients about each 

process—from first contact all the way 

through recovery services—gives them a

chance to participate actively and make informed decisions across the continuum of care. 

Familiarizing clients with trauma-informed 

services extends beyond explaining program 

services or treatment processes; it involves 

explaining the value and type of traumarelated questions that may be asked during an

intake process, educating clients about trauma 

to help normalize traumatic stress reactions, 

and discussing trauma-specific interventions 

and other available services (including explanations of treatment methodologies and of the

rationale behind specific interventions). Developmentally appropriate psychoeducation

about trauma-informed services allows clients 

to be informed participants. 

Incorporate Universal Routine 

Screenings for Trauma 

Screening universally for client histories, experiences, and symptoms of trauma at intake can 

benefit clients and providers. Most providers

know that clients can be affected by trauma,

but universal screening provides a steady reminder to be watchful for past traumatic experiences and their potential influence upon a

client’s interactions and engagement with services across the continuum of care. Screening

should guide treatment planning; it alerts the

staff to potential issues and serves as a valuable 

tool to increase clients’ awareness of the possible impact of trauma and the importance of

addressing related issues during treatment. 

Nonetheless, screenings are only as useful as 

the guidelines and processes established to

address positive screens (which occur when

clients respond to screening questions in a way 

that signifies possible trauma-related symptoms or histories). Staff should be trained to

use screening tools consistently so that all clients are screened in the same way. Staff members also need to know how to score 

screenings and when specific variables (e.g.,

race/ethnicity, native language, gender, culture)

may influence screening results. For example, a

woman who has been sexually assaulted by a

man may be wary of responding to questions if

a male staff member or interpreter administers 

the screening or provides translation services.

Likewise, a person in a current abusive or violent relationship may not acknowledge the 

interpersonal violence in fear of retaliation or 

as a result of disconnection or denial of his or 

her experience, and he or she may have difficulty in processing and then living between 

two worlds—what is acknowledged in treatment versus what is experienced at home. 

In addition, staff training on using traumarelated screening tools needs to center on how 

and when to gather relevant information after

the screening is complete. Organizational policies and procedures should guide staff members on how to respond to a positive screening,

such as by making a referral for an indepth

assessment of traumatic stress, providing the 

client with an introductory psychoeducational 

session on the typical biopsychosocial effects 

of trauma, and/or coordinating care so that the

client gains access to trauma-specific services 

that meet his or her needs. Screening tool selection is an important ingredient in incorporating routine, universal screening practices 

into behavioral health services. Many screening tools are available, yet they differ in format 

25 
 

 

 

Trauma-Informed Care in Behavioral Health Services 

and in how they present questions. Select tools

based not just on sound test properties, but

also according to whether they encompass a

broad range of experiences typically considered traumatic and are flexible enough to allow for an individual’s own interpretation of

traumatic events. For more information on 

screening and assessment of trauma and trauma-related symptoms and effects, see Chapter

4, “Screening and Assessment,” in this TIP. 

View Trauma Through a 

Sociocultural Lens 

To understand how trauma affects an individual, family, or community, you must first understand life experiences and cultural 

background as key contextual elements for 

that trauma. As demonstrated in Exhibit 1.1­

2, many factors shape traumatic experiences 

and individual and community responses to it;

one of the most significant factors is culture. It

influences the interpretation and meaning of

traumatic events, individual beliefs regarding

personal responsibility for the trauma and

subsequent responses, and the meaning and

acceptability of symptoms, support, and helpseeking behaviors. As this TIP proceeds to

describe the differences among cultures pertaining to trauma, remember that there are

numerous cross-cutting factors that can directly or indirectly influence the attitudes, beliefs,

behaviors, resources, and opportunities within

a given culture, subculture, or racial and/or

ethnic group (Exhibit 1.1-4). For an indepth 

Exhibit 1.1-4: Cross-Cutting Factors of Culture 

26 
 

 

 

“Trauma -informed care recognizes symp -

toms as originating from adaptations to 

the traumatic event(s) or context. Validating resilience is important even when past 

coping behaviors are now causing problems. Understanding a symptom as an 

adaptation reduces a survivor’s guilt and 

shame, increases their self -esteem and 

provides a guideline for developing new 

skills and resources to allow new and better adaptation to the current situation.” 

(Elliot et al., 2005, p. 467) 

Culture and Trauma 

• Some populations and cultures are more likely than others to experience a traumatic event or a 

specific type of trauma. 

• Rates of traumatic stress are high across all diverse populations and cultures that face military 

action and political violence. 

• Culture influences not only whether certain events are perceived as traumatic, but also how an 

individual interprets and assigns meaning to the trauma. 

• Some traumas may have greater impact on a given culture because those traumas represent 

something significant for that culture or disrupt cultural practices or ways of life. 

• Culture determines acceptable responses to trauma and shapes the expression of distress. It 

significantly influences how people convey traumatic stress through behavior, emotions, and 

thinking immediately following a trauma and well after the traumatic experience has ceased. 

• Traumatic stress symptoms vary according to the type of trauma within the culture. 

• Culture affects what qualifies as a legitimate health concern and which symptoms warrant help. 

• In addition to shaping beliefs about acceptable forms of help-seeking behavior and healing practices, culture can provide a source of strength, unique coping strategies, and specific resources. 

Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective 

exploration of these cross-cutting cultural factors, refer to the planned TIP, Improving Cultural Competence (SAMHSA, planned c). 

When establishing TIC, it is vital that behavioral health systems, service providers, licensing agencies, and accrediting bodies build

culturally responsive practices into their curricula, standards, policies and procedures, and 

credentialing processes. The implementation

of culturally responsive practices will further

guide the treatment planning process so that

trauma-informed services are more appropriate and likely to succeed. 

Use a Strengths-Focused 

Perspective: Promote Resilience 

Fostering individual strengths is a key step in

prevention when working with people who

have been exposed to trauma. It is also an essential intervention strategy—one that builds 

on the individual’s existing resources and views 

him or her as a resourceful, resilient survivor.

Individuals who have experienced trauma develop many strategies and/or behaviors to

adapt to its emotional, cognitive, spiritual, and

physical consequences. Some behaviors may be 

effective across time, whereas others may 

eventually produce difficulties and disrupt the 

healing process. Traditionally, behavioral

health services have tended to focus on presenting problems, risk factors, and symptoms 

in an attempt to prevent negative outcomes,

provide relief, increase clients’ level of functioning, and facilitate healing. However, focusing too much on these areas can undermine 

clients’ sense of competence and hope. Targeting only presenting problems and symptoms 

does not provide individuals with an opportunity to see their own resourcefulness in

managing very stressful and difficult experiences. It is important for providers to engage 

in interventions using a balanced approach

that targets the strengths clients have 

27 
 

 

 

Advice to Counselors and Administrators: Using Strengths-Oriented Questions 

Knowing a client’s strengths can help you understand, redefine, and reframe the client’s presenting 

problems and challenges. By focusing and building on an individual’s strengths, counselors and other 

behavioral health professionals can shift the focus from “What is wrong with you?” to “What has 

worked for you?” It moves attention away from trauma-related problems and toward a perspective 

that honors and uses adaptive behaviors and strengths to move clients along in recovery. 

Potential strengths-oriented questions include: 

• The history that you provided suggests that you’ve accomplished a great deal since the trauma. 

What are some of the accomplishments that give you the most pride? 

• What would you say are your strengths? 

• How do you manage your stress today? 

• What behaviors have helped you survive your traumatic experiences (during and afterward)? 

• What are some of the creative ways that you deal with painful feelings? 

• You have survived trauma. What characteristics have helped you manage these experiences and 

the challenges that they have created in your life? 

• If we were to ask someone in your life, who knew your history and experience with trauma, to 

name two positive characteristics that help you survive, what would they be? 

• What coping tools have you learned from your _____ (fill in: cultural history, spiritual practices, 

athletic pursuits, etc.)? 

• Imagine for a moment that a group of people are standing behind you showing you support in 

some way. Who would be standing there? It doesn’t matter how briefly or when they showed up 

in your life, or whether or not they are currently in your life or alive. 

• How do you gain support today? (Possible answers include family, friends, activities, coaches, 

counselors, other supports, etc.) 

• What does recovery look like for you? 

Trauma-Informed Care in Behavioral Health Services 

developed to survive their experiences and to

thrive in recovery. A strengths-based, 

resilience-minded approach lets trauma survivors begin to acknowledge and appreciate 

their fortitude and the behaviors that help

them survive. 

Foster Trauma-Resistant Skills 

Trauma-informed services build a foundation 

on which individuals can begin to explore the 

role of trauma in their lives; such services can

also help determine how best to address and

tailor interventions to meet their needs. Prevention, mental health, and substance abuse

treatment services should include teaching

clients about how trauma can affect their lives;

these services should also focus on developing

self-care skills, coping strategies, supportive 

networks, and a sense of competence. Building

trauma-resistant skills begins with normalizing the symptoms of traumatic stress and 

helping clients who have experienced trauma

connect the dots between current problems 

and past trauma when appropriate. 

Nevertheless, TIC and trauma-specific interventions that focus on skill-building should

not do so at the expense of acknowledging

individual strengths, creativity in adapting to

trauma, and inherent attributes and tools clients possesses to combat the effects of trauma.

Some theoretical models that use skillbuilding strategies base the value of this approach on a deficit perspective; they assume 

that some individuals lack the necessary tools 

to manage specific situations and, because of

this deficiency, they encounter problems that

others with effective skills would not experience. This type of perspective further assumes 

that, to recover, these individuals must learn

new coping skills and behavior. TIC, on the

other hand, makes the assumption that clients 

28 
 

 

 

 

 

 

 

Advice to Administrators: Self-Assessment for Trauma-Informed Systems 

NCTIC has developed a self-assessment package for trauma-informed systems to help administrators 

structurally incorporate trauma into programs and services. The self-assessment can be used by systems of care to guide quality improvement with the goal of establishing fully trauma-informed treatment and recovery efforts (NCTIC, Center for Mental Health Services, 2007). Behavioral health 

treatment program administrators can use these materials and NCTIC as resources for improvement 

in delivering TIC. 

Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective 

are the experts in their own lives and have 

learned to adapt and acquire skills to survive.

The TIC approach honors each individual’s 

adaptations and acquired skills, and it helps 

clients explore how these may not be working

as well as they had in the past and how their

current repertoire of responses may not be as 

effective as other strategies. 

Demonstrate Organizational and 

Administrative Commitment to 

TIC 

Becoming a trauma-informed organization

requires administrative guidance and support

across all levels of an agency. Behavioral health

staff will not likely sustain TIC practices

without the organization’s ongoing commitment to support professional development and

to allocate resources that promote these practices. An agency that wishes to commit to TIC

will benefit from an organizational assessment

of how staff members identify and manage

trauma and trauma-related reactions in their 

clients. Are they trauma aware—do they recognize that trauma can significantly affect a 

client’s ability to function in one or more areas 

of his or her life? Do the staff members understand that traumatic experiences and traumarelated reactions can greatly influence clients’ 

engagement, participation, and response to

services? 

Agencies need to embrace specific strategies 

across each level of the organization to create 

trauma-informed services; this begins with

staff education on the impact of trauma 

among clients. Other agency strategies that 

reflect a trauma-informed infrastructure include, but are not limited to:

•	 Universal screening and assessment procedures for trauma. 

•	 Interagency and intra-agency collaboration

to secure trauma-specific services. 

•	 Referral agreements and networks to match

clients’ needs. 

•	 Mission and value statements endorsing the 

importance of trauma recognition. 

•	 Consumer- and community-supported

committees and trauma response teams. 

•	 Workforce development strategies, including hiring practices. 

•	 Professional development plans, including

staff training/supervision focused on TIC. 

•	 Program policies and procedures that ensure trauma recognition and secure traumainformed practices, trauma-specific services,

and prevention of retraumatization. 

TIC requires organizational commitment, and

often, cultural change. For more information

on implementing TIC in organizations, see

Part 2, Chapter 1 of this TIP. 

Develop Strategies To Address 

Secondary Trauma and Promote 

Self-Care 

Secondary trauma is a normal occupational

hazard for mental health and substance abuse 

professionals, particularly those who serve 

populations that are likely to include survivors 

of trauma (Figley, 1995; Klinic Community

Health Centre, 2008). Behavioral health staff

members who experience secondary trauma

present a range of traumatic stress reactions 

29 
 

 

Trauma is similar to a rock hitting the water’s 

surface. The impact first creates the largest 

wave, which is followed by ever-expanding, but 

less intense, ripples. Likewise, the influence of 

a given trauma can be broad, but generally, its 

effects are less intense for individuals further 

removed from the trauma; eventually, its impact dissipates all around. For trauma survivors, 

the impact of trauma can be far-reaching and 

can affect life areas and relationships long after 

the trauma occurred. This analogy can also 

broadly describe the recovery process for individuals who have experienced trauma and for 

those who have the privilege of hearing their 

stories. As survivors reveal their trauma-related 

experiences and struggles to a counselor or 

another caregiver, the trauma becomes a 

shared experience, although it is not likely to 

be as intense for the caregiver as it was for the 

individual who experienced the trauma. The 

caregiver may hold onto the trauma’s known 

and unknown effects or may consciously decide 

to engage in behaviors that provide support to 

further dissipate the impact of this trauma and 

the risk of secondary trauma. 

Trauma-Informed Care in Behavioral Health Services 

and effects from providing services focused

on trauma or listening to clients recount

traumatic experiences. So too, when a counselor has a history of personal trauma, working with trauma survivors may evoke 

memories of the counselor’s own trauma history, which may increase the potential for 

secondary traumatization. 

The range of reactions that manifest with secondary trauma can be, but are not necessarily,

similar to the reactions presented by clients 

who have experienced primary trauma. Symptoms of secondary trauma can produce varying

levels of difficulty, impairment, or distress in

daily functioning; these may or may not meet

diagnostic thresholds for acute stress, posttraumatic stress, or adjustment, anxiety, or 

mood disorders (Bober & Regehr, 2006).

Symptoms may include physical or psychological reactions to traumatic memories clients 

have shared; avoidance behaviors during client

interactions or when recalling emotional content in supervision; numbness, limited emotional expression, or diminished affect; somatic

complaints; heightened arousal, including insomnia; negative thinking or depressed mood;

and detachment from family, friends, and other supports (Maschi & Brown, 2010). 

Working daily with individuals who have been

traumatized can be a burden for counselors 

and other behavioral health service providers, 

but all too often, they blame the symptoms 

resulting from that burden on other stressors 

at work or at home. Only in the past 2 decades

have literature and trainings begun paying

attention to secondary trauma or compassion

fatigue; even so, agencies often do not translate this knowledge into routine prevention

practices. Counselors and other staff members 

may find it difficult to engage in activities that

could ward off secondary trauma due to time 

constraints, workload, lack of agency resources, and/or an organizational culture that 

disapproves of help-seeking or provides inadequate staff support. The demands of providing

care to trauma survivors cannot be ignored,

lest the provider become increasingly impaired

and less effective. Counselors with 

unacknowledged secondary trauma can cause 

harm to clients via poorly enforced boundaries, missed appointments, or even abandonment of clients and their needs (Pearlman &

Saakvitne, 1995). 

Essential components of TIC include organizational and personal strategies to address 

The Impact of Trauma 

30 
 

 

 

Advice to Counselors: Decreasing the Risk of Secondary Trauma and Promoting 

Self-Care 

• Peer support. Maintaining adequate social support will help prevent isolation and depression. 

• Supervision and consultation. Seeking professional support will enable you to understand your 

own responses to clients and to work with them more effectively. 

• Training. Ongoing professional training can improve your belief in your abilities to assist clients in 

their recoveries. 

• Personal therapy. Obtaining treatment can help you manage specific problems and become 

better able to provide good treatment to your clients. 

• Maintaining balance. A healthy, balanced lifestyle can make you more resilient in managing any 

difficult circumstances you may face. 

Setting clear limits and boundaries with clients. Clearly separating your personal and work life 

allows time to rejuvenate from stresses inherent in being a professional caregiver. 

Part 1, Chapter 1—Trauma-Informed Care: A Sociocultural Perspective 

secondary trauma and its physical, cognitive,

emotional, and spiritual consequences. In

agencies and among individual providers, it is

key for the culture to promote acceptability,

accessibility, and accountability in seeking

help, accessing support and supervision, and

engaging in self-care behaviors in and outside

of the agency or office. Agencies should involve staff members who work with trauma in 

developing informal and formal agency practices and procedures to prevent or address secondary trauma. Even though a number of

community-based agencies face fiscal constraints, prevention strategies for secondary 

trauma can be intertwined with the current 

infrastructure (e.g., staff meetings, education,

case consultations and group case discussions,

group support, debriefing sessions as appropriate, supervision). For more information on 

strategies to address and prevent secondary 

trauma, see Part 2, Chapter 2 of this TIP. 

Provide Hope—Recovery Is 

Possible 

What defines recovery from trauma-related

symptoms and traumatic stress disorders? Is 

it the total absence of symptoms or consequences? Does it mean that clients stop having nightmares or being reminded, by cues, of

past trauma? When clients who have experienced trauma enter into a helping relationship 

to address trauma specifically, they are often

looking for a cure, a remission of symptoms, or

relief from the pain as quickly as possible. 

However, they often possess a history of unpredictable symptoms and symptom intensity 

that reinforces an underlying belief that recovery is not possible. On one hand, clients are

looking for a message that they can be cured,

while on the other hand, they have serious 

doubts about the likely success of any 

intervention. 

Clients often express ambivalence about dealing with trauma even if they are fully aware of

trauma’s effects on their lives. The idea of living with more discomfort as they address the 

past or as they experiment with alternative

ways of dealing with trauma-related symptoms

or consequences is not an appealing prospect,

and it typically elicits fear. Clients may interpret the uncomfortable feelings as dangerous 

or unsafe even in an environment and relationship that is safe and supportive. 

How do you promote hope and relay a message that recovery is possible? First, maintain

consistency in delivering services, promoting

and providing safety for clients, and showing

respect and compassion within the client–

provider relationship. Along with clients’ 

commitment to learning how to create safety 

for themselves, counselors and agencies need 

31 
 

 

Trauma-Informed Care in Behavioral Health Services 

to be aware of, and circumvent, practices that

could retraumatize clients. Projecting hope 

and reinforcing the belief that recovery is possible extends well beyond the practice of establishing safety; it also encompasses 

discussing what recovery means and how it

looks to clients, as well as identifying how

they will know that they’ve entered into recovery in earnest. 

Providing hope involves projecting an attitude

that recovery is possible. This attitude also

involves viewing clients as competent to make 

changes that will allow them to deal with

trauma-related challenges, providing opportunities for them to practice dealing with difficult situations, and normalizing discomfort or

difficult emotions and framing these as manageable rather than dangerous. If you convey 

this attitude consistently to your clients, they 

will begin to understand that discomfort is not 

a signal to avoid, but a sign to engage—and

that behavioral, cognitive, and emotional responses to cues associated with previous traumas are a normal part of the recovery process.

It’s not the absence of responses to such triggers that mark recovery, but rather, how clients 

experience and manage those responses. Clients can also benefit from interacting with

others who are further along in their recovery 

from trauma. Time spent with peer support

staff or sharing stories with other trauma survivors who are well on their way to recovery is

invaluable—it sends a powerful message that 

recovery is achievable, that there is no shame 

in being a trauma survivor, and that there is a 

future beyond the trauma. 

As You Proceed 

This chapter has established the foundation

and rationale of this TIP, reviewed traumainformed concepts and terminology, and provided an overview of TIC principles and a 

guiding framework for this text. As you proceed, be aware of the wide-ranging responses 

to trauma that occur not only across racially 

and ethnically diverse groups but also within

specific communities, families, and individuals.

Counselors, prevention specialists, other behavioral health workers, supervisors, and organizations all need to develop skills to create 

an environment that is responsive to the

unique attributes and experiences of each client. As you read this TIP, remember that

many cross-cutting factors influence the experiences, help-seeking behaviors, intervention 

responses, and outcomes of individuals, families, and populations who have survived trauma. Single, multiple, or chronic exposures to

traumatic events, as well as the emotional,

cognitive, behavioral, and spiritual responses to

trauma, need to be understood within a socialecological framework that recognizes the 

many ingredients prior to, during, and after 

traumatic experiences that set the stage for 

recovery. 

32 
 

 

IN THIS CHAPTER 

• Types of Trauma

• Characteristics of Trauma

• Individual and

Sociocultural Features

Trauma Awareness 2 

Traumatic experiences typically do not result in long-term impairment for most individuals. It is normal to experience such

events across the lifespan; often, individuals, families, and communities respond to them with resilience. This chapter explores 

several main elements that influence why people respond differently to trauma. Using the social-ecological model outlined in

Part 1, Chapter 1, this chapter explores some of the contextual 

and systemic dynamics that influence individual and community 

perceptions of trauma and its impact. The three main foci are:

types of trauma, objective and subjective characteristics of trauma,

and individual and sociocultural features that serve as risk or protective factors. 

This chapter’s main objective is to highlight the key characteristics of traumatic experiences. Trauma-informed behavioral health

service providers understand that many influences shape the effects of trauma among individuals and communities—it is not 

just the event that determines the outcome, but also the event’s 

context and the resultant interactions across systems. 

Types of Trauma 

The following section reviews various forms and types of trauma.

It does not cover every conceivable trauma that an individual,

group, or community may encounter. Specific traumas are reviewed only once, even when they could fit in multiple categories 

of trauma. Additionally, the order of appearance does not denote 

a specific trauma’s importance or prevalence, and there is no lack

of relevance implied if a given trauma is not specifically addressed

in this Treatment Improvement Protocol (TIP). The intent is to

give a broad perspective of the various categories and types of

trauma to behavioral health workers who wish to be trauma informed. 

33 
 

For information on resources to prepare 

States, Territories, and local entities to 

deliver effective mental health and substance abuse responses during disasters, 

contact the Substance Abuse and Mental 

Health Services Administration’s 

(SAMHSA’s) Disaster Technical Assistance 

Center: 

4350 East -West Hwy, Suite 1100 

Bethesda, MD 20814 -6233 

Phone: 1 -800 -308 -3515 

Fax: 1 -800 -311 -7691 

Email: DTAC@samhsa.hhs.gov 

Trauma-Informed Care in Behavioral Health Services 

TIC Framework in Behavioral Health Services—Trauma Awareness 

Natural or Human-Caused 

Traumas 

The classification of a trauma as natural or 

caused by humans can have a significant impact on the ways people react to it and on the 

types of assistance mobilized in its aftermath

(see Exhibit 1.2-1 for trauma examples). Natural traumatic experiences can directly affect a

small number of people, such as a tree falling

on a car during a rainstorm, or many people 

and communities, as with a hurricane. Natural 

events, often referred to as “acts of God,” are

typically unavoidable. Human-caused traumas 

are caused by human failure (e.g., technological catastrophes, accidents, malevolence) or by

human design (e.g., war). Although multiple 

factors contribute to the severity of a natural 

or human-caused trauma, traumas perceived

as intentionally harmful often make the event

more traumatic for people and communities. 

34 
 

 

 

 

 

Part 1, Chapter 2—Trauma Awareness 

Exhibit 1.2-1: Trauma Examples 

Caused Naturally Caused by People . 

Tornado 

Lightning strike 

Wildfire 

Avalanche 

Physical ailment or disease 

Fallen tree 

Earthquake 

Dust storm 

Volcanic eruption 

Blizzard 

Hurricane 

Cyclone 

Typhoon 

Meteorite 

Flood 

Tsunami 

Epidemic 

Famine 

Landslide or fallen boulder 

Accidents, Technological 

Catastrophes Intentional Acts 

Train derailment 

Roofing fall 

Structural collapse 

Mountaineering accident 

Aircraft crash 

Car accident due to 

malfunction 

Mine collapse or fire 

Radiation leak 

Crane collapse 

Gas explosion 

Electrocution 

Machinery-related accident 

Oil spill 

Maritime accident 

Accidental gun shooting 

Sports-related death 

Arson 

Terrorism 

Sexual assault and abuse 

Homicides or suicides 

Mob violence or rioting 

Physical abuse and neglect 

Stabbing or shooting 

Warfare 

Domestic violence 

Poisoned water supply 

Human trafficking 

School violence 

Torture 

Home invasion 

Bank robbery 

Genocide 

Medical or food tampering 

How survivors of natural trauma respond to

the experience often depends on the degree of

devastation, the extent of individual and

community losses, and the amount of time it

takes to reestablish daily routines, activities,

and services (e.g., returning to school or work,

being able to do laundry, having products to

buy in a local store). The amount, accessibility, and duration of relief services can significantly influence the duration of traumatic

stress reactions as well as the recovery process. 

Alongside the disruption of daily routines, the

presence of community members or outsiders 

in affected areas may add significant stress or

create traumatic experiences in and of themselves. Examples include the threat of others 

stealing what remains of personal property, 

restrictions on travel or access to property or 

living quarters, disruption of privacy within

shelters, media attention, and subsequent exposure to repetitive images reflecting the devastation. Therefore, it isn’t just the natural 

disaster or event that can challenge an individual or community; often, the consequences 

of the event and behavioral responses from 

others within and outside the community play 

a role in pushing survivors away from effective 

coping or toward resilience and recovery. 

Human-caused traumas are fundamentally

different from natural disasters. They are either intentional, such as a convenience store 

robbery at gunpoint, or unintentional, such as 

the technological accident of a bridge collapse 

(as occurred in Minneapolis, Minnesota, in 

2007; U.S. Fire Administration, 2007). The

subsequent reactions to these traumas often

depend on their intentionality. However, a

person or group of people is typically the target of the survivors’ anger and blame. Survivors of an unintentionally human-caused 

traumatic event may feel angry and frustrated

because of the lack of protection or care offered by the responsible party or government,

particularly if there has been a perceived act of 

omission. After intentional human-caused 

acts, survivors often struggle to understand the 

35 
 

Case Illustrations: Quecreek Mine Flood and Greensburg’s Tornado 

Quecreek Mine Flood 

The year following the rescue of nine miners from the Quecreek mine in western Pennsylvania in 

2002 was a difficult one for residents of Somerset County. The dazzle of publicity surrounding a 

handful of workers from a small town, tension between miners and rescuers, and animosity over 

money for movie and book deals, in addition to the trauma itself, resulted in a rescuer’s suicide, a 

number of miners having trauma-related symptoms, and several rescuers needing to seek treatment 

for posttraumatic stress disorder (PTSD; Goodell, 2003). 

Greensburg’s Tornado 

Greensburg, a small town in southern Kansas, was hit by a large tornado in 2007 that killed 11 residents and leveled 95 percent of the town while causing severe damage to the remaining 5 percent. 

Families and community members experienced significant grief and traumatic stress after the disaster. Yet today, Greensburg is rebuilding with a focus on being “green”—that is, environmentally 

responsible—from design to construction and all the way through demolition. This town has the 

highest number of Leadership in Energy and Environmental Design–certified buildings in the world. A 

reality television show about the town’s reinvention ran for three seasons, demonstrating the town’s 

residents and business owners working with local government and various corporations to make their 

home an even better place than it was before the tornado. 

Trauma-Informed Care in Behavioral Health Services 

motives for performing the act, the calculated

or random nature of the act, and the psychological makeup of the perpetrator(s). 

Individual, Group, Community, 

and Mass Traumas 

In recognizing the role of trauma and understanding responses to it, consider whether the 

trauma primarily affected an individual and 

perhaps his or her family (e.g., automobile 

accident, sexual or physical assault, severe illness); occurred within the context of a group

(e.g., trauma experienced by first responders 

or those who have seen military combat) or

community (e.g., gang-related shootings); 

transpired within a certain culture; or was a

large-scale disaster (e.g., hurricane, terrorist

attack). This context can have significant implications for whether (and how) people experience shame as a result of the trauma, the 

kinds of support and compassion they receive,

whether their experiences are normalized or

diminished by others, and even the kinds of

services they are offered to help them recover

and cope. 

Individual trauma 

An individual trauma refers to an event that 

only occurs to one person. It can be a single 

event (e.g., mugging, rape, physical attack,

work-related physical injury) or multiple or

prolonged events (e.g., a life-threatening illness, multiple sexual assaults). Although the 

trauma directly affects just one individual,

others who know the person and/or are aware 

of the trauma will likely experience emotional 

repercussions from the event(s) as well, such

as recounting what they said to the person

before the event, reacting in disbelief, or

thinking that it could just as easily have happened to them, too. 

Survivors of individual trauma may not receive 

the environmental support and concern that

members of collectively traumatized groups 

and communities receive. They are less likely 

to reveal their traumas or to receive validation 

of their experiences. Often, shame distorts 

their perception of responsibility for the trauma. Some survivors of individual traumas,

especially those who have kept the trauma

secret, may not receive needed comfort and 

36 
 

 

 

 

 

Advice to Counselors: Working With Clients Who Have Experienced Individual 

Traumas 

In working with clients who have histories of individual trauma, counselors should consider that: 

• Empathy, or putting oneself in the shoes of another, is more potent than sympathy (expressing a 

feeling of sorrow for another person). 

• Some clients need to briefly describe the trauma(s) they have experienced, particularly in the 

early stages of recovery. Strategies that focus on reexperiencing the trauma, retrieving feelings 

related to the trauma, and bringing past experiences to the forefront should only be implemented if trauma-specific treatment planning and services are available. 

• Understanding the trauma, especially in early recovery, should begin with educating the client 

about and normalizing trauma-related symptoms, creating a sense of safety within the treatment 

environment, and addressing how trauma symptoms may interfere with the client’s life in the 

present. 

• It is helpful to examine how the trauma affects opportunities to receive substance abuse and/or 

mental health treatment as well as treatment for and recovery from the trauma itself (e.g., by limiting one’s willingness to share in or participate in group counseling). 

Identifying and exploring strengths in the client’s history can help the client apply those strengths 

to his or her ability to function in the present. 

Acute stress disorder (ASD) prevalence 

among patients at medical trauma centers 

is very high, making trauma -related disorders some of the most common complications seen in physically injured patients. 

Clients who have sustained serious injuries 

in car crashes, fires, stabbings, shootings, 

falls, and other events have an increased 

likelihood of developing trauma -related 

mental disorders. Research suggests that 

PTSD and/or problem drinking is evident 

in nearly 50 percent of patients 1 year 

after discharge from trauma surgical units. 

(Zatzick, Jurkovich, Gentilello, Wisner, & 

Rivara, 2002) 

Part 1, Chapter 2—Trauma Awareness 

acceptance from others; they are also are more 

likely to struggle with issues of causation (e.g.,

a young woman may feel unduly responsible 

for a sexual assault), to feel isolated by the 

trauma, and to experience repeated trauma

that makes them feel victimized. 

Physical injuries 

Physical injuries are among the most prevalent

individual traumas. Millions of emergency 

room (ER) visits each year relate directly to

physical injuries. Most trauma patients are 

relatively young; about 70 percent of injuryrelated ER cases are people younger than 45

years old (McCaig & Burt, 2005). Dedicated 

ER hospital units, known as “trauma centers,”

specialize in physical traumas such as gunshot

wounds, stabbings, and other immediate physical injuries. The term “trauma” in relation to

ERs does not refer to psychological trauma,

which is the focus of this TIP, yet physical 

injuries can be associated with psychological 

trauma. Sudden, unexpected, adverse healthrelated events can lead to extensive psychological trauma for patients and their families. 

Excessive alcohol use is the leading risk factor

for physical injuries; it’s also the most promising target for injury prevention. Studies consistently connect injuries and substance use 

(Gentilello, Ebel, Wickizer, Salkever, &

Rivara, 2005); nearly 50 percent of patients

admitted to trauma centers have injuries attributable to alcohol abuse and dependence 

(Gentilello et al., 1999). One study found that

two thirds of ambulatory assault victims presenting to an ER had positive substance use 

urinalysis results; more than half of all victims 

had PTSD 3 months later (Roy-Byrne et al., 

37 
 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

2004). Nearly 28 percent of patients whose 

drinking was identified as problematic during

an ER visit for a physical injury will have a 

new injury within 1 year (Gentilello et al.,

2005). For further information, see TIP 16,

Alcohol and Other Drug Screening of Hospitalized Trauma Patients (Center for Substance 

Abuse Treatment [CSAT], 1995a). 

Group trauma 

The term “group trauma” refers to traumatic

experiences that affect a particular group of

people. This TIP intentionally distinguishes 

group trauma from mass trauma to highlight 

the unique experiences and characteristics of

trauma-related reactions among small groups.

These groups often share a common identity 

and history, as well as similar activities and

concerns. They include vocational groups who

specialize in managing traumas or who routinely place themselves in harm’s way—for

example, first responders, a group including

police and emergency medical personnel.

Some examples of group trauma include crews 

and their families who lose members from a 

commercial fishing accident, a gang whose

members experience multiple deaths and injuries, teams of firefighters who lose members in

a roof collapse, responders who attempt to

save flood victims, and military service members in a specific theater of operation. 

Survivors of group trauma can have different

experiences and responses than survivors of

individual or mass traumas. Survivors of group

trauma, such as military service members and

first responders, are likely to experience repeated trauma. They tend to keep the trauma

experiences within the group, feeling that others outside the group will not understand;

group outsiders are generally viewed as intruders. Members may encourage others in the

group to shut down emotionally and repress 

their traumatic experiences—and there are

some occupational roles that necessitate the 

repression of reactions to complete a mission

or to be attentive to the needs at hand. Group

members may not want to seek help and may 

discourage others from doing so out of fear

that it may shame the entire group. In this

environment, members may see it as a violation of group confidentiality when a member

seeks assistance outside the group, such as by 

going to a counselor. 

Group members who have had traumatic

experiences in the past may not actively support traumatized colleagues for fear that acknowledging the trauma will increase the risk 

of repressed trauma-related emotions surfacing. However, groups with adequate resources 

for helping group members can develop a

stronger and more supportive environment

for handling subsequent traumas. These main

group features influence the course of shortand long-term adjustments, including the 

development of traumatic stress symptoms 

associated with mental and substance use 

disorders. 

Certain occupational groups are at greater risk 

of experiencing trauma—particularly multiple 

traumas. This TIP briefly reviews two main

groups as examples in the following sections:

first responders and military service members.

For more detailed information on the impact

of trauma and deployment, refer to the

planned TIP, Reintegration-Related Behavioral 

Health Issues in Veterans and Military Families 

(SAMHSA, planned f). 

First responders 

First responders are usually emergency medical technicians, disaster management personnel, police officers, rescue workers, medical 

and behavioral health professionals, journalists,

and volunteers from various backgrounds.

They also include lifeguards, military personnel, and clergy. Stressors associated with the

kinds of traumatic events and/or disasters first

responders are likely to experience include 

38 
“The excitement of the season had just begun, and then, we heard the news, oil in the 

water, lots of oil killing lots of water. It is too shocking to understand. Never in the millennium of our tradition have we thought it possible for the water to die, but it is true.” 

—Chief Walter Meganack, Port Graham, 1989 

Of all the groups negatively affected by the Exxon Valdez oil spill, in many ways Alaska Natives were 

the most devastated. The oil spill destroyed more than economic resources; it shook the core cultural 

foundation of Native life. Alaska Native subsistence culture is based on an intimate relationship with 

the environment. Not only does the environment have sacred qualities for Alaska Natives; their survival also depends on the well-being of the ecosystem and the maintenance of cultural norms of subsistence. The spill directly threatened the well-being of the environment, disrupted subsistence 

behavior, and severely disturbed the sociocultural milieu of Alaska Natives. 

Source: Gill & Picou, 1997, pp. 167–168. 

Part 1, Chapter 2—Trauma Awareness 

exposure to toxic agents, feeling responsible

for the lives of others, witnessing catastrophic

devastation, potential exposure to gruesome 

images, observing human and animal suffering

and/or death, working beyond physical exhaustion, and the external and internal pressure of working against the clock. 

Military service members 

Military personnel are likely to experience 

numerous stressors associated with trauma. 

Service members who have repeatedly deployed to a war zone are at a greater risk for

traumatic stress reactions (also known as combat stress reaction or traumatic stress injury),

other military personnel who provide support

services are also at risk for traumatic stress and 

secondary trauma (refer to the glossary portion

of the “How This TIP Is Organized” section

that precedes Part 1, Chapter 1, of this TIP).

So too, service members who anticipate deployment or redeployment may exhibit psychological symptoms associated with

traumatic stress. Some stressors that military 

service members may encounter include working while physically exhausted, exposure to

gunfire, seeing or knowing someone who has 

been injured or killed, traveling in areas 

known for roadside bombs and rockets, extended hypervigilance, fear of being struck by 

an improvised explosive device, and so forth. 

Trauma affecting communities and 

cultures 

Trauma that affects communities and cultures 

covers a broad range of violence and atrocities

that erode the sense of safety within a given

community, including neighborhoods,

schools, towns, and reservations. It may involve violence in the form of physical or sexual 

assaults, hate crimes, robberies, workplace or

gang-related violence, threats, shootings, or

stabbings—for example, the school shooting

at Virginia Polytechnic Institute and State

University in 2007. It also includes actions 

that attempt to dismantle systemic cultural 

practices, resources, and identities, such as 

making boarding school attendance mandatory for Native American children or placing

them in non-Native foster homes. Cultural 

and/or community-based trauma can also occur via indifference or limited responsiveness 

to specific communities or cultures that are 

facing a potential catastrophe. Cultural traumas are events that, whether intentionally or

not, erode the heritage of a culture—as with 

prejudice, disenfranchisement, and health

inequities (e.g., late prenatal care, inability to

afford medications, limited access to culturally 

appropriate health education, vicinity and

quality of affordable medical services), among

other examples. 

39 
 

Trauma-Informed Care in Behavioral Health Services 

Historical trauma 

Historical trauma, known also as generational 

trauma, refers to events that are so widespread

as to affect an entire culture; such events also

have effects intense enough to influence generations of the culture beyond those who experienced them directly. The enslavement,

torture, and lynching of African Americans;

the forced assimilation and relocation of 

American Indians onto reservations; the extermination of millions of Jews and others in 

Europe during World War II; and the genocidal policies of the Hutus in Rwanda and the

Khmer Rouge in Cambodia are examples of

historical trauma. 

In the past 50 years, research has explored the 

generational effects of the Holocaust upon

survivors and their families. More recent literature has extended the concept of historical or

generational trauma to the traumatic experiences of Native Americans. Reduced population, forced relocation, and acculturation are

some examples of traumatic experiences that 

Native people have endured across centuries,

beginning with the first European presence in

the Americas. These tragic experiences have 

led to significant loss of cultural identity across

generations and have had a significant impact

on the well-being of Native communities 

(Whitbeck, Chen, Hoyt, & Adams, 2004).

Data are limited on the association of mental 

and substance use disorders with historical 

trauma among Native people, but literature 

suggests that historical trauma has repercussions across generations, such as depression,

grief, traumatic stress, domestic violence, and

substance abuse, as well as significant loss of

cultural knowledge, language, and identity 

(Gone, 2009). Historical trauma can increase 

the vulnerability of multiple generations to the

effects of traumas that occur in their own 

lifetimes. 

Mass trauma 

Mass traumas or disasters affect large numbers 

of people either directly or indirectly. It is beyond the scope of this TIP to cover any specific disaster in detail; note, however, that mass 

traumas include large-scale natural and

human-caused disasters (including intentional 

acts and accidents alike). Mass traumas may 

involve significant loss of property and lives as 

well as the widespread disruption of normal 

routines and services. Responding to such

traumas often requires immediate and extensive resources that typically exceed the capacity of the affected communities, States, or

countries in which they occur. Recent examples of such large-scale catastrophes include:

•	 In January 2010, a massive earthquake hit

Haiti, killing hundreds of thousands of

people and leaving over a million homeless. 

•	 A nuclear reactor meltdown in the Ukraine 

in 1986 resulted in a technological and environmental disaster that affected tens of 

millions of people. 

•	 The tsunami in the Indian Ocean in 2005 

left hundreds of thousands dead in nine 

countries. 

One factor that influences an individual’s 

response to trauma is his or her ability to

process one trauma before another trauma

occurs. In mass traumas, the initial event

causes considerable destruction, the consequences of which may spawn additional 

traumas and other stressful events that lead to 

more difficulties and greater need for adjustments among survivors, first responders, and

disaster relief agencies. Often, a chain reaction occurs. Take, for example, Hurricane 

Katrina and its impact on the people of

Louisiana and other coastal States. After the 

initial flooding, people struggled to obtain

basic needs, including food, drinking water,

safe shelter, clothing, medicines, personal 

hygiene items, and so forth, all as concern

mounted about the safety of children and 

40 
 

 

Part 1, Chapter 2—Trauma Awareness 

other relatives, friends, and neighbors. In this

and similar cases, the destruction from the 

initial flooding led to mass displacement of

families and communities; many people had to

relocate far from New Orleans and other badly 

affected areas, while also needing to gain financial assistance, reinitiate work to generate 

income, and obtain stable housing. People 

could not assimilate one stressor before another appeared. 

Nevertheless, mass traumas can create an immediate sense of commonality—many people 

are “in the same boat,” thus removing much of

the isolation that can occur with other types of

trauma. People can acknowledge their difficulties and receive support, even from 

strangers. It is easier to ask for help because 

blame is often externalized; large-scale disasters are often referred to as “acts of God” or,

in cases of terrorism and other intentional 

events, as acts of “evil.” Even so, survivors of

mass trauma often encounter an initial rally of

support followed by quickly diminishing services and dwindling care. When the disaster

fades from the headlines, public attention and

concern are likely to decrease, leaving survivors struggling to reestablish or reinvent their

lives without much outside acknowledgment. 

The experience of mass trauma can lead to the 

development of psychological symptoms and

substance use at either a subclinical or a diagnostic level (refer to Part 3 of this TIP, available online, for more information highlighting

the relationship between trauma and behavioral health problems). Likewise, one of the 

greatest risks for traumatic stress reactions 

after a mass tragedy is the presence of preexisting mental and co-occurring disorders, and 

individuals who are in early recovery from 

substance use disorders are at greater risk for

such reactions as well. Nonetheless, people are 

amazingly resilient, and most will not develop

long-term mental or substance use disorders 

after an event; in fact, most trauma-related

symptoms will resolve in a matter of months 

(Keane & Piwowarczyk, 2006). 

Interpersonal Traumas 

Interpersonal traumas are events that occur

(and typically continue to reoccur) between

people who often know each other, such as 

spouses or parents and their children. Examples include physical and sexual abuse, sexual 

assault, domestic violence, and elder abuse. 

Intimate partner violence 

Intimate partner violence (IPV), often referred to as domestic violence, is a pattern of

actual or threatened physical, sexual, and/or

emotional abuse. It differs from simple assault

in that multiple episodes often occur and the

perpetrator is an intimate partner of the victim. Trauma associated with IPV is normally

ongoing. Incidents of this form of violence are

rarely isolated, and the client may still be in

contact with and encountering abuse from the 

perpetrator while engaged in treatment. 

Intimate partners include current and former

spouses, boyfriends, and girlfriends. The majority of all nonfatal acts of violence and intimate partner homicides are committed against

women; IPV accounts for over 20 percent of

nonfatal violence against women but only 3.6

percent of that committed against men

(Catalano, 2012). Children are the hidden

casualties of IPV. They often witness the assaults or threats directly, within earshot, or by 

being exposed to the aftermath of the violence 

(e.g., seeing bruises and destruction of property, hearing the pleas for it to stop or the promises that it will never happen again). 

Substance abuse, particularly involving alcohol, is frequently associated with IPV. It is the 

presence of alcohol-related problems in either

partner, rather than the level of alcohol consumption itself, that is the important factor. 

41 
 

 

 

 

 

Child Neglect 

Child neglect occurs when a parent or caregiver does not give a child the care he or she needs according to his or her age, even though that adult can afford to give that care or is offered help to 

give that care. Neglect can mean not providing adequate nutrition, clothing, and/or shelter. It can 

mean that a parent or caregiver is not providing a child with medical or mental health treatment or is 

not giving prescribed medicines the child needs. Neglect can also mean neglecting the child’s education. Keeping a child from school or from special education can be neglect. Neglect also includes 

exposing a child to dangerous environments (e.g., exposure to domestic violence). It can mean poor 

supervision for a child, including putting the child in the care of someone incapable of caring for children. It can mean abandoning a child or expelling him or her from home. Lack of psychological care, 

including emotional support, attention, or love, is also considered neglect—and it is the most common form of abuse reported to child welfare authorities. 

Source: dePanfilis, 2006. 

Trauma-Informed Care in Behavioral Health Services 

Drinking may or may not be the cause of the 

violence; that said, couples with alcoholrelated disorders could have more tension and 

disagreement within the relationship in general, which leads to aggression and violence.

The consumption of alcohol during a dispute 

is likely to decrease inhibitions and increase 

impulsivity, thus creating an opportunity for

an argument to escalate into a physical altercation. More information on domestic violence 

and its effects on partners and families, as well 

as its connection with substance use and 

trauma-related disorders, is available in TIP

25, Substance Abuse Treatment and Domestic 

Violence (CSAT, 1997b), and from the National Online Resource Center on Violence 

Against Women (http://www.vawnet.org/). 

Developmental Traumas 

Developmental traumas include specific events 

or experiences that occur within a given developmental stage and influence later development, adjustment, and physical and mental 

health. Often, these traumas are related to

adverse childhood experiences (ACEs), but

they can also result from tragedies that occur

outside an expected developmental or life 

stage (e.g., a child dying before a parent, being

diagnosed with a life-threatening illness as a

young adult) or from events at any point in 

the life cycle that create significant loss and 

have life-altering consequences (e.g., the 

death of a significant other in the later years

that leads to displacement of the surviving

partner). 

Adverse childhood experiences 

Some people experience trauma at a young age 

through sexual, physical, or emotional abuse 

and neglect. The Adverse Childhood Experiences Study (Felitti et al., 1998) examined the 

effects of several categories of ACEs on adult

health, including physical and emotional abuse;

sexual abuse; a substance-dependent parent; an

incarcerated, mentally ill, or suicidal household

member; spousal abuse between parents; and

divorce or separation that meant one parent

was absent during childhood. The National 

Comorbidity Studies examined the prevalence

of trauma and defined childhood adversities as 

parental death, parental divorce/separation,

life-threatening illness, or extreme economic

hardship in addition to the childhood experiences included in the Adverse Childhood 

Experiences Study (Green et al., 2010). 

ACEs can negatively affect a person’s wellbeing into adulthood. Whether or not these

experiences occur simultaneously, are timelimited, or recur, they set the stage for increased vulnerability to physical, mental, and

substance use disorders and enhance the risk 

42 
 

 

 

 

 

 

Torture and Captivity 

Torture traumatizes by taking away an individual’s personhood. To survive, victims have to give up 

their sense of self and will. They become the person the torturer designs or a nonperson, simply existing. Inevitably, the shame of the victim is enormous, because the focus of torture is to humiliate and 

degrade. As a result, victims often seek to hide their trauma and significant parts of their selfhood 

long after torture has ended and freedom has been obtained. According to Judith Herman, “the 

methods of establishing control over another person are based upon the systematic, repetitive infliction of psychological trauma. They are organized techniques of disempowerment and disconnection. 

Methods of psychological control are designed to instill terror and helplessness and to destroy the 

victim’s sense of self in relation to others.” 

Source: Herman, 1997, p. 77. 

Part 1, Chapter 2—Trauma Awareness 

for repeated trauma exposure across the life 

span. Childhood abuse is highly associated

with major depression, suicidal thoughts,

PTSD, and dissociative symptoms. So too,

ACEs are associated with a greater risk of

adult alcohol use. When a person experiences 

several adverse events in childhood, the risk of

his or her heavy drinking, self-reported alcohol dependence, and marrying a person who is 

alcohol dependent is two to four times greater

than that of a person with no ACEs (Dube,

Anda, Felitti, Edwards, & Croft, 2002). 

A detailed examination of the issues involved 

in providing substance abuse treatment to

survivors of child abuse and neglect is the subject of TIP 36, Substance Abuse Treatment for 

Persons With Child Abuse and Neglect Issues

(CSAT, 2000b). 

Political Terror and War 

Political terror and war are likely to have lasting consequences for survivors. In essence,

anything that threatens the existence, beliefs,

well-being, or livelihood of a community is 

likely to be experienced as traumatic by community members. Whether counselors are 

working with an immigrant or refugee enclave 

in the United States or in another country,

they should be aware of local events, local history, and the possibility that clients have endured trauma. (For international information

about the clinical, historical, and theoretical 

aspects of trauma and terrorism, see Danieli,

Brom, & Sills, 2005.) Terrorism is a unique 

subtype of human-caused disasters. The overall goal of terrorist attacks is to maximize the 

uncertainty, anxiety, and fear of a large community, so the responses are often epidemic

and affect large numbers of people who have

had direct or indirect exposure to an event

(Silver et al., 2004; Suvak, Maguen, Litz, 

Silver, & Holman, 2008). Terrorism has a variety of results not common to other disasters,

such as reminders of the unpredictability of

terrorist acts; increases in security measures for

the general population; intensified suspicion

about a particular population, ethnicity, or culture; and heightened awareness and/or arousal. 

Refugees 

According to the World Refugee Survey,

there are an estimated 12 million refugees and

asylum seekers, 21 million internally displaced

people, and nearly 35 million uprooted people 

(U.S. Committee for Refugees and Immigrants, 2006). Many of these people have survived horrendous ordeals with profound and 

lasting effects for individuals and whole populations. In addition to witnessing deaths by 

execution, starvation, or beatings, many survivors have experienced horrific torture. 

Refugees are people who flee their homes because they have experienced or have a reasonable fear of experiencing persecution. They 

43 
 

Vietnamese Refugees 

“Wars always have consequences, both immediate and remote, and the consequences are often 

tragic. One tragic circumstance often caused by war is the forceful, disorganized, and uncontrollable 

mass movement of both civilians and soldiers trying to escape the horrors of the wars or of an oppressive regime.... 

“Vietnamese communists, by taking power in the North in 1954 and then in the South in 1975, caused 

two major upheavals in the Land of the Small Dragon, as Vietnam was once called. The first Vietnam 

War led to the 1954 exodus during which 1 million people fled from the North to the South. The second Vietnam War resulted in the dispersion, from 1975-1992, of approximately 2 million Vietnamese all 

over the world. These significant, unplanned, and uncoordinated mass movements around the world 

not only dislocated millions of people, but also caused thousands upon thousands of deaths at sea.... 

“The second and third wave of refugees from 1976 onward went through a more difficult time. They 

had to buy their way out and to hide from soldiers and the police who hunted them down. After 

catching them, the police either asked for brides or threw the escapees into jails. Those who evaded 

police still had to face engine failures, sea storms, pirates...They then had to survive overcrowded 

boats for days or weeks, during which food and water could not be replenished and living conditions 

were terrible... Many people died from exhaustion, dehydration, and hunger. Others suffered at the 

hands of terrifying pirates... After the sea ordeal came the overcrowded camps where living conditions were most often substandard and where security was painfully lacking.... 

“In the United States, within less than 3 decades, the Vietnamese population grew from a minority of 

perhaps 1,000 persons to the second largest refugee group behind Cubans.” 

Source: Vo, 2006, pp. 1–4. 

Trauma-Informed Care in Behavioral Health Services 

differ from immigrants who willingly leave 

their homes or homeland to seek better opportunities. Although immigrants may experience trauma before migrating to or after

reaching their new destination, refugees will 

often have greater exposure to trauma before 

migration. Refugees typically come from wartorn countries and may have been persecuted

or tortured. Consequently, greater exposure to

trauma, such as torture, before migrating often

leads to more adjustment-related difficulties

and psychological symptoms after relocation

(Steel et al., 2009). 

Refugees typically face substantial difficulties 

in assimilating into new countries and cultures. Moreover, the environment can create a

new set of challenges that may include additional exposure to trauma and social isolation

(Miller et al., 2002). These as well as additional factors influence adjustment, the development of mental illness (including PTSD), and 

the occurrence of substance use disorders. Additional factors that influence outcomes after 

relocation include receptivity of the local 

community, along with opportunities for social support and culturally responsive services. 

Among refugee populations in the United

States, little research is available on rates of

mental illness and co-occurring substance use 

disorders and traumatic stress among refugee 

populations. Substance use patterns vary based

on cultural factors as well as assimilation, yet

research suggests that trauma increases the 

risk for substance use among refugees after

war-related experiences (Kozarić-Kovačić,

Ljubin, & Grappe, 2000). Therefore, providers 

should expect to see trauma-related disorders 

among refugees who are seeking treatment for

a substance use disorder and greater prevalence of substance use disorders among refugees who seek behavioral health services. 

44 
 

 

 

Advice to Counselors: Addressing Retraumatization 

• Anticipate and be sensitive to the needs of clients who have experienced trauma regarding program policies and procedures in the treatment setting that might trigger memories of trauma, 

such as lack of privacy, feeling pushed to take psychotropic medications, perceiving that they 

have limited choices within the program or in the selection of the program, and so forth. 

• Attend to clients’ experiences. Ignoring clients’ behavioral and emotional reactions to having their 

traumatic memories triggered is more likely to increase these responses than decrease them. 

• Develop an individual coping plan in anticipation of triggers that the individual is likely to experience in treatment based on his or her history. 

• Rehearse routinely the coping strategies highlighted in the coping plan. If the client does not 

practice strategies prior to being triggered, the likelihood of being able to use them effectively 

upon triggering is lessened. For example, it is far easier to practice grounding exercises in the 

absence of severe fear than to wait for that moment when the client is reexperiencing an aspect 

of a traumatic event. (For more information on grounding exercises, refer to Seeking Safety: A 

Treatment Manual for PTSD and Substance Abuse; Najavits, 2002a, pp. 125–131.) 

• Recognize that clinical and programmatic efforts to control or contain behavior in treatment can 

cause traumatic stress reactions, particularly for trauma survivors for whom being trapped was 

part of the trauma experience. 

• Listen for the specific trigger that seems to be driving the client’s reaction. It will typically help both 

the counselor and client understand the behavior and normalize the traumatic stress reactions. 

• Make sure that staff and other clients do not shame the trauma survivor for his or her behavior, 

such as through teasing or joking about the situation. 

• Respond with consistency. The client should not get conflicting information or responses from 

different staff members; this includes information and responses given by administrators. 

Part 1, Chapter 2—Trauma Awareness 

System-Oriented Traumas: 

Retraumatization 

Retraumatization occurs when clients experience something that makes them feel as 

though they are undergoing another trauma.

Unfortunately, treatment settings and clinicians can create retraumatizing experiences,

often without being aware of it, and sometimes clients themselves are not consciously 

aware that a clinical situation has actually triggered a traumatic stress reaction. Agencies that

anticipate the risk for retraumatization and

actively work on adjusting program policies 

and procedures to remain sensitive to the histories and needs of individuals who have undergone past trauma are likely to have more 

success in providing care, retaining clients, and

achieving positive outcomes. 

Staff and agency issues that can cause retraumatization include: 

•	 Being unaware that the client’s traumatic 

history significantly affects his or her life. 

•	 Failing to screen for trauma history prior to

treatment planning. 

•	 Challenging or discounting reports of abuse 

or other traumatic events. 

•	 Using isolation or physical restraints. 

•	 Using experiential exercises that humiliate 

the individual. 

•	 Endorsing a confrontational approach in

counseling. 

•	 Allowing the abusive behavior of one client

toward another to continue without 

intervention. 

•	 Labeling behavior/feelings as pathological. 

•	 Failing to provide adequate security and

safety within the program. 

•	 Limiting participation of the client in

treatment decisions and planning processes. 

•	 Minimizing, discrediting, or ignoring client 

responses. 

•	 Disrupting counselor–client relationships 

by changing counselors’ schedules and

assignments. 

•	 Obtaining urine specimens in a nonprivate

setting. 

45 
Trauma-Informed Care in Behavioral Health Services 

•	 Having clients undress in the presence of

others. 

•	 Inconsistently enforcing rules and allowing

chaos in the treatment environment. 

•	 Imposing agency policies or rules without

exceptions or an opportunity for clients to

question them. 

•	 Enforcing new restrictions within the program without staff–client communication. 

•	 Limiting access to services for ethnically 

diverse populations. 

•	 Accepting agency dysfunction, including

lack of consistent, competent leadership. 

Characteristics of Trauma 

The following section highlights several selected characteristics of traumatic experiences 

that influence the effects of traumatic stress. 

Objective characteristics are those elements of

a traumatic event that are tangible or factual;

subjective characteristics include internal processes, such as perceptions of traumatic experiences and meanings assigned to them. 

Objective Characteristics 

Was it a single, repeated, or 

sustained trauma? 

Trauma can involve a single event, numerous 

or repeated events, or sustained/chronic experiences. A single trauma is limited to a single 

point in time. A rape, an automobile accident,

the sudden death of a loved one—all are examples of a single trauma. Some people who

experience a single trauma recover without any 

specific intervention. But for others—

especially those with histories of previous 

trauma or mental or substance use disorders,

or those for whom the trauma experience is 

particularly horrific or overwhelming—a single trauma can result in traumatic stress symptoms and trauma- and stress-related disorders. 

Single traumas do not necessarily have a lesser

psychological impact than repeated traumas. 

After the terrorist attacks on September 11,

2001—a significant single trauma—many 

Manhattan residents experienced intrusive 

memories and sleep disruption whether they 

were at the site of the attacks or watched television coverage of it (Ford & Fournier, 2007;

Galea et al., 2002). 

A series of traumas happening to the same 

person over time is known as repeated trauma. 

This can include repeated sexual or physical 

assaults, exposure to frequent injuries of others, or seemingly unrelated traumas. Military 

personnel, journalists covering stories of mass 

tragedies or prolonged conflicts, and first responders who handle hundreds of cases each

year typify repeated trauma survivors. Repetitive exposure to traumas can have a cumulative 

effect over one’s lifetime. A person who was 

assaulted during adolescence, diagnosed with a 

life-threatening illness in his or her thirties,

and involved in a serious car accident later in 

life has experienced repeated trauma. 

Some repeated traumas are sustained or

chronic. Sustained trauma experiences tend to

wear down resilience and the ability to adapt.

Some examples include children who endure 

ongoing sexual abuse, physical neglect, or

emotional abuse; people who are in violent

relationships; and people who live in chronic

poverty. Individuals in chronically stressful,

traumatizing environments are particularly 

susceptible to traumatic stress reactions, substance use, and mental disorders. 

Bidirectional relationships exist between

trauma and substance use as well as trauma 

and mental illness. For example, abuse of alcohol and drugs increases the risk of a traumatic experience and creates greater

vulnerability to the effects of trauma; substance abuse reduces a person’s ability to take 

corrective and remedial actions that might

reduce the impact of the trauma. Likewise,

traumatic stress leads to a greater likelihood of 

46 
 

 

Case Illustration: Yourself 

Think of a time that was particularly stressful (but not traumatic) in your life. Revisit this period as an 

observer watching the events unfold and then ask yourself, “What made this time particularly stressful?” It is likely that a part of your answer will include the difficulty of managing one situation before 

another circumstance came along demanding your time. Stressful times denote being bombarded 

with many things at one time, perceived or actual, without sufficient time or ability to address them 

emotionally, cognitively, spiritually, and/or physically. The same goes for trauma—rapid exposure to 

numerous traumas one after another lessens one’s ability to process the event before the next onslaught. This creates a cumulative effect, making it more difficult to heal from any one trauma. 

Part 1, Chapter 2—Trauma Awareness 

substance abuse that, in turn, increases the risk 

for additional exposure to trauma. Paralleling

this bidirectional relationship, mental illness 

increases vulnerability to the effects of trauma

and raises the risk for substance use disorders 

and for encountering additional traumatic 

events. So too, early exposure to ACEs is associated with traumatic stress reactions and 

subsequent exposure to trauma in adult years. 

People who have encountered multiple and

longer doses of trauma are at the greatest risk 

for developing traumatic stress. For example,

military reservists and other military service

members who have had multiple long tours of

duty are at greater risk for traumatic stress 

reactions (see the planned TIP, ReintegrationRelated Behavioral Health Issues in Veterans and 

Military Families; SAMHSA, planned f). In 

addition, people are more likely to encounter

greater impairment and distress from trauma

if that trauma occurs with significant intensity 

and continues sporadically or unceasingly for

extended periods. 

Was there enough time to process 

the experience? 

A particularly severe pattern of ongoing trauma, sometimes referred to as “cascading trauma,” occurs when multiple traumas happen in

a pattern that does not allow an individual to

heal from one traumatic event before another 

occurs. Take, for example, California residents—they repeatedly face consecutive 

and/or simultaneous natural disasters including fires, landslides, floods, droughts, and

earthquakes. In other cases, there is ample 

time to process an event, but processing is 

limited because people don’t have supportive 

relationships or environments that model preventive practices. This can lead to greater vulnerability to traumas that occur later in life. 

How many losses has the trauma 

caused? 

Trauma itself can create significant distress,

but often, the losses associated with a trauma

have more far-reaching effects. For instance, a 

child may be forced to assume adult responsibilities, such as serving as a confidant for a 

parent who is sexually abusing him or her, and 

lose the opportunity of a childhood free from 

adult worries. In another scenario, a couple 

may initially feel grateful to have escaped a

house fire, but they may nevertheless face significant community and financial losses 

months afterward. In evaluating the impact of

trauma, it is helpful to access and discuss the 

losses associated with the initial trauma. The 

number of losses greatly influences an individual’s ability to bounce back from the tragedy. 

In the case illustration on the next page, 

Rasheed’s losses cause him to disconnect from 

his wife, who loves and supports him. Successful confrontation of losses can be difficult if 

the losses compound each other, as with

Rasheed’s loss of his friend, his disability, his 

employment struggles, and the threats to his 

marriage and liberty. People can cite a specific 

47 
Case Illustration: Rasheed 

Rasheed was referred to an employee assistance program by his employer. He considered quitting 

his job, but his wife insisted he talk to a counselor. He is a 41-year-old auto mechanic who, 4 years 

ago, caused a head-on collision while attempting to pass another vehicle. A close friend, riding in 

the passenger’s seat, was killed, and two young people in the other vehicle were seriously injured 

and permanently disabled. Rasheed survived with a significant back injury and has only been able to 

work sporadically. He was convicted of negligent homicide and placed on probation because of his 

physical disability. He is on probation for another 4 years, and if he is convicted of another felony 

during that time, he will have to serve prison time for his prior offense. 

While still in the hospital, Rasheed complained of feeling unreal, numb, and disinterested in the care 

he received. He did not remember the crash but remembers waking up in the hospital 2 days later. 

He had difficulty sleeping in the hospital and was aware of feelings of impending doom, although he 

was unaware of the legal charges he would later face. He was diagnosed with ASD. 

He was discharged from the hospital with a variety of medications, including pain pills and a sleep 

aid. He rapidly became dependent on these medications, feeling he could not face the day without 

the pain medication and being unable to sleep without sleep medicine in larger doses than had 

been prescribed. Within 3 months of the accident, he was “doctor shopping” for pain pills and even 

had a friend obtain a prescription for the sleeping medication from that friend’s doctor. In the 4 

intervening years, Rasheed’s drug use escalated, and his blunted emotions and detachment from 

friends became more profound. He became adept at obtaining pain pills from a variety of sources, 

most of them illegal. He fears that if he seeks treatment for the drug problem, he will have to admit 

to felony offenses and will probably be imprisoned. He also does not believe he can manage his life 

without the pain pills. 

In the past 2 years, he has had recurring dreams of driving a car on the wrong side of the road and 

into the headlights of an oncoming vehicle. In the dream, he cannot control the car and wakes up 

just before the vehicles crash. At unusual times—for instance, when he is just awakening in the 

morning, taking a shower, or walking alone—he will feel profound guilt over the death of his friend 

in the accident. He becomes very anxious when driving in traffic or when he feels he is driving faster 

than he should. His marriage of 18 years has been marked by increasing emotional distance, and his 

wife has talked about separating if he does not do something about his problem. He has been 

unable to work consistently because of back pain and depression. He was laid off from one job because he could not concentrate and was making too many mistakes. 

The counselor in the employee assistance program elicited information on Rasheed’s drug use, 

although she suspected Rasheed was minimizing its extent and effects. Knowledgeable about psychological trauma, the counselor helped Rasheed feel safe enough to talk about the accident and 

how it had affected his life. She was struck by how little Rasheed connected his present difficulties to 

the accident and its aftermath. The counselor later commented that Rasheed talked about the accident as if it had happened to someone else. Rasheed agreed to continue seeing the counselor for 

five additional visits, during which time a plan would be made for Rasheed to begin treatment for 

drug dependence and PTSD. 

Trauma-Informed Care in Behavioral Health Services 

event as precipitating their trauma, or, in other cases, the specific trauma can symbolize a

series of disabling events in which the person

felt his or her life was threatened or in which 

he or she felt emotionally overwhelmed, psychologically disorganized, or significantly disconnected from his or her surroundings. It 

will be important for Rasheed to understand 

how his losses played a part in his abuse of

prescription medications to cope with symptoms associated with traumatic stress and loss,

(e.g., guilt, depression, fear). If not addressed,

his trauma could increase his risk for relapse. 

48 
 

Part 1, Chapter 2—Trauma Awareness 

Was the trauma expected or 

unexpected? 

When talking about a trauma, people sometimes say they didn’t see it coming. Being unprepared, unaware, and vulnerable often 

increases the risk of psychological injury, but

these are common components of most traumas, given that most traumatic events do occur without warning (e.g., car crashes, terrorist

attacks, sexual assaults). People with substance 

use disorders, mental illness, and/or cognitive 

disabilities may be especially vulnerable in that

they may attend less or have competing concerns that diminish attention to what is going

on around them, even in high-risk environments. However, most individuals attempt to

gain some control over the tragedy by replaying the moments leading up to the event and

processing how they could have anticipated it.

Some people perseverate on these thoughts for

months or years after the event. 

Sometimes, a trauma is anticipated but has

unexpected or unanticipated consequences, as 

in the case of Hurricane Katrina. Learning

about what is likely to happen can reduce 

traumatization. For instance, training military

personnel in advance of going to combat overseas prepares them to handle traumas and can

reduce the impact of trauma. 

Were the trauma’s effects on the 

person’s life isolated or pervasive? 

When a trauma is isolated from the larger

context of life, a person’s response to it is more 

likely to be contained and limited. For instance, military personnel in combat situations 

can be significantly traumatized by what they

experience. On return to civilian life or noncombat service, some are able to isolate the 

traumatic experience so that it does not invade 

ordinary, day-to-day living. This does not

mean that the combat experience was not disturbing or that it will not resurface if the individual encounters an experience that triggers 

memories of the trauma; it just means that the

person can more easily leave the trauma in the

past and attend to the present. 

Conversely, people who remain in the vicinity 

of the trauma may encounter greater challenges in recovery. The traumatic event intertwines with various aspects of the person’s 

daily activities and interactions, thus increasing the possibility of being triggered by surrounding cues and experiencing subsequent

psychological distress. However, another way 

to view this potential dilemma for the client is 

to reframe it as an opportunity—the repetitive 

exposure to trauma-related cues may provide 

vital guidance as to when and which treatment

and coping techniques to use in the delivery of

trauma-informed and trauma-specific behavioral health services. 

Who was responsible for the trauma 

and was the act intentional? 

If the severity of a trauma is judged solely by 

whether the act was intentional or not, events 

that reflect an intention to harm would be a 

primary indicator in predicting subsequent

difficulties among individuals exposed to this 

form of trauma. For most survivors, there is an

initial disbelief that someone would conceivably intend to harm others, followed by considerable emotional and, at times, behavioral 

investment in somehow making things right

again or in making sense of a senseless, malicious act. For instance, in the wake of the 

World Trade Center attacks in New York 

City, people responded via renewed patriotism, impromptu candlelight vigils, attacks on

people of Arab and Muslim descent, and unprecedented donations and willingness to wait

in long lines to donate blood to the Red

Cross. Each example is a response that in

some way attempts to right the perceived 

wrong or attach new meaning to the event and

subsequent consequences. 

49 
 

 

 

 

 

Case Illustration: Frank 

Frank entered substance abuse treatment with diagnoses of co-occurring PTSD and substance use 

disorder. While on a whitewater kayak trip with his wife, her kayak became pinned on a rock, and 

Frank could only watch helplessly as she drowned. His drinking had increased markedly after the accident. He acknowledged a vicious cycle of sleep disturbance with intrusive nightmares followed by 

vivid memories and feelings of terror and helplessness after he awoke. He drank heavily at night to 

quiet the nightmares and memories, but heavy alcohol consumption perpetuated his trouble sleeping. He withdrew from contact with many of his old “couple friends” and his wife’s family, with whom 

he had been close. At treatment entry, he described his life as “going to work and coming home.” 

The trauma occurred 3 years before he sought treatment, but Frank continued to feel numb and disconnected from the world. His only emotion was anger, which he tried to keep in check. Integrated 

treatment for PTSD and substance abuse helped him sleep and taught him coping skills to use when 

the memories arose; it fostered his engagement and retention in long-term care for both disorders. 

Trauma-Informed Care in Behavioral Health Services 

When terrible things happen, it is human nature to assign blame. Trauma survivors can

become heavily invested in assigning blame or

finding out who was at fault, regardless of the 

type of trauma. Often, this occurs as an attempt to make sense of, give meaning to, and

reestablish a sense of predictability, control, 

and safety after an irrational or random act. It

is far easier to accept that someone, including

oneself, is at fault or could have done something different than it is to accept the fact that 

one was simply in the wrong place at the 

wrong time. 

For some trauma survivors, needing to find

out why a trauma occurred or who is at fault

can become a significant block to growth 

when the individual would be better served by 

asking, “What do I need to do to heal?” Behavioral health professionals can help clients 

translate what they have learned about responsibility in recovery to other aspects of their

lives. For instance, someone in treatment for 

co-occurring disorders who has internalized

that becoming depressed or addicted was not

his or her fault, but that recovery is a personal 

responsibility, can then apply the same principle to the experience of childhood abuse and 

thereby overcome negative judgments of self

(e.g., thinking oneself to be a bad person who

deserves abuse). The individual can then begin

to reassign responsibility by attaching the 

blame to the perpetrator(s) while at the same

time assuming responsibility for recovery. 

Was the trauma experienced directly 

or indirectly? 

Trauma that happens to someone directly 

seems to be more damaging than witnessing

trauma that befalls others. For example, it is 

usually more traumatic to be robbed at gunpoint than to witness someone else being

robbed or hearing someone tell a story about

being robbed. Yet, sometimes, experiencing

another’s pain can be equally traumatic. For

instance, parents often internalize the pain

and suffering of their children when the children are undergoing traumatic circumstances

(e.g., treatments for childhood cancer). 

There are two ways to experience the trauma

of others. An individual may witness the event,

such as seeing someone killed or seriously injured in a car accident, or may learn of an

event that happened to someone, such as a

violent personal assault, suicide, serious accident, injury, or sudden or unexpected death.

For many people, the impact of the trauma

will depend on a host of variables, including

their proximity to the event as eyewitnesses, 

the witnesses’ response in the situation, their

relationship to the victims, the degree of helplessness surrounding the experience, their exposure to subsequent consequences, and so on. 

50 
 

 

 

It is important to 

remember that 

what happened is 

not nearly as 

important as what 

the trauma means 

to the individual. 

Part 1, Chapter 2—Trauma Awareness 

The effects of traumas such as genocide and

internment in concentration camps can be felt

across generations—stories, coping behaviors,

and stress reactions can be passed across generational lines far removed from the actual 

events or firsthand accounts. Known as historical trauma, this type of trauma can affect the

functioning of families, communities, and

cultures for multiple generations. 

What happened since the trauma? 

In reviewing traumatic events, it is important

to assess the degree of disruption after the 

initial trauma has passed, such as the loss of

employment, assets, community events, behavioral health services, local stores, and recreational areas. There is typically an initial rally of

services and support following a trauma, particularly if it is on a mass scale. However, the 

reality of the trauma’s effects and their disruptiveness may have a more lasting impact. The 

deterioration of normalcy, including the disruption of day-to-day activities and the damage of structures that house these routines, will 

likely erode the common threads that provide 

a sense of safety in individual lives and communities. Hence, the degree of disruption in

resuming normal daily activities is a significant

risk factor for substance use disorders, subclinical psychological symptoms, and mental disorders. For example, adults displaced from 

their homes because of Hurricanes Katrina or 

Rita had significantly higher rates of pastmonth cigarette use, illicit drug use, and binge 

drinking than those who were not displaced

(Office of Applied Studies, 2008). 

Subjective Characteristics 

Psychological meaning of trauma 

An important clinical issue in understanding

the impact of trauma is the meaning that the

survivor has attached to the traumatic experience. Survivors’ unique cognitive interpretations of an event—that is, their beliefs and 

assumptions—

contribute to how 

they process, react to,

cope with, and recover from the trauma. 

Does the event represent retribution for 

past deeds committed

by the individual or his or her family? How 

does the individual attach meaning to his or 

her survival? Does he or she believe that it is a 

sign of a greater purpose not yet revealed?

People who attempt to share their interpretation and meaning of the event can feel misunderstood and sometimes alienated (Paulson &

Krippner, 2007; Schein, Spitz, Burlingame, &

Muskin, 2006). 

People interpret traumatic events in vastly 

different ways, and many variables shape how 

an individual assigns meaning to the experience (framing the meaning through culture,

family beliefs, prior life experiences and learning, personality and other psychological features, etc.). Even in an event that happens in a 

household, each family member may interpret

the experience differently. Likewise, the same 

type of event can occur at two different times 

in a person’s life, but his or her interpretation

of the events may differ considerably because 

of developmental differences acquired between

events, current cognitive and emotional processing skills, availability of and access to environmental resources, and so forth. 

Disruption of core assumptions and 

beliefs 

Trauma often engenders a crisis of faith

(Frankl, 1992) that leads clients to question

basic assumptions about life. Were the individual’s core or life-organizing assumptions

(e.g., about safety, perception of others, fairness, purpose of life, future dreams) challenged or disrupted during or after the 

traumatic event? (See the seminal work, 

51 
 

 

 

 

Resilience: Connection and Continuity 

Research suggests that reestablishing ties to family, community, culture, and spiritual systems is not 

only vital to the individual, but it also influences the impact of the trauma upon future generations. 

For example, Baker and Gippenreiter (1998) studied the descendants of survivors of Joseph Stalin’s 

purge. They found that families who were able to maintain a sense of connection and continuity with 

grandparents directly affected by the purge experienced fewer negative effects than those who were 

emotionally or physically severed from their grandparents. Whether the grandparents survived was 

less important than the connection the grandchildren felt to their pasts. 

Trauma-Informed Care in Behavioral Health Services 

Shattered Assumptions, by Janoff-Bulman,

1992.) For example, some trauma survivors see 

themselves as irreparably wounded or beyond

the possibility of healing. The following case 

illustration (Sonja) explores not only the importance of meaning, but also the role that 

trauma plays in altering an individual’s core 

assumptions—the very assumptions that provide meaning and a means to organize our lives 

and our interactions with the world and others. 

Cultural meaning of trauma 

Counselors should strive to appreciate the 

cultural meaning of a trauma. How do cultural 

interpretations, cultural support, and cultural 

responses affect the experience of trauma? It is 

critical that counselors do not presume to understand the meaning of a traumatic experience without considering the client’s cultural 

context. Culture strongly influences the perceptions of trauma. For instance, a trauma 

involving shame can be more profound for a

person from an Asian culture than for someone from a European culture. Likewise, an

Alaska Native individual or community, depending upon their Tribal ancestry, may believe that the traumatic experience serves as a

form of retribution. Similarly, the sudden

death of a family member or loved one can be 

less traumatic in a culture that has a strong

belief in a positive afterlife. It is important for

counselors to recognize that their perceptions 

of a specific trauma could be very different

from their clients’ perceptions. Be careful not 

to judge a client’s beliefs in light of your own

value system. For more information on culture 

and how to achieve cultural competence in

providing behavioral health services, see 

SAMHSA’s planned TIP, Improving Cultural 

Competence (SAMHSA, planned c). 

Individual and 

Sociocultural Features 

A wide variety of social, demographic, environmental, and psychological factors influence 

a person’s experience of trauma, the severity of

traumatic stress reactions following the event,

and his or her resilience in dealing with the 

short- and long-term environmental, physical,

sociocultural, and emotional consequences.

This section addresses a few known factors 

that influence the risk of trauma along with

the development of subclinical and diagnostic

traumatic stress symptoms, such as mood and

anxiety symptoms and disorders. It is not

meant to be an exhaustive exploration of these 

factors, but rather, a brief presentation to make

counselors and other behavioral health professionals aware that various factors influence risk 

for and protection against traumatic stress and

subsequent reactions. (For a broader perspective 

on such factors, refer to Part 1, Chapter 1.) 

Individual Factors 

Several factors influence one’s ability to deal

with trauma effectively and increase one’s risk 

for traumatic stress reactions. Individual factors pertain to the individual’s genetic, biological, and psychological makeup and history as 

they influence the person’s experience and 

52 
Case Illustration: Sonja 

Sonja began to talk about how her life was different after being physically assaulted and robbed in a 

parking lot at a local strip mall a year ago. She recounts that even though there were people in the 

parking lot, no one came to her aid until the assailant ran off with her purse. She sustained a cheekbone fracture and developed visual difficulties due to the inflammation from the fracture. She recently sought treatment for depressive symptoms and reported that she had lost interest in activities 

that typically gave her joy. She reported isolating herself from others and said that her perception of 

others had changed dramatically since the attack. 

Sonja had received a diagnosis of major depression with psychotic features 10 years earlier and received group therapy at a local community mental health center for 3 years until her depression 

went into remission. She recently became afraid that her depression was becoming more pronounced, and she wanted to prevent another severe depressive episode as well as the use of psychotropic medications, which she felt made her lethargic. Thus, she sought out behavioral health 

counseling. 

As the sessions progressed, and after a psychological evaluation, it was clear that Sonja had some 

depressive symptoms, but they were subclinical. She denied suicidal thoughts or intent, and her 

thought process was organized with no evidence of hallucinations or delusions. She described her 

isolation as a reluctance to shop at area stores. On one hand, Sonja was self-compassionate about 

her reasons for avoidance, but on the other hand, she was concerned that the traumatic event had 

altered how she saw life and others. “I don’t see people as very caring or kind, like I used to prior to 

the event. I don’t trust them, and I feel people are too self-absorbed. I don’t feel safe, and this 

bothers me. I worry that I’m becoming paranoid again. I guess I know better, but I just want to have 

the freedom to do what I want and go where I want.” 

Two months after Sonja initiated counseling, she came to the office exclaiming that things can indeed change. “You won’t believe it. I had to go to the grocery store, so I forced myself to go the 

shopping center that had a grocery store attached to a strip mall. I was walking by a coffee shop, 

quickly browsing the items in the front window, when a man comes out of the shop talking at me. 

He says, ‘You look like you need a cup of coffee.’ What he said didn’t register immediately. I looked 

at him blankly, and he said it again. ‘You look like you need a cup of coffee. I’m the owner of the 

shop, and I noticed you looking in the window, and we have plenty of brewed coffee left before we 

close the shop. Come on in, it’s on the house.’ So I did! From that moment on, I began to see people differently. He set it right for me—I feel as if I have myself back again, as if the assault was a sign 

that I shouldn’t trust people, and now I see that there is some goodness in the world. As small as 

this kindness was, it gave me the hope that I had lost.” 

For Sonja, the assault changed her assumptions about safety and her view of others. She also attached meaning to the event. She believed that the event was a sign that she shouldn’t trust people 

and that people are uncaring. Yet these beliefs bothered her and contradicted how she saw herself 

in the world, and she was afraid that her depressive symptoms were returning. 

For an inexperienced professional, her presentation may have ignited suspicions that she was beginning to present with psychotic features. However, it is common for trauma survivors to experience changes in core assumptions immediately after the event and to attach meaning to the trauma. 

Often, a key ingredient in the recovery process is first identifying the meaning of the event and the 

beliefs that changed following the traumatic experience. So when you hear a client say “I will never 

see life the same,” this expression should trigger further exploration into how life is different, what 

meaning has been assigned to the trauma, and how the individual has changed his or her perception 

of self, others, and the future. 

(Continued on the next page.) 

Part 1, Chapter 2—Trauma Awareness 

53 
 

 

Case Illustration: Sonja (continued) 

Sometimes, reworking the altered beliefs and assumptions occurs with no formal intervention, as 

with Sonja. In her situation, a random stranger provided a moment that challenged an assumption 

generated from the trauma. For others, counseling may be helpful in identifying how beliefs and 

thoughts about self, others, and the world have changed since the event and how to rework them to 

move beyond the trauma. It is important to understand that the meaning that an individual attaches 

to the event(s) can either undermine the healing process (e.g., believing that you should not have 

survived, feeling shame about the trauma, continuing to engage in high-risk activities) or pave the 

road to recovery (e.g., volunteering to protect victim rights after being sexually assaulted). The following questions can help behavioral health staff members introduce topics surrounding assumptions, beliefs, interpretations, and meanings related to trauma: 

• In what ways has your life been different since the trauma? 

• How do you understand your survival? (This is an important question for clients who have been 

exposed to ACEs or cumulative trauma and those who survived a tragedy when others did not.) 

• Do you believe that there are reasons that this event happened to you? What are they? 

• What meaning does this experience have for you? 

• Do you feel that you are the same person as before the trauma? In what ways are you the same? 

In what ways do you feel different? 

• How did this experience change you as a person? Would you like to return to the person you 

once were? What would you need to do, or what would need to happen, for this to occur? 

• Did the traumatic experience change you in a way that you don’t like? In what ways? 

• How do you view others and your future differently since the trauma? 

• What would you like to believe now about the experience? 

Trauma-Informed Care in Behavioral Health Services 

interpretation of, as well as his or her reactions 

to, trauma. However, many factors influence 

individual responses to trauma; it is not just

individual characteristics. Failing to recognize

that multiple factors aside from individual

attributes and history influence experiences 

during and after trauma can lead to blaming

the victim for having traumatic stress. 

History of prior psychological 

trauma 

People with histories of prior psychological 

trauma appear to be the most susceptible to

severe traumatic responses (Nishith, Mechanic, 

& Resick, 2000; Vogt, Bruce, Street, &

Stafford, 2007), particularly if they have 

avoided addressing past traumas. Because 

minimization, dissociation, and avoidance are

common defenses for many trauma survivors,

prior traumas are not always consciously available, and when they are, memories can be 

distorted to avoid painful affects. Some survivors who have repressed their experiences deny a history of trauma or are unable to explain 

their strong reactions to present situations. 

Remember that the effects of trauma are cumulative; therefore, a later trauma that outwardly appears less severe may have more 

impact upon an individual than a trauma that

occurred years earlier. Conversely, individuals

who have experienced earlier traumas may 

have developed effective coping strategies or

report positive outcomes as they have learned

to adjust to the consequences of the trauma(s).

This outcome is often referred to as posttraumatic growth or psychological growth. 

Clients in behavioral health treatment who 

have histories of trauma can respond negatively to or seem disinterested in treatment efforts.

They may become uncomfortable in groups 

that emphasize personal sharing; likewise, an

individual who experiences brief bouts of dissociation (a reaction of some trauma survivors)

may be misunderstood by others in treatment

and seen as uninterested. Providers need to 

54 
 

 

 

 

 

 

 

Part 1, Chapter 2—Trauma Awareness 

attend to histories, adjust treatment to avoid

retraumatization, and steer clear of labeling

clients’ behavior as pathological. 

History of resilience 

Resilience—the ability to thrive despite negative life experiences and heal from traumatic

events—is related to the internal strengths and

environmental supports of an individual. Most

individuals are resilient despite experiencing

traumatic stress. The ability to thrive beyond

the trauma is associated with individual factors 

as well as situational and contextual factors. 

There are not only one or two primary factors

that make an individual resilient; many factors

contribute to the development of resilience.

There is little research to indicate that there are 

specific traits predictive of resilience; instead, it

appears that more general characteristics influence resilience, including neurobiology (Feder,

Charney, & Collins, 2011), flexibility in adapting to change, beliefs prior to trauma, sense of

self-efficacy, and ability to experience positive 

emotions (Bonanno & Mancini, 2011). 

History of mental disorders 

The correlations among traumatic stress, substance use disorders, and co-occurring mental 

disorders are well known. According to the

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American Psychiatric

Association, 2013a), traumatic stress reactions 

are linked to higher rates of mood, substancerelated, anxiety, trauma, stress-related, and

other mental disorders, each of which can precede, follow, or emerge concurrently with

trauma itself. A co-occurring mental disorder 

is a significant determinant of whether an

individual can successfully address and resolve 

trauma as it emerges from the past or occurs 

in the present. Koenen, Stellman, Stellman,

and Sommer (2003) found that the risk of 

developing PTSD following combat trauma 

was higher for individuals with preexisting

conduct disorder, panic disorder, generalized 

anxiety disorder, and/or major depression than

for those without preexisting mental disorders. 

For additional information on comorbidity of

trauma and other mental disorders, see TIP

42, Substance Abuse Treatment for Persons With 

Co-Occurring Disorders (CSAT, 2005c). 

Sociodemographic Factors 

Demographic variables are not good predictors of who will experience trauma and subsequent traumatic stress reactions. Gender, age, 

race and ethnicity, sexual orientation, marital

status, occupation, income, and education can

all have some influence, but not enough to

determine who should or should not receive 

screening for trauma and traumatic stress 

symptoms. The following sections cover a few

selected variables. (For more information,

please refer to Part 3 of this TIP, the online 

literature review.) 

Gender 

In the United States, men are at greater risk 

than women for being exposed to stressful 

events. Despite the higher prevalence among

men, lifetime PTSD occurs at about twice the 

rate among women as it does in men. Less is 

known about gender differences with subclinical traumatic stress reactions. There are also 

other gender differences, such as the types of

trauma experienced by men and women.

Women are more likely to experience physical 

and sexual assault, whereas men are most likely to experience combat and crime victimization and to witness killings and serious injuries

(Breslau, 2002; Kimerling, Ouimette, &

Weitlauf, 2007; Tolin & Foa, 2006). Women

in military service are subject to the same risks 

as men and are also at a greater risk for military sexual trauma. Men’s traumas often occur 

in public; women’s are more likely to take 

place in private settings. Perpetrators of traumas against men are often strangers, but women are more likely to know the perpetrator. 

55 
 

Resilience: Cultural, Racial, and Ethnic Characteristics 

The following list highlights characteristics that often nurture resilience among individuals from diverse cultural, racial, and ethnic groups: 

• Strong kinship bonds 

• Respect for elders and the importance of extended family 

• Spirituality and religious practices (e.g., shrine visitations or the use of traditional healers) 

• Value in friendships and warm personal relationships 

• Expression of humor and creativity 

• Instilling a sense of history, heritage, and historical traditions 

• Community orientation, activities, and socialization 

• Strong work ethic 

• Philosophies and beliefs about life, suffering, and perseverance 

“Fortune owes its existence to misfortune, and misfortune is hidden in fortune.” 

–Lao-Tzu teaching, Taoism (Wong & Wong, 2006) 

Trauma-Informed Care in Behavioral Health Services 

Age 

In general, the older one becomes, the higher

the risk of trauma—but the increase is not 

dramatic. Age is not particularly important in

predicting exposure to trauma, yet at no age is

one immune to the risk. However, trauma that

occurs in the earlier and midlife years appears 

to have greater impact on people for different

reasons. For younger individuals, the trauma

can affect developmental processes, attachment, emotional regulation, life assumptions,

cognitive interpretations of later experiences,

and so forth (for additional resources, visit the 

National Child Traumatic Stress Network;

http://www.nctsn.org/). For adults in midlife,

trauma may have a greater impact due to the

enhanced stress or burden of care that often 

characterizes this stage of life—caring for 

their children and their parents at the same 

time. Older adults are as likely as younger

adults to recover quickly from trauma, yet they

may have greater vulnerabilities, including

their ability to survive without injury and their

ability to address the current trauma without

psychological interference from earlier stressful or traumatic events. Older people are naturally more likely to have had a history of

trauma because they have lived longer, thus 

creating greater vulnerability to the effects of

cumulative trauma. 

Race, ethnicity, and culture 

The potential for trauma exists in all major

racial and ethnic groups in American society,

yet few studies analyze the relationship of race 

and ethnicity to trauma exposure and/or traumatic stress reactions. Some studies show that 

certain racial and ethnic groups are at greater

risk for specific traumas. For example, African

Americans experienced higher rates of overall 

violence, aggravated assault, and robbery than

Whites but were as likely to be victims of rape 

or sexual assault (Catalano, 2004). Literature 

reflects that diverse ethnic, racial, and cultural 

groups are more likely to experience adverse 

effects from various traumas and to meet criteria for posttraumatic stress (Bell, 2011). 

Sexual orientation and gender identity 

Lesbian, gay, bisexual, and transgender individuals are likely to experience various forms 

of trauma associated with their sexual orientation, including harsh consequences from families and faith traditions, higher risk of assault

from casual sexual partners, hate crimes, lack 

of legal protection, and laws of exclusion

(Brown, 2008). Gay and bisexual men as well 

as transgender people are more likely to experience victimization than lesbians and bisexual 

women. Dillon (2001) reported a trauma exposure rate of 94 percent among lesbian, gay, 

56 
 

 

Part 1, Chapter 2—Trauma Awareness 

and bisexual individuals; more than 40 percent

of respondents experienced harassment due to

their sexual orientation. Heterosexual orientation is also a risk for women, as women in 

relationships with men are at a greater risk of

being physically and sexually abused. 

People who are homeless 

Homelessness is typically defined as the lack 

of an adequate or regular dwelling, or having a 

nighttime dwelling that is a publicly or privately supervised institution or a place not

intended for use as a dwelling (e.g., a bus station). The U.S. Department of Housing and

Urban Development (HUD) estimates that

between 660,000 and 730,000 individuals

were homeless on any given night in 2005

(HUD, 2007). Two thirds were unaccompanied persons; the other third were people in 

families. Adults who are homeless and unmarried are more likely to be male than female.

About 40 percent of men who are homeless 

are veterans (National Coalition for the

Homeless, 2002); this percentage has grown,

including the number of veterans with dependent children (Kuhn & Nakashima, 2011). 

Rates of trauma symptoms are high among

people who are homeless (76 to 100 percent of 

women and 67 percent of men; Christensen et

al., 2005; Jainchill, Hawke, & Yagelka, 2000),

and the diagnosis of PTSD is among the most

prevalent non-substance use Axis I disorders

(Lester et al., 2007; McNamara, Schumacher,

Milby, Wallace, & Usdan, 2001). People who

are homeless report high levels of trauma (especially physical and sexual abuse in childhood

or as adults) preceding their homeless status;

assault, rape, and other traumas frequently 

happen while they are homeless. Research

suggests that many women are homeless because they are fleeing domestic violence 

(National Coalition for the Homeless, 2002).

Other studies suggest that women who are 

homeless are more likely to have histories of 

childhood physical and sexual abuse and to

have experienced sexual assault as adults. A

history of physical and/or sexual abuse is even

more common among women who are homeless and have a serious mental illness. 

Youth who are homeless, especially those who

live without a parent, are likely to have experienced physical and/or sexual abuse. Between

21 and 42 percent of youth runaways report

having been sexually abused before leaving

their homes; for young women, rates range 

from 32 to 63 percent (Administration on 

Children, Youth and Families, 2002). Additionally, data reflect elevated rates of substance 

abuse for youth who are homeless and have 

histories of abuse. 

More than half of people who are homeless 

have a lifetime prevalence of mental illness 

and substance use disorders. Those who are 

homeless have higher rates of substance abuse 

(84 percent of men and 58 percent of women), 

and substance use disorders, including alcohol 

and drug abuse/dependence, increase with

longer lengths of homelessness (North,

Eyrich, Pollio, & Spitznagel, 2004). 

For more information on providing traumainformed behavioral health services to clients 

who are homeless, and for further discussion

of the incidence of trauma in this population, 

see TIP 55-R, Behavioral Health Services for 

People Who Are Homeless (SAMHSA, 2013b). 

57 

 

 

 

 

IN THIS CHAPTER 

• Sequence of Trauma

Reactions

• Common Experiences

and Responses to Trauma

• Subthreshold Trauma -

Related Symptoms 

• Specific Trauma -Related

Psychological Disorders

• Other Trauma -Related

and Co -Occurring

Disorders

Understanding the 3 Impact of Trauma 

Trauma-informed care (TIC) involves a broad understanding of

traumatic stress reactions and common responses to trauma. Providers need to understand how trauma can affect treatment presentation, engagement, and the outcome of behavioral health services.

This chapter examines common experiences survivors may encounter immediately following or long after a traumatic experience. 

Trauma, including one-time, multiple, or long-lasting repetitive 

events, affects everyone differently. Some individuals may clearly 

display criteria associated with posttraumatic stress disorder

(PTSD), but many more individuals will exhibit resilient responses 

or brief subclinical symptoms or consequences that fall outside of

diagnostic criteria. The impact of trauma can be subtle, insidious,

or outright destructive. How an event affects an individual depends 

on many factors, including characteristics of the individual, the

type and characteristics of the event(s), developmental processes,

the meaning of the trauma, and sociocultural factors. 

This chapter begins with an overview of common responses,

emphasizing that traumatic stress reactions are normal reactions to

abnormal circumstances. It highlights common short- and longterm responses to traumatic experiences in the context of individuals 

who may seek behavioral health services.This chapter discusses

psychological symptoms not represented in the Diagnostic and 

Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; 

American Psychiatric Association [APA], 2013a), and responses 

associated with trauma that either fall below the threshold of mental 

disorders or reflect resilience. It also addresses common disorders 

associated with traumatic stress.This chapter explores the role of

culture in defining mental illness, particularly PTSD, and ends by 

addressing co-occurring mental and substance-related disorders. 

59 
 

Foreshortened future: Trauma can affect 

one’s beliefs about the future via loss of 

hope, limited expectations about life, fear 

that life will end abruptly or early, or 

anticipation that normal life events won’t 

occur (e.g., access to education, ability to 

have a significant and committed 

relationship, good opportunities for work). 

Trauma-Informed Care in Behavioral Health Services 

TIC Framework in Behavioral Health Services—The Impact of Trauma 

Sequence of Trauma 

Reactions 

Survivors’ immediate reactions in the aftermath of trauma are quite complicated and are

affected by their own experiences, the accessibility of natural supports and healers, their 

coping and life skills and those of immediate 

family, and the responses of the larger community in which they live. Although reactions 

range in severity, even the most acute responses

are natural responses to manage trauma—

they are not a sign of psychopathology. Coping styles vary from action oriented to reflective and from emotionally expressive to

reticent. Clinically, a response style is less important than the degree to which coping efforts successfully allow one to continue 

necessary activities, regulate emotions, sustain

self-esteem, and maintain and enjoy interpersonal contacts. Indeed, a past error in traumatic stress psychology, particularly regarding

group or mass traumas, was the assumption

that all survivors need to express emotions

associated with trauma and talk about the 

trauma; more recent research indicates that

survivors who choose not to process their

trauma are just as psychologically healthy as 

60 
 

 

Part 1, Chapter 3—Understanding the Impact of Trauma 

those who do. The most recent psychological 

debriefing approaches emphasize respecting

the individual’s style of coping and not valuing

one type over another. 

Initial reactions to trauma can include exhaustion, confusion, sadness, anxiety, agitation,

numbness, dissociation, confusion, physical 

arousal, and blunted affect. Most responses are 

normal in that they affect most survivors and

are socially acceptable, psychologically effective, and self-limited. Indicators of more severe responses include continuous distress 

without periods of relative calm or rest, severe 

dissociation symptoms, and intense intrusive 

recollections that continue despite a return to

safety. Delayed responses to trauma can include persistent fatigue, sleep disorders,

nightmares, fear of recurrence, anxiety focused

on flashbacks, depression, and avoidance of

emotions, sensations, or activities that are associated with the trauma, even remotely. Exhibit 1.3-1 outlines some common reactions. 

Common Experiences and 

Responses to Trauma 

A variety of reactions are often reported and/or

observed after trauma. Most survivors exhibit 

immediate reactions, yet these typically resolve 

without severe long-term consequences. This

is because most trauma survivors are highly 

resilient and develop appropriate coping

strategies, including the use of social supports, to deal with the aftermath and effects 

of trauma. Most recover with time, show minimal distress, and function effectively across 

major life areas and developmental stages.

Even so, clients who show little impairment

may still have subclinical symptoms or symptoms that do not fit diagnostic criteria for 

acute stress disorder (ASD) or PTSD. Only a

small percentage of people with a history of 

trauma show impairment and symptoms that

meet criteria for trauma-related stress disorders, including mood and anxiety disorders. 

The following sections focus on some common reactions across domains (emotional,

physical, cognitive, behavioral, social, and developmental) associated with singular, multiple, and enduring traumatic events. These 

reactions are often normal responses to trauma

but can still be distressing to experience. Such

responses are not signs of mental illness, nor

do they indicate a mental disorder. Traumatic 

stress-related disorders comprise a specific

constellation of symptoms and criteria. 

Emotional 

Emotional reactions to trauma can vary greatly and are significantly influenced by the individual’s sociocultural history. Beyond the 

initial emotional reactions during the event,

those most likely to surface include anger, fear,

sadness, and shame. However, individuals may 

encounter difficulty in identifying any of these 

feelings for various reasons. They might lack

experience with or prior exposure to emotional

expression in their family or community. They 

may associate strong feelings with the past

trauma, thus believing that emotional expression is too dangerous or will lead to feeling out

of control (e.g., a sense of “losing it” or going

crazy). Still others might deny that they have

any feelings associated with their traumatic

experiences and define their reactions as 

numbness or lack of emotions. 

Emotional dysregulation 

Some trauma survivors have difficulty regulating emotions such as anger, anxiety, sadness,

and shame—this is more so when the trauma 

occurred at a young age (van der Kolk, Roth,

Pelcovitz, & Mandel, 1993). In individuals

who are older and functioning well 

61 
 

 

 

 

 

 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

Exhibit 1.3-1: Immediate and Delayed Reactions to Trauma 

Immediate Emotional Reactions Delayed Emotional Reactions 

Numbness and detachment Irritability and/or hostility 

Anxiety or severe fear Depression 

Guilt (including survivor guilt) Mood swings, instability 

Exhilaration as a result of surviving Anxiety (e.g., phobia, generalized anxiety) 

Anger Fear of trauma recurrence 

Sadness Grief reactions 

Helplessness Shame 

Feeling unreal; depersonalization (e.g., feeling Feelings of fragility and/or vulnerability 

as if you are watching yourself) Emotional detachment from anything that reDisorientation quires emotional reactions (e.g., significant 

Feeling out of control and/or family relationships, conversations 

Denial about self, discussion of traumatic events or 

Constriction of feelings reactions to them) 

Feeling overwhelmed 

Immediate Physical Reactions Delayed Physical Reactions 

Nausea and/or gastrointestinal distress Sleep disturbances, nightmares 

Sweating or shivering Somatization (e.g., increased focus on and 

Faintness worry about body aches and pains) 

Muscle tremors or uncontrollable shaking Appetite and digestive changes 

Elevated heartbeat, respiration, and blood Lowered resistance to colds and infection 

pressure Persistent fatigue 

Extreme fatigue or exhaustion Elevated cortisol levels 

Greater startle responses Hyperarousal 

Depersonalization Long-term health effects including heart, liver, 

autoimmune, and chronic obstructive pulmonary disease 

Immediate Cognitive Reactions 

Difficulty concentrating 

Rumination or racing thoughts (e.g., replaying 

the traumatic event over and over again) 

Distortion of time and space (e.g., traumatic 

event may be perceived as if it was happening in slow motion, or a few seconds can be 

perceived as minutes) 

Memory problems (e.g., not being able to recall important aspects of the trauma) 

Strong identification with victims 

Delayed Cognitive Reactions 

Intrusive memories or flashbacks 

Reactivation of previous traumatic events 

Self-blame 

Preoccupation with event 

Difficulty making decisions 

Magical thinking: belief that certain behaviors, 

including avoidant behavior, will protect 

against future trauma 

Belief that feelings or memories are dangerous 

Generalization of triggers (e.g., a person who 

experiences a home invasion during the daytime may avoid being alone during the day) 

Suicidal thinking 

Immediate Behavioral Reactions Delayed Behavioral Reactions 

Startled reaction Avoidance of event reminders 

Restlessness Social relationship disturbances 

Sleep and appetite disturbances Decreased activity level 

Difficulty expressing oneself Engagement in high-risk behaviors 

Argumentative behavior Increased use of alcohol and drugs 

Increased use of alcohol, drugs, and tobacco Withdrawal 

Withdrawal and apathy 

Avoidant behaviors 

(Continued on the next page.) 

62 
 

 

 

 

 

 

 

 

Part 1, Chapter 3—Understanding the Impact of Trauma 

Exhibit 1.3-1: Immediate and Delayed Reactions to Trauma (continued) 

Immediate Existential Reactions 

Intense use of prayer 

Restoration of faith in the goodness of others 

(e.g., receiving help from others) 

Loss of self-efficacy 

Despair about humanity, particularly if the 

event was intentional 

Delayed Existential Reactions 

Questioning (e.g., “Why me?”) 

Increased cynicism, disillusionment 

Increased self-confidence (e.g., “If I can survive this, I can survive anything”) 

Loss of purpose 

Renewed faith 

Immediate disruption of life assumptions (e.g., 

fairness, safety, goodness, predictability of 

life) 

Hopelessness 

Reestablishing priorities 

Redefining meaning and importance of life 

Reworking life’s assumptions to accommodate 

the trauma (e.g., taking a self-defense class 

to reestablish a sense of safety) 

Sources: Briere & Scott, 2006b; Foa, Stein, & McFarlane, 2006; Pietrzak, Goldstein, Southwick, & 

Grant, 2011. 

prior to the trauma, such emotional dysregulation is usually short lived and represents an

immediate reaction to the trauma, rather than

an ongoing pattern. Self-medication—namely,

substance abuse—is one of the methods that 

traumatized people use in an attempt to regain

emotional control, although ultimately it causes

even further emotional dysregulation (e.g.,

substance-induced changes in affect during

and after use). Other efforts toward emotional 

regulation can include engagement in highrisk or self-injurious behaviors, disordered

eating, compulsive behaviors such as gambling

or overworking, and repression or denial of

emotions; however, not all behaviors 

associated with self-regulation are considered 

negative. In fact, some individuals find creative, healthy, and industrious ways to manage

strong affect generated by trauma, such as 

through renewed commitment to physical 

activity or by creating an organization to support survivors of a particular trauma. 

Traumatic stress tends to evoke two emotional 

extremes: feeling either too much (overwhelmed) or too little (numb) emotion.

Treatment can help the client find the optimal 

level of emotion and assist him or her with 

appropriately experiencing and regulating difficult emotions. In treatment, the goal is to

help clients learn to regulate their emotions

without the use of substances or other unsafe 

behavior. This will likely require learning new 

coping skills and how to tolerate distressing

emotions; some clients may benefit from 

mindfulness practices, cognitive restructuring,

and trauma-specific desensitization approaches,

such as exposure therapy and eye movement

desensitization and reprocessing (EMDR;

refer to Part 1, Chapter 6, for more information on trauma-specific therapies). 

Numbing 

Numbing is a biological process whereby emotions are detached from thoughts, behaviors,

and memories. In the following case illustration, Sadhanna’s numbing is evidenced by her

limited range of emotions associated with interpersonal interactions and her inability to

associate any emotion with her history of

abuse. She also possesses a belief in a foreshortened future. A prospective longitudinal study 

(Malta, Levitt, Martin, Davis, & Cloitre, 2009) 

that followed the development of PTSD in

disaster workers highlighted the importance of

understanding and appreciating numbing as a

traumatic stress reaction. Because numbing 

63 
 

 

Case Illustration: Sadhanna 

Sadhanna is a 22-year-old woman mandated to outpatient mental health and substance abuse treatment as the alternative to incarceration. She was arrested and charged with assault after arguing and 

fighting with another woman on the street. At intake, Sadhanna reported a 7-year history of alcohol 

abuse and one depressive episode at age 18. She was surprised that she got into a fight but admitted that she was drinking at the time of the incident. She also reported severe physical abuse at the 

hands of her mother’s boyfriend between ages 4 and 15. Of particular note to the intake worker was 

Sadhanna’s matter-of-fact way of presenting the abuse history. During the interview, she clearly indicated that she did not want to attend group therapy and hear other people talk about their feelings, 

saying, “I learned long ago not to wear emotions on my sleeve.” 

Sadhanna reported dropping out of 10th grade, saying she never liked school. She didn’t expect 

much from life. In Sadhanna’s first weeks in treatment, she reported feeling disconnected from other 

group members and questioned the purpose of the group. When asked about her own history, she 

denied that she had any difficulties and did not understand why she was mandated to treatment. She 

further denied having feelings about her abuse and did not believe that it affected her life now. 

Group members often commented that she did not show much empathy and maintained a flat affect, 

even when group discussions were emotionally charged. 

Trauma-Informed Care in Behavioral Health Services 

symptoms hide what is going on inside emotionally, there can be a tendency for family 

members, counselors, and other behavioral 

health staff to assess levels of traumatic stress 

symptoms and the impact of trauma as less 

severe than they actually are. 

Physical 

Diagnostic criteria for PTSD place considerable emphasis on psychological symptoms, but

some people who have experienced traumatic

stress may present initially with physical 

symptoms. Thus, primary care may be the first

and only door through which these individuals

seek assistance for trauma-related symptoms.

Moreover, there is a significant connection 

between trauma, including adverse childhood

experiences (ACEs), and chronic health conditions. Common physical disorders and

symptoms include somatic complaints; sleep

disturbances; gastrointestinal, cardiovascular,

neurological, musculoskeletal, respiratory, and

dermatological disorders; urological problems; 

and substance use disorders. 

Somatization 

Somatization indicates a focus on bodily

symptoms or dysfunctions to express emotional distress. Somatic symptoms are more likely

to occur with individuals who have traumatic 

stress reactions, including PTSD. People from

certain ethnic and cultural backgrounds may 

initially or solely present emotional distress via

physical ailments or concerns. Many individuals who present with somatization are likely 

unaware of the connection between their emotions and the physical symptoms that they’re 

experiencing. At times, clients may remain

resistant to exploring emotional content and

remain focused on bodily complaints as a

means of avoidance. Some clients may insist

that their primary problems are physical even

when medical evaluations and tests fail to confirm ailments. In these situations, somatization may be a sign of a mental illness.

However, various cultures approach emotional 

distress through the physical realm or view 

emotional and physical symptoms and wellbeing as one. It is important not to assume 

that clients with physical complaints are using

somatization as a means to express emotional 

pain; they may have specific conditions or

disorders that require medical attention.

Foremost, counselors need to refer for medical 

evaluation. 

64 
Part 1, Chapter 3—Understanding the Impact of Trauma 

 

Advice to Counselors: Using Information About Biology and Trauma 

• Educate your clients: 

­ Frame reexperiencing the event(s), hyperarousal, sleep disturbances, and other physical 

symptoms as physiological reactions to extreme stress. 

­ Communicate that treatment and other wellness activities can improve both psychological 

and physiological symptoms (e.g., therapy, meditation, exercise, yoga). You may need to refer 

certain clients to a psychiatrist who can evaluate them and, if warranted, prescribe psychotropic medication to address severe symptoms. 

­ Discuss traumatic stress symptoms and their physiological components. 

­ Explain links between traumatic stress symptoms and substance use disorders, if appropriate. 

­ Normalize trauma symptoms. For example, explain to clients that their symptoms are not a 

sign of weakness, a character flaw, being damaged, or going crazy. 

• Support your clients and provide a message of hope—that they are not alone, they are not at 

fault, and recovery is possible and anticipated. 

Case Illustration: Kimi 

Kimi is a 35-year-old Native American woman who was group raped at the age of 16 on her walk 

home from a suburban high school. She recounts how her whole life changed on that day. “I never 

felt safe being alone after the rape. I used to enjoy walking everywhere. Afterward, I couldn’t tolerate 

the fear that would arise when I walked in the neighborhood. It didn’t matter whether I was alone or 

with friends—every sound that I heard would throw me into a state of fear. I felt like the same thing 

was going to happen again. It’s gotten better with time, but I often feel as if I’m sitting on a tree limb 

waiting for it to break. I have a hard time relaxing. I can easily get startled if a leaf blows across my 

path or if my children scream while playing in the yard. The best way I can describe how I experience 

life is by comparing it to watching a scary, suspenseful movie—anxiously waiting for something to 

happen, palms sweating, heart pounding, on the edge of your chair.” 

Biology of trauma 

Trauma biology is an area of burgeoning research, with the promise of more complex and

explanatory findings yet to come. Although a

thorough presentation on the biological aspects of trauma is beyond the scope of this 

publication, what is currently known is that

exposure to trauma leads to a cascade of biological changes and stress responses. These 

biological alterations are highly associated

with PTSD, other mental illnesses, and substance use disorders. These include: 

•	 Changes in limbic system functioning. 

•	 Hypothalamic–pituitary–adrenal axis activity changes with variable cortisol levels. 

•	 Neurotransmitter-related dysregulation of

arousal and endogenous opioid systems. 

As a clear example, early ACEs such as 

abuse, neglect, and other traumas affect brain 

development and increase a person’s vulnerability to encountering interpersonal violence 

as an adult and to developing chronic diseases

and other physical illnesses, mental illnesses,

substance-related disorders, and impairment

in other life areas (Centers for Disease 

Control and Prevention, 2012). 

Hyperarousal and sleep disturbances 

A common symptom that arises from traumatic experiences is hyperarousal (also called

hypervigilance). Hyperarousal is the body’s 

way of remaining prepared. It is characterized 

by sleep disturbances, muscle tension, and a

lower threshold for startle responses and can 

persist years after trauma occurs. It is also one 

of the primary diagnostic criteria for PTSD. 

Hyperarousal is a consequence of biological 

changes initiated by trauma. Although it 

65 
Cognitions and Trauma 

The following examples reflect some of the types of cognitive or thought-process changes that can 

occur in response to traumatic stress. 

Cognitive errors: Misinterpreting a current situation as dangerous because it resembles, even remotely, a previous trauma (e.g., a client overreacting to an overturned canoe in 8 inches of water, as 

if she and her paddle companion would drown, due to her previous experience of nearly drowning 

in a rip current 5 years earlier). 

Excessive or inappropriate guilt: Attempting to make sense cognitively and gain control over a 

traumatic experience by assuming responsibility or possessing survivor’s guilt, because others who 

experienced the same trauma did not survive. 

Idealization: Demonstrating inaccurate rationalizations, idealizations, or justifications of the perpetrator’s behavior, particularly if the perpetrator is or was a caregiver. Other similar reactions mirror 

idealization; traumatic bonding is an emotional attachment that develops (in part to secure survival) 

between perpetrators who engage in interpersonal trauma and their victims, and Stockholm syndrome involves compassion and loyalty toward hostage takers (de Fabrique, Van Hasselt, Vecchi, & 

Romano, 2007). 

Trauma-induced hallucinations or delusions: Experiencing hallucinations and delusions that, 

although they are biological in origin, contain cognitions that are congruent with trauma content 

(e.g., a woman believes that a person stepping onto her bus is her father, who had sexually abused 

her repeatedly as child, because he wore shoes similar to those her father once wore). 

Intrusive thoughts and memories: Experiencing, without warning or desire, thoughts and memories 

associated with the trauma. These intrusive thoughts and memories can easily trigger strong emotional and behavioral reactions, as if the trauma was recurring in the present. The intrusive thoughts 

and memories can come rapidly, referred to as flooding, and can be disruptive at the time of their 

occurrence. If an individual experiences a trigger, he or she may have an increase in intrusive 

thoughts and memories for a while. For instance, individuals who inadvertently are retraumatized 

due to program or clinical practices may have a surge of intrusive thoughts of past trauma, thus making it difficult for them to discern what is happening now versus what happened then. Whenever 

counseling focuses on trauma, it is likely that the client will experience some intrusive thoughts and 

memories. It is important to develop coping strategies before, as much as possible, and during the 

delivery of trauma-informed and trauma-specific treatment. 

Trauma-Informed Care in Behavioral Health Services 

serves as a means of self-protection after 

trauma, it can be detrimental. Hyperarousal 

can interfere with an individual’s ability to

take the necessary time to assess and appropriately respond to specific input, such as loud

noises or sudden movements. Sometimes,

hyperarousal can produce overreactions to

situations perceived as dangerous when, in

fact, the circumstances are safe. 

Along with hyperarousal, sleep disturbances 

are very common in individuals who have experienced trauma. They can come in the form 

of early awakening, restless sleep, difficulty 

falling asleep, and nightmares. Sleep disturbances are most persistent among individuals 

who have trauma-related stress; the disturbances sometimes remain resistant to intervention long after other traumatic stress 

symptoms have been successfully treated.

Numerous strategies are available beyond

medication, including good sleep hygiene 

practices, cognitive rehearsals of nightmares,

relaxation strategies, and nutrition. 

Cognitive 

Traumatic experiences can affect and alter 

cognitions. From the outset, trauma challenges the just-world or core life assumptions that 

66 
 

 

Part 1, Chapter 3—Understanding the Impact of Trauma 

help individuals navigate daily life (JanoffBulman, 1992). For example, it would be difficult to leave the house in the morning if you 

believed that the world was not safe, that all 

people are dangerous, or that life holds no

promise. Belief that one’s efforts and intentions can protect oneself from bad things 

makes it less likely for an individual to perceive personal vulnerability. However, traumatic events—particularly if they are 

unexpected—can challenge such beliefs. 

Let’s say you always considered your driving

time as “your time”—and your car as a safe

place to spend that time. Then someone hits 

you from behind at a highway entrance. Almost immediately, the accident affects how 

you perceive the world, and from that moment 

onward, for months following the crash, you 

feel unsafe in any car. You become hypervigilant about other drivers and perceive that other cars are drifting into your lane or failing to

stop at a safe distance behind you. For a time, 

your perception of safety is eroded, often leading to compensating behaviors (e.g., excessive

glancing into the rearview mirror to see 

whether the vehicles behind you are stopping)

until the belief is restored or reworked. Some 

individuals never return to their previous belief

systems after a trauma, nor do

they find a way to rework

them—thus leading to a 

worldview that life is unsafe. 

Still, many other individuals 

are able to return to organizing core beliefs that support

their perception of safety. 

Many factors contribute to

cognitive patterns prior to,

during, and after a trauma.

Adopting Beck and colleagues’ 

cognitive triad model (1979),

trauma can alter three main 

cognitive patterns: thoughts 

about self, the world (others/environment),

and the future. To clarify, trauma can lead

individuals to see themselves as incompetent

or damaged, to see others and the world as 

unsafe and unpredictable, and to see the future 

as hopeless—believing that personal suffering

will continue, or negative outcomes will preside for the foreseeable future (see Exhibit

1.3-2). Subsequently, this set of cognitions

can greatly influence clients’ belief in their 

ability to use internal resources and external 

support effectively. From a cognitive–

behavioral perspective, these cognitions have a

bidirectional relationship in sustaining or contributing to the development of depressive and

anxiety symptoms after trauma. However, it is 

possible for cognitive patterns to help protect

against debilitating psychological symptoms as

well. Many factors contribute to cognitive

patterns prior to, during, and after a trauma. 

Feeling different 

An integral part of experiencing trauma is

feeling different from others, whether or not 

the trauma was an individual or group experience. Traumatic experiences typically feel surreal and challenge the necessity and value of

mundane activities of daily life. Survivors 

Exhibit 1.3-2: Cognitive Triad of Traumatic Stress 

67 
 

 

 

 

Advice to Counselors: Helping Clients Manage Flashbacks and Triggers 

If a client is triggered in a session or during some aspect of treatment, help the client focus on what is 

happening in the here and now; that is, use grounding techniques. Behavioral health service providers should be prepared to help the client get regrounded so that they can distinguish between what 

is happening now versus what had happened in the past (see Covington, 2008, and Najavits, 2002b, 

2007b, for more grounding techniques). Offer education about the experience of triggers and flashbacks, and then normalize these events as common traumatic stress reactions. Afterward, some clients need to discuss the experience and understand why the flashback or trigger occurred. It often 

helps for the client to draw a connection between the trigger and the traumatic event(s). This can be 

a preventive strategy whereby the client can anticipate that a given situation places him or her at 

higher risk for retraumatization and requires use of coping strategies, including seeking support. 

Source: Green Cross Academy of Traumatology, 2010. 

Trauma-Informed Care in Behavioral Health Services 

often believe that others will not fully understand their experiences, and they may think

that sharing their feelings, thoughts, and reactions related to the trauma will fall short of 

expectations. However horrid the trauma may 

be, the experience of the trauma is typically 

profound. 

The type of trauma can dictate how an individual feels different or believes that they are 

different from others. Traumas that generate 

shame will often lead survivors to feel more 

alienated from others—believing that they are

“damaged goods.” When individuals believe 

that their experiences are unique and incomprehensible, they are more likely to seek support, if they seek support at all, only with

others who have experienced a similar trauma. 

Triggers and flashbacks 

Triggers 

A trigger is a stimulus that sets off a memory 

of a trauma or a specific portion of a traumatic

experience. Imagine you were trapped briefly 

in a car after an accident. Then, several years

later, you were unable to unlatch a lock after

using a restroom stall; you might have begun

to feel a surge of panic reminiscent of the accident, even though there were other avenues 

of escape from the stall. Some triggers can be 

identified and anticipated easily, but many are

subtle and inconspicuous, often surprising the 

individual or catching him or her off guard. In

treatment, it is important to help clients identify potential triggers, draw a connection between strong emotional reactions and triggers,

and develop coping strategies to manage those 

moments when a trigger occurs. A trigger is 

any sensory reminder of the traumatic event: a

noise, smell, temperature, other physical sensation, or visual scene. Triggers can generalize to

any characteristic, no matter how remote, that

resembles or represents a previous trauma,

such as revisiting the location where the trauma

occurred, being alone, having your children

reach the same age that you were when you 

experienced the trauma, seeing the same breed

of dog that bit you, or hearing loud voices.

Triggers are often associated with the time of

day, season, holiday, or anniversary of the event. 

Flashbacks 

A flashback is reexperiencing a previous traumatic experience as if it were actually happening in that moment. It includes reactions that 

often resemble the client’s reactions during the 

trauma. Flashback experiences are very brief

and typically last only a few seconds, but the 

emotional aftereffects linger for hours or longer. Flashbacks are commonly initiated by a

trigger, but not necessarily. Sometimes, they

occur out of the blue. Other times, specific 

physical states increase a person’s vulnerability

to reexperiencing a trauma, (e.g., fatigue, high 

68 
 

 

Potential Signs of Dissociation 

•	 Fixed or “glazed” eyes 

•	 Sudden flattening of affect 

•	 Long periods of silence 

•	 Monotonous voice 

•	 Stereotyped movements 

•	 Responses not congruent with the 

present context or situation 

•	 Excessive intellectualization
 

(Briere, 1996a)
 

Part 1, Chapter 3—Understanding the Impact of Trauma 

stress levels). Flashbacks can feel like a brief

movie scene that intrudes on the client. For 

example, hearing a car backfire on a hot, sunny 

day may be enough to cause a veteran to respond as if he or she were back on military 

patrol. Other ways people reexperience trauma, besides flashbacks, are via nightmares and

intrusive thoughts of the trauma. 

Dissociation, depersonalization, and 

derealization 

Dissociation is a mental process that severs 

connections among a person’s thoughts,

memories, feelings, actions, and/or sense of 

identity. Most of us have experienced dissociation—losing the ability to recall or track a 

particular action (e.g., arriving at work but not

remembering the last minutes of the drive).

Dissociation happens because the person is 

engaged in an automatic activity and is not

paying attention to his or her immediate environment. Dissociation can also occur during

severe stress or trauma as a protective element

whereby the individual incurs distortion of

time, space, or identity. This is a common

symptom in traumatic stress reactions. 

Dissociation helps distance the experience 

from the individual. People who have experienced severe or developmental trauma may 

have learned to separate themselves from distress to survive. At times, dissociation can be 

very pervasive and symptomatic of a mental 

disorder, such as dissociative identity disorder 

(DID; formerly known as multiple personality 

disorder). According to the DSM-5, “dissociative disorders are characterized by a disruption of and/or discontinuity in the normal 

integration of consciousness, memory, identity, emotion, perception, body representation,

motor control, and behavior” (APA, 2013a, p. 

291). Dissociative disorder diagnoses are

closely associated with histories of severe 

childhood trauma or pervasive, human-caused,

intentional trauma, such as that experienced

by concentration camp survivors or victims of

ongoing political imprisonment, torture, or

long-term isolation. A mental health professional, preferably with significant training in

working with dissociative disorders and with

trauma, should be consulted when a dissociative disorder diagnosis is suspected. 

The characteristics of DID can be commonly 

accepted experiences in other cultures, rather 

than being viewed as symptomatic of a traumatic experience. For example, in nonWestern cultures, a sense of alternate beings 

within oneself may be interpreted as being

inhabited by spirits or ancestors (Kirmayer,

1996). Other experiences associated with dissociation include depersonalization—

psychologically “leaving one’s body,” as if

watching oneself from a distance as an observer

or through derealization, leading to a sense that

what is taking place is unfamiliar or is not real. 

If clients exhibit signs of dissociation, behavioral health service providers can use grounding techniques to help them reduce this 

defense strategy. One major long-term consequence of dissociation is the difficulty it causes

in connecting strong emotional or physical 

reactions with an event. Often, individuals

may believe that they are going crazy because 

they are not in touch with the nature of their

reactions. By educating clients on the resilient

qualities of dissociation while also emphasizing that it prevents them from addressing or 

69 
 

 

 

 

 

 

Resilient Responses to Trauma 

Many people find healthy ways to cope with, respond to, and heal from trauma. Often, people automatically reevaluate their values and redefine what is important after a trauma. Such resilient responses include: 

• Increased bonding with family and community. 

• Redefined or increased sense of purpose and meaning. 

• Increased commitment to a personal mission. 

• Revised priorities. 

• Increased charitable giving and volunteerism. 

Trauma-Informed Care in Behavioral Health Services 

validating the trauma, individuals can begin to

understand the role of dissociation. All in all,

it is important when working with trauma

survivors that the intensity level is not so great

that it triggers a dissociative reaction and prevents the person from engaging in the process. 

Behavioral 

Traumatic stress reactions vary widely; often,

people engage in behaviors to manage the 

aftereffects, the intensity of emotions, or the 

distressing aspects of the traumatic experience.

Some people reduce tension or stress through 

avoidant, self-medicating (e.g., alcohol abuse),

compulsive (e.g., overeating), impulsive (e.g.,

high-risk behaviors), and/or self-injurious 

behaviors. Others may try to gain control over

their experiences by being aggressive or subconsciously reenacting aspects of the trauma. 

Behavioral reactions are also the consequences 

of, or learned from, traumatic experiences. For

example, some people act like they can’t control their current environment, thus failing to

take action or make decisions long after the

trauma (learned helplessness). Other associate

elements of the trauma with current activities,

such as by reacting to an intimate moment in

a significant relationship as dangerous or unsafe years after a date rape. The following sections discuss behavioral consequences of

trauma and traumatic stress reactions. 

Reenactments 

A hallmark symptom of trauma is reexperiencing the trauma in various ways. Reexperiencing can occur through reenactments (literally, to “redo”), by which trauma survivors

repetitively relive and recreate a past trauma in

their present lives. This is very apparent in

children, who play by mimicking what occurred during the trauma, such as by pretending to crash a toy airplane into a toy building

after seeing televised images of the terrorist 

attacks on the World Trade Center on September 11, 2001. Attempts to understand

reenactments are very complicated, as reenactments occur for a variety of reasons. Sometimes, individuals reenact past traumas to

master them. Examples of reenactments include a variety of behaviors: self-injurious behaviors, hypersexuality, walking alone in

unsafe areas or other high-risk behaviors, driving recklessly, or involvement in repetitive 

destructive relationships (e.g., repeatedly getting into romantic relationships with people 

who are abusive or violent), to name a few. 

Self-harm and self-destructive 

behaviors 

Self-harm is any type of intentionally selfinflicted harm, regardless of the severity of

injury or whether suicide is intended. Often, 

self-harm is an attempt to cope with emotional or physical distress that seems overwhelming or to cope with a profound sense of

dissociation or being trapped, helpless, and

“damaged” (Herman, 1997; Santa Mina &

Gallop, 1998). Self-harm is associated with

past childhood sexual abuse and other forms 

of trauma as well as substance abuse. Thus, 

70 
Part 1, Chapter 3—Understanding the Impact of Trauma 

 

 

Case Illustration: Marco 

Marco, a 30-year-old man, sought treatment at a local mental health center after a 2-year bout of 

anxiety symptoms. He was an active member of his church for 12 years, but although he sought help 

from his pastor about a year ago, he reports that he has had no contact with his pastor or his church 

since that time. Approximately 3 years ago, his wife took her own life. He describes her as his soulmate and has had a difficult time understanding her actions or how he could have prevented them. 

In the initial intake, he mentioned that he was the first person to find his wife after the suicide and 

reported feelings of betrayal, hurt, anger, and devastation since her death. He claimed that everyone 

leaves him or dies. He also talked about his difficulty sleeping, having repetitive dreams of his wife, 

and avoiding relationships. In his first session with the counselor, he initially rejected the counselor 

before the counselor had an opportunity to begin reviewing and talking about the events and discomfort that led him to treatment. 

In this scenario, Marco is likely reenacting his feelings of abandonment by attempting to reject others 

before he experiences another rejection or abandonment. In this situation, the counselor will need to 

recognize the reenactment, explore the behavior, and examine how reenactments appear in other 

situations in Marco’s life. 

addressing self-harm requires attention to the 

client’s reasons for self-harm. More than likely, the client needs help recognizing and coping with emotional or physical distress in

manageable amounts and ways. 

Among the self-harm behaviors reported in

the literature are cutting, burning skin by heat

(e.g., cigarettes) or caustic liquids, punching

hard enough to self-bruise, head banging, hair

pulling, self-poisoning, inserting foreign objects into bodily orifices, excessive nail biting,

excessive scratching, bone breaking, gnawing

at flesh, interfering with wound healing, tying

off body parts to stop breathing or blood flow,

swallowing sharp objects, and suicide. Cutting

and burning are among the most common

forms of self-harm. 

Self-harm tends to occur most in people who

have experienced repeated and/or early trauma 

(e.g., childhood sexual abuse) rather than in

those who have undergone a single adult

trauma (e.g., a community-wide disaster or a

serious car accident). There are strong associations between eating disorders, self-harm, and 

substance abuse (Claes &Vandereycken, 2007; 

for discussion, see Harned, Najavits, & Weiss,

2006). Self-mutilation is also associated with 

(and part of the diagnostic criteria for) a number of personality disorders, including borderline and histrionic, as well as DID, depression,

and some forms of schizophrenia; these disorders can co-occur with traumatic stress reactions and disorders. 

It is important to distinguish self-harm that is

suicidal from self-harm that is not suicidal and 

to assess and manage both of these very serious 

dangers carefully. Most people who engage in

self-harm are not doing so with the intent to

kill themselves (Noll, Horowitz, Bonanno, 

Trickett, & Putnam, 2003)—although selfharm can be life threatening and can escalate 

into suicidality if not managed therapeutically.

Self-harm can be a way of getting attention or

manipulating others, but most often it is not.

Self-destructive behaviors such as substance 

abuse, restrictive or binge eating, reckless automobile driving, or high-risk impulsive behavior are different from self-harming

behaviors but are also seen in clients with a 

history of trauma. Self-destructive behaviors 

differ from self-harming behaviors in that

there may be no immediate negative impact of

the behavior on the individual; they differ 

from suicidal behavior in that there is no intent to cause death in the short term. 

71 
Advice to Counselors: Working With Clients Who Are Self-Injurious 

Counselors who are unqualified or uncomfortable working with clients who demonstrate selfharming, self-destructive, or suicidal or homicidal ideation, intent, or behavior should work with their 

agencies and supervisors to refer such clients to other counselors. They should consider seeking 

specialized supervision on how to manage such clients effectively and safely and how to manage 

their feelings about these issues. The following suggestions assume that the counselor has had sufficient training and experience to work with clients who are self-injurious. To respond appropriately to 

a client who engages in self-harm, counselors should: 

• Screen the client for self-harm and suicide risk at the initial evaluation and throughout treatment. 

• Learn the client’s perspective on self-harm and how it “helps.” 

• Understand that self-harm is often a coping strategy to manage the intensity of emotional 

and/or physical distress. 

• Teach the client coping skills that improve his or her management of emotions without self-harm. 

• Help the client obtain the level of care needed to manage genuine risk of suicide or severe selfinjury. This might include hospitalization, more intensive programming (e.g., intensive outpatient, partial hospitalization, residential treatment), or more frequent treatment sessions. The 

goal is to stabilize the client as quickly as possible, and then, if possible, begin to focus treatment on developing coping strategies to manage self-injurious and other harmful impulses. 

• Consult with other team members, supervisors, and, if necessary, legal experts to determine 

whether one’s efforts with and conceptualization of the self-harming client fit best practice 

guidelines. See, for example, Treatment Improvement Protocol (TIP) 42, Substance Abuse 

Treatment for Persons With Co-Occurring Disorders (Center for Substance Abuse Treatment 

[CSAT], 2005c). Document such consultations and the decisions made as a result of them thoroughly and frequently. 

• Help the client identify how substance use affects self-harm. In some cases, it can increase the 

behavior (e.g., alcohol disinhibits the client, who is then more likely to self-harm). In other cases, 

it can decrease the behavior (e.g., heroin evokes relaxation and, thus, can lessen the urge to 

self-harm). In either case, continue to help the client understand how abstinence from substances 

is necessary so that he or she can learn more adaptive coping. 

• Work collaboratively with the client to develop a plan to create a sense of safety. Individuals are 

affected by trauma in different ways; therefore, safety or a safe environment may mean something entirely different from one person to the next. Allow the client to define what safety means 

to him or her. 

Counselors can also help the client prepare a safety card that the client can carry at all times. The 

card might include the counselor’s contact information, a 24-hour crisis number to call in emergencies, contact information for supportive individuals who can be contacted when needed, and, if appropriate, telephone numbers for emergency medical services. The counselor can discuss with the 

client the types of signs or crises that might warrant using the numbers on the card. Additionally, the 

counselor might check with the client from time to time to confirm that the information on the card 

is current. 

TIP 50, Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment (CSAT, 2009a), 

has examples of safety agreements specifically for suicidal clients and discusses their uses in more 

detail. There is no credible evidence that a safety agreement is effective in preventing a suicide attempt or death. Safety agreements for clients with suicidal thoughts and behaviors should only be 

used as an adjunct support accompanying professional screening, assessment, and treatment for 

people with suicidal thoughts and behaviors. Keep in mind that safety plans or agreements may be 

perceived by the trauma survivor as a means of controlling behavior, subsequently replicating or 

triggering previous traumatic experiences. 

All professionals—and in some States, anyone—could have ethical and legal responsibilities to those 

clients who pose an imminent danger to themselves or others. Clinicians should be aware of the 

pertinent State laws where they practice and the relevant Federal and professional regulations. 

Trauma-Informed Care in Behavioral Health Services 

72 
 

 

 

 

Part 1, Chapter 3—Understanding the Impact of Trauma 

However, as with self-harming behavior, selfdestructive behavior needs to be recognized 

and addressed and may persist—or worsen—

without intervention. 

Consumption of substances 

Substance use often is initiated or increased 

after trauma. Clients in early recovery—

especially those who develop PTSD or have it 

reactivated—have a higher relapse risk if they 

experience a trauma. In the first 2 months 

after September 11, 2001, more than a quarter

of New Yorker residents who smoked cigarettes, drank alcohol, or used marijuana (about

265,000 people) increased their consumption.

The increases continued 6 months after the 

attacks (Vlahov, Galea, Ahern, Resnick, &

Kilpatrick, 2004). A study by the Substance 

Abuse and Mental Health Services Administration (SAMHSA, Office of Applied 

Studies, 2002) used National Survey on Drug

Use and Health data to compare the first three

quarters of 2001 with the last quarter and reported an increase in the prevalence rate for

alcohol use among people 18 or older in the

New York metropolitan area during the fourth

quarter. 

Interviews with New York City residents who

were current or former cocaine or heroin users 

indicated that many who had been clean for 6

months or less relapsed after September 11,

2001. Others, who lost their income and could

no longer support their habit, enrolled in

methadone programs (Weiss et al., 2002).

After the Oklahoma City bombing in 1995,

Oklahomans reported double the normal rate 

of alcohol use, smoking more cigarettes, and a

higher incidence of initiating smoking months 

and even years after the bombing (Smith,

Christiansen, Vincent, & Hann, 1999). 

Self-medication 

Khantzian’s self-medication theory (1985) 

suggests that drugs of abuse are selected for 

their specific effects. However, no definitive 

pattern has yet emerged of the use of particular substances in relation to PTSD or trauma 

symptoms. Use of substances can vary based

on a variety of factors, including which trauma 

symptoms are most prominent for an individual and the individual’s access to particular

substances. Unresolved traumas sometimes 

lurk behind the emotions that clients cannot 

allow themselves to experience. Substance use 

and abuse in trauma survivors can be a way to

self-medicate and thereby avoid or displace 

difficult emotions associated with traumatic 

experiences. When the substances are withdrawn, the survivor may use other behaviors to

self-soothe, self-medicate, or avoid emotions.

As likely, emotions can appear after abstinence 

in the form of anxiety and depression. 

Avoidance 

Avoidance often coincides with anxiety and

the promotion of anxiety symptoms. Individuals begin to avoid people, places, or situations 

to alleviate unpleasant emotions, memories, or

circumstances. Initially, the avoidance works,

but over time, anxiety increases and the perception that the situation is unbearable or

dangerous increases as well, leading to a greater need to avoid. Avoidance can be adaptive,

but it is also a behavioral pattern that reinforces

perceived danger without testing its validity,

and it typically leads to greater problems 

across major life areas (e.g., avoiding emotionally oriented conversations in an intimate relationship). For many individuals who have

traumatic stress reactions, avoidance is commonplace. A person may drive 5 miles longer

to avoid the road where he or she had an accident. Another individual may avoid crowded 

places in fear of an assault or to circumvent

strong emotional memories about an earlier

assault that took place in a crowded area.

Avoidance can come in many forms. When

people can’t tolerate strong affects associated

with traumatic memories, they avoid, project, 

73 
 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

deny, or distort their trauma-related emotional 

and cognitive experiences. A key ingredient in

trauma recovery is learning to manage triggers,

memories, and emotions without avoidance—

in essence, becoming desensitized to traumatic

memories and associated symptoms. 

Social/Interpersonal 

A key ingredient in the early stage of TIC is

to establish, confirm, or reestablish a support

system, including culturally appropriate activities, as soon as possible. Social supports and

relationships can be protective factors against

traumatic stress. However, trauma typically 

affects relationships significantly, regardless of 

whether the trauma is interpersonal or is of 

some other type. Relationships require emotional exchanges, which means that others 

who have close relationships or friendships 

with the individual who survived the trauma(s)

are often affected as well—either through secondary traumatization or by directly experiencing the survivor’s traumatic stress reactions. 

In natural disasters, social and community 

supports can be abruptly eroded and difficult

to rebuild after the initial disaster relief efforts 

have waned. 

Survivors may readily rely on family members,

friends, or other social supports—or they may 

avoid support, either because they believe that

no one will be understanding or trustworthy

or because they perceive their own needs as a

burden to others. Survivors who have strong

emotional or physical reactions, including

outbursts during nightmares, may pull away 

further in fear of being unable to predict their

own reactions or to protect their own safety

and that of others. Often, trauma survivors 

feel ashamed of their stress reactions, which

further hampers their ability to use their support systems and resources adequately. 

Many survivors of childhood abuse and interpersonal violence have experienced a significant sense of betrayal. They have often encountered trauma at the hands of trusted caregivers and family members or through

significant relationships. This history of betrayal can disrupt forming or relying on supportive relationships in recovery, such as peer

supports and counseling. Although this fear of 

trusting others is protective, it can lead to difficulty in connecting with others and greater

vigilance in observing the behaviors of others,

including behavioral health service providers.

It is exceptionally difficult to override the feeling that someone is going to hurt you, take 

advantage of you, or, minimally, disappoint

you. Early betrayal can affect one’s ability to

develop attachments, yet the formation of

supportive relationships is an important antidote in the recovery from traumatic stress. 

Developmental 

Each age group is vulnerable in unique ways 

to the stresses of a disaster, with children and

the elderly at greatest risk. Young children

may display generalized fear, nightmares,

heightened arousal and confusion, and physical symptoms, (e.g., stomachaches, headaches). School-age children may exhibit

symptoms such as aggressive behavior and

anger, regression to behavior seen at younger

ages, repetitious traumatic play, loss of ability 

to concentrate, and worse school performance.

Adolescents may display depression and social 

withdrawal, rebellion, increased risky activities 

such as sexual acting out, wish for revenge and

action-oriented responses to trauma, and sleep

and eating disturbances (Hamblen, 2001).

Adults may display sleep problems, increased

agitation, hypervigilance, isolation or withdrawal, and increased use of alcohol or drugs.

Older adults may exhibit increased withdrawal 

and isolation, reluctance to leave home, worsening of chronic illnesses, confusion, depression, and fear (DeWolfe & Nordboe, 2000b). 

74 
Like PTSD, the symptoms can be misdiagnosed as depression, anxiety, or another mental illness. Likewise, clients who have 

experienced trauma may link some of their

symptoms to their trauma and diagnose themselves as having PTSD, even though they do

not meet all criteria for that disorder. 

Combat Stress Reaction 

A phenomenon unique to war, and one that

counselors need to understand well, is combat

stress reaction (CSR). CSR is an acute anxiety 

reaction occurring during or shortly after participating in military conflicts and wars as well 

as other operations within the war zone,

known as the theater. CSR is not a formal 

diagnosis, nor is it included in the DSM-5

(APA, 2013a). It is similar to acute stress 

Neurobiological Development: Consequences of Early Childhood Trauma 

Findings in developmental psychobiology suggest that the consequences of early maltreatment produce enduring negative effects on brain development (DeBellis, 2002; Liu, Diorio, Day, Francis, & 

Meaney, 2000; Teicher, 2002). Research suggests that the first stage in a cascade of events produced by early trauma and/or maltreatment involves the disruption of chemicals that function as 

neurotransmitters (e.g., cortisol, norepinephrine, dopamine), causing escalation of the stress response (Heim, Mletzko, Purselle, Musselman, & Nemeroff, 2008; Heim, Newport, Mletzko, Miller, & 

Nemeroff, 2008; Teicher, 2002). These chemical responses can then negatively affect critical neural 

growth during specific sensitive periods of childhood development and can even lead to cell death. 

Adverse brain development can also result from elevated levels of cortisol and catecholamines by 

contributing to maturational failures in other brain regions, such as the prefrontal cortex (Meaney, 

Brake, & Gratton, 2002). Heim, Mletzko et al. (2008) found that the neuropeptide oxytocin— 

important for social affiliation and support, attachment, trust, and management of stress and anxiety—was markedly decreased in the cerebrospinal fluid of women who had been exposed to childhood maltreatment, particularly those who had experienced emotional abuse. The more childhood 

traumas a person had experienced, and the longer their duration, the lower that person’s current 

level of oxytocin was likely to be and the higher her rating of current anxiety was likely to be. 

Using data from the Adverse Childhood Experiences Study, an analysis by Anda, Felitti, Brown et al. 

(2006) confirmed that the risk of negative outcomes in affective, somatic, substance abuse, memory, 

sexual, and aggression-related domains increased as scores on a measure of eight ACEs increased. 

The researchers concluded that the association of study scores with these outcomes can serve as a 

theoretical parallel for the effects of cumulative exposure to stress on the developing brain and for 

the resulting impairment seen in multiple brain structures and functions. 

The National Child Traumatic Stress Network (http://www.nctsn.org) offers information about childhood abuse, stress, and physiological responses of children who are traumatized. Materials are available for counselors, educators, parents, and caregivers. There are special sections on the needs of 

children in military families and on the impact of natural disasters on children’s mental health. 

Part 1, Chapter 3—Understanding the Impact of Trauma 

Subthreshold TraumaRelated Symptoms 

Many trauma survivors experience symptoms 

that, although they do not meet the diagnostic

criteria for ASD or PTSD, nonetheless limit

their ability to function normally (e.g., regulate emotional states, maintain steady and

rewarding social and family relationships,

function competently at a job, maintain a 

steady pattern of abstinence in recovery).

These symptoms can be transient, only arising

in a specific context; intermittent, appearing

for several weeks or months and then receding; or a part of the individual’s regular pattern

of functioning (but not to the level of DSM-5

diagnostic criteria). Often, these patterns are 

termed “subthreshold” trauma symptoms. 

75 
 

 

Case Illustration: Frank 

Frank is a 36-year-old man who was severely beaten in a fight outside a bar. He had multiple injuries, 

including broken bones, a concussion, and a stab wound in his lower abdomen. He was hospitalized 

for 3.5 weeks and was unable to return to work, thus losing his job as a warehouse forklift operator. 

For several years, when faced with situations in which he perceived himself as helpless and overwhelmed, Frank reacted with violent anger that, to others, appeared grossly out of proportion to the 

situation. He has not had a drink in almost 3 years, but the bouts of anger persist and occur three to 

five times a year. They leave Frank feeling even more isolated from others and alienated from those 

who love him. He reports that he cannot watch certain television shows that depict violent anger; he 

has to stop watching when such scenes occur. He sometimes daydreams about getting revenge on 

the people who assaulted him. 

Psychiatric and neurological evaluations do not reveal a cause for Frank’s anger attacks. Other than 

these symptoms, Frank has progressed well in his abstinence from alcohol. He attends a support 

group regularly, has acquired friends who are also abstinent, and has reconciled with his family of 

origin. His marriage is more stable, although the episodes of rage limit his wife’s willingness to commit fully to the relationship. In recounting the traumatic event in counseling, Frank acknowledges 

that he thought he was going to die as a result of the fight, especially when he realized he had been 

stabbed. As he described his experience, he began to become very anxious, and the counselor observed the rage beginning to appear. 

After his initial evaluation, Frank was referred to an outpatient program that provided trauma-specific 

interventions to address his subthreshold trauma symptoms. With a combination of cognitive– 

behavioral counseling, EMDR, and anger management techniques, he saw a gradual decrease in 

symptoms when he recalled the assault. He started having more control of his anger when memories 

of the trauma emerged. Today, when feeling trapped, helpless, or overwhelmed, Frank has resources for coping and does not allow his anger to interfere with his marriage or other relationships. 

Trauma-Informed Care in Behavioral Health Services 

reaction, except that the precipitating event

or events affect military personnel (and civilians exposed to the events) in an armed conflict situation. The terms “combat stress 

reaction” and “posttraumatic stress injury” are 

relatively new, and the intent of using these 

new terms is to call attention to the unique 

experiences of combat-related stress as well as 

to decrease the shame that can be associated 

with seeking behavioral health services for

PTSD (for more information on veterans and

combat stress reactions, see the planned TIP,

Reintegration-Related Behavioral Health Issues 

for Veterans and Military Families; SAMHSA, 

planned f). 

Although stress mobilizes an individual’s 

physical and psychological resources to perform more effectively in combat, reactions to

the stress may persist long after the actual 

danger has ended. As with other traumas, the 

nature of the event(s), the reactions of others,

and the survivor’s psychological history and

resources affect the likelihood and severity of

CSR. With combat veterans, this translates to

the number, intensity, and duration of threat 

factors; the social support of peers in the veterans’ unit; the emotional and cognitive resilience of the service members; and the quality 

of military leadership. CSR can vary from

manageable and mild to debilitating and severe. Common, less severe symptoms of CSR

include tension, hypervigilance, sleep problems, anger, and difficulty concentrating. If

left untreated, CSR can lead to PTSD. 

Common causes of CSR are events such as a 

direct attack from insurgent small arms fire or

a military convoy being hit by an improvised

explosive device, but combat stressors encompass a diverse array of traumatizing events,

such as seeing grave injuries, watching others 

76 
Part 1, Chapter 3—Understanding the Impact of Trauma 

 

 

 

 

Advice to Counselors: Understanding the Nature of Combat Stress 

Several sources of information are available to help counselors deepen their understanding of combat stress and postdeployment adjustment. Friedman (2006) explains how a prolonged combat-ready 

stance, which is adaptive in a war zone, becomes hypervigilance and overprotectiveness at home. He 

makes the point that the “mutual interdependence, trust, and affection” (p. 587) that are so necessarily a part of a combat unit are different from relationships with family members and colleagues in a 

civilian workplace. This complicates the transition to civilian life. Wheels Down: Adjusting to Life After 

Deployment (Moore & Kennedy, 2011) provides practical advice for military service members, including inactive or active duty personnel and veterans, in transitioning from the theater to home. 

The following are just a few of the many resources and reports focused on combat-related psychological and stress issues: 

• Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services 

to Assist Recovery (Tanielian & Jaycox, 2008) 

• On Killing (Grossman, 1995), an indepth analysis of the psychological dynamics of combat 

• Haunted by Combat (Paulson & Krippner, 2007), which contains specific chapters on Reserve and 

National Guard troops and female veterans 

• Treating Young Veterans: Promoting Resilience Through Practice and Advocacy (Kelly, HoweBarksdale, & Gitelson, 2011) 

die, and making on-the-spot decisions in ambiguous conditions (e.g., having to determine

whether a vehicle speeding toward a military 

checkpoint contains insurgents with explosives 

or a family traveling to another area). Such

circumstances can lead to combat stress. Military personnel also serve in noncombat positions (e.g., healthcare and administrative

roles), and personnel filling these supportive 

roles can be exposed to combat situations by 

proximity or by witnessing their results. 

Specific Trauma-Related 

Psychological Disorders 

Part of the definition of trauma is that the 

individual responds with intense fear, helplessness, or horror. Beyond that, in both the

short term and the long term, trauma comprises a range of reactions from normal (e.g.,

being unable to concentrate, feeling sad, having

trouble sleeping) to warranting a diagnosis of a

trauma-related mental disorder. Most people 

who experience trauma have no long-lasting

disabling effects; their coping skills and the 

support of those around them are sufficient to

help them overcome their difficulties, and 

their ability to function on a daily basis over

time is unimpaired. For others, though, the

symptoms of trauma are more severe and last

longer. The most common diagnoses associated with trauma are PTSD and ASD, but

trauma is also associated with the onset of 

other mental disorders—particularly substance 

use disorders, mood disorders, various anxiety 

disorders, and personality disorders. Trauma

also typically exacerbates symptoms of preexisting disorders, and, for people who are predisposed to a mental disorder, trauma can

precipitate its onset. Mental disorders can occur almost simultaneously with trauma exposure or manifest sometime thereafter. 

Acute Stress Disorder 

ASD represents a normal response to stress.

Symptoms develop within 4 weeks of the

trauma and can cause significant levels of distress. Most individuals who have acute stress 

reactions never develop further impairment or

PTSD. Acute stress disorder is highly associated with the experience of one specific trauma rather than the experience of long-term 

exposure to chronic traumatic stress. Diagnostic criteria are presented in Exhibit 1.3-3. 

77 
Exhibit 1.3-3: DSM-5 Diagnostic Criteria for ASD 

A. Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the 

following ways: 

1. Directly experiencing the traumatic event(s). 

2. Witnessing, in person, the event(s) as it occurred to others. 

3. Learning that the event(s) occurred to a close family member or close friend. Note: In cases 

of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. 

4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) 

(e.g., first responders collecting human remains, police officers repeatedly exposed to details of child abuse). Note: This does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. 

B. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the 

traumatic event(s) occurred: 

Intrusion Symptoms: 

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In 

children, repetitive play may occur in which themes or aspects of the traumatic event(s) are 

expressed. 

2. Recurrent distressing dreams in which the content and/or affect of the dream are related to 

the event(s). Note: In children, there may be frightening dreams without recognizable 

content. 

3. Dissociative reactions (e.g., flashbacks), during which the individual feels or acts as if the 

traumatic event(s) were recurring. Such reactions may occur on a continuum, with the most 

extreme expression being a complete loss of awareness of present surroundings. Note: In 

children, trauma-specific reenactment may occur in play. 

4. Intense or prolonged psychological distress or marked physiological reactions in response to 

internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 

Negative Mood: 

5. Persistent inability to experience positive emotions (e.g., inability to experience happiness, 

satisfaction, or loving feelings). 

Dissociative Symptoms: 

6. An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself from another’s perspective, being in a daze, time slowing). 

7. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors, such as head injury, alcohol, or drugs). 

Avoidance Symptoms: 

 8. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with 

the traumatic event(s). 

9. Efforts to avoid external reminders (e.g., people, places, conversations, activities, objects, 

situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 

Arousal Symptoms: 

10. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep). 

11. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as 

verbal or physical aggression toward people or objects. 

12. Hypervigilance. 

13. Problems with concentration. 

14. Exaggerated startle response. 

(Continued on the next page.) 

Trauma-Informed Care in Behavioral Health Services 

78 
 

 

 

Part 1, Chapter 3—Understanding the Impact of Trauma 

Exhibit 1.3-3: DSM-5 Diagnostic Criteria for ASD (continued) 

C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure. 

Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3 days 

and up to a month is needed to meet disorder criteria. 

D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

E. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or 

alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder. 

Source: APA, 2013a, pp. 280–281. 

The primary presentation of an individual

with an acute stress reaction is often that of 

someone who appears overwhelmed by the

traumatic experience. The need to talk about

the experience can lead the client to seem selfcentered and unconcerned about the needs of 

others. He or she may need to describe, in

repetitive detail, what happened, or may seem 

obsessed with trying to understand what happened in an effort to make sense of the experience. The client is often hypervigilant and

avoids circumstances that are reminders of the 

trauma. For instance, someone who was in a

serious car crash in heavy traffic can become

anxious and avoid riding in a car or driving in

traffic for a finite time afterward. Partial amnesia for the trauma often accompanies ASD,

and the individual may repetitively question

others to fill in details. People with ASD

symptoms sometimes seek assurance from 

others that the event happened in the way

they remember, that they are not “going crazy”

or “losing it,” and that they could not have 

prevented the event. The next case illustration

demonstrates the time-limited nature of ASD. 

Differences between ASD and PTSD 

It is important to consider the differences between ASD and PTSD when forming a diagnostic impression. The primary difference is 

the amount of time the symptoms have been

present. ASD resolves 2 days to 4 weeks after

an event, whereas PTSD continues beyond 

the 4-week period. The diagnosis of ASD can

change to a diagnosis of PTSD if the condition is noted within the first 4 weeks after the 

event, but the symptoms persist past 4 weeks. 

ASD also differs from PTSD in that the ASD 

diagnosis requires 9 out of 14 symptoms from 

five categories, including intrusion, negative

mood, dissociation, avoidance, and arousal. 

These symptoms can occur at the time of the 

trauma or in the following month. Studies 

indicate that dissociation at the time of trauma is a good predictor of subsequent PTSD,

so the inclusion of dissociative symptoms 

makes it more likely that those who develop

ASD will later be diagnosed with PTSD

(Bryant & Harvey, 2000). Additionally, ASD

is a transient disorder, meaning that it is present in a person’s life for a relatively short time 

and then passes. In contrast, PTSD typically 

becomes a primary feature of an individual’s 

life. Over a lengthy period, PTSD can have 

profound effects on clients’ perceptions of

safety, their sense of hope for the future, their

relationships with others, their physical health,

the appearance of psychiatric symptoms, and

their patterns of substance use and abuse. 

There are common symptoms between PTSD

and ASD, and untreated ASD is a possible 

predisposing factor to PTSD, but it is unknown whether most people with ASD are 

likely to develop PTSD. There is some suggestion that, as with PTSD, ASD is more 

79 
 

 

Case Illustration: Sheila 

Two months ago, Sheila, a 55-year-old married woman, experienced a tornado in her home town. In 

the previous year, she had addressed a long-time marijuana use problem with the help of a treatment program and had been abstinent for about 6 months. Sheila was proud of her abstinence; it 

was something she wanted to continue. She regarded it as a mark of personal maturity; it improved 

her relationship with her husband, and their business had flourished as a result of her abstinence. 

During the tornado, an employee reported that Sheila had become very agitated and had grabbed 

her assistant to drag him under a large table for cover. Sheila repeatedly yelled to her assistant that 

they were going to die. Following the storm, Sheila could not remember certain details of her behavior during the event. Furthermore, Sheila said that after the storm, she felt numb, as if she was floating out of her body and could watch herself from the outside. She stated that nothing felt real and it 

was all like a dream. 

Following the tornado, Sheila experienced emotional numbness and detachment, even from people 

close to her, for about 2 weeks. The symptoms slowly decreased in intensity but still disrupted her 

life. Sheila reported experiencing disjointed or unconnected images and dreams of the storm that 

made no real sense to her. She was unwilling to return to the building where she had been during 

the storm, despite having maintained a business at this location for 15 years. In addition, she began 

smoking marijuana again because it helped her sleep. She had been very irritable and had uncharacteristic angry outbursts toward her husband, children, and other family members. 

As a result of her earlier contact with a treatment program, Sheila returned to that program and 

engaged in psychoeducational, supportive counseling focused on her acute stress reaction. She regained abstinence from marijuana and returned shortly to a normal level of functioning. Her symptoms slowly diminished over a period of 3 weeks. With the help of her counselor, she came to 

understand the link between the trauma and her relapse, regained support from her spouse, and 

again felt in control of her life. 

Trauma-Informed Care in Behavioral Health Services 

prevalent in women than in men (Bryant &

Harvey, 2003). However, many people with

PTSD do not have a diagnosis or recall a history of acute stress symptoms before seeking

treatment for or receiving a diagnosis of PTSD. 

Effective interventions for ASD can significantly reduce the possibility of the subsequent

development of PTSD. Effective treatment of

ASD can also reduce the incidence of other 

co-occurring problems, such as depression,

anxiety, dissociative disorders, and compulsive 

behaviors (Bryant & Harvey, 2000). Intervention for ASD also helps the individual develop

coping skills that can effectively prevent the

recurrence of ASD after later traumas. 

Although predictive science for ASD and

PTSD will continue to evolve, both disorders 

are associated with increased substance use 

and mental disorders and increased risk of 

relapse; therefore, effective screening for ASD

and PTSD is important for all clients with

these disorders. Individuals in early recovery—

lacking well-practiced coping skills, lacking

environmental supports, and already operating

at high levels of anxiety—are particularly susceptible to ASD. Events that would not normally be disabling can produce symptoms of

intense helplessness and fear, numbing and

depersonalization, disabling anxiety, and an

inability to handle normal life events. Counselors should be able to recognize ASD and

treat it rather than attributing the symptoms

to a client’s lack of motivation to change, being “dry drunk” (for those in substance abuse 

recovery), or being manipulative. 

Posttraumatic Stress Disorder 

The trauma-related disorder that receives the 

greatest attention is PTSD; it is the most 

80 
 

 

Part 1, Chapter 3—Understanding the Impact of Trauma 

Case Illustration: Michael 

Michael is a 62-year-old Vietnam veteran. He is a divorced father of two children and has four grandchildren. Both of his parents were dependent on alcohol. He describes his childhood as isolated. His 

father physically and psychologically abused him (e.g., he was beaten with a switch until he had welts 

on his legs, back, and buttocks). By age 10, his parents regarded him as incorrigible and sent him to 

a reformatory school for 6 months. By age 15, he was using marijuana, hallucinogens, and alcohol 

and was frequently truant from school. 

At age 19, Michael was drafted and sent to Vietnam, where he witnessed the deaths of six American 

military personnel. In one incident, the soldier he was next to in a bunker was shot. Michael felt helpless as he talked to this soldier, who was still conscious. In Vietnam, Michael increased his use of both 

alcohol and marijuana. On his return to the United States, Michael continued to drink and use marijuana. He reenlisted in the military for another tour of duty. 

His life stabilized in his early 30s, as he had a steady job, supportive friends, and a relatively stable 

family life. However, he divorced in his late 30s. Shortly thereafter, he married a second time, but 

that marriage ended in divorce as well. He was chronically anxious and depressed and had insomnia 

and frequent nightmares. He periodically binged on alcohol. He complained of feeling empty, had 

suicidal ideation, and frequently stated that he lacked purpose in his life. 

In the 1980s, Michael received several years of mental health treatment for dysthymia. He was hospitalized twice and received 1 year of outpatient psychotherapy. In the mid-1990s, he returned to outpatient treatment for similar symptoms and was diagnosed with PTSD and dysthymia. He no longer used 

marijuana and rarely drank. He reported that he didn’t like how alcohol or other substances made him 

feel anymore—he felt out of control with his emotions when he used them. Michael reported symptoms of hyperarousal, intrusion (intrusive memories, nightmares, and preoccupying thoughts about 

Vietnam), and avoidance (isolating himself from others and feeling “numb”). He reported that these 

symptoms seemed to relate to his childhood abuse and his experiences in Vietnam. In treatment, he 

expressed relief that he now understood the connection between his symptoms and his history. 

commonly diagnosed trauma-related disorder, and its symptoms can be quite debilitating over time. Nonetheless, it is important to

remember that PTSD symptoms are represented in a number of other mental illnesses, 

including major depressive disorder (MDD), 

anxiety disorders, and psychotic disorders (Foa

et al., 2006). The DSM-5 (APA, 2013a) 

identifies four symptom clusters for PTSD:

presence of intrusion symptoms, persistent

avoidance of stimuli, negative alterations in

cognitions and mood, and marked alterations 

in arousal and reactivity. Individuals must

have been exposed to actual or threatened

death, serious injury, or sexual violence, and

the symptoms must produce significant distress and impairment for more than 4 weeks 

(Exhibit 1.3-4). 

Certain characteristics make people more susceptible to PTSD, including one’s unique personal vulnerabilities at the time of the 

traumatic exposure, the support (or lack of

support) received from others at the time of

the trauma and at the onset of trauma-related 

symptoms, and the way others in the person’s 

environment gauge the nature of the traumatic

event (Brewin, Andrews, & Valentine, 2000). 

People with PTSD often present varying clinical profiles and histories. They can experience 

symptoms that are activated by environmental 

triggers and then recede for a period of time.

Some people with PTSD who show mostly 

psychiatric symptoms (particularly depression

and anxiety) are misdiagnosed and go untreated for their primary condition. For many people, the trauma experience and diagnosis 

81 
 

Exhibit 1.3-4: DSM-5 Diagnostic Criteria for PTSD 

Note: The following criteria apply to adults, adolescents, and children older than 6 years. For children 6 years and younger, see the DSM-5 section titled “Posttraumatic Stress Disorder for Children 

6 Years and Younger” (APA, 2013a). 

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the 

following ways: 

1. Directly experiencing the traumatic event(s). 

2. Witnessing, in person, the event(s) as it occurred to others. 

3. Learning that the traumatic event(s) occurred to a close family member or close friend. In 

cases of actual or threatened death of a family member or friend, the event(s) must have 

been violent or accidental. 

4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) 

(e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. 

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic 

event(s), beginning after the traumatic event(s) occurred: 

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In 

children older than 6 years, repetitive play may occur in which themes or aspects of the 

traumatic event(s) are expressed. 

2. Recurrent distressing dreams in which the content and/or affect of the dream are related to 

the traumatic event(s). Note: In children, there may be frightening dreams without recognizable content. 

3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic 

event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme 

expression being a complete loss of awareness of present surroundings.) Note: In children, 

trauma-specific reenactment may occur in play. 

4. Intense or prolonged psychological distress at exposure to internal or external cues that 

symbolize or resemble an aspect of the traumatic event(s). 

5. Marked physiological reactions to internal or external cues that symbolize or resemble an 

aspect of the traumatic event(s). 

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following: 

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely 

associated with the traumatic event(s). 

2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, 

objects, situations) that arouse distressing memories, thoughts, or feelings about or closely 

associated with the traumatic event(s). 

D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or 

worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 

1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia, and not to other factors such as head injury, alcohol, or drugs). 

2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the 

world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” 

“My whole nervous system is permanently ruined”). 

3. Persistent, distorted cognitions about the cause or consequences of the traumatic 

event(s) that lead the individual to blame himself/herself or others. 

4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). 

5. Markedly diminished interest or participation in significant activities. 

6. Feelings of detachment or estrangement from others. 

7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings). 

(Continued on the next page.) 

Trauma-Informed Care in Behavioral Health Services 

82 
Posttraumatic stress disorder: 

Timing of symptoms 

Although symptoms of PTSD usually begin

within 3 months of a trauma in adulthood,

there can be a delay of months or even years 

before symptoms appear for some people.

Some people may have minimal symptoms 

after a trauma but then experience a crisis later

in life.Trauma symptoms can appear suddenly,

even without conscious memory of the original 

trauma or without any overt provocation. Survivors of abuse in childhood can have a delayed

response triggered by something that happens

to them as adults. For example, seeing a movie 

about child abuse can trigger symptoms related 

are obscured by co-occurring substance use 

disorder symptoms. The important feature of

PTSD is that the disorder becomes an orienting feature of the individual’s life. How well 

the person can work, with whom he or she 

associates, the nature of close and intimate 

relationships, the ability to have fun and rejuvenate, and the way in which an individual

goes about confronting and solving problems 

in life are all affected by the client’s trauma 

experiences and his or her struggle to recover. 

Part 1, Chapter 3—Understanding the Impact of Trauma 

Exhibit 1.3-4: DSM-5 Diagnostic Criteria for PTSD (continued) 

E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or 

worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 

1. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as 

verbal or physical aggression toward people or objects. 

2. Reckless or self-destructive behavior. 

3. Hypervigilance. 

4. Exaggerated startle response. 

5. Problems with concentration. 

6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). 

F. Duration of the disturbance (Criteria B, C, D and E) is more than 1 month. 

G. The disturbance causes clinically significant distress or impairment in social, occupational, or 

other important areas of functioning. 

H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, 

alcohol) or another medical condition. 

Specify whether: 

With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic 

stress disorder, and in addition, in response to the stressor, the individual experiences persistent 

or recurrent symptoms of either of the following: 

1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if 

one were an outside observer of, one’s mental processes or body (e.g., feeling as though 

one were in a dream; feeling a sense of unreality of self or body or of time moving slowly). 

2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the 

world around the individual is experienced as unreal, dreamlike, distant, or distorted). Note: 

To use this subtype, the dissociative symptoms must not be attributable to the physiological 

effects of a substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures). 

Specify whether: 

With delayed expression: If the full diagnostic criteria are not met until at least 6 months after 

the event (although the onset and expression of some symptoms may be immediate). 

Source: APA, 2013a, pp. 271–272. 

83 
 

 

 

 

 

 

Advice to Counselors: Helping Clients With Delayed Trauma Responses 

Clients who are experiencing a delayed trauma response can benefit if you help them to: 

• Create an environment that allows acknowledgment of the traumatic event(s). 

• Discuss their initial recall or first suspicion that they were having a traumatic response. 

• Become educated on delayed trauma responses. 

• Draw a connection between the trauma and presenting trauma-related symptoms. 

• Create a safe environment. 

• Explore their support systems and fortify them as needed. 

• Understand that triggers can precede traumatic stress reactions, including delayed responses to 

trauma. 

• Identify their triggers. 

• Develop coping strategies to navigate and manage symptoms. 

Trauma-Informed Care in Behavioral Health Services 

to the trauma. Other triggers include returning to the scene of the trauma, being reminded

of it in some other way, or noting the anniversary of an event. Likewise, combat veterans 

and survivors of community-wide disasters 

may seem to be coping well shortly after a

trauma, only to have symptoms emerge later

when their life situations seem to have stabilized. Some clients in substance abuse recovery 

only begin to experience trauma symptoms 

when they maintain abstinence for some time.

As individuals decrease tension-reducing or 

self-medicating behaviors, trauma memories 

and symptoms can emerge. 

Culture and posttraumatic stress 

Although research is limited across cultures,

PTSD has been observed in Southeast Asian,

South American, Middle Eastern, and Native

American survivors (Osterman & de Jong,

2007; Wilson & Tang, 2007). As Stamm and

Friedman (2000) point out, however, simply 

observing PTSD does not mean that it is the

“best conceptual tool for characterizing posttraumatic distress among non-Western individuals” (p. 73). In fact, many trauma-related

symptoms from other cultures do not fit the 

DSM-5 criteria. These include somatic and 

psychological symptoms and beliefs about the 

origins and nature of traumatic events. Moreover, religious and spiritual beliefs can affect 

how a survivor experiences a traumatic event

and whether he or she reports the distress. For

example, in societies where attitudes toward

karma and the glorification of war veterans are

predominant, it is harder for war veterans to

come forward and disclose that they are emotionally overwhelmed or struggling. It would

be perceived as inappropriate and possibly 

demoralizing to focus on the emotional distress that he or she still bears. (For a review of

cultural competence in treating trauma, refer

to Brown, 2008.) 

Methods for measuring PTSD are also culturally specific. As part of a project begun in

1972, the World Health Organization

(WHO) and the National Institutes of Health 

(NIH) embarked on a joint study to test the

cross-cultural applicability of classification

systems for various diagnoses. WHO and

NIH identified apparently universal factors of

psychological disorders and developed specific

instruments to measure them. These instruments, the Composite International Diagnostic Interview and the Schedules for Clinical 

Assessment in Neuropsychiatry, include certain criteria from the DSM (Fourth Edition,

Text Revision; APA, 2000a) as well as criteria

from the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10; Exhibit 1.3-5). 

84 
Part 1, Chapter 3—Understanding the Impact of Trauma 

Exhibit 1.3-5: ICD-10 Diagnostic Criteria for PTSD 

A. The patient must have been exposed to a stressful event or situation (either brief or long-lasting) 

of exceptionally threatening or catastrophic nature, which would be likely to cause pervasive distress in almost anyone. 

B. There must be persistent remembering or “reliving” of the stressor in intrusive “flashbacks,” vivid 

memories, or recurring dreams, or in experiencing distress when exposed to circumstances resembling or associated with the stressor. 

C. The patient must exhibit an actual or preferred avoidance of circumstances resembling or associated with the stressor, which was not present before exposure to the stressor. 

D. Either of the following must be present: 

1. Inability to recall, either partially or completely, some important aspects of the period of exposure to the stressor. 

2. Persistent symptoms of increased psychological sensitivity and arousal (not present before 

exposure to the stressor), shown by any two of the following: 

a. Difficulty in falling or staying asleep. 

b. Irritability or outbursts of anger. 

c. Difficulty in concentrating. 

d. Exaggerated startle response. 

E. Criteria B, C, and D must all be met within 6 months of the stressful event or at the end of a period of stress. (For some purposes, onset delayed more than 6 months can be included, but this 

should be clearly specified.) 

Source: WHO, 1992. 

 

 

 

The term “co -occurring disorders” refers 

to cases when a person has one or more 

mental disorders as well as one or more 

substance use disorders (including sub -

stance abuse). Co -occurring disorders are 

common among individuals who have a 

history of trauma and are seeking help. 

Complex trauma and complex 

traumatic stress 

When individuals experience multiple traumas, prolonged and repeated trauma during

childhood, or repetitive trauma in the context 

of significant interpersonal relationships, their

reactions to trauma have unique characteristics 

(Herman, 1992). This unique constellation of 

reactions, called complex traumatic stress, is 

not recognized diagnostically in the DSM-5, 

but theoretical discussions and research have 

begun to highlight the similarities and differences in symptoms of posttraumatic stress 

versus complex traumatic stress (Courtois &

Ford, 2009). Often, the symptoms generated

from complex trauma do not fully match

PTSD criteria and exceed the severity of

PTSD. Overall, literature reflects that PTSD

criteria or subthreshold symptoms do not fully 

account for the persistent and more impairing

clinical presentation of complex trauma. Even

though current research in the study of traumatology is prolific, it is still in the early stages 

of development. The idea that there may be 

more diagnostic variations or subtypes is 

forthcoming, and this will likely pave the way 

for more client-matching interventions to

better serve those individuals who have been 

repeatedly exposed to multiple, early childhood, and/or interpersonal traumas. 

Other Trauma-Related and 

Co-Occurring Disorders 

The symptoms of PTSD and other mental 

disorders overlap considerably; these disorders

often coexist and include mood, anxiety, 

85 
 

 

 

 

Advice to Counselors: Universal Screening and Assessment 

Only people specifically trained and licensed in mental health assessment should make diagnoses; 

trauma can result in complicated cases, and many symptoms can be present, whether or not they 

meet full diagnostic criteria for a specific disorder. Only a trained assessor can distinguish accurately 

among various symptoms and in the presence of co-occurring disorders. However, behavioral health 

professionals without specific assessment training can still serve an important role in screening for 

possible mental disorders using established screening tools (CSAT, 2005c; see also Chapter 4 of this 

TIP). In agencies and clinics, it is critical to provide such screenings systematically—for each client—as 

PTSD and other co-occurring disorders are typically underdiagnosed or misdiagnosed. 

Many survivors with severe mental 

disorders function fairly well following 

trauma, including disasters, as long as 

essential services aren’t interrupted. For 

others, additional mental health supports 

may be necessary. For more information, 

see Responding to the Needs of People 

With Serious and Persistent Mental Illness 

in Times of Major Disaster (Center for 

Mental Health Services, 1996). 

Trauma-Informed Care in Behavioral Health Services 

substance use, and personality disorders. Thus,

it’s common for trauma survivors to be underdiagnosed or misdiagnosed. If they have not 

been identified as trauma survivors, their psychological distress is often not associated with 

previous trauma, and/or they are diagnosed

with a disorder that marginally matches their

presenting symptoms and psychological sequelae of trauma. The following sections present a brief overview of some mental disorders 

that can result from (or be worsened by)

traumatic stress. PTSD is not the only diagnosis related to trauma nor its only psychological consequence; trauma can broadly

influence mental and physical health in clients 

who already have behavioral health disorders. 

People With Mental Disorders 

MDD is the most common co-occurring disorder in people who have experienced trauma

and are diagnosed with PTSD. A wellestablished causal relationship exists between

stressful events and depression, and a prior

history of MDD is predictive of PTSD after 

exposure to major trauma (Foa et al., 2006). 

Co-occurrence is also linked with greater impairment and more severe symptoms of both

disorders, and the person is less likely to experience remission of symptoms within 6 months. 

Generalized anxiety, obsessive–compulsive,

and other anxiety disorders are also associated

with PTSD. PTSD may exacerbate anxiety

disorder symptoms, but it is also likely that

preexisting anxiety symptoms and anxiety disorders increase vulnerability to PTSD. Preexisting anxiety primes survivors for greater 

hyperarousal and distress. Other disorders,

such as personality and somatization disorders,

are also associated with trauma, but the history of trauma is often overlooked as a significant factor or necessary target in treatment. 

The relationship between PTSD and other

disorders is complex. More research is now

examining the multiple potential pathways 

among PTSD and other disorders and how

various sequences affect clinical presentation.

TIP 42, Substance Abuse Treatment for Persons 

With Co-Occurring Disorders (CSAT, 2005c), is

valuable in understanding the relationship of

substance use to other mental disorders. 

People With Substance Use 

Disorders 

There is clearly a correlation between trauma

(including individual, group, or mass trauma)

and substance use as well as the presence of

posttraumatic stress (and other trauma-related

disorders) and substance use disorders. Alcohol and drug use can be, for some, an effort to 

86 
Part 1, Chapter 3—Understanding the Impact of Trauma 

Co-Occurring PTSD and Other Mental Disorders 

• Individuals with PTSD often have at least one additional diagnosis of a mental disorder. 

• The presence of other disorders typically worsens and prolongs the course of PTSD and complicates clinical assessment, diagnosis, and treatment. 

• The most common co-occurring disorders, in addition to substance use disorders, include mood 

disorders, various anxiety disorders, eating disorders, and personality disorders. 

• Exposure to early, severe, and chronic trauma is linked to more complex symptoms, including 

impulse control deficits, greater difficulty in emotional regulation and establishing stable relationships, and disruptions in consciousness, memory, identity, and/or perception of the environment 

(Dom, De, Hulstijn, & Sabbe, 2007; Waldrop, Back, Verduin, & Brady, 2007). 

• Certain diagnostic groups and at-risk populations (e.g., people with developmental disabilities, 

people who are homeless or incarcerated) are more susceptible to trauma exposure and to developing PTSD if exposed but less likely to receive appropriate diagnosis and treatment. 

• Given the prevalence of traumatic events in clients who present for substance abuse treatment, 

counselors should assess all clients for possible trauma-related disorders. 

 

 

 

manage traumatic stress and specific PTSD

symptoms. Likewise, people with substance 

use disorders are at higher risk of developing

PTSD than people who do not abuse substances. Counselors working with trauma survivors or clients who have substance use 

disorders have to be particularly aware of the

possibility of the other disorder arising. 

Timeframe: PTSD and the onset of 

substance use disorders 

Knowing whether substance abuse or PTSD

came first informs whether a causal relationship exists, but learning this requires thorough

assessment of clients and access to complete 

data on PTSD; substance use, abuse, and dependence; and the onset of each. Much current research focuses solely on the age of onset

of substance use (not abuse), so determining

causal relationships can be difficult.

The relationship between PTSD and substance use disorders is thought to be bidirectional and cyclical: substance use increases 

trauma risk, and exposure to trauma escalates 

substance use to manage trauma-related

symptoms. Three other causal pathways described by Chilcoat and Breslau’s seminal work 

(1998) further explain the relationship between PTSD and substance use disorders: 

1.	 The “self-medication” hypothesis suggests 

that clients with PTSD use substances to 

manage PTSD symptoms (e.g., intrusive 

memories, physical arousal). Substances 

such as alcohol, cocaine, barbiturates, opioids, and amphetamines are frequently 

abused in attempts to relieve or numb

emotional pain or to forget the event. 

2.	 The “high-risk” hypothesis states that 

drug and alcohol use places people who

use substances in high-risk situations that

increase their chances of being exposed to

events that lead to PTSD. 

3.	 The “susceptibility” hypothesis suggests 

that people who use substances are more 

susceptible to developing PTSD after exposure to trauma than people who do not.

Increased vulnerability may result from 

failure to develop effective stress management strategies, changes in brain chemistry, or damage to neurophysiological 

systems due to extensive substance use. 

PTSD and substance abuse 

treatment 

PTSD can limit progress in substance abuse 

recovery, increase the potential for relapse, and

complicate a client’s ability to achieve success 

in various life areas. Each disorder can mask or 

hide the symptoms of the other, and both need 

87 
 

 

 

 

 

 

Case Illustration: Maria 

Maria is a 31-year-old woman diagnosed with PTSD and alcohol dependence. From ages 8 to 12, she 

was sexually abused by an uncle. Maria never told anyone about the abuse for fear that she would 

not be believed. Her uncle remains close to the family, and Maria still sees him on certain holidays. 

When she came in for treatment, she described her emotions and thoughts as out of control. Maria 

often experiences intrusive memories of the abuse, which at times can be vivid and unrelenting. She 

cannot predict when the thoughts will come; efforts to distract herself from them do not always 

work. She often drinks in response to these thoughts or his presence, as she has found that alcohol 

can dull her level of distress. Maria also has difficulty falling asleep and is often awakened by nightmares. She does not usually remember the dreams, but she wakes up feeling frightened and alert 

and cannot go back to sleep. 

Maria tries to avoid family gatherings but often feels pressured to go. Whenever she sees her uncle, 

she feels intense panic and anger but says she can usually “hold it together” if she avoids him. Afterward, however, she describes being overtaken by these feelings and unable to calm down. She 

also describes feeling physically ill and shaky. At these times, she often isolates herself, stays in her 

apartment, and drinks steadily for several days. Maria also reports distress pertaining to her relationship with her boyfriend. In the beginning of their relationship, she found him comforting and enjoyed 

his affection, but more recently, she has begun to feel anxious and unsettled around him. Maria tries 

to avoid sex with him, but she sometimes gives in for fear of losing the relationship. She finds it easier to have sex with him when she is drunk, but she often experiences strong feelings of dread and 

disgust reminiscent of her abuse. Maria feels guilty and confused about these feelings. 

Trauma-Informed Care in Behavioral Health Services 

to be assessed and treated if the individual is 

to have a full recovery. There is a risk of misinterpreting trauma-related symptoms in substance abuse treatment settings. For example,

avoidance symptoms in an individual with

PTSD can be misinterpreted as lack of motivation or unwillingness to engage in substance 

abuse treatment; a counselor’s efforts to address substance abuse–related behaviors in 

early recovery can likewise provoke an exaggerated response from a trauma survivor who

has profound traumatic experiences of being

trapped and controlled. Exhibit 1.3-6 lists 

important facts about PTSD and substance 

use disorders for counselors. 

Sleep, PTSD, and substance use 

Many people have trouble getting to sleep

and/or staying asleep after a traumatic event; 

consequently, some have a drink or two to

help them fall asleep. Unfortunately, any initially helpful effects are likely not only to wane 

quickly, but also to incur a negative rebound

effect. When someone uses a substance before 

going to bed, “sleep becomes lighter and more 

easily disrupted,” and rapid eye movement

sleep (REM) “increases, with an associated

increase in dreams and nightmares,” as the

effects wear off (Auerbach, 2003, p. 1185). 

People with alcohol dependence report multiple types of sleep disturbances over time, and

it is not unusual for clients to report that they 

cannot fall asleep without first having a drink.

Both REM and slow wave sleep are reduced

in clients with alcohol dependence, which is

also associated with an increase in the amount 

of time it takes before sleep occurs, decreased

overall sleep time, more nightmares, and reduced sleep efficiency. Sleep during withdrawal is “frequently marked by severe insomnia 

and sleep fragmentation...a loss of restful 

sleep and feelings of daytime fatigue. Nightmares and vivid dreams are not uncommon” 

(Auerbach, 2003, pp. 1185–1186). 

Confounding changes in the biology of sleep

that occur in clients with PTSD and substance 

use disorders often add to the problems of 

88 
Part 1, Chapter 3—Understanding the Impact of Trauma 

Exhibit 1.3-6: PTSD and Substance Use Disorders: Important Treatment Facts 

Profile Severity 

• PTSD is one of the most common co-occurring mental disorders found in clients in substance 

abuse treatment (CSAT, 2005c). 

• People in treatment for PTSD tend to abuse a wide range of substances, including opioids, cocaine, marijuana, alcohol, and prescription medications. 

• People in treatment for PTSD and substance abuse have a more severe clinical profile than those 

with just one of these disorders. 

• PTSD, with or without major depression, significantly increases risk for suicidality (CSAT, 2009a). 

Gender Differences 

• Rates of trauma-related disorders are high in men and women in substance abuse treatment. 

• Women with PTSD and a substance use disorder most frequently experienced rape or witnessed 

a killing or injury; men with both disorders typically witnessed a killing or injury or were the victim 

of sudden injury or accident (Cottler, Nishith, & Compton, 2001). 

Risk of Continued Cycle of Violence 

• While under the influence of substances, a person is more vulnerable to traumatic events (e.g., 

automobile crashes, assaults). 

• Perpetrators of violent assault often are under the influence of substances or test positive for 

substances at the time of arrest. 

Treatment Complications 

• It is important to recognize and help clients understand that becoming abstinent from substances does not resolve PTSD; in fact, some PTSD symptoms become worse with abstinence for 

some people. Both disorders must be addressed in treatment. 

• Treatment outcomes for clients with PTSD and a substance use disorder are worse than for clients 

with other co-occurring disorders or who only abuse substances (Brown, Read, & Kahler, 2003). 

recovery. Sleep can fail to return to normal for

months or even years after abstinence, and the

persistence of sleep disruptions appears related

to the likelihood of relapse. Of particular clinical importance is the vicious cycle that can

also begin during “slips”; relapse initially improves sleep, but continued drinking leads to

sleep disruption. This cycle of initial reduction 

of an unpleasant symptom, which only ends 

up exacerbating the process as a whole, can

take place for clients with PTSD as well as for

clients with substance use disorders. There are 

effective cognitive–behavioral therapies and

nonaddictive pharmacological interventions

for sleep difficulties. 

89 

 

 

 

 

 

 

IN THIS CHAPTER 

• Screening and

Assessment

• Barriers and Challenges

to Trauma -Informed

Screening and

Assessment

• Cross -Cultural Screening

and Assessment

• Choosing Instruments

• Trauma -Informed

Screening and

Assessment

• Concluding Note

Screening to 

identify clients who 

have histories of 

trauma and 

experience trauma -

related symptoms is 

a prevention 

strategy. 

Screening and 4 Assessment 

Why screen universally for trauma in behavioral health services? Exposure to trauma is common; in many surveys, more than half of respondents report a history of trauma, and the rates are even higher

among clients with mental or substance use disorders. Furthermore,

behavioral health problems, including substance use and mental disorders, are more difficult to treat if trauma-related symptoms and

disorders aren’t detected early and treated effectively (Part 3, Section

1, of this Treatment Improvement Protocol [TIP], available online,

summarizes research on the prevalence of trauma and its relationship with other behavioral health problems). 

Not addressing traumatic stress symptoms, trauma-specific disorders, and other symptoms/disorders related to trauma can impede 

successful mental health and substance abuse treatment. Unrecognized, unaddressed trauma symptoms can lead to poor engagement

in treatment, premature termination, greater risk for relapse of psychological symptoms or substance use, and worse outcomes.

Screening can also prevent misdiagnosis and inappropriate treatment planning. People with histories of trauma often display 

symptoms that meet criteria for other disorders. 

Without screening, clients’ trauma histories and related symptoms 

often go undetected, leading providers to direct services toward

symptoms and disorders that may only partially explain client

presentations and distress. Universal

screening for trauma history and traumarelated symptoms can help behavioral 

health practitioners identify individuals at

risk of developing more pervasive and severe symptoms of traumatic stress.

Screening, early identification, and intervention serves as a prevention strategy. 

91 
 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

Trauma-Informed Care Framework in Behavioral Health Services—Screening and 

Assessment 

The chapter begins with a discussion of

screening and assessment concepts, with a

particular focus on trauma-informed screening. It then highlights specific factors that 

influence screening and assessment, including

timing and environment. Barriers and challenges in providing trauma-informed screening are discussed, along with culturally specific

screening and assessment considerations and

guidelines. Instrument selection, traumainformed screening and assessment tools, and

trauma-informed screening and assessment

processes are reviewed as well. For a more 

research-oriented perspective on screening and

assessment for traumatic stress disorders,

please refer to the literature review provided in

Part 3 of this TIP, which is available online. 

Screening and Assessment 

Screening 

The first two steps in screening are to determine whether the person has a history of

trauma and whether he or she has traumarelated symptoms. Screening mainly obtains

answers to “yes” or “no” questions: “Has this

client experienced a trauma in the past?” and

“Does this client at this time warrant further 

assessment regarding trauma-related symptoms?” If someone acknowledges a trauma

history, then further screening is necessary to

determine whether trauma-related symptoms 

are present. However, the presence of such

symptoms does not necessarily say anything

about their severity, nor does a positive screen

indicate that a disorder actually exists. Positive 

92 
 

 

Screening is often the first contact 

between the client and the treatment 

provider, and the client forms his or her 

first impression of treatment during this 

intake process. Thus, how screening is 

conducted can be as important as the 

actual information gathered, as it sets the 

tone of treatment and begins the 

relationship with the client. 

Part 1, Chapter 4—Screening and Assessment 

screens only indicate that assessment or further evaluation is warranted, and negative

screens do not necessarily mean that an individual doesn’t have symptoms that warrant 

intervention. 

Screening procedures should always define the 

steps to take after a positive or negative

screening. That is, the screening process establishes precisely how to score responses to

screening tools or questions and clearly defines 

what constitutes a positive score (called a “cutoff score”) for a particular potential problem.

The screening procedures detail the actions to

take after a client scores in the positive range.

Clinical supervision is helpful—and sometimes necessary—in judging how to proceed. 

Trauma-informed screening is an essential 

part of the intake evaluation and the treatment 

planning process, but it is not an end in itself.

Screening processes can be developed that

allow staff without advanced degrees or graduate-level training to conduct them, whereas 

assessments for trauma-related disorders require a mental health professional trained in

assessment and evaluation processes. The 

most important domains to screen among

individuals with trauma histories include: 

•	 Trauma-related symptoms. 

•	 Depressive or dissociative symptoms, sleep

disturbances, and intrusive experiences. 

•	 Past and present mental disorders, including typically trauma-related disorders (e.g.,

mood disorders). 

•	 Severity or characteristics of a specific

trauma type (e.g., forms of interpersonal violence, adverse childhood events, combat

experiences). 

•	 Substance abuse. 

•	 Social support and coping styles. 

•	 Availability of resources. 

•	 Risks for self-harm, suicide, and violence. 

•	 Health screenings. 

Assessment 

When a client screens positive for substance 

abuse, trauma-related symptoms, or mental 

disorders, the agency or counselor should follow up with an assessment. A positive screening calls for more action—an assessment that

determines and defines presenting struggles to

develop an appropriate treatment plan and to

make an informed and collaborative decision 

about treatment placement. Assessment determines the nature and extent of the client’s 

problems; it might require the client to respond to written questions, or it could involve 

a clinical interview by a mental health or substance abuse professional qualified to assess 

the client and arrive at a diagnosis. A clinical

assessment delves into a client’s past and current experiences, psychosocial and cultural 

history, and assets and resources. 

Assessment protocols can require more than a

single session to complete and should also use 

multiple avenues to obtain the necessary clinical information, including self-assessment

tools, past and present clinical and medical 

records, structured clinical interviews, assessment measures, and collateral information

from significant others, other behavioral

health professionals, and agencies. Qualifications for conducting assessments and clinical 

interviews are more rigorous than for screening. Advanced degrees, licensing or certification, and special training in administration,

scoring, and interpretation of specific assessment instruments and interviews are often 

93 
 

 

 

 

 

Advice to Counselors: Screening and Assessing Clients 

• Ask all clients about any possible history of trauma; use a checklist to increase proper identification of such a history (see the online Adverse Childhood Experiences Study Score Calculator 

[http://acestudy.org/ace_score] for specific questions about adverse childhood experiences). 

• Use only validated instruments for screening and assessment. 

• Early in treatment, screen all clients who have histories of exposure to traumatic events for psychological symptoms and mental disorders related to trauma. 

• When clients screen positive, also screen for suicidal thoughts and behaviors (see TIP 50, Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment; Center for Substance 

Abuse Treatment [CSAT], 2009a). 

• Do not delay screening; do not wait for a period of abstinence or stabilization of symptoms. 

• Be aware that some clients will not make the connection between trauma in their histories and 

their current patterns of behavior (e.g., alcohol and drug use and/or avoidant behavior). 

• Do not require clients to describe emotionally overwhelming traumatic events in detail. 

• Focus assessment on how trauma symptoms affect clients’ current functioning. 

• Consider using paper-and-pencil instruments for screening and assessment as well as self-report 

measures when appropriate; they are less threatening for some clients than a clinical interview. 

• Talk about how you will use the findings to plan the client’s treatment, and discuss any immediate 

action necessary, such as arranging for interpersonal support, referrals to community agencies, or 

moving directly into the active phase of treatment. It is helpful to explore the strategies clients 

have used in the past that have worked to relieve strong emotions (Fallot & Harris, 2001). 

• At the end of the session, make sure the client is grounded and safe before leaving the interview 

room (Litz, Miller, Ruef, & McTeague, 2002). Readiness to leave can be assessed by checking on 

the degree to which the client is conscious of the current environment, what the client’s plan is 

for maintaining personal safety, and what the client’s plans are for the rest of the day. 

Trauma-Informed Care in Behavioral Health Services 

required. Counselors must be familiar with

(and obtain) the level of training required for

any instruments they consider using. 

For people with histories of traumatic life

events who screen positive for possible traumarelated symptoms and disorders, thorough

assessment gathers all relevant information

necessary to understand the role of the trauma

in their lives; appropriate treatment objectives,

goals, planning, and placement; and any ongoing diagnostic and treatment considerations, 

including reevaluation or follow-up. 

Overall, assessment may indicate symptoms 

that meet diagnostic criteria for a substance

use or mental disorder or a milder form of 

symptomatology that doesn’t reach a diagnostic level—or it may reveal that the positive

screen was false and that there is no significant 

cause for concern. Information from an assessment is used to plan the client’s treatment. 

The plan can include such domains as level of

care, acute safety needs, diagnosis, disability,

strengths and skills, support network, and

cultural context. Assessments should reoccur 

throughout treatment. Ongoing assessment

during treatment can provide valuable information by revealing further details of trauma

history as clients’ trust in staff members grows 

and by gauging clients’ progress. 

Timing of Screening and 

Assessment 

As a trauma-informed counselor, you need to

offer psychoeducation and support from the 

outset of service provision; this begins with

explaining screening and assessment and with

proper pacing of the initial intake and evaluation process. The client should understand the 

screening process, why the specific questions 

are important, and that he or she may choose 

to delay a response or to not answer a question 

94 
 

 

Conduct Assessments Throughout 

Treatment 

Ongoing assessments let counselors: 

• Track changes in the presence, frequency, 

and intensity of symptoms. 

• Learn the relationships among the client’s 

trauma, presenting psychological symptoms, and substance abuse. 

• Adjust diagnoses and treatment plans as 

needed. 

• Select prevention strategies to avoid more 

pervasive traumatic stress symptoms. 

Part 1, Chapter 4—Screening and Assessment 

at all. Discussing the occurrence or consequences of traumatic events can feel as unsafe 

and dangerous to the client as if the event 

were reoccurring. It is important not to encourage avoidance of the topic or reinforce the 

belief that discussing trauma-related material 

is dangerous, but be sensitive when gathering

information in the initial screening. Initial

questions about trauma should be general and

gradual. Taking the time to prepare and explain the screening and assessment process to

the client gives him or her a greater sense of

control and safety over the assessment process. 

Clients with substance use disorders 

No screening or assessment of trauma should

occur when the client is under the influence of 

alcohol or drugs. Clients under the influence 

are more likely to give inaccurate information.

Although it’s likely that clients in an active 

phase of use (albeit not at the assessment itself ) or undergoing substance withdrawal can

provide consistent information to obtain a 

valid screening and assessment, there is insufficient data to know for sure. Some theorists 

state that no final assessment of trauma or 

posttraumatic stress disorder (PTSD) should

occur during these early phases (Read,

Bollinger, & Sharkansky, 2003), asserting that

symptoms of withdrawal can mimic PTSD

and thus result in overdiagnosis of PTSD and

other trauma-related disorders. Alcohol or 

drugs can also cause memory impairment that

clouds the client’s history of trauma symptoms. However, Najavits (2004) and others

note that underdiagnosis, not overdiagnosis, of

trauma and PTSD has been a significant issue

in the substance abuse field and thus claim 

that it is essential to obtain an initial assessment early, which can later be modified if

needed (e.g., if the client’s symptom pattern

changes). Indeed, clinical observations suggest

that assessments for both trauma and PTSD— 

even during active use or withdrawal—appear 

robust (Coffey, Schumacher, Brady, & Dansky,

2003). Although some PTSD symptoms and

trauma memories can be dampened or increased to a degree, their overall presence or

absence, as assessed early in treatment, appears 

accurate (Najavits, 2004). 

The Setting for Trauma Screening 

and Assessment 

Advances in the development of simple, brief,

and public-domain screening tools mean that

at least a basic screening for trauma can be

done in almost any setting. Not only can clients be screened and assessed in behavioral 

health treatment settings; they can also be 

evaluated in the criminal justice system, educational settings, occupational settings, physicians’ offices, hospital medical and trauma 

units, and emergency rooms. Wherever they 

occur, trauma-related screenings and subsequent assessments can reduce or eliminate 

wasted resources, relapses, and, ultimately,

treatment failures among clients who have 

histories of trauma, mental illness, and/or substance use disorders. 

Creating an effective screening and 

assessment environment 

You can greatly enhance the success of treatment by paying careful attention to how you 

approach the screening and assessment process. Take into account the following points: 

95 
 

 

 

 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

•	 Clarify for the client what to expect in the

screening and assessment process. For example, tell the client that the screening and assessment phase focuses on identifying

issues that might benefit from treatment.

Inform him or her that during the trauma

screening and assessment process, uncomfortable thoughts and feelings can arise.

Provide reassurance that, if they do, you’ll 

assist in dealing with this distress—but also

let them know that, even with your assistance, some psychological and physical reactions to the interview may last for a few 

hours or perhaps as long as a few days after

the interview, and be sure to highlight the

fact that such reactions are normal (Read et

al., 2003). 

•	 Approach the client in a matter-of-fact, yet

supportive, manner. Such an approach

helps create an atmosphere of trust, respect,

acceptance, and thoughtfulness (Melnick &

Bassuk, 2000). Doing so helps to normalize 

symptoms and experiences generated by the 

trauma; consider informing clients that

such events are common but can cause continued emotional distress if they are not

treated. Clients may also find it helpful for

you to explain the purpose of certain difficult questions. For example, you could say,

“Many people have experienced troubling

events as children, so some of my questions 

are about whether you experienced any

such events while growing up.” Demonstrate kindness and directness in equal 

measure when screening/assessing clients 

(Najavits, 2004). 

•	 Respect the client’s personal space. Cultural 

and ethnic factors vary greatly regarding the

appropriate physical distance to maintain

during the interview. You should respect the

client’s personal space, sitting neither too

far from nor too close to the client; let your

observations of the client’s comfort level 

during the screening and assessment process guide the amount of distance. Clients 

with trauma may have particular sensitivity 

about their bodies, personal space, and

boundaries. 

•	 Adjust tone and volume of speech to suit the

client’s level of engagement and degree of

comfort in the interview process. Strive to 

maintain a soothing, quiet demeanor. Be

sensitive to how the client might hear what 

you have to say in response to personal disclosures. Clients who have been traumatized may be more reactive even to benign

or well-intended questions. 

•	 Provide culturally appropriate symbols of

safety in the physical environment. These 

include paintings, posters, pottery, and

other room decorations that symbolize 

the safety of the surroundings to the client population. Avoid culturally inappropriate or insensitive items in the physical 

environment. 

•	 Be aware of one’s own emotional responses to 

hearing clients’ trauma histories. Hearing 

about clients’ traumas may be very painful 

and can elicit strong emotions.The client

may interpret your reaction to his or her

revelations as disinterest, disgust for the client’s behavior, or some other inaccurate interpretation. It is important for you to

monitor your interactions and to check in 

with the client as necessary. You may also

feel emotionally drained to the point that it

interferes with your ability to accurately listen to or assess clients.This effect of exposure to traumatic stories, known as 

secondary traumatization, can result in

symptoms similar to those experienced by 

the client (e.g., nightmares, emotional 

numbing); if necessary, refer to a colleague 

for assessment (Valent, 2002). Secondary

traumatization is addressed in greater detail

in Part 2, Chapter 2, of this TIP. 

•	 Overcome linguistic barriers via an interpreter. Deciding when to add an interpreter

requires careful judgment.The interpreter

should be knowledgeable of behavioral 

96 
 

 

 

 

 

Part 1, Chapter 4—Screening and Assessment 

health terminology, be familiar with the

concepts and purposes of the interview and

treatment programming, be unknown to

the client, and be part of the treatment 

team. Avoid asking family members or

friends of the client to serve as interpreters. 

• Elicit only the information necessary for

determining a history of trauma and the

possible existence and extent of traumatic

stress symptoms and related disorders.

There is no need to probe deeply into the

details of a client’s traumatic experiences at

this stage in the treatment process. Given

the lack of a therapeutic relationship in

which to process the information safely,

pursuing details of trauma can cause retraumatization or produce a level of response that neither you nor your client is 

prepared to handle. Even if a client wants 

to tell his or her trauma story, it’s your job

to serve as “gatekeeper” and preserve the 

client’s safety. Your tone of voice when suggesting postponement of a discussion of

trauma is very important. Avoid conveying

the message, “I really don’t want to hear 

about it.” Examples of appropriate statements are: 

− “Your life experiences are very important, but at this early point in our

work together, we should start with 

what’s going on in your life currently 

rather than discussing past experiences 

in detail. If you feel that certain past

experiences are having a big effect on

your life now, it would be helpful for us 

to discuss them as long as we focus on

your safety and recovery right now.” 

− “Talking about your past at this point 

could arouse intense feelings—even

more than you might be aware of right

now. Later, if you choose to, you can

talk with your counselor about how to

work on exploring your past.” 

− “Often, people who have a history of

trauma want to move quickly into the 

details of the trauma to gain relief. I 

understand this desire, but my concern

for you at this moment is to help you 

establish a sense of safety and support

before moving into the traumatic experiences. We want to avoid retraumatization—meaning, we want to establish

resources that weren’t available to you

at the time of the trauma before delving into more content.” 

• Give the client as much personal control as

possible during the assessment by: 

− Presenting a rationale for the interview 

and its stress-inducing potential, making clear that the client has the right to

refuse to answer any and all questions. 

− Giving the client (where staffing permits) the option of being interviewed

by someone of the gender with which

he or she is most comfortable. 

− Postponing the interview if necessary 

(Fallot & Harris, 2001). 

•	 Use self-administered, written checklists

rather than interviews when possible to assess trauma. Traumas can evoke shame,

guilt, anger, or other intense feelings that

can make it difficult for the client to report 

them aloud to an interviewer. Clients are 

more likely to report trauma when they use 

self-administered screening tools; however,

these types of screening instruments only 

guide the next step. Interviews should coincide with self-administered tools to create a 

sense of safety for the client (someone is 

present as he or she completes the screening) and to follow up with more indepth

data gathering after a self-administered

screening is complete. The Trauma History 

Questionnaire (THQ) is a selfadministered tool (Green, 1996). It has

been used successfully with clinical and

nonclinical populations, including medical patients, women who have experienced domestic violence, and people with

serious mental illness (Hooper, Stockton, 

97 
 

 

 

Exhibit 1.4-1: Grounding Techniques 

Grounding techniques are important skills for assessors and all other behavioral health service providers who interact with traumatized clients (e.g., nurses, security, administrators, clinicians). Even if 

you do not directly conduct therapy, knowledge of grounding can help you defuse an escalating 

situation or calm a client who is triggered by the assessment process. Grounding strategies help a 

person who is overwhelmed by memories or strong emotions or is dissociating; they help the person 

become aware of the here and now. A useful metaphor is the experience of walking out of a movie 

theater. When the person dissociates or has a flashback, it’s like watching a mental movie; grounding techniques help him or her step out of the movie theater into the daylight and the present environment. The client’s task is not only to hold on to moments from the past, but also to acknowledge 

that what he or she was experiencing is from the past. Try the following techniques: 

1. Ask the client to state what he or she observes. 

Guide the client through this exercise by using statements like, “You seem to feel very 

scared/angry right now. You’re probably feeling things related to what happened in the past. 

Now, you’re in a safe situation. Let’s try to stay in the present. Take a slow deep breath, relax 

your shoulders, put your feet on the floor; let’s talk about what day and time it is, notice what’s 

on the wall, etc. What else can you do to feel okay in your body right now?” 

2. Help the client decrease the intensity of affect. 

• “Emotion dial”: A client imagines turning down the volume on his or her emotions. 

• Clenching fists can move the energy of an emotion into fists, which the client can then release. 

• Guided imagery can be used to visualize a safe place. 

• Distraction (see #3 below). 

• Use strengths-based questions (e.g., “How did you survive?” or “What strengths did you 

possess to survive the trauma?”). 

3. Distract the client from unbearable emotional states. 

• Have the client focus on the external environment (e.g., name red objects in the room). 

• Ask the client to focus on recent and future events (e.g., “to do” list for the day). 

• Help the client use self-talk to remind himself or herself of current safety. 

• Use distractions, such as counting, to return the focus to current reality. 

• Somatosensory techniques (toe-wiggling, touching a chair) can remind clients of current reality. 

4. Ask the client to use breathing techniques. 

• Ask the client to inhale through the nose and exhale through the mouth. 

• Have the client place his or her hands on his or her abdomen and then watch the hands go 

up and down while the belly expands and contracts. 

Source: Melnick & Bassuk, 2000. 

Trauma-Informed Care in Behavioral Health Services 

Krupnick, & Green, 2011). Screening instruments (including the THQ) are included in Appendix D of this TIP. 

•	 Interview the client if he or she has trouble 

reading or writing or is otherwise unable to

complete a checklist. Clients who are likely 

to minimize their trauma when using a

checklist (e.g., those who exhibit significant

symptoms of dissociation or repression)

benefit from a clinical interview. A trained 

interviewer can elicit information that a 

self-administered checklist does not capture. Overall, using both a self-administered 

questionnaire and an interview can help

achieve greater clarity and context. 

•	 Allow time for the client to become calm and 

oriented to the present if he or she has very 

intense emotional responses when recalling

or acknowledging a trauma. At such times,

avoid responding with such exclamations 

as “I don’t know how you survived that!”

(Bernstein, 2000). If the client has difficulty self-soothing, guide him or her through 

grounding techniques (Exhibit 1.4-1),

which are particularly useful—perhaps 

even critical—to achieving a successful 

98 
Part 1, Chapter 4—Screening and Assessment 

 

 

 

interview when a client has dissociated or is 

experiencing intense feelings in response to

screening and/or interview questions. 

•	 Avoid phrases that imply judgment about 

the trauma. For example, don’t say to a client who survived Hurricane Katrina and 

lost family members, “It was God’s will,”

or “It was her time to pass,” or “It was 

meant to be.” Do not make assumptions 

about what a person has experienced. Rather, listen supportively without imposing

personal views on the client’s experience. 

•	 Provide feedback about the results of the 

screening. Keep in mind the client’s vulnerability, ability to access resources, strengths,

and coping strategies. Present results in a

synthesized manner, avoiding complicated,

overly scientific jargon or explanations. Allow time to process client reactions during

the feedback session. Answer client questions and concerns in a direct, honest, and 

compassionate manner. Failure to deliver

feedback in this way can negatively affect

clients’ psychological status and severely 

weaken the potential for developing a therapeutic alliance with the client. 

•	 Be aware of the possible legal implications

of assessment. Information you gather during the screening and assessment process 

can necessitate mandatory reporting to authorities, even when the client does not

want such information disclosed (Najavits,

2004). For example, you can be required to

report a client’s experience of child abuse 

even if it happened many years ago or the 

client doesn’t want the information reported. Other legal issues can be quite complex, such as confidentiality of records,

pursuing a case against a trauma perpetrator and divulging information to third parties while still protecting the legal status of

information used in prosecution, and child

custody issues (Najavits, 2004). It’s essential that you know the laws in your State, 

have an expert legal consultant available,

and access clinical supervision. 

Barriers and Challenges to 

Trauma-Informed 

Screening and Assessment 

Barriers 

It is not necessarily easy or obvious to identify 

an individual who has survived trauma without screening. Moreover, some clients may 

deny that they have encountered trauma and

its effects even after being screened or asked

direct questions aimed at identifying the occurrence of traumatic events. The two main 

barriers to the evaluation of trauma and its 

related disorders in behavioral health settings 

are clients not reporting trauma and providers 

overlooking trauma and its effects. 

Concerning the first main barrier, some events 

will be experienced as traumatic by one person

but considered nontraumatic by another. A

history of trauma encompasses not only the 

experience of a potentially traumatic event, but

also the person’s responses to it and the meanings he or she attaches to the event. Certain

situations make it more likely that the client

will not be forthcoming about traumatic

events or his or her responses to those events.

Some clients might not have ever thought of a

particular event or their response to it as traumatic and thus might not report or even recall 

the event. Some clients might feel a reluctance 

to discuss something that they sense might

bring up uncomfortable feelings (especially 

with a counselor whom they’ve only recently 

met). Clients may avoid openly discussing

traumatic events or have difficulty recognizing

or articulating their experience of trauma for 

other reasons, such as feelings of shame, guilt,

or fear of retribution by others associated with

the event (e.g., in cases of interpersonal or 

99 
 

 

Common Reasons Why Some Providers Avoid Screening Clients for Trauma 

Treatment providers may avoid screening for traumatic events and trauma-related symptoms due to: 

• A reluctance to inquire about traumatic events and symptoms because these questions are not a 

part of the counselor’s or program’s standard intake procedures. 

• Underestimation of the impact of trauma on clients’ physical and mental health. 

• A belief that treatment of substance abuse issues needs to occur first and exclusively, before 

treating other behavioral health disorders. 

• A belief that treatment should focus solely on presenting symptoms rather than exploring the 

potential origins or aggravators of symptoms. 

• A lack of training and/or feelings of incompetence in effectively treating trauma-related problems 

(Salyers, Evans, Bond, & Meyer, 2004). 

• Not knowing how to respond therapeutically to a client’s report of trauma. 

• Fear that a probing trauma inquiry will be too disturbing to clients. 

• Not using common language with clients that will elicit a report of trauma (e.g., asking clients if 

they were abused as a child without describing what is meant by abuse). 

• Concern that if disorders are identified, clients will require treatment that the counselor or program does not feel capable of providing (Fallot & Harris, 2001). 

• Insufficient time for assessment to explore trauma histories or symptoms. 

• Untreated trauma-related symptoms of the counselor, other staff members, and administrators. 

Trauma-Informed Care in Behavioral Health Services 

domestic violence). Still others may deny their

history because they are tired of being interviewed or asked to fill out forms and may believe it doesn’t matter anyway. 

A client may not report past trauma for many 

reasons, including:

•	 Concern for safety (e.g., fearing more abuse 

by a perpetrator for revealing the trauma). 

•	 Fear of being judged by service providers. 

•	 Shame about victimization. 

•	 Reticence about talking with others in response to trauma. 

•	 Not recalling past trauma through dissociation, denial, or repression (although genuine 

blockage of all trauma memory is rare 

among trauma survivors; McNally, 2003). 

•	 Lack of trust in others, including behavioral health service providers. 

•	 Not seeing a significant event as traumatic. 

Regarding the second major barrier, counselors 

and other behavioral health service providers 

may lack awareness that trauma can significantly affect clients’ presentations in treatment 

and functioning across major life areas, such as 

relationships and work. In addition, some 

counselors may believe that their role is to 

treat only the presenting psychological and/or

substance abuse symptoms, and thus they may 

not be as sensitive to histories and effects of 

trauma. Other providers may believe that a

client should abstain from alcohol and drugs 

for an extended period before exploring trauma symptoms. Perhaps you fear that addressing a clients’ trauma history will only 

exacerbate symptoms and complicate treatment. Behavioral health service providers who

hold biases may assume that a client doesn’t 

have a history of trauma and thus fail to ask

the “right” questions, or they may be uncomfortable with emotions that arise from listening to client experiences and, as a result,

redirect the screening or counseling focus. 

Challenges 

Awareness of acculturation and 

language 

Acculturation levels can affect screening and

assessment results.Therefore, indepth discussions may be a more appropriate way to gain an 

understanding of trauma from the client’s point

of view. During the intake, prior to trauma 

screening, determine the client’s history of 

100 
 

 

 

 

 

 

 

Common Assessment Myths 

Several common myths contribute to underassessment of trauma-related disorders (Najavits, 2004): 

• Myth #1: Substance abuse itself is a trauma. However devastating substance abuse is, it does 

not meet the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; 

American Psychiatric Association [APA], 2013a), criteria for trauma per se. Nevertheless, high-risk 

behaviors that are more likely to occur during addiction, such as interpersonal violence and selfharm, significantly increase the potential for traumatic injury. 

• Myth #2: Assessment of trauma is enough. Thorough assessment is the best way to identify the 

existence and extent of trauma-related problems. However, simply identifying trauma-related 

symptoms and disorders is just the first step. Also needed are individualized treatment protocols 

and action to implement these protocols. 

• Myth #3: It is best to wait until the client has ended substance use and withdrawal to assess 

for PTSD. Research does not provide a clear answer to the controversial question of when to assess for PTSD; however, Najavits (2004) and others note that underdiagnosis of trauma and PTSD 

has been more significant in the substance abuse field than overdiagnosis. Clinical experience 

shows that the PTSD diagnosis is rather stable during substance use or withdrawal, but symptoms 

can become more or less intense; memory impairment from alcohol or drugs can also cloud the 

symptom picture. Thus, it is advisable to establish a tentative diagnosis and then reassess after a 

period of abstinence, if possible. 

Part 1, Chapter 4—Screening and Assessment 

migration, if applicable, and primary language.

Questions about the client’s country of birth,

length of time in this country, events or reasons 

for migration, and ethnic self-identification are

also appropriate at intake. Also be aware that

even individuals who speak English well might

have trouble understanding the subtleties of

questions on standard screening and assessment

tools. It is not adequate to translate items simply from English into another language; words,

idioms, and examples often don’t translate directly into other languages and therefore need

to be adapted. Screening and assessment should

be conducted in the client’s preferred language 

by trained staff members who speak the language or by professional translators familiar

with treatment jargon. 

Awareness of co-occurring diagnoses 

A trauma-informed assessor looks for psychological symptoms that are associated with

trauma or simply occur alongside it. Symptom 

screening involves questions about past or

present mental disorder symptoms that may 

indicate the need for a full mental health assessment. A variety of screening tools are 

available, including symptom checklists. 

However, you should only use symptom 

checklists when you need information about

how your client is currently feeling; don’t use 

them to screen for specific disorders. Responses

will likely change from one administration of 

the checklist to the next. 

Basic mental health screening tools are available. For example, the Mental Health Screening

Form-III screens for present or past symptoms 

of most mental disorders (Carroll & McGinley,

2001); it is available at no charge from Project

Return Foundation, Inc. and is also reproduced

in TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT, 

2005c). Other screening tools, such as the Beck 

Depression Inventory II and the Beck Anxiety 

Inventory (Beck, Wright, Newman, & Liese,

1993), also screen broadly for mental and substance use disorders, as well as for specific disorders often associated with trauma. For 

further screening information and resources on

depression and suicide, see TIP 48, Managing 

Depressive Symptoms in Substance Abuse Clients 

During Early Recovery (CSAT, 2008), and TIP 

50, Addressing Suicidal Thoughts and Behaviors

in Substance Abuse Treatment (CSAT, 2009a). 

101 
 

 

 

 

 

 

 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

For screening substance use disorders, see TIP

11, Simple Screening Instruments for Outreach

for Alcohol and Other Drug Abuse and Infectious 

Diseases (CSAT, 1994); TIP 24, A Guide to 

Substance Abuse Services for Primary Care Clinicians (CSAT, 1997a); TIP 31, Screening and

Assessing Adolescents for Substance Use Disorders

(CSAT, 1999c); TIP 42, Substance Abuse 

Treatment for Persons With Co-Occurring Disorders (CSAT, 2005c); and TIP 51, Substance 

Abuse Treatment: Addressing the Specific Needs

of Women (CSAT, 2009d). 

A common dilemma in the assessment of 

trauma-related disorders is that certain trauma 

symptoms are also symptoms of other disorders. Clients with histories of trauma typically

present a variety of symptoms; thus, it is important to determine the full scope of symptoms and/or disorders present to help improve 

treatment planning. Clients with traumarelated and substance use symptoms and disorders are at increased risk for additional Axis 

I and/or Axis II mental disorders (Brady,

Killeen, Saladin, Dansky, & Becker, 1994;

Cottler, Nishith, & Compton, 2001). These

symptoms need to be distinguished so that

other presenting subclinical features or disorders do not go unidentified and untreated. To

accomplish this, a comprehensive assessment

of the client’s mental health is recommended. 

Misdiagnosis and underdiagnosis 

Many trauma survivors are either misdiagnosed

(i.e., given diagnoses that are not accurate) or

underdiagnosed (i.e., have one or more diagnoses that have not been identified at all). Such

diagnostic errors could result, in part, from the 

fact that many general instruments to evaluate 

mental disorders are not sufficiently sensitive to

identify posttraumatic symptoms and can misclassify them as other disorders, including personality disorders or psychoses. Intrusive

posttraumatic symptoms, for example, can

show up on general measures as indicative of 

hallucinations or obsessions. Dissociative 

symptoms can be interpreted as indicative of

schizophrenia. Trauma-based cognitive symptoms can be scored as evidence for paranoia or

other delusional processes (Briere, 1997). Some 

of the most common misdiagnoses in clients 

with PTSD and substance abuse are: 

•	 Mood and anxiety disorders. Overlapping

symptoms with such disorders as major depression, generalized anxiety disorder, and

bipolar disorder can lead to misdiagnosis. 

•	 Borderline personality disorder. Historically,

this has been more frequently diagnosed

than PTSD. Many of the symptoms, including a pattern of intense interpersonal 

relationships, impulsivity, rapid and unpredictable mood swings, power struggles in

the treatment environment, underlying

anxiety and depressive symptoms, and transient, stress-related paranoid ideation or severe dissociative symptoms overlap. The 

effect of this misdiagnosis on treatment can

be particularly negative; counselors often

view clients with a borderline personality 

diagnosis as difficult to treat and unresponsive to treatment. 

•	 Antisocial personality disorder. For men and 

women who have been traumatized in 

childhood, “acting out” behaviors, a lack of

empathy and conscience, impulsivity, and

self-centeredness can be functions of trauma and survival skills rather than true antisocial characteristics. 

•	 Attention def icit hyperactivity disorder

(ADHD). For children and adolescents,

impulsive behaviors and concentration

problems can be diagnosed as ADHD rather than PTSD. 

It is possible, however, for clients to legitimately have any of these disorders in addition

to trauma-related disorders. Given the overlap

of posttraumatic symptoms with those of other disorders, a wide variety of diagnoses often

needs to be considered to avoid misidentifying 

102 
 

Culture-Specific Stress Responses 

Culture-bound concepts of distress exist that don’t necessarily match diagnostic criteria. Culturespecific symptoms and syndromes can involve physical complaints, broad emotional reactions, or 

specific cognitive features. Many such syndromes are unique to a specific culture but can broaden to 

cultures that have similar beliefs or characteristics. Culture-bound syndromes are typically treated by 

traditional medicine and are known throughout the culture. Cultural concepts of distress include: 

• Ataques de nervios. Recognized in Latin America and among individuals of Latino descent, the 

primary features of this syndrome include intense emotional upset (e.g., shouting, crying, trembling, dissociative or seizure-like episodes). It frequently occurs in response to a traumatic or 

stressful event in the family. 

• Nervios. This is considered a common idiom of distress among Latinos; it includes a wide range 

of emotional distress symptoms including headaches, nervousness, tearfulness, stomach discomfort, difficulty sleeping, and dizziness. Symptoms can vary widely in intensity, as can impairment 

from them. This often occurs in response to stressful or difficult life events. 

• Susto. This term, meaning “fright,” refers to a concept found in Latin American cultures, but it is 

not recognized among Latinos from the Caribbean. Susto is attributed to a traumatic or frightening event that causes the soul to leave the body, thus resulting in illness and unhappiness; extreme cases may result in death. Symptoms include appetite or sleep disturbances, sadness, lack 

of motivation, low self-esteem, and somatic symptoms. 

• Taijin kyofusho. Recognized in Japan and among some American Japanese, this “interpersonal 

fear” syndrome is characterized by anxiety about and avoidance of interpersonal circumstances. 

The individual presents worry or a conviction that his or her appearance or social interactions are 

inadequate or offensive. Other cultures have similar cultural descriptions or syndromes associated with social anxiety. 

Sources: APA, 2013, pp. 833–837; Briere & Scott, 2006b. 

Part 1, Chapter 4—Screening and Assessment 

other disorders as PTSD and vice versa. A 

trained and experienced mental health professional will be required to weigh differential 

diagnoses. TIP 42 (CSAT, 2005c) explores 

issues related to differential diagnosis. 

Cross-Cultural Screening 

and Assessment 

Many trauma-related symptoms and disorders 

are culture specific, and a client’s cultural 

background must be considered in screening

and assessment (for review of assessment and

cultural considerations when working with

trauma, see Wilson & Tang, 2007). Behavioral 

health service providers must approach screening and assessment processes with the influences of culture, ethnicity, and race firmly in

mind. Cultural factors, such as norms for expressing psychological distress, defining trauma, and seeking help in dealing with trauma, 

can affect: 

•	 How traumas are experienced. 

•	 The meaning assigned to the event(s). 

•	 How trauma-related symptoms are expressed (e.g., as somatic expressions of distress, level of emotionality, types of avoidant

behavior). 

•	 Willingness to express distress or identify

trauma with a behavioral health service 

provider and sense of safety in doing so. 

•	 Whether a specific pattern of behavior,

emotional expression, or cognitive process is 

considered abnormal. 

•	 Willingness to seek treatment inside and 

outside of one’s own culture. 

•	 Response to treatment. 

•	 Treatment outcome. 

When selecting assessment instruments, counselors and administrators need to choose, 

103 
 

 

The DSM-5 and Updates to Screening and Assessment Instruments 

The recent publication of the DSM-5 (APA, 2013a) reflects changes to certain diagnostic criteria, 

which will affect screening tools and criteria for trauma-related disorders. Criterion A2 (specific to 

traumatic stress disorders, acute stress, and posttraumatic stress disorders), included in the fourth 

edition (text revision) of the DSM (DSM-IV-TR; APA, 2000a), has been eliminated; this criterion stated 

that the individual’s response to the trauma needs to involve intense fear, helplessness, or horror. 

There are now four cluster symptoms, not three: reexperiencing, avoidance, arousal, and persistent 

negative alterations in cognitions and mood. Changes to the DSM-5 were made to symptoms within 

each cluster. Thus, screening will need modification to adjust to this change (APA, 2012b). 

Trauma-Informed Care in Behavioral Health Services 

whenever possible, instruments that are culturally appropriate for the client. Instruments 

that have been normed for, adapted to, and

tested on specific cultural and linguistic groups 

should be used. Instruments that are not 

normed for the population are likely to contain cultural biases and produce misleading

results. Subsequently, this can lead to misdiagnosis, overdiagnosis, inappropriate treatment

plans, and ineffective interventions. Thus, it is 

important to interpret all test results cautiously and to discuss the limitations of instruments 

with clients from diverse ethnic populations

and cultures. For a review of cross-cultural 

screening and assessment considerations, refer

to the planned TIP, Improving Cultural Competence (Substance Abuse and Mental Health

Services Administration, planned c). 

Choosing Instruments 

Numerous instruments screen for trauma history, indicate symptoms, assess trauma-related

and other mental disorders, and identify related clinical phenomena, such as dissociation.

One instrument is unlikely to meet all screening or assessment needs or to determine the 

existence and full extent of trauma symptoms

and traumatic experiences. The following sections present general considerations in selecting standardized instruments. 

Purpose 

Define your assessment needs. Do you need a

standardized screening or assessment instrument for clinical purposes? Do you need information on a specific aspect of trauma, such

as history, PTSD, or dissociation? Do you

wish to make a formal diagnosis, such as 

PTSD? Do you need to determine quickly 

whether a client has experienced a trauma? Do

you want an assessment that requires a clinician to administer it, or can the client complete the instrument himself or herself? Does 

the instrument match the current and specific

diagnostic criteria established in the DSM-5? 

Population 

Consider the population to be assessed (e.g.,

women, children, adolescents, refugees, disaster

survivors, survivors of physical or sexual violence, survivors of combat-related trauma, people whose native language is not English); 

some tools are appropriate only for certain

populations. Is the assessment process developmentally and culturally appropriate for your

client? Exhibit 1.4-2 lists considerations in 

choosing a screening or assessment instrument

for trauma and/or PTSD. 

Instrument Quality 

An instrument should be psychometrically 

adequate in terms of sensitivity and specificity 

or reliability and validity as measured in several ways under varying conditions. Published

research offers information on an instrument’s 

psychometric properties as well as its utility in

both research and clinical settings. For further

information on a number of widely used

trauma evaluation tools, see Appendix D and

Antony, Orsillo, and Roemer’s paper (2001). 

104 
 

Exhibit 1.4-2: Key Areas of Trauma Screening and Assessment 

Trauma 

Key question: Did the client experience a trauma? 

Examples of measures: Life Stressor Checklist-Revised (Wolfe & Kimerling, 1997); Trauma History 

Questionnaire (Green, 1996); Traumatic Life Events Questionnaire (Kubany et al., 2000). 

Note: A good trauma measure identifies events a person experienced (e.g., rape, assault, accident) 

and also evaluates other trauma-related symptoms (e.g., presence of fear, helplessness, or horror). 

Acute Stress Disorder (ASD) and PTSD 

Key question: Does the client meet criteria for ASD or PTSD? 

Examples of measures: Clinician-Administered PTSD Scale (CAPS; Blake et al., 1990); Modified PTSD 

Symptom Scale (Falsetti, Resnick, Resnick, & Kilpatrick, 1993); PTSD Checklist (Weathers, Litz, 

Herman, Huska, & Keane, 1993); Stanford Acute Stress Reaction Questionnaire (Cardena, Koopman, 

Classen, Waelde, & Spiegel, 2000). 

Note: A PTSD diagnosis requires the person to meet criteria for having experienced a trauma; some 

measures include this, but others do not and require use of a separate trauma measure. The CAPS is 

an interview; the others listed are self-report questionnaires and take less time. 

Other Trauma-Related Symptoms 

Key question: Does the client have other symptoms related to trauma? These include depressive 

symptoms, self-harm, dissociation, sexuality problems, and relationship issues, such as distrust. 

Examples of measures: Beck Depression Inventory II (Beck, 1993; Beck et al., 1993); Dissociative 

Experiences Scale (Bernstein & Putnam, 1986; Carlson & Putnam, 1993); Impact of Event Scale 

(measures intrusion and avoidance due to exposure to traumatic events; Horowitz, Wilner, & Alvarez, 

1979; Weiss & Marmar, 1997); Trauma Symptom Inventory (Briere, 1995); Trauma Symptom Checklist 

for Children (Briere, 1996b); Modified PTSD Symptom Scale (Falsetti et al., 1993). 

Note: These measures can be helpful for clinical purposes and for outcome assessment because they 

gauge levels of symptoms. Trauma-related symptoms are broader than diagnostic criteria and thus 

useful to measure, even if the patient doesn’t meet criteria for any specific diagnoses. 

Other Trauma-Related Diagnoses 

Key question: Does the client have other disorders related to trauma? These include mood disorders, anxiety disorders besides traumatic stress disorders, and dissociative disorders. 

Examples of measures: Mental Health Screening Form III (Carroll & McGinley, 2001); The MiniInternational Neuropsychiatric Interview (M.I.N.I.) Structured Clinical Interview for DSM-IV-TR, Patient Edition (First, Spitzer, Gibbon, & Williams, revised 2011); Structured Clinical Interview for DSMIV-TR, Non-Patient Edition (First, Spitzer, Gibbon, & Williams, revised 2011a). 

Note: For complex symptoms and diagnoses such as dissociation and dissociative disorders, interviews are recommended. Look for measures that incorporate DSM-5 criteria. 

Sources: Antony et al., 2001; Najavits, 2004. 

Part 1, Chapter 4—Screening and Assessment 

105 
 

 

 

 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

Practical Issues 

Is the instrument freely and readily available,

or is there a fee? Is costly and extensive training required to administer it? Is the instrument too lengthy to be used in the clinical 

setting? Is it easily administered and scored

with accompanying manuals and/or other

training materials? How will results be presented to or used with the client? Is technical 

support available for difficulties in administration, scoring, or interpretation of results? Is 

special equipment required such as a microphone, a video camera, or a touch-screen computer with audio? 

Trauma-Informed 

Screening and Assessment 

The following sections focus on initial screening. For more information on screening and

assessment tools, including structured interviews, see Exhibit 1.4-2. Screening is only as 

good as the actions taken afterward to address 

a positive screen (when clients acknowledge

that they experience symptoms or have encountered events highlighted within the

screening). Once a screening is complete and a

positive screen is acquired, the client then

needs referral for a more indepth assessment

to ensure development of an appropriate

treatment plan that matches his or her presenting problems. 

Establish a History of Trauma 

A person cannot have ASD, PTSD, or any

trauma-related symptoms without experiencing trauma; therefore, it is necessary to inquire 

about painful, difficult, or overwhelming past

experiences. Initial information should be 

gathered in a way that is minimally intrusive 

yet clear. Brief questionnaires can be less 

threatening to a client than face-to-face interviews, but interviews should be an integral 

part of any screening and assessment process. 

If the client initially denies a history of trauma

(or minimizes it), administer the questionnaire 

later or delay additional trauma-related questions until the client has perhaps developed

more trust in the treatment setting and feels 

safer with the thoughts and emotions that 

might arise in discussing his or her trauma

experiences. 

The Stressful Life Experiences (SLE) screen

(Exhibit 1.4-3) is a checklist of traumas that

also considers the client’s view of the impact 

of those events on life functioning. Using the 

SLE can foster the client–counselor relationship. By going over the answers with the client, you can gain a deep understanding of your

client, and the client receives a demonstration

of your sensitivity and concern for what the

client has experienced. The National Center

for PTSD Web site offers similar instruments 

(http://www.ptsd.va.gov/professional/pages/as

sessments/assessment.asp). 

In addition to broad screening tools that capture various traumatic experiences and symptoms, other screening tools, such as the 

Combat Exposure Scale (Keane et al., 1989)

and the Intimate Partner Violence Screening

Tool (Exhibit 1.4-4), focus on acknowledging

a specific type of traumatic event. 

Screen for Trauma-Related 

Symptoms and Disorders in 

Clients With Histories of Trauma 

This step evaluates whether the client’s trauma 

resulted in subclinical or diagnosable disorders. The counselor can ask such questions as,

“Have you received any counseling or therapy?

Have you ever been diagnosed or treated for a

psychological disorder in the past? Have you 

ever been prescribed medications for your

emotions in the past?” Screening is typically 

conducted by a wide variety of behavioral

health service providers with different levels

of training and education; however, all 

106 
 

 

Part 1, Chapter 4—Screening and Assessment 

Exhibit 1.4-3: SLE Screening 

Sources: Hudnall Stamm, 1996, 1997. Used with permission. 

107 
 

 

 

 

Exhibit 1.4-4: STaT Intimate Partner 

Violence Screening Tool 

1. Have you ever been in a relationship where 

your partner has pushed or Slapped you? 

2. Have you ever been in a relationship where 

your partner Threatened you with violence? 

3. Have you ever been in a relationship where 

your partner has thrown, broken, or 

punched Things? 

Source: Paranjape & Liebschutz, 2003. Used 

with permission 

Exhibit 1.4-5: PC-PTSD Screen 

In your life, have you ever had any experience 

that was so frightening, horrible, or upsetting 

that, in the past month, you... 

1. Have had nightmares about it or thought 

about it when you did not want to? 

 YES NO 

2. Tried hard not to think about it or went out 

of your way to avoid situations that reminded you of it? 

 YES NO 

3. Were constantly on guard, watchful, or 

easily startled? 

 YES NO 

4. Felt numb or detached from others, activities, or your surroundings? 

 YES NO 

Source: Prins et al., 2004. Material used is in the 

public domain. 

Exhibit 1.4-6: The SPAN 

The SPAN instrument is a brief screening tool 

that asks clients to identify the trauma in their 

past that is most disturbing to them currently. 

It then poses four questions that ask clients to 

rate the frequency and severity with which they 

have experienced, in the past week, different 

types of trauma-related symptoms (startle, 

physiological arousal, anger, and numbness). 

To order this screening instrument, use the 

following contact information: 

Multi-Health Systems, Inc. 

P.O. Box 950 

North Tonawanda, NY 

14120-0950 

Phone: 800-456-3003 

Source: Meltzer-Brody et al., 1999. 

Trauma-Informed Care in Behavioral Health Services 

individuals who administer screenings, regardless of education level and experience, should

be aware of trauma-related symptoms,

grounding techniques, ways of creating safety 

for the client, proper methods for introducing

screening tools, and the protocol to follow

when a positive screen is obtained. (See Appendix D for information on specific instruments.) Exhibit 1.4-5 is an example of a

screening instrument for trauma symptoms,

the Primary Care PTSD (PC-PTSD) Screen. 

Current research (Prins et al., 2004) suggests 

that the optimal cutoff score for the PC-PTSD 

is 3. If sensitivity is of greater concern than

efficiency, a cutoff score of 2 is recommended. 

Another instrument that can screen for traumatic stress symptoms is the four-item selfreport SPAN, summarized in Exhibit 1.4-6, 

which is derived from the 17-item Davidson 

Trauma Scale (DTS). SPAN is an acronym for

the four items the screening addresses: startle,

physiological arousal, anger, and numbness. It

was developed using a small, diverse sample of

adult patients (N=243; 72 percent women;

17.4 percent African American; average age =

37 years) participating in several clinical studies, including a family study of rape trauma,

combat veterans, and Hurricane Andrew survivors, among others. 

The SPAN has a high diagnostic accuracy of

0.80 to 0.88, with sensitivity (percentage of

true positive instances) of 0.84 and specificity

(percentage of true negative instances) of 0.91

(Meltzer-Brody, Churchill, & Davidson, 

1999). SPAN scores correlated highly with the

full DTS (r = 0.96) and other measures, such

as the Impact of Events Scale (r = 0.85) and

the Sheehan Disability Scale (r = 0.87). 

The PTSD Checklist (Exhibit 1.4-7), developed by the National Center for PTSD, is in

the public domain. Originally developed for

combat veterans of the Vietnam and Persian 

108 
Exhibit 1.4-7: The PTSD Checklist 

Instructions to Client: Below is a list of problems and complaints that people sometimes have in 

response to stressful experiences. Please read each one carefully and circle the number that indicates how much you have been bothered by that problem in the past month. 

1. Repeated, disturbing memories, thoughts, or images of a stressful experience? 

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5. Extremely 

2. Repeated, disturbing dreams of a stressful experience? 

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5. Extremely 

3. Suddenly acting or feeling as if a stressful experience were happening again (as if you 

were reliving it)? 

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5. Extremely 

4. Feeling very upset when something reminded you of a stressful experience? 

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5. Extremely 

5. Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of a stressful experience? 

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5. Extremely 

6. Avoiding thinking about or talking about a stressful experience or avoiding having feelings 

related to it? 

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5. Extremely 

7. Avoiding activities or situations because they reminded you of a stressful experience? 

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5. Extremely 

8. Trouble remembering important parts of a stressful experience? 

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5. Extremely 

9. Loss of interest in activities that you used to enjoy? 

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5. Extremely 

10. Feeling distant or cut off from other people? 

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5. Extremely 

11. Feeling emotionally numb or being unable to have loving feelings for those close to you? 

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5. Extremely 

12. Feeling as if your future will somehow be cut short? 

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5. Extremely 

13. Trouble falling or staying asleep? 

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5. Extremely 

14. Feeling irritable or having angry outbursts? 

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5. Extremely 

15. Having difficulty concentrating? 

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5. Extremely 

16. Being “super-alert” or watchful or on guard? 

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5. Extremely 

17. Feeling jumpy or easily startled? 

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5. Extremely 

Source: Weathers et al., 1993. Material used is in the public domain. 

Part 1, Chapter 4—Screening and Assessment 

109 
 

 

 

 

 

 

Exhibit 1.4-8: Resilience Scales 

A number of scales with good psychometric 

properties measure resilience: 

• Resilience Scale (Wagnild & Young, 1993) 

• Resilience Scale for Adults (Friborg, 

Hjemdal, Rosenvinge, & Martinussen, 2003) 

• Connor Davidson Resilience Scale, 25-,10-, 

and 2-Item (Connor & Davidson, 2003; 

Campbell-Sills & Stein, 2007; Vaishnavi, 

Connor, & Davidson, 2007, respectively) 

• Dispositional Resilience Scale, 45-,30-, 15­

item forms (Bartone, Roland, Picano, 

&Williams, 2008) 

Trauma-Informed Care in Behavioral Health Services 

Gulf Wars, it has since been validated on a

variety of noncombat traumas (Keane, Brief,

Pratt, & Miller, 2007). When using the 

checklist, identify a specific trauma first and

then have the client answer questions in relation to that one specific trauma. 

Other Screening and Resilience 

Measures 

Along with identifying the presence of

trauma-related symptoms that warrant assessment to determine the severity of symptoms as well as whether or not the individual 

possesses subclinical symptoms or has met

criteria for a trauma-related disorder, clients 

should receive other screenings for symptoms 

associated with trauma (e.g., depression, suicidality). It is important that screenings address both external and internal resources (e.g.,

support systems, strengths, coping styles).

Knowing the client’s strengths can significantly shape the treatment planning process by 

allowing you to use strategies that have already

worked for the client and incorporating strategies to build resilience (Exhibit 1.4-8). 

Preliminary research shows improvement of

individual resilience through treatment interventions in other populations (Lavretsky,

Siddarth, & Irwin, 2010). 

Screen for suicidality 

All clients—particularly those who have experienced trauma—should be screened for suicidality by asking, “In the past, have you ever

had suicidal thoughts, had intention to commit suicide, or made a suicide attempt? Do

you have any of those feelings now? Have you 

had any such feelings recently?” Behavioral

health service providers should receive training

to screen for suicide. Additionally, clients with

substance use disorders and a history of psychological trauma are at heightened risk for

suicidal thoughts and behaviors; thus, screening for suicidality is indicated. See TIP 50,

Addressing Suicidal Thoughts and Behaviors in

Substance Abuse Treatment (CSAT, 2009a). For

additional descriptions of screening processes 

for suicidality, see TIP 42 (CSAT, 2005c). 

Concluding Note 

Screenings are only beneficial if there are 

follow-up procedures and resources for handling positive screens, such as the ability to

review results with and provide feedback to

the individual after the screening, sufficient

resources to complete a thorough assessment

or to make an appropriate referral for an assessment, treatment planning processes that

can easily incorporate additional traumainformed care objectives and goals, and availability and access to trauma-specific services 

that match the client’s needs. Screening is only 

the first step! 

110 
 

 

 

 

IN THIS CHAPTER 

• Trauma -Informed

Prevention and Treatment

Objectives

• Treatment Issues

• Making Referrals to

Trauma -Specific Services

Clinical Issues Across 5 Services 

Many clients in behavioral health treatment may have histories of

trauma, so counselors should be prepared to help them address issues that arise from those histories. This chapter begins with a

thorough discussion of trauma-informed prevention and treatment

objectives along with practical counselor strategies. Specific treatment issues related to working with trauma survivors in a clinical 

setting are discussed as well, including client engagement, pacing

and timing, traumatic memories, and culturally appropriate and

gender-responsive services. The chapter ends with guidelines for 

making referrals to trauma-specific services. 

Trauma-Informed Prevention and 

Treatment Objectives 

Trauma-informed care (TIC) not only focuses on identifying individuals who have histories of trauma and traumatic stress symptoms; it also places considerable effort in creating an environment

that helps them recognize the impact of trauma and determine the 

next course of action in a safe place. For some individuals, psychoeducation and development or reinforcement of coping strategies will be the most suitable and effective strategy, whereas others 

may request or warrant a referral for more trauma-specific interventions (see Part 1, Chapter 6, of this Treatment Improvement

Protocol [TIP]). Although research is limited in the area of building resilience to prevent exacerbation of trauma symptoms and

traumatic stress disorders, TIC also focuses on prevention strategies to avoid retraumatization in treatment, to promote resilience, 

and to prevent the development of trauma-related disorders. The 

following sections highlight key trauma-informed prevention and

treatment objectives. 

111 
 

 

 

Trauma-Informed Care in Behavioral Health Services 

TIC Framework in Behavioral Health Services—Clinical Issues Across Services 

seemingly without provocation; feelings of

sadness, anger, shame, or being overwhelmed;

or not having control over sudden disconnections from others make moment-to-moment 

living feel unsafe. Clients might express feeling unsafe through statements such as, “I can’t 

control my feelings,” or, “I just space out and

disconnect from the world for no reason,” or,

“I’m afraid to go to sleep because of the 

nightmares.” The intense feelings that accompany trauma can also make clients feel unsafe.

They may wake up in the morning feeling fine 

but become immobilized by depression as the

day progresses. Clients with histories of trauma may experience panicky feelings of being 

trapped or abandoned. An early effort in

trauma treatment is thus helping the client 

Establish Safety 

Beyond identifying trauma and trauma-related 

symptoms, the initial objective of TIC is establishing safety. Borrowing from Herman’s 

(1992) conceptualization of trauma recovery,

safety is the first goal of treatment. Establishing safety is especially crucial at the outset of

trauma-informed treatment and often becomes a recurrent need when events or therapeutic changes raise safety issues, such as a

change in treatment staffing due to vacations. 

In the context of TIC, safety has a variety of

meanings. Perhaps most importantly, the client has to have some degree of safety from 

trauma symptoms. Recurring intrusive nightmares; painful memories that burst forth 

112 
 

 

 

 

Advice to Counselors: Strategies To Promote Safety 

Strategy #1: Teach clients how and when to use grounding exercises when they feel unsafe or 

overwhelmed. 

Strategy #2: Establish some specific routines in individual, group, or family therapy (e.g., have an 

opening ritual or routine when starting and ending a group session). A structured setting can provide 

a sense of safety and familiarity for clients with histories of trauma. 

Strategy #3: Facilitate a discussion on safe and unsafe behaviors. Have clients identify, on paper, 

behaviors that promote safety and behaviors that feel unsafe for them today. 

Strategy #4: Refer to Seeking Safety: A Treatment Manual for PTSD and Substance Abuse (Najavits, 

2002a). This menu-based manual covers an array of treatment topics, including the core concept of 

safety. Each topic consists of several segments, including preparing for the session, session format, 

session content, handouts, and guidelines. 

Strategy #5: Encourage the development of a safety plan. Depending on the type of trauma, personal safety can be an issue; work with the client to develop a plan that will help him or her feel in 

control and prepared for the unexpected. If the trauma was a natural or human-caused disaster, encourage thinking about how family and friends will respond and connect in the event of another crisis. If sexual abuse or rape was the event, encourage thinking about future steps that could help 

make the client safer. There is a delicate balance between preparation and the realization that one 

cannot prepare for all possible traumatic events. Nonetheless, an action plan can help the client regain a sense of environmental balance. 

Part 1, Chapter 5—Clinical Issues Across Services 

gain more control over trauma symptoms (and

be able to label them as such) by learning

more about the client and helping him or her

develop new coping skills to handle symptoms 

when they arise and stay more grounded when

flooded with feelings or memories. 

A second aspect is safety in the environment. 

Trauma reactions can be triggered by sudden

loud sounds (e.g., television at high volume,

raised voices), tension between people, certain

smells, or casual touches that are perceived as 

invasions of physical boundaries. The vulnerability of exposing one’s history in the treatment setting can manifest in the client as 

feeling physically vulnerable and unsafe in the 

treatment environment. Sudden or inadequately explained treatment transitions, such

as moving from one level of treatment to another or changing counselors, can also evoke 

feelings of danger, abandonment, or instability. Early in treatment, trauma survivors generally value routine and predictability. The 

counselor should recognize these needs and 

respond appropriately by offering information

in advance, providing nonshaming responses 

to a client’s reactions to stimuli in his or her 

environment, and helping the client build a 

daily structure that feels safe. 

A third aspect of safety is preventing a recurrence of trauma. People with histories of

trauma and substance abuse are more likely to

engage in high-risk behaviors and to experience subsequent traumas. Early treatment

should focus on helping clients stop using

unsafe coping mechanisms, such as substance

abuse, self-harm, and other self-destructive 

behaviors, and replacing them with safe and

healthy coping strategies. Helping clients 

learn to protect themselves in reasonable ways 

is a positive goal of treatment. 

Prevent Retraumatization 

A key objective in TIC is to prevent retraumatization generated by intervention and treatment practices and policies. Unfortunately,

treatment settings and clinicians can 

113 
 

 

 

 

 

 

Advice to Counselors: Strategies To Prevent Retraumatization 

Strategy #1: Be sensitive to the needs of clients who have experienced trauma regarding behaviors 

in the treatment setting that might trigger memories of the trauma. 

Strategy #2: Do not ignore clients’ symptoms and demands when clients with trauma histories act out 

in response to triggered trauma memories; doing so may replicate the original traumatic experience. 

Strategy #3: Be mindful that efforts to control and contain a client’s behaviors in treatment can produce an abnormal reaction, particularly for trauma survivors for whom being trapped was part of the 

trauma experience. 

Strategy #4: Listen for specific triggers that seem to be driving the client’s reaction. An important 

step in recovery is helping the client identify these cues and thereby reach a better understanding of 

reactions and behaviors. 

Trauma-Informed Care in Behavioral Health Services 

unintentionally create retraumatizing experiences (for a review of traumas that can occur

when treating serious mental illness, see Frueh

et al., 2005). For instance, compassionate inquiry into a client’s history can seem similar to

the interest shown by a perpetrator many years

before. Direct confrontation by counselors 

about behaviors related to substance abuse can 

be seen, by someone who has been repeatedly 

physically assaulted, as provocation building

up to assault. Counselor and program efforts 

to help clients constrain destructive behaviors 

can be interpreted as efforts to control and

dominate the individual. Intrusive shaming or

insensitive behavior demonstrated by another

client in the program can threaten a trauma

survivor whose boundaries have been disregarded in the past—thus making the experience of treatment feel dangerous rather than

safe. Some staff and agency issues that can

result in retraumatization include: 

•	 Disrespectfully challenging reports of abuse 

or other traumatic events. 

•	 Discounting a client’s report of a traumatic 

event. 

•	 Using isolation. 

•	 Using physical restraints. 

•	 Allowing the abusive behavior of one client

toward another to continue without 

intervention. 

•	 Labeling intense rage and other feelings as 

pathological. 

•	 Minimizing, discrediting, or ignoring client 

responses. 

•	 Disrupting counselor–client relationships 

by changing counselors’ schedules and assignments. 

•	 Obtaining urine specimens in a nonprivate

and/or disrespectful manner. 

•	 Having clients undress in the presence of

others. 

•	 Being insensitive to a client’s physical or 

emotional boundaries. 

•	 Inconsistently enforcing rules and allowing

chaos in the treatment environment. 

•	 Applying rigid agency policies or rules 

without an opportunity for clients to question them. 

•	 Accepting agency dysfunction, including a

lack of consistent, competent leadership. 

Provide Psychoeducation 

Trauma-informed education informs clients 

about traumatic stress and trauma-related 

symptoms and disorders as well as the related 

consequences of trauma exposure. It focuses 

on giving information to clients to help normalize presenting symptoms, to highlight potential short-term and long-term 

consequences of trauma and various paths to

recovery, and to underscore the message that

recovery is possible. Education frequently 

takes place prior to or immediately following

an initial screening as a way to prepare clients 

114 
 

 

 

 

Advice to Counselors: Strategies To Implement Psychoeducation 

Strategy #1: Remember that this may be the client’s first experience with treatment. It’s easy to use 

program or clinical jargon when you’re around it every day, but most individuals who seek help are 

unfamiliar with clinical language, how the program works, and treatment objectives. Psychoeducation 

begins with understanding the client’s expectations and reasons for seeking help, followed by educating the client and other family members about the program. Remember that this is all new for 

them. 

Strategy #2: After obtaining acknowledgment of a trauma history, provide an overview of common 

symptoms and consequences of traumatic stress, regardless of whether the client affirms having 

trauma-related symptoms. It is equally important to educate the client on resilience factors associated with recovery from trauma (Wessely et al., 2008). A trauma-informed perspective provides a message that trauma reactions are normal responses to an abnormal situation. 

Strategy #3: Develop a resource box that provides an array of printed or multimedia educational 

materials that address the program, specific symptoms and tools to combat trauma-related symptoms, treatment options and therapy approaches, advantages of peer support, and steps in developing specific coping strategies. 

Strategy #4: Develop a rotating educational group that matches services and client schedules to 

complement treatment. Remember that education can play a pivotal role in enhancing motivation, in 

normalizing experiences, and in creating a sense of safety as individuals move further into treatment. 

For some survivors, education can be a powerful intervention or prevention strategy. 

Part 1, Chapter 5—Clinical Issues Across Services 

for hearing results or to place the screening

and subsequent assessment findings in proper

context. Education in and of itself, however,

does not necessarily constitute a stand-alone 

treatment; rather, it can be conceptualized as a

first step and/or component of more comprehensive treatment. Nonetheless, education

may be a prevention and intervention strategy 

for individuals who have histories of trauma 

without current consequences or symptoms 

and/or those who have reported a resolution

of past trauma(s). For example, some clients

may have significantly delayed onset of traumatic stress symptoms. In this scenario, earlier 

education can enhance recognition of symptoms and ease the path of seeking treatment. 

Some clients do not recognize the link between their current difficulties and their trauma histories; education can help them 

understand the possible origin of their difficulties. Psychoeducation presents traumarelated symptoms that follow a trauma as 

normal reactions. By identifying the source of 

clients’ current difficulties and framing them 

as normal thoughts, emotions, and behaviors 

in response to trauma, many trauma survivors 

report a reduction in the intensity of the difficulties or symptoms. Often, a client will express relief that his or her reactions are

normal. You may find the U.S. Department of

Veterans Affairs (VA) National Center on

PTSD’s educational handouts on traumatic 

stress reactions useful. 

Psychoeducation goes beyond the identification of traumatic stress symptoms and/or

learning about the psychological, cognitive,

and physical impacts of trauma. Numerous 

curricula are available that use psychoeducation as a first-line or complementary approach

to trauma-specific therapies to enhance coping

strategies in key areas, including safety, emotional regulation, help-seeking, avoidant behavior, and so forth. An example is S.E.L.F.,

a trauma-informed psychoeducational group

curriculum with educational components related to trauma recovery in the following 

115 
 

 “This might not sound like a big deal, but 

for many people relationships have 

become all about getting: telling your 

problem story and then getting help with 

it. There is little, if any, emphasis placed 

on giving back. That’s a big deal!!! Service 

relationships are like a one -way street and 

both people’s roles are clearly defined. 

But in ‘regular’ relationships in your 

community, people give and take all the 

time. No one is permanently on the taking 

side or the giving side. This exchange 

contributes to people feeling ok about 

being vulnerable (needing help) as well as 

confident about what they’re offering. For 

many of us, being the role of ‘getter’ all 

the time has shaken our confidence, 

making us feel like we have nothing 

worthwhile to contribute. Peer support 

breaks that all down. It gets complicated 

somewhat when one of us is paid, but 

modeling this kind of relationship in which 

both of us learn, offers us the real practice 

we need to feel like a ‘regular’ community 

member as opposed to an ‘integrated 

mental patient’.” 

(Mead, 2008, p.7) 

Case Illustration: Linda 

Linda served as an Army nurse in an evacuation hospital in Vietnam. She reported her postdeployment adjustment as difficult and isolating but denied any significant symptoms of traumatic stress 

throughout her life. Four years ago, Linda sought treatment for alcohol dependence; during the intake, she recalls denying trauma-related symptoms. “I distinctly remember the session,” she recounts. “The counselor first took my history but then gave information on typical symptoms and 

reactions to trauma. I thought, ‘Why do I need to hear this? I’ve survived the worst trauma in my life.’ 

I didn’t see the value of this information. Then 3 weeks ago, I began to have recurrent nightmares, 

the same graphic type I occasionally had when I was in Vietnam. Since then, I’ve been very anxious, 

reliving horrible scenes that I’d experienced as a nurse and postponing going to bed in fear of having 

the dreams again. I didn’t understand it. I am 70 years old, and the war happened a long time ago. 

Then I began putting it together. Recently, the emergency helicopter flight pattern and approach to 

the area’s hospital changed. I began hearing the helicopter periodically in my living room, and it reminded me of Vietnam. I knew then that I needed help; I couldn’t stop shaking. I felt as if I was losing 

control of my emotions. I remembered how the intake counselor took the time to explain common 

symptoms of trauma. That’s why I’m here today.” 

Trauma-Informed Care in Behavioral Health Services 

areas: creating Safety, regulating Emotions, 

addressing Loss, and redefining the Future 

(Bloom, Foderaro, & Ryan, 2006). 

Offer Trauma-Informed Peer 

Support 

Living with a history of trauma can be isolating and consuming. The experience of trauma

can reinforce beliefs about being different,

alone, and marred by the experience. At times,

behavioral health treatment for trauma-related 

effects can inadvertently reinforce these beliefs. Simply engaging in treatment or receiving specialized services (although warranted)

can further strengthen clients’ beliefs that 

there is something wrong with them. Formalized peer support can enhance the treatment

experience. Treatment plus peer support can

break the cycle of beliefs that reinforce traumatic stress (e.g., believing that one is permanently damaged; that nobody could

understand; that no one should or could tolerate one’s story). Peer support provides opportunities to form mutual relationships; to learn

how one’s history shapes perspectives of self,

others, and the future; to move beyond trauma; and to mirror and learn alternate coping

strategies. Peer support defines recovery as an 

116 
Advice to Counselors: Strategies To Enhance Peer Support 

Strategy #1: Provide education on what peer support is and is not. Roles and expectations of peer 

support can be confusing, so providing clarification in the beginning can be quite useful. It is important to provide initial education about peer support and the value of using this resource. 

Strategy #2: Use an established peer support curriculum to guide the peer support process. For example, Intentional Peer Support: An Alternative Approach (Mead, 2008) is a workbook that highlights 

four main tasks for peer support: building connections, understanding one’s worldview, developing 

mutuality, and helping each other move toward set desires and goals. This curriculum provides extensive materials for peer support staff members as well as for the individuals seeking peer support. 

interactive process, not as a definitive moment

wherein someone fixes the “problem.” 

Normalize Symptoms 

Symptoms of trauma can become serious barriers to recovery from substance use and mental disorders, including trauma-related ones.

Counselors should be aware of how trauma 

symptoms can present and how to respond to

them when they do appear. A significant step

in addressing symptoms is normalizing them.

People with traumatic stress symptoms need

to know that their symptoms are not unique 

and that their reactions are common to their 

experience(s). Often, normalizing symptoms 

gives considerable relief to clients who may 

have thought that their symptoms signified

Advice to Counselors: Strategies To some pervasive, untreatable mental disorder. 

Normalize Symptoms 

Strategy #1: Provide psychoeducation on the 

common symptoms of traumatic stress. 

Strategy #2: Research the client’s most prevalent symptoms specific to trauma, and then 

provide education to the client. For example, 

an individual who was conscious and trapped 

during or as a result of a traumatic event will 

more likely be hypervigilant about exits, plan 

escape routes even in safe environments, and 

have strong reactions to interpersonal and 

environmental situations that are perceived as 

having no options for avoidance or resolution 

(e.g., feeling stuck in a work environment 

where the boss is emotionally abusive). 

Strategy #3: First, have the client list his or her 

symptoms. After each symptom, ask the client 

to list the negative and positive consequences 

of the symptom. Remember that symptoms 

serve a purpose, even if they may not appear 

to work well or work as well as they had in the 

past. Focus on how the symptoms have served 

the client in a positive way (see Case Illustration: Hector). This exercise can be difficult, 

because clients as well as counselors often 

don’t focus on the value of symptoms. 

Case Illustration: Hector 

Hector was referred to a halfway house specializing in co-occurring disorders after inpatient 

treatment for methamphetamine dependence 

and posttraumatic stress disorder (PTSD). In 

the halfway house, he continued to feel overwhelmed with the frequency and intensity of 

flashbacks. He often became frustrated, expressing anger and a sense of hopelessness, 

followed by emotional withdrawal from others 

in the house. Normalization strategy #3 was 

introduced in the session. During this exercise, 

he began to identify many negative aspects of 

flashbacks. He felt that he couldn’t control the 

occurrence of flashbacks even though he wanted to, and he realized that he often felt shame 

afterward. In the same exercise, he was also 

urged to identify positive aspects of flashbacks. 

Although this was difficult, he realized that 

flashbacks were clues about content that he 

needed to address in trauma-specific treatment. “I realized that a flashback, for me, was a 

billboard advertising what I needed to focus on 

in therapy.” 

Part 1, Chapter 5—Clinical Issues Across Services 

117 
 

Advice to Counselors: Strategies To Identify and Manage Trauma-Related 

Triggers 

Strategy #1: Use the Sorting the Past From the Present technique for cognitive realignment 

(Blackburn, 1995) to help separate the current situation from the past trauma. Identify one trigger at 

a time, and then discuss the following questions with the client: 

• When and where did you begin to notice a reaction? 

• How does this situation remind you of your past history or past trauma? 

• How are your reactions to the current situation similar to your past reactions to the trauma(s)? 

• How was this current situation different from the past trauma? 

• How did you react differently to the current situation than to the previous trauma? 

• How are you different today (e.g., factors such as age, abilities, strength, level of support)? 

• What choices can you make that are different from the past and that can help you address the 

current situation (trigger)? 

After reviewing this exercise several times in counseling, put the questions on a card for the client to 

carry and use outside of treatment. Clients with substance use disorders can benefit from using the 

same questions (slightly reworded) to address relapse triggers. 

Strategy #2: After the individual identifies the trigger and draws connections between the trigger 

and past trauma, work with him or her to establish responses and coping strategies to deal with 

triggers as they occur. Initially, the planned responses will not immediately occur after a trigger, but 

with practice, the planned responses will move closer to the time of the trigger. Some strategies 

include an acronym that reflects coping strategies (Exhibit 1.5-1), positive self-talk generated by 

cognitive–behavioral covert modeling exercises (rehearsal of coping statements), breathing retraining, and use of support systems (e.g., calling someone). 

Strategy #3: Self-monitoring is any strategy that asks a client to observe and record the number of 

times something happens, to note the intensity of specific experiences, or to describe a specific 

behavioral, emotional, or cognitive phenomenon each time it occurs. For individuals with histories of 

trauma, triggers and flashbacks can be quite frightening, intense, and powerful. Even if the client has 

had just one or two triggers or flashbacks, he or she may perceive flashbacks as happening constantly. 

Often, it takes time to recover from these experiences. Using self-monitoring and asking the client 

to record each time a trigger occurs, along with describing the trigger and its intensity level (using a 

scale from 1–10), clients and counselors will gain an understanding of the type of triggers present 

and the level of distress that each one produces. Moreover, the client may begin to see that the 

triggers don’t actually happen all the time, even though they may seem to occur frequently. 

Trauma-Informed Care in Behavioral Health Services 

Identify and Manage TraumaRelated Triggers 

Many clients who have traumatic stress are 

caught off guard with intrusive thoughts, feelings, sensations, or environmental cues of the 

trauma. This experience can be quite disconcerting, but often, the individual does not

draw an immediate connection between the 

internal or external trigger and his or her reactions. At other times, the trigger is so potent 

that the individual is unable to discern the 

present trigger from the past trauma and begins to respond as if the trauma is reoccurring. 

Key steps in identifying triggers are to reflect

back on the situation, surroundings, or sensations prior to the strong reaction. By doing so,

you and your client may be able to determine 

the connections among these cues, the past

trauma(s), and the client’s reaction. Once the 

cue is identified, discuss the ways in which it

is connected to past trauma. For some cues,

there will be an obvious and immediate connection (e.g., having someone say “I love you”

in a significant relationship as an adult and

connecting this to an abuser who said the

same thing prior to a sexual assault). Other 

118 
Exhibit 1.5-1: The OBSERVATIONS 

Coping Strategy 

• Take a moment to just Observe what is 

happening. Pay attention to your body, 

your senses, and your environment. 

• Focus on your Breathing. Allow your feelings and sensations to wash over you. 

Breathe. 

• Name the Situation that initiated your 

response. In what way is this situation familiar to your past? How is it different? 

• Remember that Emotions come and go. 

They may be intense now, but later they 

will be less so. Name your feelings. 

• Recognize that this situation does not define you or your future. It does not dictate 

how things will be, nor is it a sign of things 

to come. Even if it is familiar, it is only one 

event. 

• Validate your experience. State, at least 

internally, what you are feeling, thinking, 

and experiencing. 

• Ask for help. You don’t have to do this 

alone. Seek support. Other people care for 

you. Let them! 

• This too shall pass. Remember: There are 

times that are good and times that are not 

so good. This hard time will pass. 

• I can handle this. Name your strengths. 

Your strengths have helped you survive. 

• Keep an Open mind. Look for and try out 

new solutions. 

• Name strategies that have worked before. 

Choose one and apply it to this situation. 

• Remember you have survived. You are a 

Survivor! 

cues will not be as obvious. With practice, the

client can begin to track back through what 

occurred immediately before an emotional,

physical, or behavioral reaction and then examine how that experience reminds him or

her of the past. 

Draw Connections 

Mental health and substance abuse treatment 

providers have historically underestimated the 

effects of trauma on their clients for many 

reasons. Some held a belief that substance 

Advice to Counselors: Strategies To 

Help Clients Draw Connections 

Strategy #1: Writing about trauma can help 

clients gain awareness of their thoughts, feelings, and current experiences and can even 

improve physical health outcomes (Pennebaker, 

Kiecolt-Glaser, & Glaser, 1988; Smyth, 

Hockemeyer, & Tulloch, 2008). Although this 

tool may help some people draw connections 

between current experiences and past traumas, 

it should be used with caution; others may find 

that it brings up too much intense trauma material (especially among vulnerable trauma survivors with co-occuring substance abuse, 

psychosis, and current domestic violence). Journal writing is safest when you ask clients to write 

about present-day specific targets, such as logging their use of coping strategies or identifying 

strengths with examples. Writing about trauma 

can also be done via key questions or a workbook that provides questions centered upon 

trauma experiences and recovery. 

Strategy #2: Encourage clients to explore the 

links among traumatic experiences and mental 

and substance use disorders. Recognition that 

a mental disorder or symptom developed after 

the trauma occurred can provide relief and 

hope that the symptoms may abate if the 

trauma is addressed. Ways to help clients connect substance use with trauma histories include (Najavits, 2002b; Najavits, Weiss, & 

Shaw, 1997): 

• Identifying how substances have helped 

“solve” trauma or PTSD symptoms in the 

short term (e.g., drinking to get to sleep). 

• Teaching clients how trauma, mental, and 

substance use disorders commonly cooccur so that they will not feel so alone and 

ashamed about these issues. 

• Discussing how substance abuse has impeded healing from trauma (e.g., by blocking feelings and memories). 

• Helping clients recognize trauma symptoms as triggers for relapse to substance 

use and mental distress. 

• Working on new coping skills to recover 

from trauma and substance abuse at the 

same time. 

• Recognizing how both trauma and substance abuse often occur in families 

through multiple generations. 

Part 1, Chapter 5—Clinical Issues Across Services 

119 
 

 

 

 

 

 

The Subjective Units of Distress Scale 

(SUDS) uses a 0 –10 rating scale, with 0 

representing content that causes no or 

minimal distress and 10 representing 

content that is exceptionally distressing 

and overwhelming. 

(Wolpe & Abrams, 1991) 

Advice to Counselors: Strategy To Teach Balance 

Strategy #1: Teach and use the SUDS in counseling. This scale can be useful from the outset as a 

barometer for the client and counselor to measure the level of distress during and outside of sessions. 

It provides a common language for the client and counselor, and it can also be used to guide the 

intensity of sessions. SUDS can tangibly show a client’s progress in managing experiences. Without a 

scale, it is more difficult to grasp that a distressing symptom or circumstance is becoming less and 

less severe without some repeated measure. 

Trauma-Informed Care in Behavioral Health Services 

abuse should be addressed before attending to

any co-occurring conditions. Others did not

have the knowledge and training to evaluate 

trauma issues or were uncomfortable or reluctant to discuss these sensitive issues with clients (Ouimette & Brown, 2003). Similarly, in

other behavioral health settings, clinicians

sometimes address trauma-related symptoms

but do not have experience or training in the 

treatment of substance abuse. 

So too, people who have histories of trauma

will often be unaware of the connection between the traumas they’ve experienced and

their traumatic stress reactions.They may notice depression, anger, or anxiety, or they may

describe themselves as “going crazy” without 

being able to pinpoint a specific experience that

produced the trauma symptoms. Even if clients

recognize the events that precipitated their

trauma symptoms, they may not understand 

how others with similar experiences can have 

different reactions. Thus, a treatment goal for 

trauma survivors is helping them gain awareness of the connections between their histories 

of trauma and subsequent consequences. Seeing

the connections can improve clients’ ability to

work on recovery in an integrated fashion. 

Teach Balance 

You and your clients need to walk a thin line

when addressing trauma. Too much work 

focused on highly distressing content can turn

a desensitization process into a session whereby the client dissociates, shuts down, or becomes emotionally overwhelmed. On the 

other hand, too little focus by the client or 

counselor can easily reinforce avoidance and

confirm the client’s internal belief that it is too 

dangerous to deal with the aftermath of the

trauma. Several trauma-specific theories offer 

guidelines on acceptable levels of distress associated with the traumatic content that the 

therapy addresses. For example, some traditional desensitization processes start at a very 

low level of subjective distress, gradually working up through a hierarchy of trauma memories and experiences until those experiences 

produce minimal reactions when paired with

some coping strategy, such as relaxation training. Other desensitization processes start at a

higher level of intensity to provide more rapid

extinction of traumatic associations and to 

decrease the risk of avoidance—a behavior 

that reinforces traumatic stress. 

Working with trauma is a delicate balancing

act between the development and/or use of 

coping strategies and the need to process the 

traumatic experiences. Individuals will choose 

different paths to recovery; it’s a myth that 

every traumatic experience needs to be expressed and every story told. For some individuals, the use of coping skills, support, and

spirituality are enough to recover. Regardless 

of theoretical beliefs, counselors must teach 

120 
 

 

 

 

 

 

Advice to Counselors: Strategies To 

Build Resilience 

Strategy #1: Help clients reestablish personal 

and social connections. Access community and 

cultural resources; reconnect the person to 

healing resources such as mutual-help groups 

and spiritual supports in the community. 

Strategy #2: Encourage the client to take action. Recovery requires activity. Actively taking 

care of one’s own needs early in treatment can 

evolve into assisting others later on, such as by 

volunteering at a community organization or 

helping military families. 

Strategy #3: Encourage stability and predictability in the daily routine. Traumatic stress reactions can be debilitating. Keeping a daily 

routine of sleep, eating, work, errands, household chores, and hobbies can help the client 

see that life continues. Like exercise, daily living skills take time to take hold as the client 

learns to live through symptoms. 

Strategy #4: Nurture a positive view of personal, social, and cultural resources. Help clients recall ways in which they successfully 

handled hardships in the past, such as the loss 

of a loved one, a divorce, or a major illness. 

Revisit how those crises were addressed. 

Strategy #5: Help clients gain perspective. All 

things pass, even when facing very painful 

events. Foster a long-term outlook; help clients 

consider stress and suffering in a spiritual 

context. 

Strategy #6: Help maintain a hopeful outlook. 

An optimistic outlook enables visions of good 

things in life and can keep people going even 

in the hardest times. There are positive aspects 

to everyone’s life. Taking time to identify and 

appreciate these enhances the client’s outlook 

and helps him or her persevere. 

Strategy #7: Encourage participation in peer 

support, 12-Step, and other mutual-help 

programs. 

Source: American Psychological Association, 

2003. 

Part 1, Chapter 5—Clinical Issues Across Services 

coping strategies as soon as possible. Retraumatization is a risk whenever clients are exposed to their traumatic histories without 

sufficient tools, supports, and safety to manage 

emotional, behavioral, and physical reactions. 

Build Resilience 

Survivors are resilient! Often, counselors and

clients who are trauma survivors focus on the 

negative consequences of trauma while failing

to recognize the perseverance and attributes 

that have helped them survive. It is natural to

focus on what’s not working rather than what

has worked. To promote growth after trauma

and establish a strengths-based approach, focus on building on clients’ resilience. Current 

resilience theories claim that building or reinforcing resilience prevents further development

of trauma-related symptoms and disorders.The

following Advice to Counselors box is adapted

from the American Psychological Association’s 

2003 statement on resilience. 

Address Sleep Disturbances 

Sleep disturbances are one of the most enduring symptoms of traumatic stress and are a

particularly common outcome of severe and

prolonged trauma. Sleep disturbances increase 

one’s risk of developing traumatic stress; they 

significantly alter physical and psychological 

processes, thus causing problems in daytime 

functioning (e.g., fatigue, cognitive difficulty,

excessive daytime sleepiness). People with

sleep disturbances have worse general health

and quality of life. The cardiovascular and 

immune systems, among others, may be affected as well. Sleep disturbances can worsen

traumatic stress symptoms and interfere with

healing by impeding the brain’s ability to process and consolidate traumatic memories 

(Caldwell & Redeker, 2005). 

Sleep disturbances vary among trauma survivors and can include decreased ability to stay

asleep, frequent awakenings, early morning 

unintentional awakening, trouble falling

asleep, poor quality of sleep, and disordered 

121 
 

 

Advice to Counselors: Strategies To Conduct a Sleep Intervention 

Strategy #1: Conduct a sleep history assessment focused first on the client’s perception of his or her 

sleep patterns. Assess whether there is difficulty initiating or staying asleep, a history of frequent or 

early morning awakenings, physically restless sleep, sleepwalking, bedtime aversion, and/or disruptive physical and emotional states upon awakening (e.g., confusion, agitation, feeling unrested). Also 

determine total sleep time, pattern of nightmares, and use of medications, alcohol, and/or caffeine 

(see Moul, Hall, Pikonis, & Buysse, 2004, for a review of self-report measures). 

Strategy #2: Use a sleep hygiene measure to determine the presence of habits that typically interfere with sleep (e.g., falling asleep while watching television). The National Sleep Foundation Web 

site (http://www.sleepfoundation.org) provides simple steps for promoting good sleep hygiene.. 

Strategy #3: Provide education on sleep hygiene practices. Introduce clients to the idea that practicing good sleep hygiene is one step toward gaining control over their sleep disturbances. 

Strategy #4: Reassess sleep patterns and history during the course of treatment. Sleep patterns 

often reflect current client status. For example, clients who are struggling are more likely to have 

disturbed sleep patterns; sleep disturbances significantly influence clients’ mental health status. 

Strategy #5: Use interventions such as nightmare rehearsals to target recurrent nightmares. There 

are numerous examples of imagery-based nightmare rehearsals. Clients may be instructed to rehearse repetitively the recurrent nightmare a few hours before bedtime. In this instruction, the client 

either rehearses the entire nightmare with someone or visualizes the nightmare several times to gain 

control over the material and become desensitized to the content. Other strategies involve imagining a change in the outcome of the nightmare (e.g., asking the client to picture getting assistance 

from others, even though his or her original nightmare reflects dealing with the experience alone). 

Case Illustration: Selena 

Selena initially sought treatment for ongoing depression (dysthymia). During treatment, she identified 

being sexually assaulted while attending a party at college. At times, she blames herself for the incident because she didn’t insist that she and her girlfriends stay together during the party and on the 

way back to their dorm afterward. Selena reported that she only had two drinks that night: “I could 

never manage more than two drinks before I wanted to just sleep, so I never drank much socially.” 

She was assaulted by someone she barely knew but considered a “big brother” in the brother fraternity of her sorority. “I needed a ride home. During that ride, it happened,” she said. For years thereafter, Selena reported mild bouts of depression that began lasting longer and increasing in number. 

She also reported nightmares and chronic difficulty in falling asleep. In therapy, she noted avoiding 

her bed until she’s exhausted, saying, “I don’t like going to sleep; I know what’s going to happen.” 

She describes fear of sleeping due to nightmares. “It’s become a habit at night. I get very involved in 

playing computer games to lose track of time. I also leave the television on through the night because then I don’t sleep as soundly and have fewer nightmares. But I’m always exhausted.” 

Trauma-Informed Care in Behavioral Health Services 

breathing during sleep (Caldwell & Redeker,

2005). Most traumatic stress literature focuses 

on nightmares, insomnia, and frequent awakenings. These disturbances are connected to

two main symptoms of traumatic stress: hyperarousal (which causes difficulty in falling

and remaining asleep) and reexperiencing the 

trauma (e.g., through recurrent nightmares). 

Other sleep disturbances trauma survivors 

report include sleep avoidance or resistance to

sleep (see Case Illustration: Selena), panic

awakenings, and restless or unwanted body 

movements (e.g., hitting your spouse unintentionally in bed while asleep; Habukawa,

Maeda, & Uchimura, 2010). 

122 
 

 

 

Advice to Counselors: Strategies To Build Trust 

Strategy #1: Clients can benefit from a support or counseling group composed of other trauma survivors. By comparing themselves with others in the group, they can be inspired by those who are 

further along in the recovery process and helpful to those who are not faring as well as they are. 

These groups also motivate clients to trust others by experiencing acceptance and empathy. 

Strategy #2: Use conflicts that arise in the program as opportunities. Successful negotiation of a 

conflict between the client and the counselor is a major milestone (van der Kolk, McFarlane, & Van 

der Hart, 1996). Helping clients understand that conflicts are healthy and inevitable in relationships 

(and that they can be resolved while retaining the dignity and respect of all involved) is a key lesson 

for those whose relationship conflicts have been beset by violence, bitterness, and humiliation. 

Strategy #3: Prepare clients for staff changes, vacations, or other separations. Some clients may feel 

rejected or abandoned if a counselor goes on vacation or is absent due to illness, especially during a 

period of vulnerability or intense work. A phone call to the client during an unexpected absence can 

reinforce the importance of the relationship and the client’s trust. You can use these opportunities in 

treatment to help the client understand that separation is part of relationships; work with the client 

to view separation in a new light. 

Strategy #4: Honor the client–counselor relationship, and treat it as significant and mutual. You can 

support the development of trust by establishing clear boundaries, being dependable, working with 

the client to define explicit treatment goals and methods, and demonstrating respect for the client’s 

difficulty in trusting you and the therapeutic setting. 

Part 1, Chapter 5—Clinical Issues Across Services 

Build Trust 

Some traumatic experiences result from trusting others (e.g., interpersonal trauma). In other cases, trust was violated during or after the 

traumatic experience, as in cases when help

was late to arrive on the scene of a natural 

disaster. This lack of trust can leave individuals 

alienated, socially isolated, and terrified of

developing relationships. Some feel that the 

trauma makes them different from others who 

haven’t had similar experiences. Sometimes, a 

client’s trust issues arise from a lack of trust in 

self—for instance, a lack of trust in one’s perceptions, judgment, or memories. People who

have also experienced severe mental or substance use disorders may have difficulty trusting others because, during the course of their

illness, they felt alienated or discriminated

against for behaviors and emotions generated

by or associated with the disorders. 

Some client groups (e.g., gay, lesbian, and bisexual clients; people from diverse cultures;

those with serious mental illness) evidence 

significant mistrust because their trust has

been repeatedly violated in the past. Traumatic

experiences then compound this mistrust.

Mistrust can come from various sources, is 

usually unstated, and, if left unaddressed, can

impede treatment. For example, some clients 

leave treatment early or do not engage in potentially beneficial treatments. Others avoid

issues of trust and commitment by leaving

treatment when those issues begin to arise. 

Establishing a safe, trusting relationship is 

paramount to healing—yet this takes time in

the counseling process. Counselors and other

behavioral health professionals need to be 

consistent throughout the course of treatment;

this includes maintaining consistency in the

parameters set for availability, attendance, and

level of empathy. Trust is built on behavior

shown inside and outside of treatment; you 

should immediately address any behavior that

may even slightly injure the relationship (e.g.,

being 5 minutes late for an appointment, not

responding to a phone message in a timely 

manner, being distracted in a session). 

123 
 

 

Case Illustration: Abby 

Abby, a 30-year-old, nervous-looking woman, is brought by her parents to a community mental 

health clinic near their home in rural Indiana. During the intake process, the counselor learns that 

Abby is an Army Reservist who returned from 12 months of combat duty 3 years ago. The war experience changed her in many ways. Her deployment pulled her away from veterinary school as well as 

the strong emotional support of family, friends, and fellow classmates. She got along with her unit in 

Iraq and had no disciplinary problems. While there, she served as a truck driver in the Sunni Triangle. 

Her convoy was attacked often by small arms fire and was once struck by an improvised explosive 

device. Although Abby sustained only minor injuries, two of her close friends were killed. With each 

successive convoy, her level of fear and foreboding grew, but she continued performing as a driver. 

Since returning to the United States, she has mostly stayed at home and has not returned to school, 

although she is helping out on the farm with various chores. Abby has isolated herself from both 

family members and lifelong friends, saying she doesn’t think others can understand what she went 

through and that she prefers being alone. She reports to her parents and the counselor that she is 

vaguely afraid to be in cars and feels most comfortable in her room or working alone, doing routine 

tasks, at home. Abby also says that she now understands how fragile life can be. 

She has admitted to her parents that she drinks alcohol on a regular basis, something she did not do 

before her deployment, and that on occasion, she has experienced blackouts. Abby feels she needs 

a drink before talking with strangers or joining in groups of friends or family. She confided to her 

father that she isolates herself so that she can drink without having to explain her drinking to others. 

The counselor recognizes Abby’s general sense of lacking internal control and feeling powerless 

over what will happen to her in the future. He adopts a motivational interviewing style to establish 

rapport and a working alliance with Abby. During sessions, the counselor asks Abby to elaborate on 

her strengths; he reinforces strengths that involve taking action in life, positive self-statements, and 

comments that deal with future plans. He also introduces Abby to an Iraq War veteran who came 

home quite discouraged about putting his life together but has done well getting reintegrated. The 

counselor urges Abby go to the local VA center so that she can meet and bond with other recently 

returned veterans. He also encourages Abby to attend Alcoholics Anonymous meetings, emphasizing that she won’t be pressured to talk or interact with others more than she chooses to. 

The counselor continues to see Abby every week and begins using cognitive–behavioral techniques 

to help her examine some of her irrational fears about not being able to direct her life. He asks Abby 

to keep a daily diary of activities related to achieving her goals of getting back to school and 

reestablishing a social network. In each session, Abby reviews her progress using the diary as a 

memory aid, and the counselor reinforces these positive efforts. After 4 months of treatment, Abby 

reenrolls in college and is feeling optimistic about her ability to achieve her career plans. 

Trauma-Informed Care in Behavioral Health Services 

Support Empowerment 

Strong feelings of powerlessness can arise in

trauma survivors seeking to regain some control of their lives. Whether a person has survived a single trauma or chronic trauma, the 

survivor can feel crushed by the weight of

powerlessness. Mental illness and substance 

abuse, too, can be disempowering; clients may 

feel that they’ve lost control over their daily 

lives, over a behavior such as drug use, or over 

powerful emotions such as fear, sadness, or

anger. Empowerment means helping clients 

feel greater power and control over their lives,

as long as such control is within safe and

healthy bounds. A key facet of empowerment

is to help clients build on their strengths. Empowerment is more than helping clients discover what they “should” do; it is also helping

them take the steps they feel ready to take. 

124 
 

•	 Loved one’s death resulting from disaster:

unexpected, untimely, sudden, and shocking (New South Wales Institute of Psychiatry & Centre for Mental Health, 2000). 

Advice to Counselors: Strategies To Support Empowerment 

Strategy #1: Offer clients information about treatment; help them make informed choices. Placing 

appropriate control for treatment choices in the hands of clients improves their chances of success. 

Strategy #2: Give clients the chance to collaborate in the development of their initial treatment plan, 

in the evaluation of treatment progress, and in treatment plan updates. Incorporate client input into 

treatment case consultations and subsequent feedback. 

Strategy #3: Encourage clients to assume an active role in how the delivery of treatment services 

occurs. An essential avenue is regularly scheduled and structured client feedback on program and 

clinical services (e.g., feedback surveys). Some of the most effective initiatives to reinforce client empowerment are the development of peer support services and the involvement of former clients in 

parts of the organizational structure, such as the advisory board or other board roles. 

Strategy #4: Establish a sense of self-efficacy in clients; their belief in their own ability to carry out a 

specific task successfully—is key. You can help clients come to believe in the possibility of change 

and in the hope of alternative approaches to achieving change. Supporting clients in accepting increasing responsibility for choosing and carrying out personal change can facilitate their return to 

empowerment (Miller & Rollnick, 2002). 

Advice to Counselors: Strategies To 

Acknowledge and Address Grief 

Strategy #1: Help the client grieve by being 

present, by normalizing the grief, and by assessing social supports and resources. 

Strategy #2: When the client begins to discuss 

or express grief, focus on having him or her 

voice the losses he or she experienced due to 

trauma. Remember to clarify that losses include 

internal experiences, not just physical losses. 

Strategy #3: For a client who has difficulty 

connecting feelings to experiences, assign a 

feelings journal in which he or she can log and 

name each feeling he or she experiences, rate 

the feeling’s intensity numerically, and describe 

the situation during which the feeling occurred. 

The client may choose to share the journal in 

an individual or group session. 

Strategy #4: Note that some clients benefit 

from developing a ritual or ceremony to honor 

their losses, whereas others prefer offering 

time or resources to an association that represents the loss. 

Part 1, Chapter 5—Clinical Issues Across Services 

Acknowledge Grief and 

Bereavement 

The experience of loss is common after traumas, whether the loss is psychological (e.g., no

longer feeling safe) or physical (e.g., death of a

loved one, destruction of community, physical 

impairment). Loss can cause public displays of

grief, but it is more often a private experience.

Grieving processes can be emotionally overwhelming and can lead to increased substance 

use and other impulsive behaviors as a way to

manage grief and other feelings associated

with the loss. Even for people who experienced trauma years prior to treatment, grief is 

still a common psychological issue. Delayed or

absent reactions of acute grief can cause exhaustion, lack of strength, gastrointestinal 

symptoms, and avoidance of emotions. 

Risk factors of chronic bereavement (grief

lasting more than 6 months) can include:

•	 Perceived lack of social support. 

•	 Concurrent crises or stressors (including

reactivation of PTSD symptoms). 

•	 High levels of ambivalence about the loss. 

•	 An extremely dependent relationship prior

to the loss. 

125 
 

Advice to Counselors: Strategies To 

Monitor and Facilitate Stability 

Strategy #1: If destabilization occurs during 

the intake process or treatment, stop exploring 

the material that triggered the reaction, offer 

emotional support, and demonstrate ways for 

the client to self-soothe. 

Strategy #2: Seek consultation from supervisors and/or colleagues (e.g., to explore whether a new case conceptualization is needed at 

this point). 

Strategy #3: Refer the client for a further assessment to determine whether a referral is 

necessary for trauma-specific therapy or a 

higher level of care, or use of multiple levels of 

care (e.g., intensive outpatient care, partial 

hospitalization, residential treatment). 

Strategy #4: Focus on coping skills and encourage participation in a peer support 

program. 

Strategy #5: When a client becomes agitated 

and distressed, carefully explore with the client 

what is causing this state. When such feelings 

arise because of current threats in the client’s 

life or environment, it is dangerous to halt or 

soothe away responses that act as warning 

signals (Pope & Brown, 1996). When a client is 

in a situation involving domestic violence, lives 

in a dangerous neighborhood, or has run out of 

money for food, he or she requires direct and 

concrete assistance rather than simple emotional support. 

Source: Briere & Scott, 2006b. 

 

Managing Destabilization 

When a client becomes destabilized during a 

session, you can respond in the following manner: “Let’s slow down and focus on helping you 

be and feel safe. What can we do to allow you 

to take care of yourself at this moment? Then, 

when you feel ready, we can decide what to 

focus on next.” 

Trauma-Informed Care in Behavioral Health Services 

Monitor and Facilitate Stability 

Stability refers to an ongoing psychological 

and physical state whereby one is not overwhelmed by disruptive internal or external 

stimuli (Briere & Scott, 2006b). It’s common 

for individuals to have an increase in symptoms, distress, or impairment when dealing

with the impact of their trauma or talking

about specific aspects of their trauma. There is 

a thin line that the client and counselor need 

to negotiate and then walk when addressing 

trauma. Too much work focused on highly 

distressing content can turn a desensitization

process into a session that causes the client to

dissociate, shut down, or become emotionally 

overwhelmed. On the other hand, too little 

focus by the client or counselor can easily reinforce avoidance and confirm the client’s internal belief that it is too dangerous to deal with

the aftermath of the trauma. 

Clients should have some psychological stability to engage in trauma-related work. An important distinction can be made between a 

normative increase in symptoms (e.g., the typical up-and-down course of traumatic stress 

reactions or substance abuse) and destabilization (dangerous, significant decrease in functioning). Signs of destabilization include

(Green Cross Academy of Traumatology,

2007; Najavits, 2002b): 

•	 Increased substance use or other unsafe 

behavior (e.g., self-harm). 

•	 Increased psychiatric symptoms (e.g., depression, agitation, anxiety, withdrawal, 

anger). 

•	 Increased symptoms of trauma (e.g., severe

dissociation). 

•	 Helplessness or hopelessness expressed

verbally or behaviorally. 

•	 Difficulty following through on commitments (e.g., commitment to attend treatment sessions). 

•	 Isolation. 

•	 Notable decline in daily activities (e.g.,

self-care, hygiene, care of children or pets,

going to work). 

126 
Advice to Counselors: Strategies To 

Foster Engagement 

Strategy #1: According to Mahalik (2001), the 

standard method of handling clients’ lack of 

engagement is exploring it with them, clarifying the situation through discussion with 

them, reinterpreting (e.g., from “can’t” to 

“won’t” to “willing”), and working through the 

situation toward progress. 

Strategy #2: To improve engagement into 

treatment, try motivational interviewing and 

enhancement techniques. For additional information on such techniques, see TIP 35, Enhancing Motivation for Change in Substance 

Abuse Treatment (Center for Substance Abuse 

Treatment [CSAT], 1999b). 

Part 1, Chapter 5—Clinical Issues Across Services 

Treatment Issues 

The treatment environment itself can significantly affect how clients experience traumatic

stress and how the client responds to treatment. Some specific issues related to working

with trauma survivors in a clinical setting are

discussed in the following sections. 

Client Engagement 

A lack of engagement in treatment is the client’s inability to make progress toward treatment goals, deal with important topics in

treatment, or complete treatment. Clients who

have histories of trauma will express ambivalence about treatment similarly to others, except that clients who have traumatic stress can

feel more “stuck” and perceive themselves as 

having fewer options. In addition, clients may

be avoiding engagement in treatment because 

it is one step closer to addressing their trauma.

You should attend to the client’s motivation to 

change, implement strategies that address ambivalence toward treatment, and use approaches that help clients overcome avoidant

behavior. 

Pacing and Timing 

Although your training or role as a counselor

may prohibit you from providing traumaspecific services, you must still be prepared for

the fact that clients are not as focused on 

when or where it is most appropriate to address trauma—they want relief, and most lay 

and professional people have been taught that

the only path to recovery is disclosure. Some 

clients are reluctant to talk about anything

associated with their histories of trauma. Other clients immediately want to delve into the 

memories of their trauma without developing

a safe environment. The need to gain any relief

for the traumatic stress pushes some individuals to disclose too quickly, without having the

necessary support and coping skills to manage 

the intensity of their memories. Clients who

enter treatment and immediately disclose past

trauma often don’t return because the initial 

encounter was so intense or because they experienced considerable emotional distress for

several days afterward and/or in anticipation

of the next session. 

Proper pacing of sessions, disclosure, and intensity is paramount. Clients who immediately disclose without proper safety nets are 

actually retraumatizing themselves by reliving

the experience without adequate support—

often placing themselves in the same circumstances that occurred during the actual traumas they experienced. Although you should

not adamantly direct clients not to talk about 

what happened, it is important to discuss with 

the clients, even if you have to interrupt them

empathically and respectfully, the potential

consequences of disclosing too soon and too 

fast. Ask whether they have done this before,

and then inquire about the outcome. Reinforce with clients that trauma heals when 

there are support, trust, and skills in place to

manage the memories of the traumatic experiences. Ideally, disclosure begins after these 

elements are secured, but realistically, it is a 

127 
 

balancing act for both the counselor and client

as to when and how much should be addressed in any given session. Remember not to

inadvertently give a message that it is too dangerous to talk about trauma; instead, reinforce

the importance of addressing trauma without

further retraumatization. 

Advice to Counselors: Strategies To Establish Appropriate Pacing and Timing 

Strategy #1: Frequently discuss and request feedback from clients about pacing and timing. Moving 

too quickly into discussion of the trauma can increase the risk of dissociation, overactivation of 

memories, and feeling overwhelmed. 

Strategy #2: Use the SUDS as a barometer of intensity to determine the level of work. 

Strategy #3: Slowly increase the speed of interventions and continually adjust the intensity of interventions; move in and out of very intense work, or use strategies that decrease the intensity when 

necessary. One approach that typically decreases the intensity of traumatic memories is to ask the 

individual to imagine that he or she is seeing the scene through a window or on a television screen. 

This helps decrease intensity and the risk of dissociation. It provides an opportunity for the client to 

view the trauma from a different perspective and a strategy to use outside of treatment to shift from 

reliving the trauma to observing it from a neutral position. 

Strategy #4: Monitor clients to ensure that treatment does not overwhelm their internal capacities, 

retraumatize them, or result in excessive avoidance; make sure therapy occurs in the “therapeutic 

window” (Briere & Scott, 2006b). 

Strategy #5: Be alert to signs that discussions of trauma, including screening, assessment, and intake processes, are going too fast. Mild to moderate signs are: 

• Missing counseling appointments after discussions of important material. 

• Periods of silence. 

• Dissociation. 

• Misunderstanding what are usually understandable concepts. 

• Redirecting the focus of the discussion when certain issues arise. 

Strategy #6: Observe the client’s emotional state. Slow down; seek consultation if the client exhibits: 

• Persistent resistance to addressing trauma symptoms. 

• Repetitive flashbacks. 

• Increase in dissociation. 

• Regression. 

• Difficulty in daily functioning (e.g., trouble maintaining everyday self-care tasks). 

• Substance use relapses. 

• Self-harm or suicidal thoughts/behaviors (e.g., talking about suicide). 

Strategy #7: Use caution and avoid (Briere, 1996b, p. 115): 

• Encouraging clients to describe traumatic material in detail before they can deal with the consequences of disclosure. 

• Using overly stressful interventions (e.g., intensive role-plays, group confrontation, guided 

imagery). 

• Confrontations or interpretations that are too challenging given the client’s current functioning. 

• Demanding that the client work harder and stop resisting. 

Source: Strategies 1–6: Green Cross Academy of Traumatology, 2001. Adapted with permission. 

Trauma-Informed Care in Behavioral Health Services 

Length of Treatment 

Many factors influence decisions regarding the 

length of treatment for a given client. Severity 

of addiction, type of substance abused, type of

trauma, age at which the trauma occurred,

level of social support, and the existence of 

128 
 

Memories of Trauma 

Points for counselors to remember are: 

• Some people are not able to completely 

remember past events, particularly events 

that occurred during high-stress and destabilizing moments. 

• In addition to exploring the memories 

themselves, it can be beneficial to explore 

how a memory of an event helps the client 

understand his or her feeling, thinking, and 

behaving in the present. 

• Persistently trying to recall all the details of 

a traumatic event can impair focus on the 

present. 

Part 1, Chapter 5—Clinical Issues Across Services 

mental disorders all influence length of treatment. External factors, such as transportation

and childcare, caps on insurance coverage, and

limitations in professional resources, can also

affect length of treatment. In general, longer

treatment experiences should be expected for 

clients who have histories of multiple or early 

traumas, meet diagnostic criteria for multiple

Axis I or Axis II diagnoses, and/or require 

intensive case management. Most of the empirically studied and/or manual-based models 

described in the next chapter are short-term 

models (e.g., lasting several months); however,

ongoing care is indicated for clients with more 

complex co-occurring trauma disorders. 

Traumatic Memories 

One of the most controversial issues in the 

trauma field is the phenomenon of “recovered

memories” or “traumatic amnesia” (Brewin,

2007). Practitioners working with traumatized

individuals are particularly concerned about

the possibility of new memories of the traumatic event emerging during the course of

therapy and the possibility of these memories 

being induced by the clinician. Scientific reviews indicate that people can experience amnesia and delayed recall for some memories of a

wide variety of traumas, including military 

combat and prisoner of war experiences, natural 

disasters and accidents, childhood sexual abuse,

and political torture (Bowman & Mertz, 1996;

Brewin, 2007; Karon & Widener, 1997;

McNally, 2005). In some cases, the survivor

will not remember some of what happened,

and the counselor may need to help the client

face the prospect of never knowing all there is 

to know about the past and accept moving on

with what is known. 

Legal Issues 

Legal issues can emerge during treatment. A

client, for instance, could seek to prosecute a

perpetrator of trauma (e.g., for domestic violence) or to sue for damages sustained in an 

accident or natural disaster. The counselor’s 

role is not to provide legal advice, but rather,

to offer support during the process and, if

needed, refer the client to appropriate legal

help (see Advice to Counselors box on p. 131). 

A legal matter can dominate the treatment

atmosphere for its duration. Some clients have 

difficulty making progress in treatment until 

most or all legal matters are resolved and no

longer act as ongoing stressors. 

Forgiveness 

Clients may have all sorts of reactions to what 

has happened to them. They may feel grateful 

for the help they received, joy at having survived, and dedication to their recovery. At the

other extreme, they may have fantasies of revenge, a loss of belief that the world is a good 

place, and feelings of rage at what has happened. They may hold a wide variety of beliefs 

associated with these feelings. 

One issue that comes up frequently among

counselors is whether to encourage clients to

forgive. The issue of forgiveness is a very delicate one. It is key to allow survivors their feelings, even if they conflict with the counselor’s 

own responses. Some may choose to forgive 

the perpetrator, whereas others may remain

angry or seek justice through the courts and

other legal means. Early in recovery from 

129 
 

Advice to Counselors: Strategies To Manage Traumatic Memories 

Strategy #1: Most people who were sexually abused as children remember all or part of what happened to them, although they do not necessarily fully understand or disclose it. Do not assume that 

the role of the clinician is to investigate, corroborate, or substantiate allegations or memories of 

abuse (American Psychiatric Association [APA], 2000b). 

Strategy #2: Be aware that forgotten memories of childhood abuse can be remembered years later. 

Clinicians should maintain an empathic, nonjudgmental, neutral stance toward reported memories of 

sexual abuse or other trauma. Avoid prejudging the cause of the client’s difficulties or the veracity of 

the client’s reports. A counselor’s prior belief that physical or sexual abuse, or other factors, are or 

are not the cause of the client’s problems can interfere with appropriate assessment and treatment 

(APA, 2000b). 

Strategy #3: Focus on assisting clients in coming to their own conclusions about the accuracy of 

their memories or in adapting to uncertainty regarding what actually occurred. The therapeutic goal 

is to help clients understand the impact of the memories or abuse experiences on their lives and to 

reduce their detrimental consequences in the present and future (APA, 2000b). 

Strategy #4: Some clients have concerns about whether or not a certain traumatic event did or did 

not happen. In such circumstances, educate clients about traumatic memories, including the fact that 

memories aren’t always exact representations of past events; subsequent events and emotions can 

have the effect of altering the original memory. Inform clients that it is not always possible to determine whether an event occurred but that treatment can still be effective in alleviating distress. 

Strategy #5: There is evidence that suggestibility can be enhanced and pseudomemories can develop in some individuals when hypnosis is used as a memory enhancement or retrieval strategy. Hypnosis and guided imagery techniques can enhance relaxation and teach self-soothing strategies with 

some clients; however, use of these techniques is not recommended in the active exploration of 

memories of abuse (Academy of Traumatology, 2007). 

Strategy #6: When clients are highly distressed by intrusive flashbacks of delayed memories, help 

them move through the distress. Teach coping strategies and techniques on how to tolerate strong 

affect and distress (e.g., mindfulness practices). 

Trauma-Informed Care in Behavioral Health Services 

trauma, it is best to direct clients toward focusing on stabilization and a return to normal

functioning; suggest that, if possible, they delay major decisions about forgiveness until 

they have a clearer mind for making decisions

(Herman, 1997). Even in later stages of recovery, it’s not essential for the client to forgive in

order to recover. Forgiveness is a personal 

choice independent of recovery. Respect clients’ personal beliefs and meanings; don’t push 

clients to forgive or impose your own beliefs 

about forgiveness onto clients. 

In the long-term healing process, typically 

months or years after the trauma(s), forgiveness may become part of the discussion for 

some people and some communities. For example, in South Africa, years after the bitter

and bloody apartheid conflicts, a Truth and

Reconciliation Commission was established by 

the Government. Public hearings created dialog and aired what had been experienced as a

means, ultimately, to promote forgiveness and

community healing. By addressing very difficult topics in public, all could potentially 

benefit from the discourse. Similarly, a parental survivor of the Oklahoma City bombing

was, at first, bitter about his daughter’s early,

unfair, and untimely death. Today, he gives 

talks around the world about the abolition of 

the death penalty. He sat with convicted 

130 
 

Advice to Counselors: Strategies To Manage Legal Proceedings 

Strategy #1: If you’re aware of legal proceedings, you can play a key role in helping your client prepare emotionally for their impact, such as what it might be like to describe the trauma to a judge or 

jury, or how to cope with seeing the perpetrator in court. When helping a client prepare, however, 

be careful not to provide legal advice. 

Strategy #2: Help clients separate a successful legal outcome from a successful treatment outcome. 

If clients connect these two outcomes, difficulties can arise. For example, a client may discontinue 

treatment after his or her assailant is sentenced to serve prison time, believing that the symptoms 

will abate without intervention. 

Strategy #3: If clients express interest in initiating a civil or criminal suit, encourage them to consider 

the ways in which they are and are not prepared for this, including their own mental states, capacity 

for resilience, and inevitable loss of confidentiality (Pope & Brown, 1996). Inform clients coping with 

legal issues that involvement in the legal process can be retraumatizing. 

Strategy #4: Emphasize, for trauma survivors who are involved in legal proceedings against an assailant, that “not guilty” is a legal finding—it is based on the degree of available evidence and is not 

a claim that certain events in question did not occur. They should also receive, from an attorney or 

other qualified individual, information on: 

• The nature of the legal process as it pertains to the clients’ specific cases. 

• The estimated duration and cost of legal services, if applicable. 

• What to expect during police investigations. 

• Court procedures. 

• Full information on all possible outcomes. 

• What to expect during cross-examination. 

Strategy #5: Counselors can be called on to assist with a legal case involving trauma. The court may 

require you to provide treatment records, to write a letter summarizing your client’s progress, or to 

testify at a trial. Always seek supervisory and legal advice in such situations and discuss with the client the possible repercussions that this might have for the therapeutic relationship. As a general 

rule, it is best practice to avoid dual roles or relationships. 

Part 1, Chapter 5—Clinical Issues Across Services 

bomber Timothy McVeigh’s father while the 

man’s son was executed in Indiana at a Federal 

prison several years after the bombing. For this 

man, forgiveness and acceptance helped him 

attain personal peace. Other trauma survivors 

may choose never to forgive what happened,

and this, too, is a legitimate response. 

Culturally and Gender Responsive 

Services 

Culture is the lens through which reality is 

interpreted. Without an understanding of culture, it is difficult to gauge how individuals

organize, interpret, and resolve their traumas.

The challenge is to define how culture affects 

individuals who have been traumatized. 

Increased knowledge of PTSD (Wilson &

Tang, 2007), mental illness, and substance use 

disorders and recovery (Westermeyer, 2004)

requires behavioral health practitioners to consider the complicated interactions between

culture, personality, mental illness, and substance abuse in adapting treatment protocols.

This section offers some general guidelines for

working with members of cultures other than 

one’s own. Treatment for traumatic stress,

mental illness, substance use disorders, and cooccurring trauma-related symptoms is more 

effective if it is culturally responsive. 

131 
 

 

 

 

 

 

 

 

Cultural Competence 

Cultural competence includes a counselor’s 

knowledge of: 

• Whether the client is a survivor of cultural 

trauma (e.g., genocide, war, government 

oppression, torture, terrorism). 

• How to use cultural brokers (i.e., authorities 

within the culture who can help interpret 

cultural patterns and serve as liaisons to 

those outside the culture). 

• How trauma is viewed by an individual’s 

sociocultural support network. 

• How to differentiate PTSD, trauma-related 

symptoms, and other mental disorders in 

the culture. 

For more specific information on cultural competence in trauma therapy, see Brown (2008). 

Trauma-Informed Care in Behavioral Health Services 

The U.S. Department of Health and Human

Services (2003) has defined the term “cultural

competence” as follows: 

Cultural competence is a set of values, behaviors, attitudes, and practices within a system,

organization, program, or among individuals

that enables people to work effectively across

cultures. It refers to the ability to honor and

respect the beliefs, language, interpersonal

styles, and behaviors of individuals and families receiving services, as well as staff who are

providing such services. Cultural competence

is a dynamic, ongoing, developmental process

that requires a long-term commitment and is

achieved over time (p. 12). 

Cultural competence is a process that begins 

with an awareness of one’s own culture and 

beliefs and includes an understanding of how 

those beliefs affect one’s attitudes toward people of other cultures. It is rooted in respect,

validation, and openness toward someone 

whose social and cultural background is different from one’s own. For a thorough review of 

cultural competence, see the planned TIP, Improving Cultural Competence (Substance Abuse 

and Mental Health Services Administration 

[SAMHSA], planned c). 

In some cultures, an individual’s needs take 

precedence over group needs (Hui & Triandis,

1986), and problems are seen as deriving from 

the self. In other cultures, however, complex

family, kin, and community systems take precedence over individual needs. Considerable 

heterogeneity exists within and across most

ethnic subcultures and across lines of gender,

class, age, and political groups (CSAT, 1999b).

Subcultures abound in every culture, such as 

gangs; populations that are homeless or use 

substances; orphaned or disenfranchised people; religious, ethnic, and sexual minorities;

indigenous people; and refugee and immigrant

populations. Some subcultures have more in

common with similar subcultures in other 

countries than with their own cultures (e.g.,

nonheterosexual populations). 

Trauma and substance abuse can themselves 

be a basis for affiliation with a subculture. De 

Girolamo (1993) reports that “disaster subcultures” exist within many cultures. These cultures of victimization, like all subcultures, have 

unique worldviews, codes of conduct, and perceptions of the larger society. In a disaster subculture, people are, to some extent, inured to

disaster and heedless of warnings of impending disaster. For example, riverbank erosion in

Bangladesh displaces thousands of people each

year, yet few believe that it is a serious problem 

or that the displacement will be permanent

(Hutton, 2000). Israelis who have lived with

unpredictable violence for many years behave 

differently in public areas and have adapted to

different norms than people who don’t commonly experience violence (Young, 2001). 

Many people identify with more than one 

subculture. Some identify with a particular

culture or subculture, but not with all of its

values. Individual identities are typically a mosaic of factors, including developmental 

achievements, life experiences, behavioral

health histories, traumatic experiences, and 

132 
Part 1, Chapter 5—Clinical Issues Across Services 

 

 

 

 

 

 

 

 

 

 

 

 

Community-Based Treatment for 

Native American Historical Trauma 

Key beliefs in community healing: 

• Clients carry childhood pain that has led to 

adult dysfunction. 

• Childhood pain must be confronted, confessed, and addressed, if relief is to be 

obtained. 

• Cathartic expression is the initial step in the 

healing journey toward a lifelong pursuit of 

introspection and self-improvement. 

• The healing journey entails reclamation of 

indigenous heritage, identity, spirituality, 

and practices to remedy the pathogenic effects of colonization and other sources of 

historical trauma. 

Source: Gone, 2009. 

alcohol and illicit drug use; levels of acculturation and/or assimilation vary from one individual to the next as well. 

Importance of the trauma aftermath 

Counselors working in the immediate aftermath of trauma—whether individual, group, or

community in nature—face many challenges.

For example, survivors may be forced to adjust

without access to other health services, employment, support, or insurance. In these instances, counselors must often work with 

individuals and communities coping with the

trauma while struggling daily to meet basic

needs. Research suggests that reestablishing

ties to family, community, culture, and spiritual 

systems can not only be vital to the individual,

but can also influence the impact of the trauma upon future generations. For example,

Baker and Gippenreiter (1998) studied the

descendants of people victimized by Joseph

Stalin’s purge. They found that families who

were able to maintain a sense of connection 

and continuity with grandparents affected by 

the purge experienced fewer negative effects 

than did those who were emotionally or physically severed from their grandparents. The 

researchers also found that whether the 

grandparents survived was less important than

the connection the grandchildren managed to

keep to their past. Ties to family and community can also have an adverse effect, especially 

if the family or community downplays the 

trauma or blames the victim. Counselors need 

to have a full understanding of available support before advocating a particular approach. 

Treatment strategies 

Many traditional healing ways have been

damaged, forgotten, or lost—yet much wisdom remains. Drawing on the best traditional 

and contemporary approaches to human distress and defining culturally competent curricula regarding identity and healing (Huriwai,

2002; Wilson & Tang, 2007) both require 

respect and appreciation for the many ways in

which various people characterize and resolve

trauma and how they use addictive substances 

to bear the burdens of human distress. 

It is not yet known how well existing PTSD

treatments work for individuals who identify

primarily with cultures other than mainstream 

American culture. It is possible that such 

treatments do work for clients of other cultures, though some cultural adaptation and

translation may be required. For example,

some PTSD treatments that have been used 

with subculture groups without adaptation

other than language translation and that appear to be effective across cultures include eye

movement desensitization and reprocessing

(Bleich, Gelkopf, & Solomon, 2003) and

Seeking Safety (Daouest et al., 2012). 

Gender 

Gender differences exist in traumatic stress,

mental disorders, and substance use disorders.

For example, women have higher rates of

PTSD, whereas men have higher rates of substance abuse (Kessler, Chiu, Demler,

Merikangas, & Walters, 2005; Stewart, 

Ouimette, & Brown, 2002; Tolin & Foa, 2006). 

133 
 

 

 

 

 

Working With Clients From Diverse Cultures: Trauma and Substance Abuse 

• In socially appropriate ways, educate clients, their loved ones, and possibly members of their 

extended community about the relationship between substance abuse and PTSD, how substance 

abuse is often used to cope with trauma, and what treatment entails. 

• Make serious efforts to connect clients to supportive and understanding people (preferably within 

culturally identified groups). 

• Help clients understand that many who have not experienced trauma or do not have substance 

use disorders will not understand the psychological, spiritual, and interpersonal insights that they 

have gained during their recovery processes. 

Trauma-Informed Care in Behavioral Health Services 

The types of interpersonal trauma experienced

by men and by women are often different. A

number of studies (Kimerling, Ouimette, &

Weitlauf, 2007) indicate that men experience

more combat and crime victimization and 

women experience more physical and/or sexual assault—implying that men’s traumas often 

occur in public, whereas the traumatization of 

women is more likely to take place in a private 

setting, such as a home. Men’s abusers are 

more often strangers. Those who abuse women, on the other hand, are more often in a relationship with them. Women (and girls) often

are told, “I love you,” during the same time 

period when the abuse occurs. However, women now serve in the military and thus are increasingly subject to some of the same traumas 

as men and also to military sexual trauma,

which is much more common for women to 

experience. Similarly, men can be subject to

domestic violence or sexual abuse. 

In treatment, gender considerations are relevant in a variety of ways, including, but not

limited to, the role and impact of societal gender stereotypes upon assessment processes,

treatment initiation, and engagement of services (e.g., peer support systems); the selection

and implementation of gender-specific and 

gender-responsive approaches for both men

and women at each level of intervention; and

the best selection of trauma-related interventions that account for gender-specific differences related to traumatic stress. For an 

extensive review and discussion of genderspecific and gender-responsive care for traumatic stress and substance use, see the TIP 51,

Substance Abuse Treatment: Addressing the

Specific Needs of Women (CSAT, 2009d), and 

TIP 56, Addressing the Specific Behavioral

Health Needs of Men (SAMHSA, 2013a). 

Beyond the complexities of gender considerations, one must also consider whether clients 

should be given the choice of working with a

male or a female counselor. Some clients who 

have been traumatized have no preference,

particularly if their trauma wasn’t associated 

with gender (e.g., a natural disaster, act of terrorism, fire, serious accident). If gender did 

play a role in trauma (e.g., childhood sexual 

abuse), clients can have strong fears of working with a counselor who is the same gender

as the perpetrator. Many women who experienced sexual abuse (whose perpetrators are 

typically men) feel uncomfortable being treated by men because of the intense emotions 

that can be evoked (e.g., anger, fear). Men who

experienced sexual abuse (whose perpetrators

are also typically men) can feel uncomfortable 

for the same reasons, or they may feel shame 

when talking to men due to feelings evoked

about masculinity, homosexuality, and so forth.

However, not all clients with trauma histories 

prefer female therapists. 

Discuss with clients the possible risks (e.g.,

initial emotional discomfort) and benefits of

being treated by a woman or man (e.g., developing a therapeutic relationship with a man

might challenge a client’s belief that all men 

are dangerous), and, if possible, let them then

choose the gender of their counselor. Tell 

134 
 

 

Part 1, Chapter 5—Clinical Issues Across Services 

them that if they experience initial emotional 

discomfort, and the discomfort does not decrease, they can switch to a counselor of the

opposite gender. For group therapy that focuses 

on trauma, similar considerations apply. Generally, gender-specific groups are recommended

when possible, but mixed-gender groups also

work. Gender also comes into play in substance 

abuse treatment. Research and clinical observation indicate that significant gender differences

occur in many facets of substance abuse and its 

treatment. For example, men and women experience different physical repercussions of substance use (e.g., women have more health

problems), different trajectories (e.g., women

become addicted more quickly), and different

treatment considerations (e.g., traditional substance abuse treatment was designed for men). 

Sexual orientation 

Lesbian, gay, bisexual, and transgender

(LGBT) clients face specific issues in behavioral health treatment settings, including histories of abuse and discrimination relating to

sexual orientation, homophobia in treatment

on the part of counselors or other clients, potential difficulty addressing traumatic experiences related to their sexuality or sexual 

orientation, and often, a significant lack of

trust toward others. LGBT people sometimes 

think that others can’t understand them and 

their specific needs and thus are reluctant to

engage in treatment programs in which the

clientele is predominantly heterosexual. Some

clients react with judgment, anger, or embarrassment when an LGBT client attempts to

describe sexual trauma relating to homosexual 

behavior, making it even harder for LGBT

clients to describe their experiences. 

Often, individual counseling can address issues 

the LGBT client isn’t comfortable discussing

in group treatment. “Providing one-on-one

services may decrease the difficulty of mixing

heterosexual and LGBT clients in treatment 

groups and decrease the likelihood that heterosexism or homophobia will become an issue”

(CSAT, 2001, p. 56). For more on treating

LGBT individuals, see A Provider’s Introduction to Substance Abuse Treatment for Lesbian,

Gay, Bisexual, and Transgender Individuals

(CSAT, 2001). 

Making Referrals to 

Trauma-Specific Services 

Many people who experience trauma do not

exhibit persistent traumatic stress symptoms.

In fact, people do recover on their own. So

how do you determine who is at higher risk

for developing more persistent symptoms of

traumatic stress, trauma-related disorders, and

traumatic stress disorders? One main factor is 

the severity of symptoms at the time of

screening and assessment. Other factors, beyond trauma characteristics and pretrauma

individual characteristics, to consider in making referrals include (Ehlers & Clark, 2003):

•	 Cognitive appraisals that are excessively 

negative regarding trauma sequelae, including consequences, changes after the

event(s), responses of other people to the

trauma, and symptoms. 

•	 Acknowledgment of intrusive memories. 

•	 Engagement in behaviors that reinforce or

prevent resolution of trauma, including

avoidance, dissociation, and substance use. 

•	 History of physical consequences of trauma

(e.g., chronic pain, disfigurement, health

problems). 

•	 Experiences of more traumas or stressful 

life events after the prior trauma. 

•	 Identification of co-occurring mood disorders or serious mental illness. 

The next chapter provides an overview of

trauma-specific services to complement this 

chapter and to provide trauma-informed

counselors with a general knowledge of

trauma-specific treatment approaches. 

135 

IN THIS CHAPTER 

• Introduction

• Trauma -Specific

Treatment Models

• Integrated Models for

Trauma

• Emerging Interventions

• Concluding Note

 

 

 

6 Trauma-Specific Services

This chapter covers various treatment approaches designed specifically to treat trauma-related symptoms, trauma-related disorders,

and specific disorders of traumatic stress. The models presented do

not comprise an exhaustive list, but rather, serve as examples.

These models require training and supervised experience to be 

conducted safely and effectively. The chapter begins with a section

on trauma-specific treatment models, providing a brief overview of

interventions that can be delivered immediately after a trauma, as 

well as trauma-specific interventions for use beyond the immediate 

crisis. The second segment focuses on integrated care that targets 

trauma-specific treatment for mental, substance use, and cooccurring disorders. Even though entry-level, trauma-informed 

behavioral health service providers are unlikely to be in a position

to use these interventions, having some knowledge of them is nevertheless important. Currently, more research is needed to tease 

out the most important ingredients of early interventions and their 

role in the prevention of more pervasive traumatic stress symptoms. More science-based evidence is available for trauma-specific 

treatments that occur and extend well beyond the immediate reactions to trauma. The last part of the chapter provides a brief review 

of selected emerging interventions that have not been covered

elsewhere in this Treatment Improvement Protocol (TIP). 

Introduction 

Trauma-specific therapies vary in their approaches and objectives.

Some are present focused, some are past focused, and some are 

combinations (Najavits, 2007a). Present-focused approaches primarily address current coping skills, psychoeducation, and managing symptoms for better functioning. Past-focused approaches

primarily focus on telling the trauma story to understand the impact of the trauma on how the person functions today, experiencing emotions that were too overwhelming to experience in the past,

and helping clients more effectively cope in the present with their 

137 
 

Trauma-Informed Care in Behavioral Health Services 

Trauma-Informed Care Framework in Behavioral Health Services—TraumaSpecific Services 

traumatic experiences. Clients participating in

present-focused approaches may reveal some 

of their stories; past-focused approaches emphasize how understanding the past influences 

current behavior, emotion, and thinking,

thereby helping clients cope more effectively 

with traumatic experiences in the present. 

The distinction between these approaches lies 

in the primary emphasis of the approach. Depending on the nature of the trauma and the

specific needs of the client, one approach may 

be more suitable than the other. For instance,

in short-term treatment for clients in early 

recovery from mental illness and/or substance 

abuse, present-focused, cognitive–behavioral,

or psychoeducational approaches are generally 

more appropriate. For clients who are stable in

their recovery and have histories of developmental trauma where much of the trauma has 

been repressed, a past-focused orientation may 

be helpful. Some clients may benefit from 

both types, either concurrently or sequentially. 

This chapter discusses a number of treatment

models, general approaches, and techniques. A

treatment model is a set of practices designed

to alleviate symptoms, promote psychological 

well-being, or restore mental health. Treatment techniques are specific procedures that

can be used as part of a variety of models.

Some models and techniques described in this 

chapter can be used with groups, some with

individuals, and some with both. This chapter

is selective rather than comprehensive; additional models are described in the literature. 

See, for example, the PILOTS database on the 

Web site of the National Center for PTSD 

138 
 

 

 

Federal Agencies 

Both the American Red Cross and the Federal 

Emergency Management Agency (FEMA) respond to disasters. Behavioral health service 

providers should understand the basics about 

these major emergency response agencies. For 

example, the Red Cross can respond rapidly 

with funding for food, shelter, and immediate 

needs, whereas FEMA assistance requires a 

period of gearing up but provides for longerterm needs. SAMHSA, along with other Federal 

agencies, assists FEMA in a number of areas of 

emergency response planning activities. See 

also SAMHSA’s Disaster Technical Assistance 

Center Web site (http://www.samhsa.gov/dtac) 

and Technical Assistance Publication 34, Disaster Planning Handbook for Behavioral Health 

Treatment Programs (SAMHSA, 2013). 

Part 1, Chapter 6—Trauma-Specific Services 

(NCPTSD; http://www.ptsd.va.gov) for 

treatment literature related to trauma and 

posttraumatic stress disorder (PTSD). For an

overview of models for use with both adult 

and child populations, refer to Models for Developing Trauma-Informed Behavioral Health

Systems and Trauma-Specific Services (Center 

for Mental Health Services, 2008). 

Some treatments discussed in this chapter are

described as evidence based. Because research 

on integrated treatment models is so new, many 

have only been examined in a few studies. Given these circumstances and the fact that an 

outcome study provides only limited evidence

of efficacy, the term “evidence based” should be

interpreted cautiously. Additional scientific

study is needed to determine whether some 

treatments discussed herein are, in fact, evidence based. A good resource for evaluating

evidence-based, trauma-specific treatment

models is Effective Treatments for PTSD (Foa, 

Keane, Friedman, & Cohen, 2009). Although 

evidence-based interventions should be a primary consideration in selecting appropriate

treatment models for people with symptoms of

trauma that co-occur with mental and substance use disorders (see Allen, 2001, for an

indepth discussion of trauma and serious mental illness), other factors must also be weighed,

including the specific treatment needs of the 

client; his or her history of trauma, psychosocial 

and cultural background, and experiences in

prior trauma treatment; the overall treatment

plan for the client; and the competencies of the 

program’s clinical staff. Although behavioral

health counselors can prepare to help their clients address some of the issues discussed in 

Chapter 5, specialized training is necessary to

provide treatment for co-occurring substance 

use and mental disorders related to trauma. 

The Substance Abuse and Mental Health Services Administration (SAMHSA) has created

the National Registry of Evidence-Based Programs and Practices (NREPP) as a resource for

reviewing and identifying effective treatment

programs. Programs can be nominated for consideration as co-occurring disorders programs

or substance abuse prevention or treatment

programs, and their quality of evidence, readiness for dissemination, and training considerations are then reviewed. For more detailed 

information, including details about several

evidence-based co-occurring trauma treatment

programs, visit the NREPP Web site 

(http://www.nrepp.samhsa.gov). Program models for specialized groups, such as adolescents,

can also be found on the NREPP Web site. For 

specific research-oriented information on 

trauma-specific treatments, refer to Part 3 of

this TIP, which provides a literature review and

links to select abstracts (available online). 

Trauma-Specific 

Treatment Models 

Immediate Interventions 

Intervention in the first 48 hours 

The acute intervention period comprises the

first 48 hours after a traumatic event. In a 

139 
 

 

 

 

“One day I was called out of bed at 5:00 a.m. to go to a town approximately 30 miles away because a 

levee had broken.... By 6:00 a.m., my colleagues and I were there with many of the townspeople, with 

helicopters flying overhead, with trucks going in and out by the main road trying to empty the factories. 

When we got there, as far as you could see was farmland. By 11 a.m., you could see a ‘lake’ in the distance. By 2 p.m., the water was on the edge of the town. Being there, at that town, before, during, and 

after the water came was probably the most valuable function we performed. We were able to share in 

the grief of the hundreds of people as we stayed with them while their fields, houses, and workplaces 

were flooded. We witnessed the death of a town, and the people reacted with disbelief, anger, sadness, and numbness. Each person had a different story, but all grieved, and we provided many an opportunity to express it. People cried as the water started rising into their houses. Some had to watch. 

Some had to leave. At times it was utterly silent as we all waited. There was a woman whose parents 

sent her away during the floods of ‘43 and she had been angry for 50 years about it. She was determined that her children and grandchildren would see everything. I spent 12 hours that day just giving 

support, listening, giving information, and sometimes shedding a tear or two myself.” 

—Rosemary Schwartzbard, Ph.D., responder to floods along the Mississippi River in 1993 

Source: Schwartzbard, 1997. 

Trauma-Informed Care in Behavioral Health Services 

disaster, rescue operations usually begin with

local agencies prior to other organizations arriving on the scene. Law enforcement is likely 

to take a primary role on site. Whether it is a

disaster, group trauma, or individual trauma 

(including a trauma that affects an entire family, such as a house fire), a hierarchy of needs 

should be established: survival, safety, security,

food, shelter, health (physical and mental), orientation of survivors to immediate local services, and communication with family, friends,

and community (National Institute of Mental

Health, 2002). In this crucial time, appropriate

interventions include educating survivors about

resources; educating other providers, such as

faith-based organizations and social service

groups, to screen for increased psychological 

effects including use of substances; and use of a

trauma response team that assists clients with

their immediate needs. No formal interventions 

should be attempted at this time, but a professionally trained, empathic listener can offer

solace and support (Litz & Gray, 2002). 

Basic needs 

Basic necessities, such as shelter, food, and

water, are key to survival and a sense of safety.

It is important to focus on meeting these basic

needs and on providing a supportive environment. Clients’ access to prescribed medications 

may be interrupted after a trauma, particularly 

a disaster, so providers should identify clients’ 

medication needs for preexisting physical and

mental disorders, including methadone or 

other pharmacological treatment for substance 

use. For example, after September 11, 2001,

substance abuse treatment program administrators in New York had to seek alternative 

methadone administration options (Frank,

Dewart, Schmeidler, & Demirjian, 2006). 

Psychological first aid 

The psychological first aid provided in the 

first 48 hours after a disaster is designed to

ensure safety, provide an emotionally supportive environment and activities, identify those 

with high-risk reactions, and facilitate communication, including strong, reassuring leadership immediately after the event. The 

primary helping response of psychological first

aid is to provide a calm, caring, and supportive

environment to set the scene for psychological 

recovery. It is also essential that all those first 

responding to a trauma—rescue workers, medical professionals, behavioral health workers 

(including substance abuse counselors), journalists, and volunteers—be familiar with relevant aspects of traumatic stress. Approaching 

140 
Part 1, Chapter 6—Trauma-Specific Services 

 

Advice to Counselors: Core Actions in 

Preparing To Deliver Psychological 

First Aid 

• Contact and engagement 

• Safety and comfort 

• Stabilization 

• Information gathering: Current needs and 

concerns 

• Practical assistance 

• Connection with social supports 

• Information on coping 

• Linkage with collaborative services 

Source: National Child Traumatic Stress Network & NCPTSD, 2012. 

Advice to Counselors: Evidence 

Related to Immediate Interventions 

Evidence related to immediate interventions 

suggests that: 

• Early, brief, focused psychotherapeutic 

intervention provided in an individual or 

group format can reduce distress in bereaved spouses, parents, and children. 

• Selected cognitive–behavioral approaches 

may help reduce the incidence, duration, 

and severity of acute stress disorder (ASD), 

PTSD, and depression in trauma survivors. 

• A one-session individual recital of events 

and expression of emotions evoked by a 

traumatic event does not consistently reduce risk of later developing PTSD. In fact, 

it may increase the risk for adverse outcomes. Perhaps CISD hinders the natural 

recovery mechanisms that restore pretrauma functioning (Bonanno, 2004). 

• The focus initially should be upon screening with follow-up as indicated. 

survivors with genuine respect, concern, and

knowledge increases the likelihood that the 

caregiver can (NCPTSD, 2002):

•	 Answer questions about what survivors may 

be experiencing. 

•	 Normalize their distress by affirming that

what they are experiencing is normal. 

•	 Help them learn to use effective coping

strategies. 

•	 Help them be aware of possible symptoms 

that may require additional assistance. 

•	 Provide a positive experience that will increase their chances of seeking help if they 

need it in the future. 

Clinical experience suggests that care be taken

to respect a survivor’s individual method of 

coping; some may want information, for example, whereas others do not. Similarly, some 

may want to talk about the event, but others 

won’t. An excellent guide to providing psychological first aid is available online from the

Terrorism and Disaster Branch of the National 

Child Traumatic Stress Network 

(http://www.nctsn.org/content/psychologicalfirst-aid). 

Critical incident stress debriefing 

Initially developed for work with first responders and emergency personnel, critical 

incident stress debriefing (CISD; Mitchell & 

Everly, 2001) is now widely used and encompasses various group protocols used in a variety of settings. This facilitator-led group

intervention is for use soon after a traumatic 

event with exposed people. The goal is to provide psychological closure by encouraging participants to talk about their experiences and

then giving a didactic presentation on common stress reactions and management. 

The widespread use of CISD has occurred

despite the publication of conflicting results 

regarding its efficacy. Claims that singlesession psychological debriefing can prevent

development of chronic negative psychological 

sequelae are not empirically supported (van

Emmerik, Kamphuis, Hulsbosch, &

Emmelkamp, 2002). Some controlled studies 

suggest that it may impede natural recovery 

from trauma (McNally, Bryant, & Ehlers, 

2003). Other research suggests emphasizing

screening to determine the need for early interventions. Mitchell and Everly (2001) point

out that many of the studies showing negative 

141 
 

 

 

 

 A widely accepted framework in treating 

trauma, substance use disorders, and 

mental illness categorizes therapies as 

single (treatment of only one disorder), 

sequential (treatment of one disorder first, 

then the other), or parallel (concurrent 

treatment of multiple disorders delivered 

by separate clinicians or in separate 

programs that do not necessarily address 

the interactions between symptoms and 

disorders). 

Trauma-Informed Care in Behavioral Health Services 

results were not conducted with first responders; that is, CISD may be appropriate for

some, but not all, groups. A recent study of

952 U.S. peacekeepers and CISD by the U.S.

Army Research Unit–Europe (Adler et al.,

2008) found mixed results. 

Interventions Beyond the Initial 

Response to Trauma 

In the interest of increasing your overall familiarity with relevant approaches, the following

sections review several traumatic stress treatment approaches that counselors will most

likely encounter when collaborating with clinicians or agencies that specialize in traumaspecific services and treating traumatic stress. 

Cognitive–behavioral therapies 

Most PTSD models involve cognitive–

behavioral therapy (CBT) that integrates cognitive and behavioral theories by incorporating

two ideas: first, that cognitions (or thoughts)

mediate between situational demands and 

one’s attempts to respond to them effectively,

and second, that behavioral change influences 

acceptance of altered cognitions about oneself

or a situation and establishment of newly 

learned cognitive–behavioral interaction patterns. In practice, CBT uses a wide range of

coping strategies. 

There are many different varieties of CBT.

CBT originated in the 1970s (Beck, Rush, 

Shaw & Emery, 1979; Ellis & Harper, 1975) 

and has expanded since then to address various populations, including people who use 

substances, people who experience anxiety,

people with PTSD or personality disorders,

children and adolescents, individuals involved

in the criminal justice system, and many others. CBT has also been expanded to include 

various techniques, coping skills, and approaches, such as dialectical behavior therapy

(DBT; Linehan, 1993), Seeking Safety 

(Najavits, 2002a), and mindfulness (Segal, 

Williams, & Teasdale, 2002). Traditional CBT

emphasizes symptom reduction or resolution,

but recent CBT approaches have also emphasized the therapeutic relationship, a particularly important dynamic in trauma treatment

( Jackson, Nissenson, & Cloitre, 2009). 

CBT has been applied to the treatment of

trauma and has also been widely and effectively used in the treatment of substance use. A

review of efficacy research on CBT for PTSD

is provided by Rothbaum, Meadows, Resick,

and Foy (2000). Najavits and colleagues

(2009) and O’Donnell and Cook (2006) offer

an overview of CBT therapies for treating

PTSD and substance abuse. In addition, a free

online training resource incorporating CBT 

for traumatized children within the community, Trauma-Focused CBT, is available from 

the Medical University of South Carolina

(http://tfcbt.musc.edu/). 

Cognitive processing therapy 

Cognitive processing therapy (CPT) is a

manualized 12-session treatment approach

that can be administered in a group or individual setting (Resick & Schnicke, 1992,

1993). CPT was developed for rape survivors

and combines elements of existing treatments

for PTSD, specifically exposure therapy (see 

the “Exposure Therapy” section later in this

chapter) and cognitive therapy. The exposure 

therapy component of treatment consists of 

142 
 

 

 

 

Advice to Counselors: Relaxation Training, Biofeedback, and Breathing 

Retraining Strategies 

Relaxation training, biofeedback, and breathing retraining strategies may help some clients cope with 

anxiety, a core symptom of traumatic stress. However, no evidence supports the use of relaxation 

and biofeedback as effective standalone PTSD treatment techniques (Cahill, Rothbaum, Resick, & 

Follete, 2009). Both are sometimes used as complementary strategies to manage anxiety symptoms 

elicited by trauma-related stimuli. Breathing retraining uses focused or controlled breathing to reduce arousal. Breathing retraining and relaxation, along with other interventions when necessary, can 

help clients with ASD. An important caution in the use of breath work with trauma clients is that it can 

sometimes act as a trigger—for example, given its focus on the body and its potential to remind 

them of heavy breathing that occurred during assault. Biofeedback, which requires specialized 

equipment, combines stress reduction strategies (e.g., progressive muscle relaxation, guided imagery) with feedback from biological system measures (e.g., heart rate, hand temperature) that gauge 

levels of stress or anxiety reduction. Relaxation training, which requires no specialized equipment, 

encourages clients to reduce anxiety responses (including physiological responses) to trauma-related 

stimuli; it is often part of more comprehensive PTSD treatments (e.g., prolonged exposure and stress 

inoculation training [SIT]). 

Part 1, Chapter 6—Trauma-Specific Services 

clients writing a detailed account of their

trauma, including thoughts, sensations, and

emotions that were experienced during the 

event. The client then reads the narrative 

aloud during a session and at home. The cognitive therapy aspect of CPT uses six key 

PTSD themes identified by McCann and

Pearlman (1990): safety, trust, power, control, 

esteem, and intimacy. The client is guided to

identify cognitive distortions in these areas,

such as maladaptive beliefs. 

Results from randomized, placebo-controlled 

trials for the treatment of PTSD related to 

interpersonal violence (Resick, 2001; Resick,

Nishith, Weaver, Astin, & Feuer, 2002) support the use of CPT. CPT and prolonged

exposure therapy models are equally and highly positive in treating PTSD and depression in

rape survivors; CPT is superior in reducing

guilt (Nishith, Resick, & Griffin, 2002;

Resick et al., 2002; Resick, Nishith, &

Griffin, 2003). CPT has shown positive outcomes with refugees when administered in the 

refugees’ native language (Schulz, MarovicJohnson, & Huber, 2006) and with veterans 

(Monson et al., 2006). However, CPT has not 

been studied with high-complexity populations such as individuals with substance dependence, homelessness, current domestic

violence, serious and persistent mental illness,

or suicidality. CPT requires a 3-day training

plus consultation (Karlin et al., 2010). Resick 

and Schicke (1996) published a CPT treatment manual, Cognitive Processing Therapy for

Rape Victims: A Treatment Manual. 

Exposure therapy 

Exposure therapy for PTSD asks clients to

directly describe and explore trauma-related 

memories, objects, emotions, or places. Intense emotions are evoked (e.g., sadness, anxiety) but eventually decrease, desensitizing

clients through repeated encounters with

traumatic material. Careful monitoring of the

pace and appropriateness of exposure-based

interventions is necessary to prevent retraumatization (clients can become conditioned to

fear the trauma-related material even more).

Clients must have ample time to process their

memories and integrate cognition and affect,

so some sessions can last for 1.5 hours or 

more. For simple cases, exposure can work in

as few as 9 sessions; more complex cases may 

require 20 or more sessions (Foa, Hembree, &

Rothbaum, 2007). Various techniques can 

143 
 

 

A Brief Description of EMDR Therapy 

Treatment involves three main concentrations 

(past memories, present disturbances, future 

actions) and eight phases. Counselors may 

work with several phases in one session. Each 

phase is meant to be revisited either in every 

session or when appropriate (e.g., the closure 

process is meant to be conducted at the end of 

every session, in preparation for the next). 

• Phase 1: History and Treatment Planning 

(1-2 sessions) 

• Phase 2: Preparation 

• Phase 3: Assessment and Reprocessing 

• Phase 4: Desensitization 

• Phase 5: Installation 

• Phase 6: Body Scan 

• Phase 7: Closure 

• Phase 8: Reevaluation 

Source: EMDR Network, 2012. 

Advice to Counselors: Steps for 

Introducing a Breathing Exercise 

Use the following statements to lead clients 

through a breathing exercise: 

• Place your hands on your stomach. As you 

inhale, breathe deeply but slowly so that 

your hands rise with your stomach. As you 

exhale slowly, practice breathing so that 

your hands drop with your stomach. 

• Inhale slowly through your nose with your 

mouth closed; don’t rush or force in the air. 

• Exhale slowly through your mouth with 

your lips in the whistling position. 

• Breathe out for twice as long as you 

breathe in. 

Trauma-Informed Care in Behavioral Health Services 

expose the client to traumatic material. Two

of the more common methods are exposure 

through imagery and in vivo (“real life”) 

exposure. 

The effectiveness of exposure therapy has 

been firmly established (Rothbaum et al.,

2000); however, adverse reactions to exposure 

therapy have also been noted. Some individuals who have experienced trauma exhibit an

exacerbation of symptoms during or following

exposure treatments. Even so, the exacerbation may depend on counselor variables during

administration. Practitioners of exposure therapy need comprehensive training to master its 

techniques (Karlin et al., 2010); a counselor

unskilled in the methods of this treatment 

model can not only fail to help his or her clients, but also cause symptoms to worsen. 

Exposure therapy is recommended as a firstline treatment option when the prominent

trauma symptoms are intrusive thoughts, 

flashbacks, or trauma-related fears, panic, and 

avoidance. However, counselors should exercise caution when using exposure with clients 

who have not maintained stability in managing mental illness symptoms or abstinence 

from substance use disorders. Studies and routine use of exposure have consistently excluded

high-complexity clients such as those with 

substance dependence, homelessness, current

domestic violence, serious and persistent mental illness, or suicidality. The only trial of exposure therapy with a substance dependence 

sample found that it did not outperform 

standard substance abuse treatment on most 

variables (Mills et al., 2012). 

Prolonged exposure therapy for PTSD is 

listed in SAMHSA’s NREPP. For reviews of 

exposure therapy, also see Najavits (2007a) 

and Institute of Medicine (2008). In addition

to prolonged exposure therapy, other therapies 

incorporate exposure and desensitization techniques, including eye movement desensitization and reprocessing (EMDR; Shapiro, 

2001), cognitive processing, and systematic

desensitization therapies (Wolpe, 1958). 

Eye movement desensitization and 

reprocessing 

EMDR (Shapiro, 2001) is one of the most

widely used therapies for trauma and PTSD.

The treatment protocols of EMDR have

evolved into sophisticated paradigms requiring

training and, preferably, clinical supervision.

EMDR draws on a variety of theoretical 

144 
 

 

 

 

 

 

In the substance abuse treatment field, 

many clients will see a connection 

between narrative therapy and the process 

of telling their stories in 12 -Step programs, 

in which reframing life stories of feeling 

trapped, despairing, and hopeless leads to 

stories of strength, joy, and hope. Key 

storytelling points at a 12 -Step speaker 

meeting include describing what an 

experience was like, what happened, and 

what it is like now. 

Part 1, Chapter 6—Trauma-Specific Services 

frameworks, including psychoneurology, CBT, 

information processing, and nonverbal representation of traumatic memories. The goal of

this therapy is to process the experiences that

are causing problems and distress. It is an effective treatment for PTSD (Seidler &

Wagner, 2006) and is accepted as an evidencebased practice by the U.S. Department of

Veterans Affairs (VA), the Royal College of

Psychiatrists, and the International Society for

Traumatic Stress Studies (Najavits, 2007a); 

numerous reviews support its effectiveness 

(e.g., Mills et al., 2012). EMDR values the 

development of “resource installation” (calming

procedures) and engages in exposure work to

desensitize clients to traumatic material, using

external tracking techniques across the visual 

field to assist in processing distressing material. Training in EMDR, available through the

EMDR Institute, is required before counselors 

use this treatment. It is listed in SAMHSA’s 

NREPP (EMDR Network, 2012). Thus far,

there is no study examining the use of EMDR

with clients in substance abuse treatment. See 

Part 3 of this TIP, available online, to review

empirical work on EMDR. 

Narrative therapy 

Narrative therapy is an emerging approach to

understanding human growth and change; it is

founded on the premise that individuals are 

the experts on their own lives and can access 

their existing intrapsychic and interpersonal 

resources to reduce the impact of problems in

their lives. Developed for the treatment of

PTSD resulting from political or community 

violence, narrative therapy is based on CBT

principles, particularly exposure therapy

(Neuner, Schauer, Elbert, & Roth, 2002;

Neuner, Schauer, Klaschik, Karunakara, & 

Elbert, 2004). This approach views psychotherapy not as a scientific practice, but as a 

natural extension of healing practices that

have been present throughout human history.

For a trauma survivor, the narrative, as it is 

told and retold, expresses the traumatic experience, puts the trauma in the context of the

survivor’s life, and defines the options he or 

she has for change. Narrative structure helps 

clients connect events in their lives, reveals 

strings of events, explores alternative expressions of trauma, evokes explanations for clients’ behaviors, and identifies their knowledge 

and skills. The use of stories in therapy, with

the client as the storyteller, generally helps 

lessen suffering (McLeod, 1997; White, 2004). 

Skills training in affective and 

interpersonal regulation 

Skills training in affective and interpersonal 

regulation (STAIR) is a two-phase cognitive–

behavioral model that adapts therapies developed by others into a new package (Cloitre,

Koenen, Cohen, & Han, 2002). Phase 1 consists of eight weekly sessions of skills training

in affect and interpersonal regulation derived

from general CBT and DBT (Linehan, 1993)

and adapted to address trauma involving

childhood abuse. Session topics are labeling

and identifying feelings, emotion management, distress tolerance, acceptance of feelings, identifying trauma-based interpersonal 

schemas, identifying conflict between traumagenerated feelings and current interpersonal 

goals, role-plays on issues of power and control, and role-plays on developing flexibility in

interpersonal situations. Phase 2 features eight 

145 
STAIR Steps 

Phase 1, tailored to individual clients, is called Skills Training in Affect Regulation and consists of the 

following components: 

• Psychoeducation: Describe the symptoms of PTSD and explain the treatment rationale. 

• Training in experiencing and identifying feelings, triggers, and thoughts, as well as training in 

mood regulation strategies. 

• Learning history: Ask the client the following questions—How did the client deal with traumas 

past and present? How did the client’s family deal with feelings? How did the client’s family life 

affect his or her present difficulty experiencing and identifying feeling? 

• Emotion regulation skills: Identify the cognitive, behavioral, and social support modalities for 

coping. Use data gathered with self-monitoring forms to identify strengths and weaknesses in 

each coping modality. Teach skills such as breathing retraining, self-statements to reduce fear, 

and social skill training to improve social support. 

• Acceptance and tolerance of negative affect: Motivate clients to face distressing situations related to the trauma that are important to them. Review negative repercussions of avoidance. Discuss tolerating negative affect as a step toward achieving specific goals. 

• Schema therapy for improved relationships: Identify relevant schemas learned in childhood. Suggest alternative ways of viewing self and others in current relationships. Use role-playing to teach 

assertiveness, emphasizing response flexibility based on relative power in each relationship. 

Once Phase 1 of STAIR is well learned, clients move to Phase 2, which involves exposure therapy. 

Source: Mollick & Spett, 2002. 

SIT has been used to help individuals cope 

with the aftermath of exposure to stressful 

events and on a preventative basis to 

“inoculate” individuals to future and 

ongoing stressors (Meichenbaum, 1996). 

This practice as a preventive strategy is 

similar to promoting disease resistance 

through immunizations. 

Trauma-Informed Care in Behavioral Health Services 

sessions of modified prolonged exposure using

a narrative approach. 

Cloitre and colleagues (2002) assigned women

with PTSD related to childhood abuse randomly to STAIR or a minimal attention waitlist, excluding clients with current substance 

dependence as well as other complexities. 

STAIR participants showed significantly

greater gains in affect regulation, interpersonal 

skills, and PTSD symptoms than the control 

participants. These gains were maintained

through follow-up at 3 and 9 months. However, it is not clear from this study whether

DBT and exposure were both needed. Phase 1

therapeutic alliance and negative mood regulation skills predicted Phase 2 exposure success 

in reducing PTSD, suggesting the importance 

of establishing a strong therapeutic relationship and emotion regulation skills before conducting exposure work with people who have

chronic PTSD. 

Stress inoculation training 

SIT was originally developed to manage

anxiety (Meichenbaum, 1994; Meichenbaum

& Deffenbacher, 1988). Kilpatrick, Veronen,

and Resick (1982) modified SIT to treat rape

survivors based on the idea that the anxiety and

fear that rape survivors experience during their

trauma generalizes to other objectively safe 

situations. SIT treatment components include 

education, skills training (muscle relaxation

training, breathing retraining, role-playing,

guided self-talk, assertiveness training, and

thought stopping [i.e., actively and forcefully 

ending negative thoughts by thinking 

146 
 

 

 

Advice to Counselors: SIT Phases 

SIT is a prevention and treatment approach that has three overlapping phases. It is often seen as a 

complementary approach to other interventions for traumatic stress. 

Phase 1: Conceptualization and education. This phase has two main objectives. The initial goal is to 

develop a collaborative relationship that supports and encourages the client to confront stressors 

and learn new coping strategies. The next objective is to increase the client’s understanding of the 

nature and impact of his or her stress and awareness of alternative coping skills. Many cognitive 

strategies are used to meet these objectives, including self-monitoring activities, Socratic questioning, identifying strengths and evidence of resilience, and modeling of coping strategies. 

Phase 2: Skill acquisition and rehearsal. This phase focuses on developing coping skills and using 

coping skills that the individual already possesses. This process includes practice across settings, so 

that the individual begins to generalize the use of his or her skills across situations through rehearsal, 

rehearsal, and more rehearsal. 

Phase 3: Implementation and following through. The main objective is to create more challenging 

circumstances that elicit higher stress levels for the client. By gradually increasing the challenge, the 

client can practice coping strategies that mimic more realistic circumstances. Through successful 

negotiation, the client builds a greater sense of self-efficacy. Common strategies in this phase include 

imagery and behavioral rehearsal, modeling, role-playing, and graded in vivo exposure. 

Source: Meichenbaum, 2007. 

Part 1, Chapter 6—Trauma-Specific Services 

“STOP” and then redirecting thoughts in a

more positive direction]), and skills application. The goal is to help clients learn to manage their anxiety and to decrease avoidant

behavior by using effective coping strategies.

Randomized controlled clinical trials have 

indicated that SIT reduces the severity of

PTSD compared with waitlist controls and

shows comparable efficacy to exposure therapy.

At follow-up (up to 12 months after treatment), gains were maintained (Foa et al., 

1999; Foa, Rothbaum, Riggs, & Murdock, 

1991). 

Other therapies 

Numerous interventions introduced in the 

past 20 years focus on traumatic stress. For

some interventions, the evidence is limited,

and for other others, it is evolving. One example is the traumatic incident reduction (TIR) 

approach. This brief memory-oriented intervention is designed for children, adolescents,

and adults who have experienced traumatic

stress (Valentine & Smith, 2001). Listed in 

SAMHSA’s NREPP, the intervention is designed to process specific traumatic incidents

or problematic themes related to the trauma,

including specific feelings, emotions, sensations, attitudes, or pain. It involves having clients talk through the traumatic incident 

repeatedly with the anticipation that changes

in affect will occur throughout the repetitions.

TIR is a client-centered approach. 

Integrated Models for 

Trauma 

This section covers models specifically designed to treat trauma-related symptoms along

with either mental or substance use disorders 

at the same time. Integrated treatments help

clients work on several presenting problems 

simultaneously throughout the treatment, a

promising and recommended strategy (DassBrailsford & Myrick, 2010; Najavits, 2002b;

Nixon & Nearmy, 2011). Thus far, research is 

limited, but what is available suggests that 

integrated treatment models effectively reduce 

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Trauma-Informed Care in Behavioral Health Services 

substance abuse, PTSD symptoms, and other

mental disorder symptoms. TIP 42, Substance 

Abuse Treatment for Persons With Co-Occurring 

Disorders (Center for Substance Abuse Treatment, 2005c), offers a detailed description of 

integrated treatment. In contrast with integrated models, other model types include single (treatment of only one disorder),

sequential (treatment of one disorder first,

then the other), or parallel (concurrent treatment of multiple disorders delivered by separate clinicians or in separate programs that do

not necessarily address the interactions between symptoms and disorders). 

Similar to single models, integrated treatment 

models are designed for use in a variety of 

settings (e.g., outpatient, day treatment,

and/or residential substance abuse and mental 

health clinics/programs). Most models listed

are manual-based treatments that address 

trauma-related symptoms, mental disorders,

and substance use disorders at the same time. 

Additional approaches and further details on

the selected approaches can be found at

NREPP (http://www.nrepp.samhsa.gov). 

Addiction and Trauma Recovery 

Integration Model 

The Addiction and Trauma Recovery Integrated Model (ATRIUM; Miller & Guidry,

2001) integrates CBT and relational treatment

through an emphasis on mental, physical, and

spiritual health. This 12-week model for individuals and groups blends psychoeducational, 

process, and expressive activities, as well as 

information on the body’s responses to addiction and traumatic stress and the impact of

trauma and addiction on the mind and spirit.

It helps clients explore anxiety, sexuality, selfharm, depression, anger, physical complaints 

and ailments, sleep difficulties, relationship

challenges, and spiritual disconnection. It was 

designed primarily for women and focuses on

developmental (childhood) trauma and interpersonal violence, but it recognizes that other

types of traumatic events occur. 

The ATRIUM model consists of three phases 

of treatment. The first stage, or “outer circle,”

consists of the counselor collecting data from 

the client about his or her trauma history, offering psychoeducation on the nature of trauma, and helping the client assess personal 

strengths. ATRIUM actively discourages the 

evocation of memories of abuse or other trauma events in this phase. The second stage, or

“middle circle,” allows clients and counselors 

to address trauma symptoms more directly and

specifically encourages clients to reach out to

and engage with support resources in the 

community. The middle circle also emphasizes learning new information about trauma and

developing additional coping skills. The third

stage of the program, the “inner circle,” focuses on challenging old beliefs that arose as a

result of the trauma. For instance, the concept

of “nonprotecting bystander” is used to represent the lack of support that the traumatized

person experienced at the time of the trauma.

This representation is replaced with the “protective presence” of supportive others today. 

ATRIUM was used in one of the nine study 

sites of SAMHSA’s Women, Co-Occurring

Disorders and Violence Study. Across all sites,

trauma-specific models achieved more favorable outcomes than control sites that did not 

use trauma-specific models (Morrissey et al., 

2005). There has not yet been a study of 

ATRIUM per se, however. A manual describing the theory behind this model in greater

depth, as well as how to implement it, is published under the title Addictions and Trauma 

Recovery: Healing the Body, Mind, and Spirit

(Miller & Guidry, 2001). 

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Part 1, Chapter 6—Trauma-Specific Services 

Beyond Trauma: A Healing 

Journey for Women 

Beyond Trauma (Covington, 2003) is a curriculum for women’s services based on theory,

research, and clinical experience. It was developed for use in residential, outpatient, and

correctional settings; domestic violence programs; and mental health clinics. It uses 

behavioral techniques and expressive arts and

is based on relational therapy. Although the

materials are designed for trauma treatment,

the connection between trauma and substance 

abuse in women’s lives is a theme throughout.

Beyond Trauma has a psychoeducational component that defines trauma by way of its process as well as its impact on the inner self

(thoughts, feelings, beliefs, values) and the 

outer self (behavior and relationships, including parenting). Coping skills are emphasized;

specific exercises develop emotional wellness. 

Concurrent Treatment of PTSD 

and Cocaine Dependence 

Concurrent Treatment of PTSD and Cocaine 

Dependence (CTPCD) is a 16-session, twiceweekly individual outpatient psychotherapy 

model designed to treat women and men with

co-occurring PTSD and cocaine dependence

(Coffey, Schumacher, Brimo, & Brady, 2005). 

CTPCD combines imagery and in vivo exposure therapy (in which the client becomes desensitized to anxiety-producing stimuli

through repeated exposure to them) for the

treatment of PTSD with elements of CBT for 

substance dependence. To balance the dual 

needs of abstinence skill building and prompt

trauma treatment, the first five sessions focus 

on coping skills for cocaine dependence. Session six transitions into exposure therapy,

which begins in earnest in session seven and is 

combined with CBT for the treatment of substance abuse. 

CTPCD helps reduce substance use and

PTSD symptoms. The use of any illicit drug,

as measured by urine screens, was quite low 

during the 16-week treatment trial and didn’t 

escalate during the second half of treatment—

when most exposure sessions occurred. PTSD

symptoms dropped significantly over the 

course of treatment, as did self-reported depressive symptoms; however, the dropout rate

was high (Coffey, Dansky, & Brady, 2003).

CTPCD was reformulated into Concurrent 

Prolonged Exposure (COPE; Mills et al.,

2012), which was compared with treatment as 

usual in a high-complexity clinical sample of 

individuals who had PTSD and substance 

dependence. Both treatment conditions resulted in improvements in PTSD with no difference at 3 months (though COPE showed 

significantly greater improvement at 9

months); moreover, the two conditions did not 

differ in impact on substance use outcomes,

depression, or anxiety. 

Integrated CBT 

Integrated CBT is a 14-session individual 

therapy model designed for PTSD and substance use. It incorporates elements such as 

psychoeducation, cognitive restructuring, and

breathing retraining (McGovern, LamberHarris, Alterman, Xie, & Meier, 2011). A randomized controlled trial showed that both 

integrated CBT and individual addiction

treatment achieved improvements in substance 

use and other measures of psychiatric symptom severity with no difference between the 

treatments. 

Seeking Safety 

Seeking Safety is an empirically validated,

present-focused treatment model that helps 

clients attain safety from trauma and substance

abuse (Najavits, 2002a). The Seeking Safety

manual (Najavits, 2002b) offers clinician guidelines and client handouts and is available in 

149 
 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

several languages.Training videos and other

implementation materials are available online

(http://www.seekingsafety.org). Seeking Safety 

is flexible; it can be used for groups and individuals, with women and men, in all settings 

and levels of care, by all clinicians, for all types 

of trauma and substance abuse. 

Seeking Safety covers 25 topics that address

cognitive, behavioral, interpersonal, and case

management domains. The topics can be 

conducted in any order, using as few or as 

many as are possible within a client’s course of 

treatment. Each topic represents a coping skill 

relevant to both trauma and substance abuse,

such as compassion, taking good care of yourself, healing from anger, coping with triggers,

and asking for help. This treatment model

builds hope through an emphasis on ideals 

and simple, emotionally evocative language 

and quotations. It attends to clinician processes and offers concrete strategies that are 

thought to be essential for clients dealing with

concurrent substance use disorders and histories of trauma. 

More than 20 published studies (which include 

pilot studies, randomized controlled trials, and

multisite trials representing various investigators and populations) provide the evidence base 

for this treatment model. For more information, see SAMHSA’s NREPP Web site 

(http://www.nrepp.samhsa.gov) as well as the

“Outcomes” section of the Seeking Safety 

Web site (http://www.seekingsafety.org/3-03­

06/studies.html). Study samples included people with chronic, severe trauma symptoms and

substance dependence who were diverse in

ethnicity and were treated in a range of settings (e.g., criminal justice, VA centers, adolescent treatment, homelessness services, public

sector). Seeking Safety has shown positive 

outcomes on trauma symptoms, substance 

abuse, and other domains (e.g., suicidality,

HIV risk, social functioning, problem-solving, 

sense of meaning); consistently outperformed

treatment as usual; and achieved high satisfaction ratings from both clients and clinicians. It

has been translated into seven languages, and a 

version for blind and/or dyslexic individuals is

available. 

The five key elements of Seeking Safety are:

1.	 Safety as the overarching goal (helping

clients attain safety in their relationships,

thinking, behavior, and emotions). 

2.	 Integrated treatment (working on trauma

and substance abuse at the same time). 

3.	 A focus on ideals to counteract the loss of 

ideals in both trauma and substance abuse. 

4.	 Four content areas: cognitive, behavioral,

interpersonal, and case management. 

5.	 Attention to clinician processes (addressing countertransference, self-care, and 

other issues). 

Substance Dependence PTSD 

Therapy 

Substance Dependence PTSD Therapy 

(Triffleman, 2000) was designed to help clients of both sexes cope with a broad range of

traumas. It combines existing treatments for

PTSD and substance abuse into a structured,

40-session (5-month, twice-weekly) individual

therapy that occurs in two phases. Phase I is 

“Trauma-Informed, Addictions-Focused

Treatment” and focuses on coping skills and

cognitive interventions as well as creating a

safe environment. Phase I draws on CBT 

models, anger management, relaxation training,

HIV risk reduction, and motivational enhancement techniques. Phase II, “TraumaFocused, Addictions-Informed Treatment,”

begins with psychoeducation about PTSD followed by “Anti-Avoidance I,” in which a modified version of stress inoculation training is 

taught in two to four sessions. Following this is 

“Anti-Avoidance II,” lasting 6 to 10 sessions, in 

which in vivo exposure is used. 

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Part 1, Chapter 6—Trauma-Specific Services 

Trauma Affect Regulation: Guide 

for Education and Therapy 

Trauma Affect Regulation: Guide for Education and Therapy (TARGET; Ford & Russo,

2006; Frisman, Ford, Lin, Mallon, & Chang, 

2008) uses emotion and information processing in a present-focused, strengths-based

approach to education and skills training for 

trauma survivors with severe mental, substance 

use, and co-occurring disorders across diverse

populations. TARGET helps trauma survivors 

understand how trauma changes the brain’s 

TARGET: The Seven-Step FREEDOM Approach 

Focus: Being focused helps a person pay attention and think about what’s happening right now 

instead of just reacting based on alarm signals tied to past trauma. This step teaches participants to 

use the SOS skill (Slow down, Orient, Self-check) to pay attention to body signals and the immediate 

environment and to use a simple scale to measure stress and control levels. 

Recognize triggers: Recognizing trauma triggers enables a person to anticipate and reset alarm 

signals as he or she learns to distinguish between a real threat and a reminder. This step helps participants identify personal triggers, take control, and short-circuit their alarm reactions. 

Emotion self-check: The goal of this skill is to identify two types of emotions. The first are “alarm” 

or reactive emotions such as terror, rage, shame, hopelessness, and guilt. Because these emotions 

are the most noticeable after trauma, they are the alarm system’s way of keeping a person primed 

and ready to fend off further danger. The second type of emotion, “main” emotions, include positive feelings (e.g., happiness, love, comfort, compassion) and feelings that represent positive strivings (e.g., hope, interest, confidence). By balancing both kinds of emotions, a person can reflect and 

draw on his or her own values and hopes even when the alarm is activated. 

Evaluate thoughts: When the brain is in alarm mode, thinking tends to be rigid, global, and catastrophic. Evaluating thoughts, as with identifying emotions, is about achieving a healthier balance of 

positive as well as negative thinking. Through a two-part process, participants learn to evaluate the 

situation and their options with a focus on how they choose to act—moving from reactive thoughts 

to “main” thoughts. This is a fundamental change from the PTSD pattern, which causes problems by 

taking a person straight from alarm signals to automatic survival reactions. 

Define goals: Reactive goals tend to be limited to just making it through the immediate situation or 

away from the source of danger. These reactive goals are necessary in true emergencies but don’t 

reflect a person’s “main” goals of doing worthwhile things and ultimately achieving a good and 

meaningful life. This step teaches one how to create “main” goals that reflect his or her deeper 

hopes and values. 

Options: The only options that are available when the brain’s alarm is turned on and won’t turn off 

are automatic “flight/fight” or “freeze/submit” reactive behaviors that are necessary in emergencies 

but often unhelpful in ordinary living. This step helps identify positive intentions often hidden by the 

more extreme reactive options generated by the alarm system. This opens the possibility for a 

greater range of options that take into consideration one’s own needs and goals as well as those of 

others. 

Make a contribution: When the brain’s alarm is turned on and reacting to ordinary stressors as if 

they were emergencies, it is very difficult for a person to come away from experiences with a feeling 

that they have made a positive difference. This can lead to feelings of alienation, worthlessness, or 

spiritual distress. The ultimate goal of TARGET is to empower adults and young people to think 

clearly enough to feel in control of their alarm reactions and, as a result, to be able to recognize the 

contribution they are making not only to their own lives, but to others’ lives as well. 

Source: Advanced Trauma Solutions, 2012. 

151 
 

 

TREM Program Format 

Each session includes an experiential exercise to promote group cohesiveness. The 33 sessions are 

divided into the following general topic areas: 

• Part I–empowerment introduces gender identity concepts, interpersonal boundaries, and selfesteem. 

• Part II–trauma recovery concentrates on sexual, physical, and emotional abuse and their relationship to psychiatric symptoms, substance abuse, and relational patterns and issues. 

• Part III–advanced trauma recovery issues addresses additional trauma issues, such as blame and 

the role of forgiveness. 

• Part IV–closing rituals allows participants to assess their progress and encourages them to plan 

for their continued healing, either on their own or as part of a community of other survivors. 

• Part V–modifications or supplements for special populations provides modifications for subgroups such as women with serious mental illness, incarcerated women, women who are parents, 

women who abuse substances, and male survivors. 

Source: Mental Health America Centers for Technical Assistance, 2012. 

Trauma-Informed Care in Behavioral Health Services 

normal stress response into an extreme 

survival-based alarm response that can lead to

PTSD, and it teaches them a seven-step approach to making the PTSD alarm response 

less distressing and more adaptive (summarized by the acronym FREEDOM: Focus,

Recognize triggers, Emotion self-check, Evaluate thoughts, Define goals, Options, and

Make a contribution). 

TARGET can be presented in individual

therapy or gender-specific psychoeducational 

groups, and it has been adapted for individuals

who are deaf; it has also been translated into

Spanish and Dutch. TARGET is a resiliencebuilding and recovery program not limited to

individual or group psychotherapy; it is also

designed to provide an educational curriculum 

and milieu intervention that affects all areas of 

practice in school, therapeutic, or correctional

programs. TARGET is listed in SAMHSA’s 

NREPP (http://www.nrepp.samhsa.gov). 

Trauma Recovery and 

Empowerment Model 

The trauma recovery and empowerment model (TREM) of therapy (Fallot & Harris, 2002;

Harris & Community Connections Trauma

Work Group, 1998) is a manualized group

intervention designed for female trauma survivors with severe mental disorders. TREM 

addresses the complexity of long-term adaptation to trauma and attends to a range of difficulties common among survivors of sexual and

physical abuse. TREM focuses mainly on developing specific recovery skills and current

functioning and uses techniques that are effective in trauma recovery services. The model’s 

content and structure, which cover 33 topics,

are informed by the role of gender in women’s 

experience of and coping with trauma. 

TREM can be adapted for shorter-term residential settings and outpatient substance abuse 

treatment settings, among others. Adaptations

of the model for men and adolescents are 

available. The model was used in SAMHSA’s 

Women, Co-Occurring Disorders and Violence Study for three of the nine study sites 

and in SAMHSA’s Homeless Families program, and it is listed in SAMHSA’s NREPP. 

This model has been used with clients in substance abuse treatment; research by Toussaint, 

VanDeMark, Bornemann, and Graeber 

(2007) shows that women in a residential substance abuse treatment program showed significantly better trauma treatment outcomes 

using TREM than they did in treatment as 

usual, but no difference in substance use. 

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Part 1, Chapter 6—Trauma-Specific Services 

Triad Women’s Project 

The Triad Project was developed as a part of

SAMHSA’s Women, Co-Occurring Disorders

and Violence Study. It is a comprehensive,

trauma-informed, consumer-responsive integrated model designed for female trauma survivors with co-occurring substance use and

mental disorders who live in semirural areas. 

Triad integrates motivational enhancement for

substance use disorders, DBT, and intensive

case management techniques for co-occurring

mental disorders. This program is a 16-week 

group intervention for women that uses integrated case management services, a

curriculum-based treatment group, and a peer

support group (Clark & Fearday, 2003). 

Emerging Interventions 

New interventions are emerging to address

traumatic stress symptoms and disorders. The 

following sections summarize a few interventions not highlighted in prior chapters; this is

not an exhaustive list. In addition to specific 

interventions, technology is beginning to

shape the delivery of care and to increase accessibility to tools that complement traumaspecific treatments. Numerous applications are 

available and evolving. For more information

on the role of technology in the delivery of

care, see the planned TIP, Using TechnologyBased Therapeutic Tools in Behavioral Health

Services (SAMHSA, planned g). 

Couple and Family Therapy 

Trauma and traumatic stress affects significant

relationships, including the survivor’s family.

Although minimal research has targeted the 

effectiveness of family therapy with trauma

survivors, it is important to consider the needs 

of the individual in the context of their relationships. Family and couples therapy may be 

key to recovery. Family members may experience secondary traumatization silently, lack 

understanding of traumatic stress symptoms or

treatment, and/or have their own histories of

trauma that influence their willingness to support the client in the family or to talk about

anything related to trauma and its effects.

Family members can engage in similar patterns of avoidance and have their own triggers 

related to the trauma being addressed at the 

time. A range of couple and family therapies 

have addressed traumatic stress and PTSD,

but few studies exist that support or refute 

their value. Current couple or family therapies 

that have some science-based evidence include 

behavioral family therapy, behavioral marital

therapy, cognitive–behavioral couples treatment, and lifestyle management courses 

(Riggs, Monson, Glynn, & Canterino, 2009). 

Mindfulness Interventions 

Mindfulness is a process of learning to be present in the moment and observing internal 

experience (e.g., thoughts, bodily sensations)

and external experience (e.g., interactions with 

others) in a nonjudgmental way. Mindfulness 

challenges limiting beliefs that arise from 

trauma, quells anxiety about future events, and

simply helps one stay grounded in the present.

It plays a significant role in helping individuals

who have been traumatized observe their experiences, increase awareness, and tolerate 

uncomfortable emotions and cognitions. 

To date, mindfulness-based interventions appear to be valuable as an adjunct to traumaspecific interventions and in decreasing arousal (Baer, 2003). It may also help individuals 

tolerate discomfort during exposure-oriented 

and trauma processing interventions. Overall,

mindfulness practices can help clients in managing traumatic stress, coping, and resilience.

In a study of firefighters, mindfulness was 

associated with fewer PTSD symptoms, depressive symptoms, physical symptoms, and

alcohol problems when controlling for other

variables (Smith et al., 2011). 

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Becoming an Observer and Learning To Tolerate Discomfort: The Leaf and 

Stream Metaphor 

The following exercise, “leaves floating on a stream,” is a classic. Many clinicians and authors provide renditions of this mindfulness practice. The main objectives are to stand back and observe 

thoughts rather than get caught up in them. Simply stated, thoughts are just thoughts. Thoughts 

come and go like water flowing down a stream. We don’t need to react to the thoughts; instead, 

we can just notice them. 

Conduct the mindfulness exercise for about 10 minutes, then process afterward. Take time to allow participants to visualize each sense as they imagine themselves sitting next to the stream. For 

example, what does it look like? What do they hear as they sit next to the stream? Don’t rush the 

exercise. As you slowly make the statements detailed in the following two paragraphs, take time in 

between each statement for participants to be in the exercise without interruption; simply offer gentle guidance. 

Begin to sit quietly, bringing your attention to your breath. If you feel comfortable, close your eyes. 

As you focus on breathing in and out, imagine that you are sitting next to a stream. In your imagination, you may clearly see and hear the stream, or you may have difficulty visualizing the stream. Follow along with the guided exercise; either way, it will work just as well. 

Now begin to notice the thoughts that come into your mind. Some thoughts rush by, while others 

linger. Just allow yourself to notice your thoughts. As you begin to notice each thought, imagine 

putting those words onto a leaf as it floats by on the stream. Just let the thoughts come, watching 

them drift by on the leaves. If your thoughts briefly stop, continue to watch the water flow down the 

stream. Eventually, your thoughts will come again. Just let them come, and as they do, place them 

onto a leaf. Your attention may wander. Painful feelings may arise. You may feel uncomfortable or 

start to think that the exercise is “stupid.” You may hook onto a thought—rehashing it repeatedly. 

That’s okay; it’s what our minds do. As soon as you notice your mind wandering or getting stuck, 

just gently bring your focus back to your thoughts, and place them onto the leaves. Now, bring your 

attention back to your breath for a moment, then open your eyes and become more aware of your 

environment. 

Facilitated Questions: 

• What was it like for you to observe your thoughts? 

• Did you get distracted? Stuck? 

• Were you able to bring yourself back to the exercise after getting distracted? 

• In what ways was the exercise uncomfortable? 

• In what ways was the exercise comforting? 

Trauma-Informed Care in Behavioral Health Services 

For clients and practitioners who want to develop a greater capacity for mindfulness, see 

Kabat-Zinn’s books Wherever You Go, There 

You Are: Mindfulness Meditation In Everyday 

Life (1994) and Full Catastrophe Living: Using

the Wisdom of Your Body and Mind to Face

Stress, Pain, and Illness (1990). For clinical

applications of mindfulness, see MindfulnessBased Cognitive Therapy for Depression: A New

Approach to Preventing Relapse (Segal et al., 

2002) and Relapse Prevention: Maintenance 

Strategies in the Treatment of Addictive Behaviors (Marlatt & Donovan, 2005). 

Pharmacological Therapy 

Pharmacotherapy for people with mental, substance use, and traumatic stress disorders 

needs to be carefully managed by physicians 

who are well versed in the treatment of each 

condition. Medications can help manage and

control symptoms; however, they are only a

part of a comprehensive treatment plan. There 

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Part 1, Chapter 6—Trauma-Specific Services 

are no specific “antitrauma” drugs; rather, certain drugs target specific trauma symptoms.

Clients receiving pharmacotherapy need careful assessment. Some clients with preexisting

mental disorders may need further adjustment

in medications due to the physiological effects 

of traumatic stress. In addition, sudden withdrawal from a pattern of self-administered

substances can not only lead to dangerous levels of physical distress, but also exacerbate the

emergence of more severe PTSD symptoms.

Distress after trauma often lessens over time,

which can sometimes make the use of medications unnecessary for some individuals. Some 

trauma survivors do not develop long-term 

psychological problems from their experiences 

that require medication; others may simply 

refuse the initiation of pharmacotherapy or the

use of additional medications. 

Concluding Note 

Behavioral health counselors can best serve 

clients who have experienced trauma by 

providing integrated treatment that combines 

therapeutic models to target presenting symptoms and disorders. Doing so acknowledges 

that the disorders interact with each other. 

Some models have integrated curricula; others

that address trauma alone can be combined 

with behavioral health techniques with which 

the counselor is already familiar. 

In part, the choice of a treatment model or

general approach will depend on the level of

evidence for the model, the counselor’s training, identified problems, the potential for prevention, and the client’s goals and readiness

for treatment. Are improved relationships with

family members a goal? Will the client be 

satisfied if sleep problems decrease, or is the 

goal resolution of broader issues? Are there 

substance use or substance-related disorders? 

Is the goal abstinence? Collaborating with

clients to decide on goals, eliciting what they 

would like from treatment, and determining

what they expect to happen can provide some 

clues as to what treatment models or techniques might be successful in keeping clients

engaged in recovery. 

155 

.

Part 2: An Implementation Guide 


for Behavioral Health Program
 

Administrators
 

 

. 

 

IN THIS CHAPTER 

• Show Organizational and Administrative Commitment to

TIC

• Use Trauma -Informed Principles in Strategic Planning

• Review and Update Vision,

Mission, and Value Statements

• Assign a Key Staff Member To 

Facilitate Change

• Create a Trauma -Informed

Oversight Committee

• Conduct an Organizational

Self -Assessment of Trauma -

Informed Services

• Develop an Implementation

Plan

• Develop Policies and Procedures To Ensure Trauma -

Informed Practices and To

Prevent Retraumatization

• Develop a Disaster Plan

• Incorporate Universal Routine

Screenings

• Apply Culturally Responsive

Principles

• Use Science -Based

Knowledge

• Create a Peer -Support Environment

• Obtain Ongoing Feedback

and Evaluations

• Change the Environment To

Increase Safety

• Develop Trauma -Informed

Collaborations

Trauma-Informed 1 Organizations 

Part 2 provides a broad overview of how to create and implement

an institutional framework for trauma-informed services in program delivery and staff development, policies and procedures, administrative practices, and organizational infrastructure in

behavioral health services. Chapter 1, “Trauma-Informed Organizations,” focuses on specific organizational strategies that will help

develop a trauma-informed culture in behavioral health settings.

Numerous strategies are presented, including organizational commitment to trauma-informed care (TIC), trauma-informed organizational assessment, implementation of universal screening for

trauma, and creation of a peer support environment. 

Chapter 2, “Building a Trauma-Informed Workforce,” focuses on

organizational activities that foster the development of a traumainformed workforce, including recruiting, hiring, and retaining

trauma-informed staff; providing training on evidence-based and 

emerging trauma-informed best practices; developing competencies specific to TIC; addressing ethical considerations; providing

trauma-informed supervision; and preventing and treating secondary trauma in behavioral health service providers. 

The strategies described in the following sections can help supervisors and other administrative staff members create a traumainformed behavioral health environment. As a starting point, the

administration should identify key personnel and consumers to

guide the organizational change process and the organizational assessment. Administrators and supervisors need to plan for and

demonstrate an ongoing commitment to these strategies, or staff 

may perceive development activities as comprising yet another idea 

or demand from the agency that is short-lived beyond the initial

thrust of training. 

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Trauma-Informed Care in Behavioral Health Services 

Creating a trauma-informed organization is a 

fluid, ongoing process; it has no completion

date. Consumer demographics change across 

time, exposure to specific types of trauma

may become more prevalent, and knowledge 

of best and evidence-based practices (EBPs) 

will continue to advance. A trauma-informed 

organization continues to demonstrate a

commitment to compassionate and effective 

practices and organizational reassessments,

and it changes to meet the needs of consumers 

with histories of trauma. It is encouraging that 

recent Substance Abuse and Mental Health 

Services Administration (SAMHSA) data 

indicates that the majority of over 10,000 programs they surveyed state that they provide 

trauma-related care (Capezza & Najavits,

2012). However, there remains a major need to 

TIC Framework in Behavioral Health Services—Trauma-Informed Organizations 

make TIC consistently high-quality, routine,

and pervasive across treatment systems. 

The following stages form the basis of creating a trauma-informed organization:

1. Commit to creating a trauma-informed

agency. 

2. Create an initial infrastructure to initiate,

support, and guide changes. 

3. Involve key stakeholders, including consumers who have histories of trauma. 

4. Assess whether and to what extent the

organization’s current policies, procedures,

and operations either support TIC or interfere with the development of a traumainformed approach. 

5. Develop an organizational plan to implement and support the delivery of TIC

within the agency. 

160 
 

 

Trauma-Informed Services and Service Systems 

“A trauma-informed service system and/or organization is one in which all components of the system 

have been reconsidered and evaluated in the light of a basic understanding of the role that violence 

and trauma play in the lives of people seeking mental health and addiction services. A ‘traumainformed’ organizational environment is capable of supporting and sustaining ‘trauma-specific’ services as they develop. A trauma-informed system recognizes that trauma results in multiple vulnerabilities and affects many aspects of a survivor’s life over the lifespan, and therefore coordinates and 

integrates trauma-related activities and training with other systems of care serving trauma survivors. 

A basic understanding of trauma and trauma dynamics...should be held by all staff and should be 

used to design systems of services in a manner that accommodates the vulnerabilities of trauma survivors and allows services to be delivered in a way that will avoid retraumatization and facilitate consumer participation in treatment. A trauma-informed service system is knowledgeable and 

competent to recognize and respond effectively to adults and children traumatically impacted by any 

of a range of overwhelming adverse experiences, both interpersonal in nature and caused by natural 

events and disasters. There should be written plans and procedures to develop a trauma-informed 

service system and/or trauma-informed organizations and facilities with methods to identify and monitor progress. Training programs for this purpose should be implemented.” 

Source: Jennings, 2009, pp. 111–112. 

Seminal Resource for Administrators 

As you investigate how best to implement 

or improve trauma -informed services 

within your organization or across systems, 

review the influential work, Using Trauma 

Theory to Design Service Systems: New 

Directions for Mental Health Services. 

(Harris & Fallot, 2001c) 

Part 2, Chapter 1—Trauma-Informed Organizations 

6.	 Create collaborations between providers

and consumers and among service providers and various community agencies. 

7.	 Put the organizational plan into action. 

8.	 Reassess the implementation of the plan

and its ability to meet the needs of consumers and to provide consistent TIC on 

an ongoing basis. 

9.	 Implement quality improvement measures 

as needs and problem areas are identified.

10. Institute practices that support sustainability, such as ongoing training, clinical supervision, consumer participation and

feedback, and resource allocation. 

Strategy #1: Show 

Organizational and 

Administrative 

Commitment to TIC 

Foremost, administrators need to understand

the impact that trauma can have on people’s 

lives. The consistent delivery of TIC is only as 

effective as the organization’s commitment, 

which must extend to administrative practices 

with staff members, program policies and procedures, program design, staffing patterns, use 

of peer support, staff and peer training and

supervision, organizational assessment and

consumer feedback, and resources to uphold

trauma-informed principles and practices.

Even short-term change is not sustainable

without the agency’s continual commitment. 

Typically, desirable organizational change

doesn’t occur by accident. It comes from 

steadfast leadership, a convincing message that

change is necessary and beneficial for staff and

consumers, and resources that support change.

Many people naturally resist change; thus, an

organization’s commitment includes a willingness to discuss with staff members the impact and role of trauma in their service setting,

patience in planning and implementation, and 

161 
Advice to Administrators: Managing 

Staff Reactions to Implementation of 

New Processes or Ideas 

A common hurdle for administrators after introducing a new process or idea is the staff 

assumption that it will require more work. 

Frontline staff members are often inundated 

with many responsibilities beyond face-to-face 

time with clients. In addition, a common misperception is that if you begin to address 

trauma, you will have difficulty containing it. 

In addition to administrative buy-in, administrators must promote rather than simply announce 

the implementation of trauma-informed services. Promotion includes educating staff about 

the rationale for trauma-informed services, offering opportunities for discussion and input 

from staff and consumers, providing training 

focused on trauma-informed skills, and so forth. 

For example, the San Diego Trauma-Informed 

Guide Team (2012) created a promotional brochure on how TIC can make staff jobs easier: 

• Focuses on root problem 

• Is preventative 

• Increases support system 

• Facilitates collaboration 

• Shares workload 

• Empowers client 

• Provides consistency in agencies/systems 

• Uses evidence-based best practices 

TIC may be cost-effective, lead to less intensive 

services and less use of services, prevent undue 

stress for staff members and clients, and prevent client crises caused by old policies that 

could retraumatize trauma survivors. 

the ability to tolerate the uncertainty that naturally accompanies transitions. 

Strategy #2: Use TraumaInformed Principles in 

Strategic Planning 

Strategic planning provides an opportunity to

explore and develop short- and long-term 

goals. The planning process often begins with

reevaluating the organizations’ values, mission, 

Statement Example 

As behavioral health service providers, we 

strive to be trauma aware—to understand the 

dynamics and impact of trauma on the lives of 

individuals, families, and communities. We 

strive to create a trauma-sensitive culture by 

demonstrating, through consumer empowerment, program design, and direct care, an understanding of the relationships among trauma, 

substance abuse, and mental illness. 

Trauma-Informed Care in Behavioral Health Services 

and vision, yet agencies cannot adequately 

develop a trauma-informed strategic plan

without obtaining specific information about

internal (staff, resources, processes) and external environmental (referral constellation,

changes in health care, funding sources, State 

and Federal standards, community needs, consumer demographics, etc.) factors and influences. Data gathered through staff, consumer,

organizational, and community assessments 

shapes the direction of the plan, including

projected demands, challenges, obstacles,

strengths, weaknesses, and resources. At the 

conclusion of this planning process, the organization will have specific goals, objectives, and

tasks to meet the needs of their stakeholders 

and to address any anticipated challenges. Ideally, strategic planning should define key steps 

in developing or refining trauma-informed

services within the organization. 

Strategy #3: Review and 

Update Vision, Mission, 

and Value Statements 

Vision, mission, and value statements provide

a conceptual framework for TIC development

and delivery. They should not be created in

isolation; they should reflect voices from the 

community, populations, and other stakeholders that the organization serves. These statements develop through input, discussion, and

assessment. They are not static; they evolve as

needs, populations, or environments change. 

162 
 

 

Advice to Administrators: How To Create Vision, Value, and Mission Statements 

Define the organization’s vision, values, and mission to be compatible with TIC. Emphasize the organizational culture needed to provide TIC. An outgrowth of that cultural shift may include an enhanced 

working environment for employees and consumers that is noncoercive and reduces conflicts, restraint, and seclusion. Even if the current mission statement is appropriate, change it anyway to symbolize intended change within the organization. To define or redefine the vision, values, and mission: 

• Involve consumers, all levels of staff, and leadership, including the director/CEO. 

• Review: 

­ Organizational priorities to identify and manage conflicting priorities. 

­ Resources to assess whether reallocation is necessary for change (e.g., to hire peer support 

specialists, to furnish comfort rooms). 

• Operationalize the vision, values, and mission at the level of individual departments 

• Evaluate progress at regular staff meetings to ensure that changing the culture of care stays on 

the agenda. 

Source: New Logic Organizational Learning, 2011. 

Part 2, Chapter 1—Trauma-Informed Organizations 

Strategy #4: Assign a Key 

Staff Member To 

Facilitate Change 

Prior to the development of an oversight committee, a senior staff member with the authority to initiate and implement changes should be 

assigned to oversee the developmental process.

By assigning a trauma-aware senior staff member who is committed to trauma-informed 

services, it is more likely that the organization’s and committee’s goals, objectives, and

plans will remain in focus. This senior staff

member is responsible for ongoing development and facilitation of the oversight committee; management of the initial organizational

assessment, reassessments, and other evaluative

and feedback processes; and facilitation and

oversight of the implementation plan and subsequent changes, including policies and procedures to ensure delivery of TIC. 

Strategy #5: Create a 

Trauma-Informed 

Oversight Committee 

The role of the oversight committee includes 

providing ongoing input and direction in the

initial organizational assessment, strategic 

plan, plan implementation, reevaluation and

development of trauma-informed policies and 

procedures, and future reassessments. The 

committee monitors progress and uses realtime data to forge a clear pathway to new processes that support TIC. The committee 

should involve stakeholders from the community, consumers, specialists, staff members, and

administrators. Leadership involvement is 

necessary. Stakeholders may be alumni, family 

members, community-based organizations,

and other institutions that interact with the 

agency or would benefit from traumainformed services. 

Initially, the agency must educate the committee on the organization’s mission, values, and

vision as well as the task at hand—developing

trauma-informed services. To ease potential 

conflicts or confusion about the organization’s

structure, the guidelines, expectations, and

roles of the committee need to be communicated directly to committee members as well 

as the organization as a whole, including board

members, support and professional staff, supervisors, and so forth. The committee also

needs to know the extent of their power and

the necessary lines of communication before, 

during, and after evaluating and implementing

changes in the organization. 

163 
 

 

 

 

Advice to Administrators: Ten Steps 

to Quality Improvement 

1. Identify new goals or problems. 

2. Gather input from each level of the organization, including consumers and other key 

stakeholders. 

3. Analyze the feedback. 

4. Explore improvement options and the 

potential barriers associated with each. 

5. Select the overall approach and specific 

strategies to address barriers (anticipate 

barriers, and try to address them before 

they occur). 

6. Develop an implementation plan, and then 

present the plan to staff members and 

other key stakeholders not directly involved in the quality improvement process. 

7. Implement the plan. 

8. Reassess the new plan. 

9. Evaluate the results and determine if new 

goals or additional problems or issues 

need to be addressed. 

10. Repeat the first nine steps. 

Trauma-Informed Care in Behavioral Health Services 

Including consumers and/or those who have 

lived through trauma is vital. They have

unique knowledge, experiences, and perspectives on the impact of treatment design, delivery, policies, and procedures. They offer

firsthand information on practices that can 

potentially retraumatize clients in behavioral

health settings and can suggest preventive,

alternative practices and solutions. Consumer

committee members keep staff and administrators aware of the goal of achieving TIC. 

Strategy #6: Conduct an 

Organizational SelfAssessment of TraumaInformed Services 

An organizational self-assessment evaluates 

the presence and/or the effectiveness of current trauma-informed practices across each

service and level of the organization. This 

assessment allows an organization to see how 

it functions within the context of traumainformed principles and provides feedback to

inform the development or revision of the 

implementation plan for TIC. In essence, this 

assessment process can serve as a blueprint for

change and as a benchmark of compliance 

with and progress in implementing traumainformed practices across time. Overall, it is a 

process of identifying organizational strengths,

weaknesses, opportunities, and threats related

to the implementation and maintenance of

TIC. Refer to Appendix F for sample organizational assessment tools for the organization

and the consumer. 

The self-assessment should obtain feedback 

from key stakeholders, particularly consumers,

family members, referral sources, community 

organizations, and all levels of the organization’s staff, including nonclinical and clinical

staff, supervisors, and administrative personnel. Similar to the universal screening process, 

an organizational self-assessment is only as 

effective as the steps taken after data are gathered and analyzed. From this assessment, an

implementation plan should be established

that highlights the goals, objectives, steps,

timeframe, and personnel responsible in overseeing the specific objective. Assessment

shouldn’t be a once-and-done project. Timely 

and regularly scheduled organizational assessments should follow to assist in quality improvement. For an explanation of more 

detailed steps to take in conducting an organizational self-assessment, see Chapter 4 of the 

planned Treatment Improvement Protocol 

(TIP), Improving Cultural Competence

(SAMHSA, planned c). 

Strategy #7: Develop an 

Implementation Plan 

Implementation plans should evolve from 

consumer participation, demographic profiles 

164 
 

Exhibit 2.1-1: TIC Planning Guidelines 

The following publications provide samples of organizational guidelines for implementing TIC. 

• Fallot, R. D. & Harris, M. (2009). Creating cultures of trauma-informed care (CCTIC): A selfassessment and planning protocol. Washington, DC: Community Connections, 2009. 

• Guarino, K., Soares, P., Konnath, K., Clervil, R., & Bassuk, E. (2009). Trauma-informed organizational toolkit. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental 

Health Services Administration; the Daniels Fund; the National Child Traumatic Stress Network; 

and the W. K. Kellogg Foundation. 

• Huckshorn, K. (2009). Transforming cultures of care toward recovery oriented services: Guidelines 

toward creating a trauma informed system of care. In Trauma informed care (TIC) planning guidelines for use in developing an organizational action plan. Alexandria, VA: National Association of 

State Mental Health Program Directors. 

• Jennings, A. (2009). Criteria for building a trauma-informed mental health service system. Retrieved on May 21, 2013, from http://www.theannainstitute.org/CBTIMHSS.pdf 

• Ohio Legal Rights Service (2007). Trauma-informed treatment in behavioral health settings. Columbus, OH: Ohio Legal Rights Service. 

• Prescott, L., Soares, P., Konnath, K., & Bassuk, E. (2008). A long journey home: A guide for creating trauma-informed services for mothers and children experiencing homelessness [draft]. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services 

Administration; the Daniels Fund; the National Child Traumatic Stress Network; and the W.K. 

Kellogg Foundation. 

The following resource is a systemwide set of guidelines for implementing TIC. 

• U.S. Department of Health and Human Services, Health Resources and Services Administration 

(2006). Model trauma system: Planning and evaluation. Rockville, MD: Health Resources and Services Administration. 

Advice to Administrators: Implementation Plan Content 

1. Introduction and overview: This includes the organization’s history, the demographics that characterize its client base, the rationale for the implementation plan, and the incorporation of TIC. 

Focus on identification of strengths, weaknesses, opportunities, and threats. Provide an overview 

of goals and objectives. 

2. Specific goals and objectives: Goals and objectives should address: 

­ Workforce development strategies for recruiting, hiring, retaining, training, supervising, and 

promoting wellness of clinical and nonclinical staff members to support TIC. 

­ Consumer participation and peer support development and implementation strategies. 

­ Policies, procedures, and practices to support TIC and culturally responsive services, to promote safety, and to prevent retraumatization. 

­ Specific evidence-based or best practice adoptions to support TIC. 

­ Strategies to amend facility design or environment (plant) operations to reinforce safety. 

­ Fiscal planning to ensure sustainability of the steps initiated in the organization. 

3. Guidelines for implementation: Guidelines should highlight the specific steps, roles, responsibilities, and timeframes for each activity to meet TIC objectives. 

Part 2, Chapter 1—Trauma-Informed Organizations 

of populations served, data from organization- the oversight committee is responsible for

al self-assessment, and research on promising designing a plan that outlines the purpose,

and evidence-based trauma-informed practic- goals, objectives, timeframes, and personnel 

es. Using the framework proposed in this TIP, responsible for each objective (Exhibit 2.1-1). 

165 
 

 

 

Program Curriculum: Roadmap to 

Seclusion-Free and Restraint-Free 

Mental Health Services 

This curriculum, written from consumer perspectives, provides behavioral health staff with 

education, strategies, and hands-on tools to 

prevent and ultimately eliminate the use of 

seclusion and restraint. It includes many 

handouts for participants and consumers. This 

training package, available online 

(http://store.samhsa.gov/product/Roadmap-toSeclusion-and-Restraint-Free-Mental-HealthServices-CD-/SMA06-4055), is divided into 

seven modules plus a resources section: 

• Module 1: The Personal Experience of 

Seclusion and Restraint 

• Module 2: Understanding the Impact of 

Trauma 

• Module 3: Creating Cultural Change 

• Module 4: Understanding Resilience and 

Recovery from the Consumer Perspective 

• Module 5: Strategies to Prevent Seclusion 

and Restraint 

• Module 6: Sustaining Change Through 

Consumer and Staff Involvement 

• Module 7: Review and Action Plan 

• Resource Section 

Source: Center for Mental Health Services 

(CMHS), SAMHSA, 2005. 

Trauma-Informed Care in Behavioral Health Services 

Strategy #8: Develop 

Policies and Procedures 

To Ensure TraumaInformed Practices and To 

Prevent Retraumatization 

In the early stage of evaluating current services 

and planning for TIC, the committee needs to

assess practices, procedures, and policies that

may have been or could be retraumatizing to

any individual, at any level of the organization,

from consumers to administrators. Programs 

that are not trauma informed are as likely to

be unaware of the impact of trauma on staff as 

they are to be unaware of its influence on consumers. In the initial review, careful scrutiny 

should be used to eliminate any practice that is 

potentially harmful, including seclusion and

restraint practices, therapeutic activities that

are shaming, treatment planning without collaboration, any medical inquiry without 

privacy, and so forth. 

Policies and procedures are the building

blocks of each agency. They guide the service 

process and, if followed, they provide an opportunity for the agency to deliver consistent

responses and care. Policies and procedures 

must incorporate trauma-informed practices

across all domains and standards, such as admissions, plant/environmental standards,

screening and assessment processes, referrals 

(to other services, including hospitalization, or

for further evaluations), treatment planning,

confidentiality, discharge, and more. They

also need to be updated periodically to incorporate new science and to meet the changing

needs of consumers. By regularly reviewing

and adapting administrative and clinical policies and procedures in response to everchanging needs and evidence, the agency can

provide staff members with good guidelines 

for providing trauma-informed services that

are consistent yet flexible. 

Strategy #9: Develop a 

Disaster Plan 

Facilities are often required to develop disaster

plans, but specific requirements vary from 

State to State. From the outset, developing a

disaster plan in behavioral health services is 

essential. Many clients in behavioral health

services have lived with trauma, so proactive

steps that reduce the impact of a new trauma

may prevent worsening of symptoms and decrease the risk for more pervasive effects. (See 

also Technical Assistance Publication 34, Disaster Planning Handbook for Behavioral Health

Treatment Programs [SAMHSA, 2013].) 

166 
 

 

 

 

 

 

Part 2, Chapter 1—Trauma-Informed Organizations 

Most disaster events cannot be accurately anticipated. Even so, behavioral health organizations can take steps to reduce the impact of a

disaster event on program functioning and on 

the lives of clients. Each service or program 

should develop a disaster response committee 

that meets regularly to develop, maintain, and

adapt policies and procedures to respond to

disasters affecting the program. Committee 

planning efforts may include:

1.	 Creating a disaster response team of program staff members tasked with coordinating program administration and

services in a disaster event. 

2.	 Establishing a communication process for

informing staff and clients of the status of

program functioning and for coordinating

staff assignments during and shortly after

the disaster event. 

3.	 Outlining a process to inform clients and

their families of available services, their location, and contact information for accessing services to meet clients’ critical needs. 

4.	 Developing plans for service provision

during a disaster event and service implementation after the event. 

5.	 Creating special plans for high-risk or

special needs clients who need services 

during and shortly after the disaster. Examples of this are clients who are homeless, in detoxification services or

methadone programs, on prescribed psychopharmaceuticals, or at risk for suicide. 

6.	 Making plans for maintaining the security 

of client records, program records, and facilities during and shortly after the event. 

7.	 Coordinating ahead with other community

resources and services to ensure that clients 

at high risk or with special needs get the 

services they require as soon as possible. 

8.	 Prioritizing how services will start back up

after a disaster event. 

9.	 Providing special services after the event to

clients at high risk for trauma reactions 

and symptoms. 

10. Establishing a postdisaster debriefing process to review disaster responses, services,

and outcomes. 

Some specific disaster events, such as hurricanes, may sometimes offer opportunities for

planning and preparation in advance of the

disaster event. This preparation time is usually 

just a few days, but it allows programs to make 

advance preparations and take advance action

to establish lines of communication, stockpile 

resources, prepare for evacuation of clients,

and protect client and program records. 

Strategy #10: Incorporate 

Universal Routine 

Screenings 

A key element of trauma-informed services is

the institution of universal routine screening

across all services, regardless of the individual’s 

path in accessing services (e.g., primary care, 

hospitalization, outpatient). Considering the 

prevalence of trauma among individuals who

seek services for mental and substance use 

disorders, the implementation of screening is 

paramount. Without screening, clients are not

identified as trauma survivors. Subsequently,

they miss recovery opportunities and treatment services that would be more likely to

meet their needs, while also running a higher

risk of being retraumatized by unexamined

organizational policies, procedures, and practices. For more information on the rationale,

processes, and instruments of universal screening for trauma, refer to Part 1, Chapter 4. 

Strategy #11: Apply 

Culturally Responsive 

Principles 

Providers must be culturally competent when

incorporating evidence-based and best practices as well as trauma-informed treatment 

167 
 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

models within the organization. Clients’ views 

of behavioral health differ according to race,

ethnicity, and culture (refer to the planned

Treatment Improvement Protocol [TIP], Improving Cultural Competence [SAMHSA,

planned c]). Likewise, cultures attach different

meanings to trauma, and responses to trauma

will vary considerable across cultures (see Part

3, the online literature review, for more information). For example, trauma survivors 

who come from a collective society or culture,

in which the goals of the group take precedence over the goals of the individual, may be 

more focused on the well-being of their family

or the family’s response to the trauma survivors’ experience. Often, this view runs in opposition to the individualistic perspective of

many behavioral health services. Subsequently, 

treatment providers who are not culturally 

competent may interpret collective values as a

sign of resistance or avoidance in dealing with

traumatic stress. CMHS (2003) outlines principles of cultural competence in disaster work 

applicable across all forms of trauma:

1.	 Recognize the importance of culture and

respect diversity. Those who value culture 

and diversity understand their own cultures, attitudes, values, and beliefs, and

they work to understand the cultures of

others. This includes being able to communicate effectively with those from other

cultures, respecting others’ feelings about

personal space, knowing about others’ social organization, understanding how time

is viewed, and being aware of others’ beliefs about the effects of their behaviors. 

2.	 Maintain a current prof ile of the cultural

composition of the community. This includes describing the community’s population in terms of race and ethnicity, age,

gender, religion, refugee and immigrant

status, housing status, income levels, rural/urban balance, unemployment, languages spoken, literacy, schools, and

businesses. 

3.	 Recruit workers who are representative of

the community or service area. If the workers who are available do not match the 

community, they should have the personal 

attributes, knowledge, and skills to develop

cultural competence. 

4.	 Provide ongoing cultural competence training to staff. Topics should include cultural 

values and traditions, family values, linguistics and literacy, immigration experiences and status, help-seeking behaviors, 

techniques and strategies for cross-cultural 

outreach, and the avoidance of stereotypes 

and labels (DeWolfe & Nordboe, 2000b). 

5.	 Ensure that services are accessible, appropriate, and equitable. In planning disaster

work or TIC, community associations and

organizations are invaluable. Gaining their

acceptance requires time and energy. 

6.	 Recognize the role of help-seeking behaviors, traditions, and natural support networks. Culture includes traditions that 

dictate whom, or which groups, to seek in 

times of need; how to handle suffering and

loss; and how healing takes place. These 

customs and traditions are respected by a

culturally responsive disaster relief 

program. 

7.	 Involve community leaders and organizations representing diverse cultural groups as

“cultural brokers.” Collaborating with

community leaders is an effective means of

learning about the community, establishing

program credibility, and ensuring that services are culturally responsive. 

8.	 Ensure that services and information are 

culturally and linguistically responsive.

Communication with individuals who do 

not speak English, who are illiterate in all 

languages or have limited literacy, and who

are deaf or hard of hearing is essential to

service provision. Local radio stations, television outlets, and newspapers that are 

multicultural are an excellent venue for 

educational information after a disaster. 

168 
 

 

 

 

 

 

 

For more detailed information on EBPs, 

visit the National Registry of Evidence -

Based Programs and Practices (NREPP) 

Web site (http://nrepp.samhsa.gov). For 

more specific research -oriented information on trauma and trauma -specific 

treatments, refer to the literature review in 

Part 3 of this TIP, available online. 

For an introduction 

to peer support 

services, see What 

Are Peer Recovery 

Support Services? 

(Center for Substance Abuse 

Treatment, 2009e). 

Part 2, Chapter 1—Trauma-Informed Organizations 

Using survivors’ friends or relatives as interpreters is not recommended, as survivors may be uncomfortable discussing

personal matters with family members or

friends. Asking children to interpret can

place too heavy a responsibility on them 

and reverses parents’ and children’s roles. 

9.	 Assess and evaluate the program’s level of 

cultural responsiveness. Self-assessment 

and process evaluation can help keep a

program on track. A variety of strategies 

can be used for collecting data and communicating findings to stakeholders. 

Strategy #12: Use 

Science-Based Knowledge 

Along with culturally responsive services,

trauma-informed organizations must use 

science-based knowledge to guide program 

development and the implementation of services, policies, procedures, and practices.This

includes the adoption of EBPs (see Part 1,

Chapter 6, and Part 3, Section 1, to review

definition, treatments, and resources for EBPs). 

TIC research is quite new; interpret these limited studies and information cautiously.

Chambless and Hollon’s (1998) criteria, which 

are still the benchmark for EBPs, are valuable 

resources for administrators. Look closely at

who was included—and excluded—from 

treatment studies. Often, the types of severe,

chronic, and unstable cases seen in community 

settings are excluded from treatment studies.

Evidence-based interventions should be a 

primary consideration in selecting appropriate 

treatment models for people with mental illness, substance use disorders, and co-occurring

psychological trauma. Nonetheless, other variables must also be contemplated before adopting EBPs in an organization, including the

cultural appropriateness of the practice; the

strength of its clinical focus on strengthsbased strategies; training and competence of 

clinical staff; the cost of training, materials,

and implementation; and the ease of maintaining EBP fidelity amidst staff turnover. 

Strategy #13: Create a 

Peer-Support Environment 

The main purpose of

peer support services 

is to provide consumer mentoring,

support, and care 

coordination for clients with histories of 

mental illness or 

substance abuse. The 

goals are to help others deal with personal and

environmental barriers that impede recovery 

and achieve wellness. Peer support accomplishes this through many activities, including

advocacy, support during crises and recovery 

activities, modeling, education, and assistance 

in accessing available resources. Peer support

programs send a powerful message to staff

members, consumers, and the community—

that recovery is possible through support, collaboration, and empowerment. These programs reinforce the trauma-informed premise 

that organizations need to reflect the populations that they serve and involve consumers in

planning, implementing, monitoring, and delivering recovery services. 

Notably, peer support services have the potential to be considerably flexible to meet client

needs at each stage of recovery. Specifically,

peer support services can be incorporated 

169 
 

 

 

 

 

“Peer recovery support services are evidence based and have been demonstrated to promote positive health outcomes 

and control the cost of healthcare. These 

services are offered by a trained individual 

with lived experience and recovery from a 

mental illness, substance use and/or 

chronic health conditions. Peer recovery 

support services minimally include chronic 

illness self -management, whole health and 

wellness promotion and engagement, 

relapse prevention, life skill coaching, and 

insurance and health systems navigation.” 

(Daniels et al., 2012, p. 22) 

 

Advice to Administrators: Sample 

Peer Support Staff Tasks 

• Use active listening skills help peers identify areas of dissatisfaction and benefits of 

changing beliefs, thoughts, and behavior. 

• Use problem-solving skills to help peers 

identify barriers to recovery and develop 

plans to meet peer-determined goals. 

• Facilitate recovery support groups. 

• Link clients with community resources. 

• Work with the treatment team to advocate 

for clients and to remove recovery barriers. 

• Participate in consumer panels to educate 

staff about the consumer perspective and 

about peer support. 

• Participate in hospital-wide committees 

and workgroups 

Source: New Logic Organizational Learning, 

2011. 

Trauma-Informed Care in Behavioral Health Services 

across the continuum of care, starting with 

outreach services and extending into longterm recovery services. Peer support specialists 

can enhance consumer motivation to change,

to initiate services, and/or to engage in recovery activities. They can play powerful liaison

roles by supporting clients entering treatment

and explaining what to expect from services.

They can ease the transition into treatment,

from one service to the next, from one modality to another (e.g., inpatient group to outpatient group), and beyond formal treatment.

Moreover, peer support services create an atmosphere focused on mutuality rather than

pathology. They provide living models of resilience and promote hope—that recovery is 

possible and attainable. 

Administrators should familiarize themselves 

with how other organizations have implemented peer support programs, current curricula, certifications and training processes,

competencies and ethics, and peer support

service State standards or recommendations, if

applicable. The Carter Center’s Summit in 

2009, The Pillars of Peer Support Services,

supported in part by SAMHSA and CMHS, 

highlighted the numerous elements necessary 

to develop a strong, vital peer workforce 

(Daniels et al., 2010). These elements include:

•	 Clear job and service descriptions. 

•	 Job-related competencies and competencebased testing processes. 

•	 Peer support certifications. 

•	 Ongoing continuing education. 

•	 Media and technology access for peer specialists. 

•	 Sustainable funding. 

•	 Research and evaluation components. 

•	 Code of ethics and conduct. 

•	 Competence-based training for supervisors. 

•	 Multilevel support and program support

teams. 

Strategy #14: Obtain 

Ongoing Feedback and 

Evaluations 

Obtain feedback on and evaluations of organizational performance on a regular basis. Give

consumers a clear avenue for offering feedback 

at any time, and make evaluations assessing

the organization’s progress toward providing

trauma-informed services standard practice.

Without feedback and further evaluation, organizations cannot assess whether they are 

170 
 

 

 

Creating Sanctuary 

The sanctuary model is a trauma-based therapeutic approach that has been used in inpatient, residential, therapeutic community, and outpatient settings with children, adolescents, and adults. It 

provides a template for changing social service delivery systems so that they are better equipped to 

respond to the complex needs of trauma survivors. Sanctuary is informed by four knowledge areas: 

“the psychobiology of trauma, the active creation of nonviolent environments, principles of social 

learning, and an understanding of the ways in which complex adaptive systems grow, change, and 

alter their course” (Bloom et al., 2003, p. 174). 

The sanctuary model describes a stage-based approach to healing that is referred to as SAGE: safety, 

affect modulation, grieving, and emancipation. This model is nonlinear; an individual does not necessarily move from one stage to another in a straight path, but progress in one area does affect progress in other areas (Bloom, 1997; Bloom et al., 2003). SAGE is a cognitive–behavioral translation of 

the sanctuary model (Bills, 2003). Early in treatment, the focuses are typically on safety and affect 

management. Safety encompasses four domains: physical, psychological, social, and moral (Bloom, 

1997; see http://www.sanctuaryweb.com for further details and a curriculum). 

Part 2, Chapter 1—Trauma-Informed Organizations 

meeting trauma-informed objectives. A routine monitoring process for TIC implementation gives the organization additional

information necessary to combat new obstacles and threats and to understand what works. 

Regular monitoring equips organizations with

the ability to formulate different strategies to

meet objectives as well as to respond to the

changing needs of the population. Ongoing

evaluation and consumer feedback are essential in improving the quality of services. 

Strategy #15: Change the 

Environment To Increase 

Safety 

Practices that generate emotional and physical

safety are necessary. Another aspect of creating

safety is reevaluating the physical facilities and

environment to enhance safety and to circumvent preventable retraumatization. Think how

traumatizing it would be if you were a female 

rape survivor and a night counselor was conducting a room check at 2:00 a.m., or a male 

security guard was walking the women’s residential wing. What would it be like if you 

were sitting with your back to the door in a

small office during an intake interview, if your

history included a physical assault and robbery? For most, it would at least increase anxiety; for others it would be retraumatizing.

Trauma-informed providers must carefully 

assess environmental safety. Although you are 

likely to identify some facility issues that could

erode safety for trauma survivors, a safe environment will only be established if regular

feedback is obtained from consumers about 

their experiences with the program. 

Strategy #16: Develop 

Trauma-Informed 

Collaborations 

TIC is about collaboration with consumers,

staff members, key stakeholders, and other

agencies. Collaborative relationships provide

opportunities for consumers to access the most

appropriate services as needs arise. Rather

than waiting for a crisis or a dire need for a

service to investigate available resources, it is 

far more efficient and compassionate to establish relationships within the agency and with 

other community resources before these needs 

arise. No agency can meet the needs of every 

client; referral agreements and/or collaborative 

arrangements that integrate the delivery of

TIC, including support services (e.g., housing,

legal, medical), are important. 

171 

 

 

 

 

IN THIS CHAPTER 

• Introduction

• Workforce Recruitment,

Hiring, and Retention

• Training in TIC

• Trauma -Informed

Counselor Competencies

• Counselor

Responsibilities and

Ethics

• Clinical Supervision and

Consultation

• Secondary Traumatization

• Counselor Self -Care

Building a Trauma­ 2 Informed Workforce
 

Introduction 

For an organization to embrace a trauma-informed care (TIC)

model fully, it must adopt a trauma-informed organizational mission and commit resources to support it. This entails implementing

an agency-wide strategy for workforce development that is in

alignment with the values and principles of TIC and the organization’s mission statement. Without a fully trained staff, an organization will not be able to implement the TIC model. However,

simply training behavioral health professionals in TIC is not

enough. Counselors will not be able to sustain the kind of focus 

required to adopt and implement a trauma-informed philosophy 

and services without the ongoing support of administrators and

clinical supervisors. 

An organizational environment of care for the health, well-being, 

and safety of, as well as respect for, its staff will enhance the ability 

of counselors to provide the best possible trauma-informed behavioral health services to clients. This culture of care must permeate

the organization from top to bottom. Behavioral health program 

administrators should aim to strengthen their workforce; doing so

“requires creating environments that support the health and wellbeing, not only of persons with mental and substance use conditions, but of the workforce as well” (Hoge, 2007, p. 58). An organizational culture of care, safety, and respect demands activities that 

foster the development of trauma-informed counselors. This chapter focuses on key workforce development activities, such as:

• Recruiting, hiring, and retaining trauma-informed staff.

• Training behavioral health service providers on the principles of,

and evidence-based and emerging best practices relevant to, TIC.

• Developing and promoting a set of counselor competencies specific to TIC.

173 
 

 

Trauma-Informed Care in Behavioral Health Services 

TIC Framework in Behavioral Health Services—Building a Trauma-Informed 

Workforce 

the importance of organization-wide support

and active involvement in workforce recruitment, hiring, and retention in behavioral

health systems. One of the key findings of this 

report is that the work environment itself in

many behavioral health settings can be toxic to

the workforce and may hinder the delivery of

individualized, respectful, collaborative, and

client-centered care to service recipients. Factors such as the downward pressure on organizations for higher productivity of counselors 

increase caseloads and decrease wages of behavioral health staff members and may create 

a high-stress environment that contributes to

low morale and worker dissatisfaction. Other 

factors that often contribute to low retention 

of qualified counselors in behavioral health

settings include the lack of professional career 

• Delineating the responsibilities of counselors and addressing ethical considerations

specifically relevant to promoting TIC.

• Providing trauma-informed clinical supervision.

• Committing to prevention and treatment

of secondary trauma of behavioral health

professionals within the organization.

Addressing each of these areas is essential to

building a trauma-informed workforce and an

organizational culture that supports TIC. 

Workforce Recruitment, 

Hiring, and Retention 

An Action Plan for Behavioral Health Workforce 

Development (Hoge et al., 2007) emphasizes 

174 
 

 

 

 

Who Is a Trauma Champion? 

“A champion understands the impact of violence and victimization on the lives of people 

seeking mental health or addiction services and 

is a front-line worker who thinks ‘trauma first.’ 

When trying to understand a person’s behavior, the champion will ask, ‘is this related to 

abuse and violence?’ A champion will also think 

about whether his or her own behavior is hurtful or insensitive to the needs of a trauma survivor. The champion is there to do an identified 

job—he is a case manager or a counselor or a 

residential specialist—but in addition to his or 

her job, a champion is there to shine the spotlight on trauma issues.” 

Source: Harris & Fallot, 2001a, p. 8. 

Part 2, Chapter 2—Building a Trauma-Informed Workforce 

ladders, fragile job security, the lack of clinical 

supervision, and an inability to influence the 

organization in which they are working (Hoge

et al., 2007). 

Added to this mix is the intensity of working

with people with the co-occurring conditions

of trauma-related mental and substance use 

disorders and the risk of secondary traumatization of counselors. In creating and sustaining a trauma-informed workforce,

organizations need to foster a work environment that parallels the treatment philosophy

of a trauma-informed system of care. Doing

so allows counselors to count on a work environment that values safety, endorses collaboration in the making of decisions at all levels,

and promotes counselor well-being. 

Recruitment and Hiring in a 

Trauma-Informed System of Care 

In a 2007 technical report ( Jennings, 2007b), 

the National Center for Trauma-Informed 

Care identified several priorities for organizations with regard to recruitment and hiring

trauma-informed staff, including:

•	 Active recruitment of and outreach to prospective employees who are traumainformed or have formal education in 

providing trauma-informed or traumaspecific services in settings such as universities, professional organizations, professional 

training and conference sites, peer support

groups, and consumer advocacy groups. 

•	 Hiring counselors and peer support staff

members with educational backgrounds 

and training in trauma-informed and/or 

trauma-specific services and/or lived experience of trauma and recovery. 

•	 Providing incentives, bonuses, and promotions for staff members during recruitment

and hiring that take into consideration

prospective employees’ trauma-related education, training, and job responsibilities. 

In addition to hiring behavioral health professionals with formal professional education and

training, organizations should also “routinely 

survey the demographics and other characteristics of the population served and recruit a

workforce of similar composition” (Hoge et

al., 2007, p. 297). Essentially, this means actively engaging in outreach to consumer advocacy groups, recovery-oriented programs, 

community and faith-based organizations, and

former clients/consumers with the intention of

recruiting potential employees whose 

knowledge and expertise comes from their

lived experience of trauma, resilience, and

recovery. Support staff members, peer support

workers, counselors in training, and apprentices can be recruited from this population and

offered incentives, such as tuition reimbursement, training stipends, and professional 

mentoring with the goal of developing a trauma-informed workforce from within the demographic served. Jennings (2007b) calls these 

staff members “trauma champions” who can 

provide needed expertise in a traumainformed organization to promote traumainformed policies, staff development, and

trauma-based services consistent with the mission of the organization (p. 135). 

175 
Advice to Administrators: Preventing Turnover and Increasing Workforce 

Retention 

To prevent behavioral health staff turnover and increase retention of qualified, satisfied, and highly 

committed trauma-informed counselors, consider: 

• Offering competitive wages, benefits, and performance incentives that take into account education, training, and levels of responsibility in providing trauma-informed or trauma-specific services. 

• Creating a safe working environment that includes both the physical plant and policies and procedures to prevent harassment, stalking, and/or violence in the workplace and to promote respectful interactions amongst staff at all levels of the organization. 

• Establishing an organizational policy that normalizes secondary trauma as an accepted part of 

working in behavioral health settings and views the problem as systemic—not the result of individual pathology or a deficit on the part of the counselor. 

• Instituting reasonable, manageable caseloads that mix clients with and without trauma-related 

concerns. 

• Letting staff offer input into clinical and administrative policies that directly affect their work experience. 

• Providing vacation, health insurance (which includes coverage for psychotherapy/personal counseling), and other benefits that promote the well-being of the staff. 

• Implementing regular, consistent clinical supervision for all clinical staff members. 

• Providing ongoing training in trauma-informed services offered by the organization. 

Trauma-Informed Care in Behavioral Health Services 

As with hiring behavioral health professionals 

who are in recovery from substance use disorders, the organization should be transparent

and explicit in its recruitment and hiring practices of trauma survivors in recovery. The organization can be transparent by advertising

the mission statement of the organization as 

part of the recruitment process and inviting

applicants who are in recovery from trauma to

apply. The needs of behavioral health staff

members who are in recovery from both substance use and trauma-related conditions and 

working in a trauma-informed system of care 

should be addressed in the organization’s ongoing training, clinical supervision, and staff

development policies and practices. 

Workforce Retention 

Staff turnover is rampant in behavioral health

settings. It is costly to the organization, and as 

a result, it is costly to clients. A strong therapeutic relationship with a counselor is one of

the largest factors in an individual’s ability to

recover from the overwhelming effects of

trauma. When behavioral health professionals 

leave an organization prematurely or in crisis 

as a result of chronic levels of high stress or

secondary traumatization, clients must deal 

with disruptions in their relationships with

counselors. Some of the organizational factors 

that contribute to chronic levels of high stress

and often lead to high staff turnover include 

expecting counselors to maintain high caseloads of clients who have experienced trauma;

not providing trauma-informed clinical supervision and training to counselors; and failing

to provide adequate vacation, health insurance, and other reasonable benefits that support counselors’ well-being. Other factors that 

may have a more profound impact on staff

retention include failing to acknowledge the 

reality of secondary traumatization, promoting

the view that counselors’ stress reactions are a 

personal failure instead of a normal response 

to engaging with clients’ traumatic material,

and not supporting personal psychotherapy for

counselors (Saakvitne, Pearlman, & Traumatic Stress Institute/Center for Adult & Adolescent Psychotherapy, 1996). 

Research on promoting counselor retention in 

behavioral health settings demonstrates that 

176 
 

 

 

 

Part 2, Chapter 2—Building a Trauma-Informed Workforce 

behavioral health staff members are interested 

in the same kind of work environment and 

benefits as employees in many other fields.

They include a “living wage with healthcare

benefits; opportunities to grow and advance;

clarity in a job role; some autonomy and input

into decisions; manageable workloads; administrative support without crushing administrative burden; basic orientation and training for

assigned responsibilities; a decent and safe 

physical work environment; a competent and

cohesive team of coworkers; the support of a

supervisor; and rewards for exceptional performance” (Hoge et al., 2007, p. 18). 

When an organization’s administration values 

its staff by providing competitive salaries and

benefits, a safe working environment, a reasonable and manageable workload, input into

the making of clinical and administrative policy decisions, and performance incentives, it

helps behavioral health workers feel connected

to the mission of the organization and become

dedicated to its sustainability and growth.

This type of work environment demonstrates 

both a level of respect for counselors (similar

to the level of respect a trauma-informed organization displays toward clients) and an 

appreciation for the complexity of their job

responsibilities and the stress they face when

working with people who have experienced

trauma in their lives. To retain behavioral 

health professionals working in a traumainformed setting, wages and performance incentives should be tied not only to education,

training, and work experience, but also to levels of responsibility in working with clients 

who have experienced trauma. 

Training in TIC 

Training for all staff members is essential in

creating a trauma-informed organization. It 

may seem that training should simply focus on

new counselors or on enhancing the skill level 

of those who have no prior experience in

working with trauma, but training should, in

fact, be more systematic across the organization to develop fully sustainable traumainformed services. All employees, including

administrative staff members, should receive 

an orientation and basic education about the 

prevalence of trauma and its impact on the

organization’s clients. To ensure safety and

reduction of harm, training should cover dynamics of retraumatization and how practice

can mimic original sexual and physical abuse

experiences, trigger trauma responses, and

cause further harm to the person. Training for 

all employees must also educate them “about

the impacts of culture, race, ethnicity, gender,

age, sexual orientation, disability, and socioeconomic status on individuals’ experiences of 

trauma” (Jennings, 2007a, p. 5). 

All clinical and direct service staff members, 

regardless of level of experience, should receive 

more indepth training in screening and assessment of substance use and trauma-related 

disorders; the relationships among trauma, 

substance use disorders, and mental disorders;

how to understand difficult client behaviors 

through a trauma-informed lens; how to avoid

retraumatizing clients in a clinical setting; the

development of personal and professional 

boundaries unique to clinical work with traumatized clients; how to identify the signs of

secondary traumatization in themselves; and

how to develop a comprehensive personal and

professional self-care plan to prevent and/or

ameliorate the effects of secondary traumatization in the workplace. All clinical staff

members who work with traumatized clients 

should receive additional training in evidencebased and promising practices for the treatment of trauma (for information on locating

training, see Appendix B.) This might include 

training done within the agency by experts in

the field or training received by attending advanced trauma trainings. Administrators 

177 
 

 

 

 

 

 

 

 

 

 

 

Case Illustration: Larry 

Larry is a 28-year-old clinical social worker who 

just finished his master’s program in social 

work and is working in a trauma-informed outpatient program for people with substance use 

disorders. He is recovering from alcohol use 

disorder and previously worked in a residential 

rehabilitation program as a recovery support 

counselor. There, his primary responsibilities 

were to take residents to Alcoholics Anonymous (AA) meetings, monitor their participation, and confront them about their substance 

use issues and noncompliance with the program’s requirement of attendance at 12-Step 

meetings. 

In Larry’s new position as a counselor, he confronts a client in his group regarding her discomfort with attending AA meetings. The 

client reports that she feels uncomfortable with 

the idea that she has to admit that she is powerless over alcohol to be accepted by the 

group of mostly men. She was sexually abused 

by her stepfather when she was a child and 

began drinking heavily and smoking pot when 

she was 11 years old. The client reacts angrily 

to Larry’s intervention. 

In supervision, Larry discusses his concerns 

regarding the client’s resistance to AA and the 

feedback that he provided to her in group. 

Beyond focusing supervision on Larry’s new 

role as a counselor in a trauma-informed program, the clinical supervisor recommends that 

Larry take an interactive, multisession, computer-assisted training on the 12-Step facilitation 

(TSF) model. The TSF model introduces clients 

to and assists them with engaging in 12-Step 

recovery support groups. The agency has the 

computer-based training available in the office, 

and Larry agrees to use follow-up coaching 

sessions with his supervisor to work on implementation of the approach. The supervisor 

recognizes that Larry is falling back on his own 

recovery experience and the strategies he relied on in his previous counseling role. He will 

benefit from further training and coaching in an 

evidence-based practice that provides a nonaggressive, focused, and structured way to 

facilitate participation in recovery support 

groups with clients who have trauma histories. 

Trauma-Informed Care in Behavioral Health Services 

should provide the time and financial resources to clinical staff members for this professional development activity. Jennings

(2007a) suggests that, whenever possible,

“trainings should be multi-system, inclusive of

staff in mental health and substance abuse,

health care, educational, criminal justice, social

services systems and agencies, and promoting

systems integration and coordination” (p. 5). 

Moreover, criminal justice settings, schools,

military/veteran programs, and other places in

which behavioral health services are provided

may benefit from approaches that are sensitive 

to the special circumstances and cultures of

these environments. For example, in exploring

trauma-informed correctional care, Miller and 

Najavits (2012, p. 1) observe: 

Prisons are challenging settings for traumainformed care. Prisons are designed to house

perpetrators, not victims. Inmates arrive shackled and are crammed into overcrowded housing units; lights are on all night, loud speakers

blare without warning and privacy is severely 

limited. Security staff is focused on maintaining order and must assume each inmate is potentially violent. The correctional environment

is full of unavoidable triggers, such as pat 

downs and strip searches, frequent discipline

from authority figures, and restricted movement....This is likely to increase traumarelated behaviors and symptoms that can be 

difficult for prison staff to manage....Yet, if

trauma-informed principles are introduced, all

staff can play a major role in minimizing triggers, stabilizing offenders, reducing critical incidents, deescalating situations, and avoiding

restraint, seclusion or other measures that may

repeat aspects of past abuse. 

The Need for Training 

Behavioral health service providers working

with clients who have mental, substance use,

and trauma-related disorders need to have the 

best knowledge, skills, and abilities. Substance

abuse counselors, in particular, require additional training and skill development to be able to

extend trauma-informed services (within the 

178 
 

 

Exhibit 2.2-1: Clinical Practice Issues Relevant to Counselor Training in TraumaInformed Treatment Settings 

• Some substance abuse counseling strategies commonly used to work through clients’ denial and 

minimization of their substance use issues may be inappropriate when working with trauma survivors (e.g., highly confrontational models can remind trauma survivors of emotional abuse). 

Training: The Stages of Change model of addiction treatment can help counselors shift from 

the traditional confrontation of denial to conceptualizing clients’ ambivalence about changing 

substance use patterns as a normal part of the precontemplation stage of change. This method 

is a respectful cognitive–behavioral approach that helps counselors match counseling strategies 

to their assessment of where each client is in each stage of change, with the ultimate goal of 

helping clients make changes to health risk behaviors. (Connors, Donovan, & DiClemente, 2001). 

• The 12-Step concept of powerlessness (Step 1) may seem unhelpful to trauma survivors for 

whom the emotional reaction to powerlessness is a major part of their trauma (particularly for 

victims of repetitive trauma, such as child abuse or intimate partner violence). It can be confusing and counterproductive to dwell on this concept of powerlessness regarding trauma when 

the therapeutic objective for trauma-informed counseling methods should be to help clients 

empower themselves. For people in recovery, powerlessness is a paradox, sometimes misunderstood by both counselors and clients, in that the acknowledgment of powerlessness often creates a sense of empowerment. Most clients, with support and respectful guidance from a 

counselor, will come to understand that powerlessness (as used in 12-Step programs) is not an 

inability to stand up for oneself or express a need, and it does not mean for one to be powerless 

in the face of abuse. With this understanding, clients may become more open to participating in 

12-Step groups as a resource for their recovery from substance use disorders. When clients continue to struggle with this concept and decline to participate in 12-Step recovery efforts, they 

may benefit from referral to other forms of mutual-help programs or recovery support groups in 

which the concept of powerlessness over the substance of abuse is not such a significant issue. 

Training: The TSF model can help counselors develop a more supportive and understanding 

approach to facilitating clients’ involvement in 12-Step recovery groups (if this is a clientgenerated recovery goal). “Although based on standard counseling models, TSF differs from 

them in several ways. These differences include TSF’s strong emphasis on therapist support, discouragement of aggressive ‘confrontation of denial’ and therapist self-disclosure, and highly focused and structured format” (Sholomskas & Carroll, 2006, p. 939). 

Another well-intentioned, but often misguided, approach by counselors who have not had formal or extensive training is “digging” for trauma memories without a clear therapeutic rationale 

or understanding of client readiness. In doing so, the counselor may unintentionally retraumatize 

the client or produce other harmful effects. In early intervention, it is sufficient simply to 

acknowledge and validate the pain and suffering of the client without uncovering or exploring 

specific trauma memories. The counselor who is insufficiently trained in trauma-informed clinical 

(Continued on the next page.) 

Part 2, Chapter 2—Building a Trauma-Informed Workforce 

limits of their professional licensure and scope 

of practice) to clients who have co-occurring

substance use, trauma-related, or mental disorders. Many clinical practice issues in traditional

substance abuse treatment are inconsistent with 

trauma-informed practice, which needs to be 

addressed with further training. Similarly, mental health clinicians often need training in

substance abuse treatment, as they typically do 

not have backgrounds or experience in that

domain. Moreover, several surveys indicate 

that clinicians consistently perceive the combination of trauma and substance abuse as 

harder to treat than either one alone (Najavits,

Norman, Kivlahan, & Kosten, 2010). It is thus

key to emphasize cross-training as part of

TIC. Exhibit 2.2-1 addresses these issues and 

offers suggestions for additional training. 

179 
 

Exhibit 2.2-1: Clinical Practice Issues Relevant to Counselor Training in TraumaInformed Treatment Settings (continued) 

practice may also press agendas that are ultimately unhelpful, such as insisting that the client 

forgive an abuser, pursue a legal case against a perpetrator, or engage in trauma treatment, even 

when the client may not be ready for such steps. These efforts are particularly inappropriate for 

clients in early recovery from substance use disorders. The first goal in treatment is stabilization 

Training: The Seeking Safety model of treating substance abuse and posttraumatic stress disorder (PTSD) can help counselors focus on the primary goal of stabilization and safety in TIC. This 

model emphasizes safety as the target goal, humanistic themes such as honesty and compassion, 

and making cognitive–behavioral therapy accessible and interesting to clients who may otherwise 

be difficult to engage (Najavits, 2002a). 

• Treatment should be client-centered; it should acknowledge the client’s right to refuse counseling for trauma-related issues. It is important to discuss the advantages and disadvantages of exploring trauma-related concerns, and then, following an open discussion, to allow clients the 

right to choose their path. This discussion should be part of the informed consent process at the 

start of treatment. Clients also have the right to change their minds. 

Training: Motivational interviewing, a client-centered, nonpathologizing counseling method, 

can aid clients in resolving ambivalence about and committing to changing health risk behaviors 

including substance use, eating disorders, self-injury, avoidant and aggressive behaviors associated with PTSD, suicidality, and medication compliance (Arkowitz, Miller, Westra, & Rollnick, 

2008; Kress & Hoffman, 2008). Training in MI can help counselors remain focused on the client’s 

agenda for change, discuss the pros and cons of treatment options, and emphasize the personal 

choice and autonomy of clients. 

Exhibit 2.2-2: Guidelines for Training in Mental Health Interventions for TraumaExposed Populations 

After a year of collaboration in 2002, the Task Force on International Trauma Training of the 

International Society for Traumatic Stress Studies published a consensus-based set of recommendations for training. Core curricular elements of the recommended training include: 

• Competence in listening. 

• Recognition of psychosocial and mental problems to promote appropriate assessment. 

• Familiarity with established interventions in the client population. 

• Full understanding of the local context, including help-seeking expectations, duration of treatment, attitudes toward intervention, cost-effectiveness of intervention, and family attitudes and 

involvement. 

• Strategies for solving problems on the individual, family, and community levels. 

• Treatment approaches for medically unexplained somatic pain. 

• Collaboration with existing local resources and change agents (e.g., clergy, traditional healers, 

informal leaders). 

• Self-care components. 

Source: Weine et al., 2002. 

Trauma-Informed Care in Behavioral Health Services 

In addition to the training needs of substance 

abuse counselors, all direct care workers in

mental health settings, community-based programs, crisis intervention settings, and criminal justice environments should receive 

training in TIC. Guidelines for training in 

assisting trauma-exposed populations are presented in Exhibit 2.2-2. 

Continuing Education 

Research on the effectiveness of single-session

didactic and/or skill-building workshops 

180 
 

Advice to Administrators: Trauma-Informed Staff Training 

• Establish training standards for the evidence-based and promising trauma-informed practice 

models (such as Seeking Safety) adopted by your organization. 

• Bring expert trainers with well-developed curricula in TIC and trauma-specific practices into your 

organization. 

• Select a core group of clinical supervisors and senior counselors to attend multisession training or 

certification programs. These clinicians can then train the rest of the staff. 

• Use sequenced, longitudinal training experiences instead of single-session seminars or workshops. 

• Emphasize interactive and experiential learning activities over purely didactic training. 

• Provide ongoing mentoring/coaching to behavioral health professionals in addition to regular 

clinical supervision to enhance compliance with the principles and practices of TIC and to foster 

counselor mastery of trauma-specific practice models. 

• Build organization-wide support for the ongoing integration of new attitudes and counselor skills 

to sustain constructive, TIC-consistent changes in practice patterns. 

• Provide adequate and ongoing training for clinical supervisors in the theory and practice of clinical supervision and the principles and practices of TIC. 

• Include information and interactive exercises on how counselors can identify, prevent, and ameliorate secondary traumatic stress (STS) reactions in staff trainings. 

• Offer cross-training opportunities to enhance knowledge of trauma-informed processes throughout the system. 

Part 2, Chapter 2—Building a Trauma-Informed Workforce 

demonstrates that immediate gains in counselor knowledge and skills diminish quickly after

the training event (Martino, Canning-Ball, 

Carroll, & Rounsaville, 2011). Consequently,

organizations may be spending their scarce 

financial resources on sending counselors to

this kind of training but may not be reaping

adequate returns with regard to long-lasting

changes in counselor skills and the development of trauma-informed and trauma-specific 

counselor competencies. Hoge et al. (2007)

suggest the implementation of training strategies for behavioral health professionals that 

have proven to be effective in improving counselor skills, attitudes, and practice approaches. 

These strategies include: “interactive approaches; sequenced, longitudinal learning

experiences; outreach visits, known as academic detailing; auditing of practice with feedback

to the learner; reminders; the use of opinion

leaders to influence practice; and patientmediated interventions, such as providing information on treatment options to persons in

recovery, which in turn influences the practice 

patterns of their providers” (p. 124). 

Trauma-Informed 

Counselor Competencies 

Hoge et al. (2007) identified a number of

counselor competencies in behavioral health

practices that are consistent with the skills 

needed to be effective in a trauma-informed 

system of care. They include person-centered 

planning, culturally competent care,

development of therapeutic alliances, shared

responsibility for decisions, collaboratively 

developed recovery plans, evidence-based

practices, recovery- and resilience-oriented 

care, interdisciplinary- and team-based

practice, and consumer/client advocacy. In

addition, counselor competencies critical to

the effective delivery of services to clients with

trauma-related disorders include: 

•	 Screening for and assessment of trauma

history and trauma-related disorders, such

as mood and anxiety disorders. 

•	 Awareness of differences between traumainformed and trauma-specific services. 

181 
 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

•	 Understanding the bidirectional relationships among substance use and mental disorders and trauma. 

•	 Engagement in person-centered counseling. 

•	 Competence in delivering trauma-informed

and trauma-specific evidence-based interventions that lessen the symptoms associated with trauma and improve quality of life 

for clients. 

•	 Awareness of and commitment to counselor self-care practices that prevent or lessen

the impact of secondary traumatization on

behavioral health workers. 

Exhibit 2.2-3 provides a checklist of competencies for counselors working in trauma-informed

behavioral health settings. Administrators and

clinical supervisors can use this checklist to

assess behavioral health professionals’ understanding of trauma awareness and counseling

skills and determine the need for additional 

training and clinical supervision. 

Counselor Responsibilities 

and Ethics 

Treating all clients in an ethical manner is an

expectation of all healthcare providers. It is of

special importance when working with clients 

who have trauma-related disorders, as their

trust in others may have been severely shaken.

Counselors who work with traumatized individuals on a regular basis have special responsibilities to their clients because of the nature 

of this work. Administrators and clinical supervisors in trauma-informed organizations

should develop policies that clearly define the 

counselors’ job and should provide education

about the role of counselors in the organization and their responsibilities to clients. 

General Principles Regarding 

Counselor Responsibilities 

The following are some general principles 

governing the responsibilities of counselors 

who provide behavioral health services for

clients with histories of trauma: 

•	 Counselors are responsible for routinely 

screening clients for traumatic experiences 

and trauma-related symptoms (Ouimette 

& Brown, 2003; see also Treatment Improvement Protocol [TIP] 42, Substance 

Abuse Treatment for Persons With CoOccurring Disorders, Center for Substance

Abuse Treatment [CSAT], 2005c). 

•	 Counselors should offer clients with substance use and trauma-related disorders 

continuing mental health services if it is

within their professional license and scope 

of practice to do so. 

•	 Counselors are responsible for referring

clients with substance use disorders and cooccurring trauma-related disorders to

treatment that addresses both disorders 

when the treatment falls outside of the 

counselor’s professional license and scope of

practice (Ouimette & Brown, 2003). 

•	 Counselors should refer clients with substance use disorders and co-occurring

trauma-related disorders to concurrent participation in mutual-help groups if appropriate (Ouimette & Brown, 2003). 

•	 Counselors have a responsibility to practice 

the principles of confidentiality in all interactions with clients and to respect clients’ 

wishes not to give up their right to privileged communication. 

•	 Counselors are responsible for educating

clients about the limits of confidentiality 

and what happens to protected health information, along with the client’s privilege,

when the client signs a release of information or agrees to assign insurance benefits to the provider. 

•	 Counselors must inform clients that treatment for trauma-related disorders is always

voluntary. 

•	 Counselors are responsible for being aware 

of their own secondary trauma and 

182 
Exhibit 2.2-3: Trauma-Informed Counselor Competencies Checklist 

Trauma Awareness 

___ Understands the difference between trauma-informed and trauma-specific services 

___ Understands the differences among various kinds of abuse and trauma, including: physical, emotional, and sexual abuse; domestic violence; experiences of war for both combat veterans and 

survivors of war; natural disasters; and community violence 

___ Understands the different effects that various kinds of trauma have on human development and 

the development of psychological and substance use issues 

___ Understands how protective factors, such as strong emotional connections to safe and nonjudgmental people and individual resilience, can prevent and ameliorate the negative impact 

trauma has on both human development and the development of psychological and substance 

use issues 

___ Understands the importance of ensuring the physical and emotional safety of clients 

___ Understands the importance of not engaging in behaviors, such as confrontation of substance 

use or other seemingly unhealthy client behaviors, that might activate trauma symptoms or 

acute stress reactions 

___ Demonstrates knowledge of how trauma affects diverse people throughout their lifespans and 

with different mental health problems, cognitive and physical disabilities, and substance use issues 

___ Demonstrates knowledge of the impact of trauma on diverse cultures with regard to the meanings various cultures attach to trauma and the attitudes they have regarding behavioral health 

treatment 

___ Demonstrates knowledge of the variety of ways clients express stress reactions both behaviorally 

(e.g., avoidance, aggression, passivity) and psychologically/emotionally (e.g., hyperarousal, 

avoidance, intrusive memories) 

Counseling Skills 

___ Expedites client-directed choice and demonstrates a willingness to work within a mutually empowering (as opposed to a hierarchical) power structure in the therapeutic relationship 

___ Maintains clarity of roles and boundaries in the therapeutic relationship 

___ Demonstrates competence in screening and assessment of trauma history (within the bounds of 

his or her licensing and scope of practice), including knowledge of and practice with specific 

screening tools 

___ Shows competence in screening and assessment of substance use disorders (within the bounds 

of his or her licensing and scope of practice), including knowledge of and practice with specific 

screening tools 

___ Demonstrates an ability to identify clients’ strengths, coping resources, and resilience 

___ Facilitates collaborative treatment and recovery planning with an emphasis on personal choice 

and a focus on clients’ goals and knowledge of what has previously worked for them 

___ Respects clients’ ways of managing stress reactions while supporting and facilitating taking risks 

to acquire different coping skills that are consistent with clients’ values and preferred identity 

and way of being in the world 

___ Demonstrates knowledge and skill in general trauma-informed counseling strategies, including, 

but not limited to, grounding techniques that manage dissociative experiences, cognitive– 

behavioral tools that focus on both anxiety reduction and distress tolerance, and stress management and relaxation tools that reduce hyperarousal 

(Continued on the next page.) 

Part 2, Chapter 2—Building a Trauma-Informed Workforce 

183 
 

 

 

 

Exhibit 2.2-3: Trauma-Informed Counselor Competencies Checklist (continued) 

___ Identifies signs of STS reactions and takes steps to engage in appropriate self-care activities that 

lessen the impact of these reactions on clinical work with clients 

___ Recognizes when the needs of clients are beyond his or her scope of practice and/or when clients’ trauma material activates persistent secondary trauma or countertransference reactions that 

cannot be resolved in clinical supervision; makes appropriate referrals to other behavioral health 

professionals 

Source: Abrahams et al., 2010. 

Trauma-Informed Care in Behavioral Health Services 

countertransference reactions and seeking

appropriate help in responding to these reactions so that they do not interfere with 

the best possible treatment for clients. 

TIC organizations have responsibilities to

clients in their care, including:

•	 Protecting client confidentiality, particularly

in relation to clients’ trauma histories. Organizations should comply with the State

and Federal laws that protect the confidentiality of clients being treated for mental 

and substance use disorders. 

•	 Providing clients with an easy-to-read

statement of their rights as consumers of

mental health and substance abuse services,

including the right to confidentiality (Exhibit 2.2-4). 

•	 Providing quality clinical supervision to all

counselors and direct-service workers, with

an emphasis on TIC. Organizations should,

at minimum, comply with State licensing

requirements for the provision of clinical 

supervision to behavioral health workers. 

•	 Establishing and maintaining appropriate

guidelines and boundaries for client and

counselor behavior in the program setting. 

•	 Creating and maintaining a traumainformed treatment environment that 

respects the clients’ right to selfdetermination and need to be treated with 

dignity and respect. 

•	 Maintaining a work environment that reinforces and supports counselor self-care. 

All behavioral health professionals are responsible for abiding by professional standards of

care that protect the client. Breaches of confidentiality, inappropriate conduct, and other

violations of trust can do further harm to clients who already have histories of trauma.

Many treatment facilities have a Client Bill of 

Rights (or a similar document) that describes 

the rights and responsibilities of both the

counselors and the participants; it often is part

of the orientation and informed consent process when a client enters treatment. However,

simply reading and acknowledging the receipt

of a piece of paper is not a substitute for the 

dialog that needs to happen in a collaborative

therapeutic partnership. Administrators are

responsible for providing clients with easy-toread information describing counselor responsibilities and client rights. Clinical supervisors 

are responsible for helping counselors engage 

in a respectful dialog with clients about those 

rights and responsibilities as part of a comprehensive informed consent process. 

Exhibit 2.2-4 is an excerpt from a Client Bill

of Rights that outlines clients’ right to confidentiality in plain language that is readable 

and easily understood. 

184 
 

Exhibit 2.2-4: Sample Statement of the Client’s Right to Confidentiality From a 

Client Bill of Rights 

Tri-County Mental Health Services is a trauma-informed mental health and substance abuse treatment agency in Maine. Below is a statement regarding clients’ right to confidentiality and staff responsibility to protect that privilege; this statement is provided in a brochure outlining consumer 

rights that is easily accessible to service recipients at the agency and online. 

Confidentiality 

We will not give out information about you to anyone without your knowledge and permission. This 

includes written information from your record and verbal information from your providers. Additionally, we will not request any information about you without your knowledge and permission. A Release of Information Form allows you to say what information can be shared and with whom. You 

determine the length of time this is valid, up to one year. 

Tri-County policies prevent any employee of the agency who does not have a direct need to know 

from having access to any information about you. The penalty for violation can include immediate 

dismissal. 

Exceptions to this rule of confidentiality include times when a client is at immediate risk of harm to self 

or others, or when ordered by the court. We will make every effort to notify you in these instances. 

Source: Tri-County Mental Health Services, 2008, pp. 6-7. 

Part 2, Chapter 2—Building a Trauma-Informed Workforce 

Ethics in Treating Traumatized 

Clients 

All behavioral health professionals must conform to the ethical guidelines established by 

their profession’s State licensing boards and/or

certifying organizations. State licensing boards

for substance abuse counseling, psychiatry,

social work, psychology, professional counseling, and other behavioral health professions 

provide regulatory standards for ethical practice in these professions. These boards also

have specific procedures for responding to

complaints regarding the actions of professional caregivers. Additionally, national professional societies have standards for ethical 

practices. Members of these organizations are 

expected to practice within the boundaries and

scope of these standards. Some of these standards are quite explicit, whereas others are more 

general; most approach professional ethics not

as a rigid set of rules, but rather, as a process 

of making ethical decisions. 

Clinical supervisors are responsible for informing counselors of their ethical responsibilities with regard to their own organization’s 

policies and procedures, monitoring supervisees’ reading and understanding the codes of

ethics of professional organizations and State

licensing boards, and promoting counselor

understanding of ethics and how to make decisions ethically as a regular part of clinical

supervision, team meetings, and counselor

training. Administrators can support high

ethical standards by creating an organizationwide ethics task group consisting of counselors, supervisors, and administrators who meet

regularly to review and revise clinical policies 

in line with State and Federal law and professional codes of ethics. Administrators may 

also act as a support mechanism for counselors 

who need additional consultation regarding

potential ethical dilemmas with clients. The 

Green Cross Academy of Traumatology provides ethical guidelines for the treatment of

clients who have experienced trauma; these 

guidelines are adapted in Exhibit 2.2-5. 

185 
Exhibit 2.2-5: Green Cross Academy of Traumatology Ethical Guidelines for the 

Treatment of Clients Who Have Been Traumatized 

Respect for the dignity of clients 

• Recognize and value the personal, social, spiritual, and cultural diversity present in society, without judgment. As a primary ethical commitment, make every effort to provide interventions with 

respect for the dignity of those served. 

Responsible caring 

• Take the utmost care to ensure that interventions do no harm. 

• Have a commitment to the care of those served until the need for care ends or the responsibility 

for care is accepted by another qualified service provider. 

• Support colleagues in their work and respond promptly to their requests for help. 

• Recognize that service to survivors of trauma can exact a toll in stress on providers. Maintain 

vigilance for signs in self and colleagues of such stress effects, and accept that dedication to the 

service of others imposes an obligation to sufficient self-care to prevent impaired functioning. 

• Engage in continuing education in the appropriate areas of trauma response. Remain current in 

the field and ensure that interventions meet current standards of care. 

Integrity in relationships 

• Clearly and accurately represent your training, competence, and credentials. Limit your practice 

to methods and problems for which you are appropriately trained and qualified. Readily refer to 

or consult with colleagues who have appropriate expertise; support requests for such referrals or 

consultations from clients. 

• Maintain a commitment to confidentiality, ensuring that the rights of confidentiality and privacy 

are maintained for all clients. 

• Do not provide professional services to people with whom you already have either emotional 

ties or extraneous relationships of responsibility. The one exception is in the event of an emergency in which no other qualified person is available. 

• Refrain from entering other relationships with present or former clients, especially sexual relationships or relationships that normally entail accountability. 

• Within agencies, ensure that confidentiality is consistent with organizational policies; explicitly 

inform individuals of the legal limits of confidentiality. 

Responsibility to society 

• Be committed to responding to the needs generated by traumatic events, not only at the individual level, but also at the level of community and community organizations in ways that are 

consistent with your qualifications, training, and competence. 

• Recognize that professions exist by virtue of societal charters in expectation of their functioning 

as socially valuable resources. Seek to educate government agencies and consumer groups 

about your expertise, services, and standards; support efforts by these agencies and groups to 

ensure social benefit and consumer protection. 

• If you become aware of activities of colleagues that may indicate ethical violations or impairment 

of functioning, seek first to resolve the matter through direct expression of concern and offers of 

help to those colleagues. Failing a satisfactory resolution in this manner, bring the matter to the 

attention of the officers of professional societies and of governments with jurisdiction over professional misconduct. 

Clients’ universal rights 

All clients have the right to: 

• Not be judged for any behaviors they used to cope, either at the time of the trauma or after the 

trauma. 

• Be treated at all times with respect, dignity, and concern for their well-being. 

• Refuse treatment, unless failure to receive treatment places them at risk of harm to self or others. 

(Continued on the next page.) 

Trauma-Informed Care in Behavioral Health Services 

186 
that create a safe therapeutic container. Some 

clients, especially those with longstanding

disorders, bring a history of client–counselor

relationships to counseling. Clients who have 

been traumatized may need help understanding the roles and responsibilities of both the 

counselor and the client. Clients with traumarelated conditions may also have special needs 

Exhibit 2.2-5: Academy of Traumatology Ethical Guidelines for the Treatment of 

Clients Who Have Been Traumatized (continued) 

• Be regarded as collaborators in their own treatment plans. 

• Provide their informed consent before receiving any treatment. 

• Not be discriminated against based on race, culture, sex, religion, sexual orientation, socioeconomic status, disability, or age. 

• Have promises kept, particularly regarding issues related to the treatment contract, role of counselor, and program rules and expectations. 

Procedures for introducing clients to treatment 

Obtain informed consent, providing clients with information on what they can expect while receiving 

professional services. In addition to general information provided to all new clients, clients presenting for treatment who have histories of trauma should also receive information on: 

• The possible short-term and long-term effects of trauma treatment on the client and the client’s 

relationships with others. 

• The amount of distress typically experienced with any particular trauma treatment. 

• Possible negative effects of a particular trauma treatment. 

• The possibility of lapses and relapses when doing trauma work, and the fact that these are a 

normal and expected part of healing. 

Reaching counseling goals through consensus 

Collaborate with clients in the design of a clearly defined contract that articulates a specific goal in a 

specific time period or a contract that allows for a more open-ended process with periodic evaluations of progress and goals. 

Informing clients about the healing process 

• Clearly explain to clients the nature of the healing process, making sure clients understand. 

• Encourage clients to ask questions about any and all aspects of treatment and the therapeutic 

relationship. Provide clients with answers in a manner they can understand. 

• Encourage clients to inform you if the material discussed becomes overwhelming or intolerable. 

• Inform clients of the necessity of contacting you or emergency services if they feel suicidal or 

homicidal, are at risk of self-injury, or have a sense of being out of touch with reality. 

• Give clients written contact information about available crisis or emergency services. 

• Inform clients about what constitutes growth and recovery and about the fact that some trauma 

symptoms may not be fully treatable. 

• Address unrealistic expectations clients may have about counseling and/or the recovery process. 

Level of functioning 

• Inform clients that they may not be able to function at the highest level of their ability––or even 

at their usual level––when working with traumatic material. 

• Prepare clients to experience trauma-related symptoms, such as intrusive memories, dissociative 

reactions, reexperiencing, avoidance behaviors, hypervigilance, or unusual emotional reactivity. 

Source: Green Cross Academy of Traumatology, 2007. Adapted with permission. 

Part 2, Chapter 2—Building a Trauma-Informed Workforce 

Boundaries in therapeutic 

relationships 

Maintaining appropriate therapeutic boundaries is a primary ethical concern for behavioral

health professionals. Counselors working with

clients who have substance use, traumarelated, and other mental disorders may feel 

challenged at times to maintain boundaries 

187 
 

 

Advice to Clinical Supervisors: Recognizing Boundary Confusion 

Clinical supervisors should be aware of the following counselor behaviors that can indicate boundary 

confusion with clients: 

• The counselor feels reluctant or embarrassed to discuss specific interactions with a client or details of the client’s treatment in supervision or team meetings. 

• The counselor feels possessive of the client, advocates with unusual and excessive vehemence for 

the client, or expresses an unreasonable sense of overresponsibility for the client. 

• The counselor becomes defensive and closed to hearing ideas from the supervisor or the treatment team members about approaches to working with a client and/or exploring his or her own 

emotional reactions to a client. 

• The clinician begins or increases personal self-disclosure to the client and is not able to identify 

legitimate clinical reasons for the self-disclosure. 

Trauma-Informed Care in Behavioral Health Services 

in establishing appropriate boundaries in the

counseling setting; they may be particularly 

vulnerable and not understand or appreciate 

the need for professional boundaries, including not engaging in dual relationships. For

example, some clients might experience a

counselor’s boundary around not giving the 

client his or her personal phone number for

emergency calls as a rejection or abandonment. Cultural considerations also influence 

therapeutic boundaries. 

Administrators, in collaboration with clinical

supervisors, are responsible for creating policies regarding counselor and client boundaries

for various issues (e.g., giving and receiving

gifts, counselor personal disclosure, and counselor roles and responsibilities when attending

the same 12-Step meetings as clients); policies

should be specific to their organization and

conform to State and Federal law and behavioral health professional codes of ethics. Clinical supervisors are responsible for training

counselors in the informed consent process 

and effective ways to discuss boundaries with

clients when they enter treatment. 

Guidelines for establishing and maintaining

boundaries in therapeutic relationships,

adapted from the Green Cross Academy of

Traumatology, are given in Exhibit 2.2-6. 

Clients with trauma histories may be especially vulnerable to counselor behaviors that are 

inconsistent or that are experienced by the 

client as boundary violations. Examples of

such behavior include: being late for appointments, ending counseling sessions early, repeatedly and excessively extending the session

time, canceling or “forgetting” appointments 

multiple times, spending time in the session

talking about their own needs and life experiences, exploring opportunities for contact outside the therapeutic relationship (including

making arrangements to meet at AA or other

12-Step recovery group meetings), and enforcing rules differently for one client than for

another. 

Due to the complex dynamics that can arise in

the treatment of clients with trauma histories,

regularly scheduled clinical supervision, where 

issues of ethics and boundaries can be discussed, is recommended for counselors. For

more information on how clinical supervision

can be effectively used, see TIP 52, Clinical 

Supervision and the Professional Development of 

the Substance Abuse Counselor (CSAT, 2009b). 

Boundary crossing and boundary 

violation 

Although guidelines and codes of ethics are

useful tools in helping clinical supervisors and

counselors understand the boundaries between 

counselors and clients, they are open to interpretation and are context-bound. Given these 

limitations, it is crucial to educate counselors 

188 
in TIC settings regarding the boundary issues 

that may arise for clients who have been traumatized and to give counselors a conceptual 

framework for understanding the contextual 

nature of boundaries. For example, it would be 

useful for clinical supervisors to discuss with 

Exhibit 2.2-6: Boundaries in Therapeutic Relationships 

Procedures for Establishing Safety 

Roles and boundaries 

Counselor roles and boundaries should be established at the start of the counseling relationship and 

reinforced periodically, particularly at times when the client is experiencing high stress. 

Ongoing Relationships and the Issue of Boundaries 

Dual relationships 

Dual relationships and inappropriate interactions with clients are to be avoided. It is important to tell 

clients at the beginning of counseling that contact between the counselor and the client can only 

occur within the boundaries of the professional relationship. This information is part of the informed 

consent process. Relationships outside these boundaries include sexual or romantic relationships, a 

counselor also serving as a client’s sponsor in 12-Step programs, and any kind of relationship in 

which the counselor exploits the client for financial gain. 

Sexual contact 

• Never engage in any form of sexual contact with clients. 

• Do not reward sexualized behaviors with attention or reactivity. 

• Directly clarify the boundaries of the therapeutic relationship, and address the underlying motivations of persisting sexualized behavior. 

• Set limits on a client’s inappropriate behaviors while maintaining an ethos of care. Maintain respect for the dignity and worth of the client at all times. 

• Understand that a client’s attempt to sexualize a therapeutic relationship may reflect an early 

history of abuse, difficulty understanding social norms, or a variety of psychological problems. 

• Readdress the absolute inappropriateness of sexual and/or romantic behavior in a nonlecturing, 

nonpunitive manner. 

• If sexual behavior between clients occurs in a treatment program, counselors should consult with 

a clinical supervisor. Document the nature of the contact and how the issue is addressed. 

• If a counselor has sexual contact with a client, he or she should take responsibility by ceasing 

counseling practice, referring clients to other treatment providers, and notifying legal and professional authorities. If a counselor is at risk for engaging with a client sexually but has not acted 

on it, the counselor should immediately consult with a supervisor, colleague, or psychotherapist. 

Boundaries 

Counselors should use care with self-disclosure or any behaviors that may be experienced as intrusive by the client, including: 

• Personal disclosures made for the counselor’s own gratification. 

• Sexualized behavior with the client. 

• Excessively intrusive questions or statements. 

• Interrupting the client frequently. 

• Violating the client’s personal space. 

• Interpersonal touch, which might activate intrusive memories or dissociative reactions or be experienced as a boundary violation by the client. 

• Being consistently late for appointments or allowing outside influences (such as telephone calls) 

to interrupt the client’s time in a counseling session. 

Source: Green Cross Academy of Traumatology, 2007. Adapted with permission. 

Part 2, Chapter 2—Building a Trauma-Informed Workforce 

189 
 

 

Case Illustration: Denise 

Denise is a 40-year-old licensed professional counselor working in an inpatient eating disorder program. She has had extensive training in trauma and eating disorder counseling approaches and has 

been working as a clinician in mental health settings for 15 years. Denise is usually open to suggestions from her supervisor and other treatment team members about specific strategies to use with 

clients who have trauma histories and eating disorders. However, in the past week, her supervisor has 

noticed that she has become defensive in team meetings and individual supervision when discussing 

a recently admitted young adult who was beaten and raped by her boyfriend; subsequently, the client was diagnosed with PTSD and anorexia. When the clinical supervisor makes note of the change in 

Denise’s attitude and behavior in team meetings since this young woman was admitted, initially 

Denise becomes defensive, saying that the team just doesn’t understand this young woman and that 

the client has repeatedly told Denise, “You’re the only counselor I trust.” 

The clinical supervisor recognizes that Denise may be experiencing secondary traumatization and 

boundary confusion due to working with this young woman and to the recent increase in the number 

of clients with co-occurring trauma-related disorders on her caseload. After further exploration, 

Denise reveals that her own daughter was raped at the same age as the young woman and that hearing her story has activated an STS reaction in Denise. Her way of coping has been to become overly 

responsible for and overprotective of the young woman. With the nonjudgmental support of her 

supervisor, Denise is able to gain perspective, recognize that this young woman is not her daughter, 

and reestablish boundaries with her that are appropriate to the inpatient treatment setting. 

Trauma-Informed Care in Behavioral Health Services 

counselors the distinction between boundary 

crossings and boundary violations in clinical

practice. Gutheil and Brodsky (2008) define 

boundary crossing as a departure from the 

customary norms of counseling practice in

relation to psychological, physical, or social 

space “that are harmless, are nonexploitative,

and may even support or advance the therapy”

(p. 20). Examples of boundary crossings include taking phone calls from a client between

sessions if the client is in crisis or telling a

client a story about the counselor’s recovery 

from trauma (without offering specific personal information or graphic/detailed description of the trauma) with the intention of

offering hope that it is possible to recover. 

Gutheil and Brodsky (2008) define boundary 

violations as boundary crossings that are unwanted and dangerous and which exploit the

client, stating that “some boundary crossings 

are inadvisable because of their intent (i.e.,

they are not done in the service of the patient’s 

well-being and growth, involve extra therapeutic gratification for the therapist) and/or

their effect (i.e., they are not likely to benefit 

the patient and entail a significant risk of

harming the patient)” (pp. 20–21). An example of a boundary violation would be when a

counselor invites a client to attend the same 

AA meetings the counselor attends or shares 

drinking and drugging “war stories” for the

counselor’s own gratification. Two key elements in understanding when a boundary 

crossing becomes a boundary violation are the

intent of the counselor and the damaging effect on the client. Maintaining a standard of

practice of nonexploitation of the client is the

primary focus for clinical supervisors and

counselors in determining when boundary 

crossings become boundary violations. 

Context is also an important consideration in

determining the acceptability of boundary 

crossings. For example, it may be acceptable 

for a counselor in a partial hospitalization program for serious mental illness to have a cup

of coffee at the kitchen table with a resident,

whereas for a counselor in an outpatient mental health program, having a cup of coffee with

a client at the local coffee shop would be a

much more questionable boundary crossing. 

190 
 

Advice to Clinical Supervisors and Administrators: Adopting an Evidence-Based 

Model of Clinical Supervision and Training 

Just as adopting evidence-based clinical practices in a trauma-informed organization is important in 

providing cost-effective and outcome-relevant services to clients, adopting an evidence-based model of clinical supervision and training clinical supervisors in that model can enhance the quality and 

effectiveness of clinical supervision for counselors. This will ultimately enhance client care. 

One of the most commonly used and researched integrative models of supervision is the discrimination model, originally published by Janine Bernard in 1979 and since updated (Bernard & Goodyear, 

2009). This model is considered a competence-based and social role model of supervision; it includes three areas of focus on counselor competencies (intervention, conceptualization, and personalization) and three possible supervisor roles (teacher, counselor, and consultant). 

Counselor competencies: 

• Intervention: The supervisor focuses on the supervisee’s intervention skills and counseling strategies used with a particular client in a given session. 

• Conceptualization: The supervisor focuses on how the supervisee understands what is happening in a session with the client. 

• Personalization: The supervisor focuses on the personal style of the counselor and countertransference responses (i.e., personal reactions) of the counselor to the client. 

Supervisor roles: 

• Teacher: The supervisor teaches the supervisee specific counseling theory and skills and guides 

the supervisee in the use of specific counseling strategies in sessions with clients. The supervisor 

as teacher is generally task-oriented. The supervisor is more likely to act as a teacher with beginning counselors. 

• Counselor: The supervisor does not act as the counselor’s therapist, but helps the counselor 

reflect on his or her counseling style and personal reactions to specific clients. The supervisor as 

counselor is interpersonally sensitive and focuses on the process and relational aspects of counseling. 

• Consultant: The supervisor is more of a guide, offering the supervisee advice on specific clinical 

situations. The supervisor as consultant invites the counselor to identify topics and set the agenda for the supervision. The supervisor is more likely to act as a consultant with more advanced 

counselors. 

This model of supervision may be particularly useful in working with counselors in TIC settings, because the supervisor’s response to the supervisee is flexible and specific to the supervisee’s needs. 

In essence, it is a counselor-centered model of supervision in which the supervisor can meet the 

most relevant needs of the supervisee in any given moment. 

For a review of other theories and methods of clinical supervision, refer to TIP 52, Clinical Supervision 

and Professional Development of the Substance Abuse Counselor (CSAT, 2009b). 

Part 2, Chapter 2—Building a Trauma-Informed Workforce 

Clinical Supervision and 

Consultation 

Organizational change toward a TIC model 

doesn’t happen in isolation. Ongoing support, 

supervision, and consultation are key ingredients that reinforce behavioral health professionals’ training in trauma-informed and 

trauma-specific counseling methods and ensure compliance with practice standards and 

consistency over time. Often, considerable 

energy and resources are spent on the transition to new clinical and programmatic approaches, but without long-range planning to

support those changes over time. The new 

treatment approach fades quickly, making it

hard to recognize and lessening its reliability. 

191 
 

 

Case Illustration: Arlene 

Arlene is a 50-year-old licensed substance abuse counselor who has a personal history of trauma, 

and she is actively engaged in her own recovery from trauma. She is an experienced counselor who 

has several years of training in trauma-informed and trauma-specific counseling practices. Her clinical 

supervisor, acting in the role of consultant, begins the supervision session by inviting her to set the 

agenda. Arlene brings up a clinical situation in which she feels stuck with a client who is acting out in 

her Seeking Safety group (for more information on Seeking Safety, see Najavits, 2002a). 

Arlene reports that her client gets up suddenly and storms out of the group room two or three times 

during the session. The supervisor, acting in the role of the counselor and focusing on personalization, asks Arlene to reflect on the client’s behavior and what feelings are activated in her in response 

to the client’s anger. Arlene is able to identify her own experience of hyperarousal and then paralysis 

as a stress reaction related to her prior experience of domestic violence in her first marriage. The 

supervisor, acting in the role of teacher and focusing on conceptualization, reminds Arlene that her 

client is experiencing a “fight-or-flight” response to some experience in the group that reminds her 

of her own trauma experience. The supervisor then suggests to Arlene that her own reactions are 

normal responses to her previous history of trauma, and that when her client is angry, Arlene is not 

reexperiencing her own trauma but is being activated by the client’s traumatic stress reaction to 

being in group. In this way, the supervisor highlights the parallel process of the client–counselor’s 

stress reactions to a perceived threat based on prior trauma experiences. 

The supervisor, acting again as a consultant and focusing on personalization this time, invites Arlene 

to reflect on the internal and external resources she might be able to bring to this situation that will 

help remind her to ground herself so she can lessen the impact of her stress reactions on her counseling strategy with this client. Arlene states that she can create a list of safe people in her life and 

place this list in her pocket before group. She can use this list as a touchstone to remind her that she 

is safe and has learned many recovery skills that can help her stay grounded, maintain her boundaries, and deal with her client’s behavior. The clinical supervisor, acting as a consultant and now focusing on intervention, asks Arlene if she has some specific ideas about how she can address the client’s 

behavior in group. Arlene and the clinical supervisor spend the remainder of the session discussing 

different options for addressing the client’s behavior and helping her feel safer in group. 

Trauma-Informed Care in Behavioral Health Services 

Ongoing supervision and consultation supports the organizational message that TIC is

the standard of practice. It normalizes secondary traumatization as a systemic issue (not the 

individual pathology of the counselor) and

reinforces the need for counselor self-care to 

prevent and lessen the impact of secondary 

traumatization. Quality clinical supervision for

direct care staff demonstrates the organization’s commitment to implementing a fully 

integrated, trauma-informed system of care. 

Supervision and Consultation 

Historically, there was an administrative belief

that counselors who had extensive clinical 

experience and training would naturally be the 

best clinical supervisors. However, research 

does not support this idea (Falender &

Shafranske, 2004). Although a competent

clinical supervisor needs to have an extensive 

clinical background in the treatment of substance use, trauma-related, and other mental

disorders, it is also essential for any counselor

moving into a supervisory role to have extensive training in the theory and practice of clinical supervision before taking on this role. In

particular, clinical supervisors in traumainformed behavioral health settings should be 

educated in how to perform clinical supervision (not just administrative supervision) of

direct service staff and in the importance of

providing continuous clinical supervision and

support for staff members working with individuals affected by trauma. Clinical 

192 
 

 

 

 

 

Part 2, Chapter 2—Building a Trauma-Informed Workforce 

supervision in a TIC organization should focus on the following priorities:

•	 General case consultation 

•	 Specialized consultation in specific and

unusual cases 

•	 Opportunities to process clients’ traumatic 

material 

•	 Boundaries in the therapeutic and supervisory relationship 

•	 Assessment of secondary traumatization 

•	 Counselor self-care and stress management 

•	 Personal growth and professional development of the counselor 

Supervision of counselors working with traumatized clients should be regularly scheduled,

with identified goals and with a supervisor

who is trained and experienced in working

with trauma survivors. The styles and types of

supervision and consultation may vary according to the kind of trauma work and its context.

For instance, trauma counseling in a major

natural disaster would require a different approach to supervision and consultation than

would counseling adults who experienced

childhood developmental trauma or counseling clients in an intensive early recovery 

treatment program using a manualized

trauma-specific counseling protocol. 

Competence-based clinical supervision is recommended for trauma-informed organizations. Competence-based clinical supervision

models identify the knowledge and clinical 

skills each counselor needs to master, and they

use targeted learning strategies and evaluation

procedures, such as direct observation of counselor sessions with clients, individualized

coaching, and performance-based feedback.

Studies on competence-based supervision approaches have demonstrated that these models 

improve counselor treatment skills and proficiency (Martino et al., 2011). 

Whichever model of clinical supervision an

organization adopts, the key to successful 

trauma-informed clinical supervision is the 

recognition that interactions between the supervisor and the counselor may parallel those 

between the counselor and the client. Clinical 

supervisors need to recognize counselors’ 

trauma reactions (whether they are primary or

secondary to the work with survivors of trauma) and understand that a confrontational or

punitive approach will be ineffective and likely 

retraumatize counselors. 

Clinical supervisors should adopt a respectful 

and collaborative working relationship with

counselors in which role expectations are 

clearly defined in an informed consent process 

similar to that used in the beginning of the

counselor–client relationship and in which

exploring the nature of boundaries in both

client–counselor and counselor–supervisor

relationships is standard practice. Clear role 

boundaries, performance expectations, open

dialog, and supervisor transparency can go a

long way toward creating a safe and respectful 

relationship container for the supervisor and

supervisee and set the stage for a mutually 

enhancing, collaborative relationship. This

respectful, collaborative supervisory relationship is the main source of training and professional growth for the counselor and for the

provision of quality care to people with behavioral health disorders. 

Secondary Traumatization 

The demands of caregiving exact a price from

behavioral health professionals that cannot be

ignored; otherwise, they may become ineffective in their jobs or, worse, emotionally or

psychologically impaired. In a study of Master’s level licensed social workers, 15.2 percent

of respondents to a survey reported STS as a 

result of indirect exposure to trauma material 

at a level that meets the diagnostic criteria for

PTSD. This rate is almost twice the rate of 

PTSD in the general population. The author 

193 
 

Advice to Clinical Supervisors: 

Recognizing Secondary 

Traumatization 

Some counselor behaviors that demonstrate 

inconsistency to clients may be outward manifestations of secondary traumatization, and 

they should be discussed with counselors 

through a trauma-informed lens. It is imperative that clinical supervisors provide a nonjudgmental, safe context in which counselors 

can discuss these behaviors without fear of 

reprisal or reprimand. Clinical supervisors 

should work collaboratively with supervisees to 

help them understand their behavior and engage in self-care activities that lessen the stress 

that may be contributing to these behaviors. 

STS is a trauma -

related stress 

reaction and set of 

symptoms resulting 

from exposure to 

another individual’s 

traumatic 

experiences rather 

than from exposure 

directly to a 

traumatic event. 

Trauma-Informed Care in Behavioral Health Services 

concluded that behavioral health professionals’ experience 

of STS is a contributing factor in staff

turnover and one 

reason why many

behavioral health 

service professionals 

leave the field 

(Bride, 2007). Secondary traumatization of behavioral health 

workers is a significant organizational issue for

clinical supervisors and administrators in substance abuse and mental health treatment programs to address. 

To prevent or lessen the impact of secondary 

traumatization on behavioral health professionals, clinical supervisors and administrators 

need to understand secondary trauma from 

the ecological perspective described in Part 1,

Chapter 1 of this TIP. The organization itself

creates a social context with risk factors that 

can increase the likelihood of counselors experiencing STS reactions, but it also contains

protective factors that can lessen the risk and

impact of STS reactions on staff members. 

Organizations can lessen the impact of the 

risk factors associated with working in

trauma-informed organizations by mixing

caseloads to contain clients both with and 

without trauma-related issues, supporting

ongoing counselor training, providing regular

clinical supervision, recognizing counselors’ 

efforts, and offering an empowering work 

environment in which counselors share in the 

responsibility of making decisions and can 

offer input into clinical and program policies

that affect their work lives. 

When organizations support their counselors 

in their work with clients who are traumatized, counselors can be more effective, more 

productive, and feel greater personal and professional satisfaction. In addition, counselors 

develop a sense of allegiance toward the organization, thus decreasing staff turnover. If

organizations do not provide this support,

counselors can become demoralized and have 

fewer emotional and psychological resources 

to manage the impact of clients’ traumatic 

material and outward behavioral expressions of 

trauma on their own well-being. Providing

counselors with the resources to help them 

build resilience and prevent feeling overwhelmed should be a high priority for administrators and clinical supervisors in TIC 

organizations. 

Risk and Protective Factors 

Associated With Secondary 

Traumatization 

Clinical and research literature on trauma describes a number of factors related to the development of secondary trauma reactions and

psychological distress in behavioral health 

professionals across a wide range of practice

settings, as well as individual and organizational factors that can prevent or lessen the 

impact of STS on staff. The risk and protective factors model of understanding secondary 

trauma is based on the ecological perspective 

194 
 

 

 

 

 

 

 

Advice to Clinical Supervisors: 

Recognizing STS in Counselors Who 

Are In Recovery 

For counselors who are in recovery from a substance use or mental disorder, the development of STS may be a potential relapse 

concern. As Burke, Carruth, and Prichard 

(2006) point out, “a return to drinking or illicit 

drug use as a strategy for dealing with secondary trauma reactions would have a profoundly 

detrimental effect on the recovering counselor” (p. 292). So too, secondary trauma may 

ignite the reappearance of depressive or anxiety symptoms associated with a previous mental 

disorder. Clinical supervisors can address these 

risk factors with counselors and support them 

in engaging with their own recovery support 

network (which might include a peer support 

group or an individual counselor) to develop a 

relapse prevention plan. 

Part 2, Chapter 2—Building a Trauma-Informed Workforce 

outlined in Part 1, Chapter 1 of this TIP. The

terms “compassion fatigue,” “vicarious traumatization,” “secondary traumatization,” and

“burnout” are used in the literature, sometimes 

interchangeably and sometimes as distinct

constructs. As stated in the terminology portion of the “How This TIP Is Organized” section that precedes Part 1, Chapter 1, of this

TIP, the term “secondary traumatization” refers to traumatic stress reactions and psychological distress from exposure to another

individual’s traumatic experiences; this term

will be used throughout this section, although 

the studies cited may use other terms. 

Risk factors 

Individual risk factors that may contribute to

the development of STS in behavioral health 

professionals include preexisting anxiety or

mood disorders; a prior history of personal 

trauma; high caseloads of clients with traumarelated disorders; being younger in age and new 

to the field with little clinical experience or

training in treating trauma-related conditions;

unhealthy coping styles, including distancing

and detachment from clients and co-workers; 

and a lack of tolerance for strong emotions 

(Newall & MacNeil, 2010). Other negative

coping strategies include substance abuse, other addictive behaviors, a lack of recreational 

activities not related to work, and a lack of

engagement with social support. A recent

study of trauma nurses found that low use of

support systems, use of substances, and a lack 

of hobbies were among the coping strategies 

that differed between nurses with and without 

STS (Von Rueden et al., 2010). Other researchers found that clinicians who engaged in 

negative coping strategies, such as alcohol and

illicit drug use, were more likely to experience 

intrusive trauma symptoms (Way, Van

Deusen, Martin, Applegate, & Janle, 2004). 

Numerous organizational factors can contribute to the development of STS in counselors 

who work with clients with trauma-related 

disorders. These risk factors include organizational constraints, such as lack of resources for

clients, lack of clinical supervision for counselors, lack of support from colleagues, and lack 

of acknowledgment by the organizational culture that secondary traumatization exists and

is a normal reaction of counselors to client 

trauma (Newall & MacNeil, 2010). In a study

of 259 individuals providing mental health

counseling services, counselors who spent

more time in session with clients with traumarelated disorders reported higher levels of

traumatic stress symptoms (Bober & Regehr,

2006). Counselors may be more at risk for

developing secondary traumatization if the 

organization does not allow for balancing the

distribution of trauma and nontrauma cases 

amongst staff members. 

Protective factors 

Much of the clinical and research literature 

focuses on individual factors that may lessen

the impact of STS on behavioral health professionals, including male gender, being older,

having more years of professional experience, 

195 
 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

having specialized training in traumainformed and trauma-specific counseling

practices, lacking a personal trauma history,

exhibiting personal autonomy in the workplace, using positive personal coping styles,

and possessing resilience or the ability to find

meaning in stressful life events and to rebound

from adversity (Sprang, Clark, & WhittWoosley, 2007). Some of these factors, like 

positive personal coping styles and the ability 

to find meaning in adversity, can be developed

and enhanced through personal growth work,

psychotherapy, engagement with spiritual 

practices and involvement in the spiritual

community, and stress reduction strategies like 

mindfulness meditation. A recent multimethod study of an 8-week workplace mindfulness training group for social workers and

other social service workers found that mindfulness meditation increased coping strategies,

reduced stress, and enhanced self-care of the

participants; findings suggested that workers

were more likely to practice stress management techniques like mindfulness at their

place of work than at home (McGarrigle &

Walsh, 2011). Organizations can support

counselors’ individual efforts to enhance positive personal coping styles, find meaning in 

adversity, and reduce stress by providing time 

for workers during the workday for personal 

self-care activities, like mindfulness meditation

and other stress reduction practices. 

One of the organizational protective factors

identified in the literature that may lessen the 

negative impact of secondary traumatization

on behavioral health professionals is providing

adequate training in trauma-specific counseling strategies, which increases providers’ sense 

of efficacy in helping clients with traumarelated disorders and reduces the sense of 

hopelessness that is often a part of the work 

(Bober & Regehr 2006). One study found that

specialized trauma training enhanced job satisfaction and reduced levels of compassion 

fatigue, suggesting that “knowledge and training might provide some protection against the 

deleterious effects of trauma exposure”

(Sprang et al., 2007, p. 272). Another protective factor that may lessen the chances of developing secondary traumatization is having a 

diverse caseload of clients. Organizations

“must determine ways of distributing workload in order to limit the traumatic exposure 

of any one worker. This may not only serve to

reduce the impact of immediate symptoms but

may also address the potential longitudinal 

effects” (Bober & Regehr, 2006, p. 8). 

Emotional support from professional colleagues can be a protective factor. A study of

substance abuse counselors working with clients who were HIV positive found that workplace support from colleagues and supervisors 

most effectively prevented burnout (Shoptaw,

Stein, & Rawson, 2000). This support was 

associated with less emotional fatigue and

depersonalization, along with a sense of greater personal accomplishment. In a study of domestic violence advocates, workers who

received more support from professional peers 

were less likely to experience secondary traumatization (Slattery & Goodman, 2009). 

In addition, counselor engagement in relationally based clinical supervision with a traumainformed supervisor acts as a protective agent.

Slattery and Goodman (2009) note that “for 

the trauma worker, good supervision can normalize the feelings and experiences, provide 

support and information about the nature and

course of the traumatic reaction, help in the

identification of transference and countertransference issues, and reveal feelings or

symptoms associated with the trauma” (p. 

1362). Workers who reported “engaging, authentic, and empowering relationships with

their supervisors” were less likely to experience 

STS (p. 1369). Thus, it is not simply the frequency and regularity of clinical supervision, 

196 
 

 

Part 2, Chapter 2—Building a Trauma-Informed Workforce 

but also the quality of the supervision and the 

quality of the supervisor–counselor relationship that can lessen the impact of STS on 

behavioral health professionals. 

Engagement with a personal practice of spirituality that provides a sense of connection to a

larger perspective and meaning in life is another protective factor that can lessen the impact of STS on counselors (Trippany, Kress, &

Wilcoxon, 2004). Although recovering counselors may look to support groups for connection to a spiritual community, other behavioral

health professionals might find support for

enhancing spiritual meaning and connection

in church, a meditation group, creative endeavors, or even volunteer work. The key is for

counselors to develop their own unique resources and practices to enhance a sense of

meaningful spirituality in their lives. Clinical 

supervisors should be aware of spiritual engagement as a protective factor in preventing

and lessening the impact of STS and should

support clinicians in including it in their selfcare plans, but they should take care not to

promote or reject any particular religious belief

system or spiritual practice. 

Another protective factor that may lessen the

impact of workers’ STS is a culture of empowerment in the organization that offers counselors a sense of autonomy, a greater ability to

participate in making decisions about clinical

and organizational policies, and obtaining

support and resources that further their professional development. Slattery & Goodman

(2009) surveyed 148 domestic violence advocates working in a range of settings. The authors found that those workers “who reported

a high level of shared power were less likely to

report posttraumatic stress symptoms, despite 

their own personal abuse history or degree of

exposure to trauma” (p. 1370). To the degree

that organizations can provide a cultural context within which behavioral health professionals have autonomy and feel empowered,

they will be able to lessen the impact of STS

on their professional and personal lives. Selfefficacy and empowerment are antidotes to the 

experience of powerlessness that often accompanies trauma. 

Strategies for Preventing 

Secondary Traumatization 

The key to prevention of secondary traumatization for behavioral health professionals in a

trauma-informed organization is to reduce

risk and enhance protective factors. Organizational strategies to prevent secondary traumatization include: 

•	 Normalize STS throughout all levels of the 

organization as a way to help counselors 

feel safe and respected, enhancing the likelihood that they will talk openly about their

experiences in team meetings, peer supervision, and clinical supervision. 

•	 Implement clinical workload policies and

practices that maintain reasonable standards for direct-care hours and emphasize 

balancing trauma-related and nontraumarelated counselor caseloads. 

•	 Increase the availability of opportunities for

supportive professional relationships by 

promoting activities such as team meetings,

peer supervision groups, staff retreats, and

counselor training that focuses on understanding secondary traumatization and selfcare. Administrators and clinical supervisors should provide time at work for counselors to engage in these activities. 

•	 Provide regular trauma-informed clinical

supervision that is relationally based. Supervisors should be experienced and trained

in trauma-informed and trauma-specific 

practices and provide a competence-based

model of clinical supervision that promotes 

counselors’ professional and personal development. Supervision limited to case consultation or case management is insufficient to 

197 
 

 

Exhibit 2.2-7: Counselor Strategies To Prevent Secondary Traumatization 

Strategies that counselors can use (with the support and encouragement of supervisors and administrators) to prevent secondary traumatization include: 

• Peer support: Maintaining adequate social support, both personally and professionally, helps 

prevent isolation and helps counselors share the emotional distress of working with traumatized 

individuals. 

• Supervision and consultation: Professional consultation will help counselors understand secondary traumatization, their own personal risks, the protective factors that can help them prevent or 

lessen its impact, and their countertransference reactions to specific clients. 

• Training: Ongoing professional training can improve counselors’ understanding of trauma and 

enhance a sense of mastery and self-efficacy in their work. 

• Personal psychotherapy or counseling: Being in counseling can help counselors become more 

self-aware and assist them in managing the psychological and emotional distress that often accompanies working with clients who have trauma histories in a number of behavioral health settings. 

• Maintaining balance in one’s life: Balancing work and personal life, developing positive coping 

styles, and maintaining a healthy lifestyle can enhance resilience and the ability to manage stress. 

• Engaging in spiritual activities that provide meaning and perspective: Connection to a spiritual community and spiritual practices (such as meditation) can help counselors gain a larger perspective on trauma and enhance resilience. 

Trauma-Informed Care in Behavioral Health Services 

reduce the risk for secondary traumatization and promote counselor resilience. 

•	 Provide opportunities for behavioral health 

professionals to enhance their sense of autonomy and feel empowered within the 

organization. Some of these activities include soliciting input from counselors on

clinical and administrative policies that affect their work lives, including how to best

balance caseloads of clients with and without histories of trauma; inviting representatives of the counseling staff to attend

selected agency board of directors and/or 

management team meetings to offer input

on workforce development; and inviting

counselors to participate in organizational

task forces that develop trauma-informed

services, plan staff retreats, or create mechanisms to discuss self-care in team meetings. Administrators and clinical

supervisors should assess the organization’s 

unique culture and develop avenues for

counselor participation in activities that

will enhance their sense of empowerment

and efficacy within the organization. 

Exhibit 2.2-7 highlights some specific strategies that individual counselors can engage in 

to prevent secondary traumatization. 

Assessment of Secondary 

Traumatization 

Counselors with unacknowledged STS can 

harm clients, self, and family and friends by 

becoming unable to focus on and attend to

their needs or those of others. They may feel

helpless or cynical and withdraw from support

systems. Exhibit 2.2-8 describes some emotional, cognitive, and behavioral signs that

may indicate that a counselor is experiencing

secondary traumatization. Clinical supervisors 

should be familiar with the manifestations of 

STS in their counselors and should address 

signs of STS immediately. 

Stamm (2009–2012) has developed and revised a self-assessment tool, the Professional 

Quality of Life Scale (ProQOL), that

measures indicators of counselor compassion

fatigue and compassion satisfaction. Compassion fatigue “is best defined as a syndrome 

consisting of a combination of the symptoms 

198 
 

Exhibit 2.2-8: Secondary Traumatization Signs 

The following are some indicators that counselors may be experiencing secondary traumatization. 

Psychological distress 

• Distressing emotions: grief, depression, anxiety, dread, fear, rage, shame 

• Intrusive imagery of client’s traumatic material: nightmares, flooding, flashbacks of client disclosures 

• Numbing or avoidance: avoidance of working with client’s traumatic material 

• Somatic issues: sleep disturbances, headaches, gastrointestinal distress, heart palpitations, 

chronic physiological arousal 

• Addictive/compulsive behaviors: substance abuse, compulsive eating, compulsive working 

• Impaired functioning: missed or canceled appointments, decreased use of supervision, decreased ability to engage in self-care, isolation and alienation 

Cognitive shifts 

• Chronic suspicion about others 

• Heightened sense of vulnerability 

• Extreme sense of helplessness or exaggerated sense of control over others or situations 

• Loss of personal control or freedom 

• Bitterness or cynicism 

• Blaming the victim or seeing everyone as a victim 

• Witness or clinician guilt if client reexperiences trauma or reenacts trauma in counseling 

• Feeling victimized by client 

Relational disturbances 

• Decreased intimacy and trust in personal/professional relationships 

• Distancing or detachment from client, which may include labeling clients, pathologizing them, 

judging them, canceling appointments, or avoiding exploring traumatic material 

• Overidentification with the client, which may include a sense of being paralyzed by one’s own 

responses to the client’s traumatic material or becoming overly responsible for the client’s life 

Frame of reference 

• Disconnection from one’s sense of identity 

• Dramatic change in fundamental beliefs about the world 

• Loss or distortion of values or principles 

• A previous sense of spirituality as comfort or resource decreases or becomes nonexistent 

• Loss of faith in something greater 

• Existential despair and loneliness 

Sources: Figley, 1995; Newall & MacNeil, 2010; Saakvitne et al., 1996. 

Part 2, Chapter 2—Building a Trauma-Informed Workforce 

of secondary traumatic stress and professional 

burnout” (Newall & MacNeil, 2010, p. 61).

Although secondary traumatization as a reaction to exposure to clients’ trauma material is 

similar to PTSD, burnout is a more general 

type of psychological distress related to the 

pressures of working in high-stress environments over time. Burnout may be a result of

secondary traumatization and/or a contributing factor in the development of secondary 

traumatization. The ProQOL includes STS

and burnout scales that have been validated in 

research studies (Adams, Figley, & Boscarino,

2008; Newall & MacNeil, 2010). 

This tool can be used in individual and group

clinical supervision, trainings on self-care, and 

team meetings as a way for counselors to

check in with themselves on their levels of 

stress and potential signs of secondary 

traumatization. 

199 
Case Illustration: Gui 

Gui is a 48-year-old licensed substance abuse counselor who has worked in a methadone maintenance clinic for 12 years. He originally decided to get his degree and become a counselor because 

he wanted to help people and make a difference in the world. Over the past 6 months, he has felt 

fatigued a great deal, gets annoyed easily with both clients and coworkers, and has developed a 

cynical attitude about the world and the people who come to the clinic for help. During this time, the 

clinic has been forced to lay off a number of counselors due to funding cutbacks. As a result, Gui and 

the remaining counselors have had a 20 percent increase in the number of weekly client contact 

hours required as part of their job duties. In addition, the level and severity of clients’ trauma-related 

and other co-occurring disorders, poverty, joblessness, and homelessness has increased. 

Gui is a valued employee, and when Gui discusses his thoughts that he might want to leave the clinic 

with his clinical supervisor, the supervisor listens to Gui’s concerns and explores the possibility of 

having him fill out the ProQOL to get a pulse on his stress level. Gui agrees and is willing to discuss 

the results with his supervisor. He is not surprised to see that he scores above average on the burnout scale of the instrument but is very surprised to see that he scores below average on the secondary traumatic stress scale and above average on the compassion satisfaction scale. He begins to feel 

more hopeful that he still finds satisfaction in his job and sees that he is resilient in many ways that he 

did not acknowledge before. 

Gui and the clinical supervisor discuss ways that the supervisor and the organization can lessen the 

impact of the stress of the work environment on Gui and support the development of a self-care plan 

that emphasizes his own ability to rebound from adversity and take charge of his self-care. 

Trauma-Informed Care in Behavioral Health Services 

The compassion satisfaction scale allows

counselors to reflect on their resilience and 

reminds them of why they choose to work with

people with substance use and trauma-related

disorders, despite the fact that this work can

lead to secondary traumatization. The compassion satisfaction subscale reminds counselors 

that they are compassionate, that one of the

reasons they are in a helping profession is that

they value service to others, and that helping

brings meaning and fulfillment to their lives.

Exhibits 2.2-9 through 2.2-11 present the most 

recent version of the ProQOL. 

Addressing Secondary 

Traumatization 

If a counselor is experiencing STS, the organization should address it immediately. Clinical 

supervisors can collaborate with counselors to

devise an individualized plan that is accessible,

acceptable, and appropriate for each counselor 

and that addresses the secondary stress reactions the counselor is experiencing, providing

specific self-care strategies to counteract the 

stress. Decisions about strategies for addressing secondary traumatization should be based

on the personal preferences of the counselor,

the opportunity for an immediate intervention

following a critical incident, and the counselor’s level of awareness regarding his or her

experience of STS. Counselors may need to

talk about what they are experiencing, feeling,

and thinking. These experiences can be processed in teams, in consultations with colleagues, and in debriefing meetings to

integrate them effectively (Myers & Wee,

2002). 

If a critical incident evokes secondary traumatization among staff––such as a client suicide,

a violent assault in the treatment program, or

another serious event––crisis intervention 

should be available for workers who would like 

to participate. Any intervention should be 

voluntary and tailored to each worker’s individual needs (e.g., peer, group, or individual 

sessions); if possible, these services should be 

offered continuously instead of just one time. 

200 
Exhibit 2.2-9: PRoQOL Scale 

COMPASSION SATISFACTION AND COMPASSION FATIGUE (PRoQOL) VERSION 5 (2009) 

When you [help] people you have direct contact with their lives. As you may have found, your compassion for those you [help] can affect you in positive and negative ways. Below are some questions 

about your experiences, both positive and negative, as a [helper]. Consider each of the following 

questions about you and your current work situation. Select the number that honestly reflects how 

frequently you experienced these things in the past 30 days. 

1=Never 2=Rarely 3=Sometimes 4=Often 5=Very Often 

___ 1. I am happy. 

___ 2. I am preoccupied with more than one person I [help]. 

___ 3. I get satisfaction from being able to [help] people. 

___ 4. I feel connected to others. 

___ 5. I jump or am startled by unexpected sounds. 

___ 6. I feel invigorated after working with those I [help]. 

___ 7. I find it difficult to separate my personal life from my life as a [helper]. 

___ 8. I am not as productive at work because I am losing sleep over traumatic experiences of a person I [help]. 

___ 9. I think that I might have been affected by the traumatic stress of those I [help]. 

___ 10. I feel trapped by my job as a [helper]. 

___ 11. Because of my [helping], I have felt “on edge” about various things. 

___ 12. I like my work as a [helper]. 

___ 13. I feel depressed because of the traumatic experiences of the people I [help]. 

___ 14. I feel as though I am experiencing the trauma of someone I have [helped]. 

___ 15. I have beliefs that sustain me. 

___ 16. I am pleased with how I am able to keep up with [helping] techniques and protocols. 

___ 17. I am the person I always wanted to be. 

___ 18. My work makes me feel satisfied. 

___ 19. I feel worn out because of my work as a [helper]. 

___ 20. I have happy thoughts and feelings about those I [help] and how I could help them. 

___ 21. I feel overwhelmed because my case [work] load seems endless. 

___ 22. I believe I can make a difference through my work. 

___ 23. I avoid certain activities or situations because they remind me of frightening experiences of 

the people I [help]. 

___ 24. I am proud of what I can do to [help]. 

___ 25. As a result of my [helping], I have intrusive, frightening thoughts. 

___ 26. I feel “bogged down” by the system. 

___ 27. I have thoughts that I am a “success” as a [helper]. 

___ 28. I can’t recall important parts of my work with trauma victims. 

___ 29. I am a very caring person. 

___ 30. I am happy that I chose to do this work. 

© B. Hudnall Stamm, 2009–2012. Professional Quality of Life: Compassion Satisfaction and Fatigue 

Version 5 (ProQOL). http://www.proqol.org. This test may be freely copied as long as (a) author is 

credited, (b) no changes are made, and (c) it is not sold. Those interested in using the test should visit 

http://www.proqol.org to verify that the copy they are using is the most current version of the test. 

Source: Stamm, 2012. Used with permission. 

Part 2, Chapter 2—Building a Trauma-Informed Workforce 

201 
Exhibit 2.2-10: Your Scores on the ProQOL: Professional Quality of Life Screening 

Based on your responses, place your personal scores below. If you have any concerns, you should 

discuss them with a physical or mental healthcare professional. 

Compassion Satisfaction _____________ 

Compassion satisfaction is about the pleasure you derive from being able to do your work well. For 

example, you may feel like it is a pleasure to help others through your work. You may feel positively 

about your colleagues or your ability to contribute to the work setting or even the greater good of 

society. Higher scores on this scale represent a greater satisfaction related to your ability to be an 

effective caregiver in your job. 

The average score is 50 (SD 10; alpha scale reliability .88). About 25% of people score higher than 

57 and about 25% of people score below 43. If you are in the higher range, you probably derive a 

good deal of professional satisfaction from your position. If your scores are below 40, you may either 

find problems with your job, or there may be some other reason—for example, you might derive 

your satisfaction from activities other than your job. 

Burnout_____________ 

Most people have an intuitive idea of what burnout is. From the research perspective, burnout is 

one of the elements of Compassion Fatigue (CF). It is associated with feelings of hopelessness and 

difficulties in dealing with work or in doing your job effectively. These negative feelings usually have 

a gradual onset. They can reflect the feeling that your efforts make no difference, or they can be 

associated with a very high workload or a non-supportive work environment. Higher scores on this 

scale mean that you are at higher risk for burnout. 

The average score on the burnout scale is 50 (SD 10; alpha scale reliability .75). About 25% of people score above 57 and about 25% of people score below 43. If your score is below 43, this probably 

reflects positive feelings about your ability to be effective in your work. If you score above 57 you 

may wish to think about what at work makes you feel like you are not effective in your position. Your 

score may reflect your mood; perhaps you were having a “bad day” or are in need of some time off. 

If the high score persists or if it is reflective of other worries, it may be a cause for concern. 

Secondary Traumatic Stress_____________ 

The second component of Compassion Fatigue (CF) is secondary traumatic stress (STS). It is about 

your work related, secondary exposure to extremely or traumatically stressful events. Developing 

problems due to exposure to other’s trauma is somewhat rare but does happen to many people 

who care for those who have experienced extremely or traumatically stressful events. For example, 

you may repeatedly hear stories about the traumatic things that happen to other people, commonly 

called Vicarious Traumatization. If your work puts you directly in the path of danger, for example, 

field work in a war or area of civil violence, this is not secondary exposure; your exposure is primary. 

However, if you are exposed to others’ traumatic events as a result of your work, for example, as a 

therapist or an emergency worker, this is secondary exposure. The symptoms of STS are usually 

rapid in onset and associated with a particular event. They may include being afraid, having difficulty 

sleeping, having images of the upsetting event pop into your mind, or avoiding things that remind 

you of the event. 

The average score on this scale is 50 (SD 10; alpha scale reliability .81). About 25% of people score 

below 43 and about 25% of people score above 57. If your score is above 57, you may want to take 

some time to think about what at work may be frightening to you or if there is some other reason for 

the elevated score. While higher scores do not mean that you do have a problem, they are an indication that you may want to examine how you feel about your work and your work environment. You 

may wish to discuss this with your supervisor, a colleague, or a healthcare professional. 

© B. Hudnall Stamm, 2009–2012. Professional Quality of Life: Compassion Satisfaction and Fatigue 

Version 5 (ProQOL). http://www.proqol.org. This test may be freely copied as long as (a) author is 

credited, (b) no changes are made, and (c) it is not sold. Those interested in using the test should visit 

http://www.proqol.org to verify that the copy they are using is the most current version of the test. 

Source: Stamm, 2012. Used with permission. 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

202 
 

 

 

 

 

*You 

Wrote 

Change 

to 

1 5 

2 4 

3 3 

4 2 

5 1 

3. ____ 

6. ____ 

12. ____ 

16. ____ 

18. ____ 

20. ____ 

22. ____ 

24. ____ 

27. ____ 

 

 

The sum 

of my 

Compassion 

Satisfaction 

questions is 

So my 

score 

equals 

And my 

Compassion 

Satisfaction 

level is 

22 or less 43 or less Low 

Between 

23 and 41 Around 50 Average 

42 or more 57 or more High 

30. ____ 

Total : _____ 

*1. ____ = ____ 

*4. ____ = ____ 

 8. ____ 

 10. ____ 

*15. ____ = ____ 

*17. ____ = ____ 

 19. ____ 

 21. ____ 

 26. ____ 

*29. ____ = ____ 

Total : _____ 

 

The sum of 

my Burnout 

questions is 

So my 

score 

equals 

And my 

Burnout 

level is 

22 or less 43 or less Low 

Between 

23 and 41 

Around 

50 Average 

42 or more 57 or 

more High 

The sum of 

my Secondary 

Trauma 

questions is 

So my 

score 

equals 

And my 

Secondary 

Traumatic 

Stress level is 

22 or less 43 or less Low 

Between 

23 and 41 Around 50 Average 

42 or more 57 or more High 

Exhibit 2.2-11: What Is My Score and What Does It Mean? 

In this section, you will score your test so you understand the interpretation for you. To find your 

score on each section, total the questions listed on the left and then find your score in the table on 

the right of the section. 

Compassion Satisfaction Scale 

Copy your rating on each of these 

questions on to this table and add 

them up. When you have added 

then up you can find your score 

on the table to the right. 

Burnout Scale 

On the burnout scale you will need 

to take an extra step. Starred items 

are “reverse scored.” If you scored 

the item 1, write a 5 beside it. The 

reason we ask you to reverse the 

scores is because scientifically the 

measure works better when these 

questions are asked in a positive 

way though they can tell us more 

about their negative form. For 

example, question 1. “I am happy” 

tells us more about the effects of 

helping when you are not happy so 

you reverse the score. 

Secondary Traumatic Stress Scale 

Just like you did on Compassion 

Satisfaction, copy your rating on 

each of these questions on to this 

table and add the[m] up. When 

you have added them up you can 

find your score on the table to the 

right. 

2. ____ 

5. ____ 

7. ____ 

9. ____ 

11. ____ 

13. ____ 

14. ____ 

23. ____ 

25. ____ 

28. ____ 

Total : _____ 

© B. Hudnall Stamm, 2009–2012. Professional Quality of Life: Compassion Satisfaction and Fatigue 

Version 5 (ProQOL). http://www.proqol.org. This test may be freely copied as long as (a) author is 

credited, (b) no changes are made, and (c) it is not sold. Those interested in using the test should visit 

http://www.proqol.org to verify that the copy they are using is the most current version of the test. 

Source: Stamm, 2012. Used with permission. 

Part 2, Chapter 2—Building a Trauma-Informed Workforce 

203 
 

Advice to Clinical Supervisors: Advantages and Disadvantages of Using 

Psychometric Measures 

Using a psychometric measure such as the ProQOL has advantages and disadvantages. It is important to understand that all tests measure averages and ranges but do not account for individual 

circumstances. 

If you use the ProQOL in clinical supervision, present it as a self-assessment tool. Let counselors opt 

out of sharing their specific results with you and/or your team if it is administered in a group. If 

counselors choose to share scores on specific items or scales with you, work collaboratively and respectfully with them to explore their own understanding of and meanings attached to their scores. If 

this tool is not presented to supervisees in a nonjudgmental, mindful way, counselors may feel as if 

they have failed if their scores on the secondary traumatization scale are above average or if their 

scores on the compassion satisfaction scale are below average. High scores on the compassion fatigue and burnout scales do not mean that counselors don’t care about their clients or that they 

aren’t competent clinicians. The scores are simply one way for you and your supervisees to get a 

sense of whether they might be at risk for secondary traumatization, what they can do to prevent it, 

how to address it, and how you can support them. 

The potential benefits of using a self-assessment tool like the ProQOL in clinical supervision are that 

it can help counselors: 

• Reflect on their emotional reactions and behaviors and identify possible triggers for secondary 

traumatization. 

• Assess their risk levels. 

• Examine alternative coping strategies that may prevent secondary traumatization. 

• Understand their own perceptions of themselves and their job satisfaction, affirming what they 

already know about their risk of secondary traumatization and their compassion satisfaction. 

• Reflect on different factors that might contribute to unexpected low or high scores, such as the 

day of the week, the intensity of the workload, whether they have just come back from the 

weekend or a vacation, and so forth. 

• Increase self-awareness and self-knowledge, because scores on specific items or scales bring to 

consciousness what is often outside of awareness. 

• Realize how resilient they are emotionally, mentally, physically, and spiritually. 

• Become aware of and open up conversations about self-care and self-care activities and resources, such as supportive coworkers, team members, and social networks outside of work. 

If used regularly, self-assessment tools can help counselors and clinical supervisors monitor STS levels, indicate significant positive and negative changes, and suggest action toward self-care in specific areas. Clinical supervisors should fill out the ProQOL and review results with their own supervisors, a 

peer supervisor, or a colleague before administering it to supervisees. Doing so enables supervisors to 

gauge their own reactions to the self-assessment and anticipate potential reactions from supervisees. 

Trauma-Informed Care in Behavioral Health Services 

The objective of debriefing a critical incident

that evokes STS reactions in counselors is to 

help them dissipate the hyperarousal associated with traumatic stress and prevent longterm aftereffects that might eventually lead to

counselor impairment. Because clinical supervisors may also be experiencing secondary 

traumatization, it is advisable for administrators to invite an outside trauma consultant 

into the organization to provide a safe space

for all staff members (including clinical supervisors) to address and process the critical stress 

incident. For noncrisis situations, secondary 

traumatization should be addressed in clinical 

supervision. Clinical supervisors and counselors should work collaboratively to incorporate 

regular screening and self-assessment of STS

into supervision sessions. 

204 
Advice to Clinical Supervisors: Is it 

Supervision or Psychotherapy? 

Although there are some aspects of clinical 

supervision that can be therapeutic and parallel 

the therapeutic and emotional support that 

occurs between the counselor and the client, 

clinical supervision is not therapy. As a result, it 

is important for clinical supervisors to maintain 

appropriate boundaries with supervisees when 

addressing their STS reactions at work. 

When does the process in supervision cross 

over into the realm of practicing therapy with a 

supervisee? One clear indicator is if the supervisor begins to explore the personal history of 

the counselor and reflects directly on that history instead of bringing it back to how the 

counselor’s history influences his or her work 

with a particular client or with clients with 

trauma histories in general. Clinical supervisors 

should focus only on counselor issues that may 

be directly affecting their clinical functioning 

with clients. If personal issues arise in clinical 

supervision, counselors should be encouraged 

to address them in their own counseling or 

psychotherapy. 

When STS issues arise, the clinical supervisor

should work with counselors to review and 

revise their self-care plans to determine what

strategies are working and whether additional

support, like individual psychotherapy or

counseling, may be warranted. 

Exhibit 2.2-12 outlines some guidelines for

clinical supervisors in addressing secondary

trauma in behavioral health professionals working with clients who have substance use, mental, and trauma-related disorders. 

Counselor Self-Care 

In light of the intensity of therapeutic work 

with clients with co-occurring substance use, 

mental, and trauma-related disorders and the

vulnerability of counselors to secondary traumatization, a comprehensive, individualized

self-care plan is highly recommended. Balance 

is the key to the development of a self-care 

Exhibit 2.2-12: Clinical Supervisor 

Guidelines for Addressing Secondary 

Traumatization 

1. Engage counselors in regular screening/self-assessment of counselors’ experience of STS. 

2. Address signs of STS with counselors in 

clinical supervision. 

3. Work collaboratively with counselors to 

develop a comprehensive self-care plan 

and evaluate its effectiveness on a regular 

basis. 

4. Provide counselors a safe and nonjudgmental environment within which to process STS in individual and group 

supervision or team meetings. 

5. Provide counselors with a safe and nonjudgmental place within which to debrief 

critical stress incidents at work; bring in an 

outside consultant if needed. 

6. Support and encourage counselors to engage in individual counseling or psychotherapy, when needed, to explore personal 

issues that may be contributing to 

secondary traumatization at work. 

plan—a balance between home and work, a 

balance between focusing on self and others,

and a balance between rest and activity

(Saakvitne, Perlman, & Traumatic Stress 

Institute/ Center for Adult & Adolescent

Psychotherapy 1996). Counselor self-care is

also about balancing vulnerability, which allows counselors to be present and available

when clients address intensely painful content,

with reasonable efforts to preserve their sense 

of integrity in situations that may threaten the

counselors’ faith or worldview (Burke et al.,

2006). A comprehensive self-care plan should

include activities that nourish the physical,

psychological/mental, emotional/relational,

and spiritual aspects of counselors’ lives. 

The literature on counselor self-care advocates 

for individual, team, and organizational strategies that support behavioral health professionals working with clients who have 

Part 2, Chapter 2—Building a Trauma-Informed Workforce 

205 
 

Case Illustration: Carla 

Carla is a 38-year-old case manager working in an integrated mental health and substance abuse 

agency. She provides in-home case management services to home-bound clients with chronic health 

and/or severe mental health and substance abuse problems. Many of her clients have PTSD and 

chronic, debilitating pain. 

Both her parents had alcohol use disorders, and as a result, Carla became the caretaker in her family. 

She loves her job; however, she often works 50 to 60 hours per week and has difficulty leaving her 

work at work. She often dreams about her clients and wakes up early, feeling anxious. She sometimes has traumatic nightmares, even though she was never physically or sexually abused, and she 

has never experienced the trauma of violence or a natural disaster. She drinks five cups of coffee and 

three to four diet sodas every day and grabs burgers and sweets for snacks while she drives from 

one client to the next. She has gained 20 pounds in the past year and has few friends outside of her 

coworkers. She has not taken a vacation in more than 2 years. She belongs to the Catholic church 

down the street, but she has stopped going because she says she is too busy and exhausted by the 

time Sunday rolls around. 

The agency brings in a trainer who meets with the case management department and guides the 

staff through a self-assessment of their current self-care practices and the development of a comprehensive self-care plan. During the training, Carla acknowledges that she has let her work take over 

the rest of her life and needs to make some changes to bring her back into balance. She writes out 

her self-care plan, which includes cutting back on the caffeine, calling a friend she knows from church 

to go to a movie, going to Mass on Sunday, dusting off her treadmill, and planning a short vacation 

to the beach. She also decides that she will discuss her plan with her supervisor and begin to ask 

around for a counselor for herself to talk about her anxiety and her nightmares. In the next supervision session, Carla’s supervisor reviews her self-care plan with her and helps Carla evaluate the effectiveness of her self-care strategies. Her supervisor also begins to make plans for how to cover Carla’s 

cases when she takes her vacation. 

Trauma-Informed Care in Behavioral Health Services 

substance use and trauma-related disorders. 

Counselors are responsible for developing

comprehensive self-care plans and committing

to their plans, but clinical supervisors and administrators are responsible for promoting

counselor self-care, supporting implementation of counselor self-care plans, and modeling

self-care. Counselor self-care is an ethical imperative; just as the entire trauma-informed 

organization must commit to other ethical

issues with regard to the delivery of services to

clients with substance use, mental, and traumarelated disorders, it must also commit to the

self-care of staff members who are at risk for 

secondary traumatization as an ethical concern. Saakvitne and colleagues (1996) suggest

that when administrators support counselorself-care, it is not only cost-effective in that it 

reduces the negative effects of secondary 

traumatization on counselors (and their clients), but also promotes “hope-sustaining behaviors” in counselors, making them more 

motivated and open to learning, and thereby 

improving job performance and client care. 

A Comprehensive Self-Care Plan 

A self-care plan should include a selfassessment of current coping skills and

strategies and the development of a holistic,

comprehensive self-care plan that addresses 

the following four domains:

1.	 Physical self-care 

2.	 Psychological self-care (includes cognitive/mental aspects) 

3.	 Emotional self-care (includes relational 

aspects) 

4.	 Spiritual self-care 

Activities that may help behavioral health 

workers find balance and cope with the stress 

206 
Advice to Clinical Supervisors: 

Spirituality 

The word “spiritual” in this context is used 

broadly to denote finding a sense of meaning 

and purpose in life and/or a connection to 

something greater than the self. Spiritual meanings and faith experiences are highly individual 

and can be found within and outside of specific 

religious contexts. 

Engaging in spiritual practices, creative endeavors, and group/community activities can foster a 

sense of meaning and connection that can counteract the harmful effects of loss of meaning, 

loss of faith in life, and cognitive shifts in 

worldview that can be part of secondary traumatization. Counselors whose clients have trauma-related disorders experience fewer 

disturbances in cognitive schemas regarding 

worldview and less hopelessness when they 

engage in spiritually oriented activities, such as 

meditation, mindfulness practices, being in nature, journaling, volunteer work, attending 

church, and finding a spiritual community (Burke 

et al., 2006). Clinical supervisors can encourage 

counselors to explore their own spirituality and 

spiritual resources by staying open and attuned 

to the multidimensional nature of spiritual meaning of supervisees and refraining from imposing 

any particular set of religious or spiritual beliefs 

on them. A strong sense of spiritual connection 

can enhance counselors’ resilience and ability to 

cope with the sometimes overwhelming effects 

of clients’ trauma material and trauma-related 

behavior (including suicidality) on counselors’ 

faith in life and sense of meaning and purpose. 

Modeling Self-Care 

“Implementing interventions was not always 

easy, and one of the more difficult coping strategies to apply had to do with staff working long 

hours. Many of the staff working at the support 

center also had full-time jobs working for the 

Army. In addition, many staff chose to volunteer 

at the Family Assistance Center and worked 16­

to 18-hour days. When we spoke with them 

about the importance of their own self-care, 

many barriers emerged: guilt over not working, 

worries about others being disappointed in 

them, fear of failure with respect to being unable to provide what the families might need, 

and a ‘strong need to be there.’ Talking with 

people about taking a break or time off proved 

problematic in that many of them insisted that 

time off was not needed, despite signs of fatigue, difficulty concentrating, and decreased 

productivity. Additionally, time off was not 

modeled. Management, not wanting to fail the 

families, continued to work long hours, despite 

our requests to do otherwise. Generally, individuals could see and understand the reasoning 

behind such endeavors. Actually making the 

commitment to do so, however, appeared to 

be an entirely different matter. In fact, our own 

team, although we kept reasonable hours (8 to 

10 per day), did not take a day off in 27 days. 

Requiring time off as part of membership of a 

Disaster Response Team might be one way to 

solve this problem.” 

—Member of a Disaster Response Team at the 

Pentagon after September 11 

Source: Walser, 2004, pp. 4–5. 

of working with clients with trauma-related 

disorders include talking with colleagues about

difficult clinical situations, attending workshops, participating in social activities with

family and friends, exercising, limiting client

sessions, balancing caseloads to include clients 

with and without trauma histories, making

sure to take vacations, taking breaks during

the workday, listening to music, walking in

nature, and seeking emotional support in both

their personal and professional lives (Saakvitne 

et al., 1996). In addition, regular clinical supervision and personal psychotherapy or counseling can be positive coping strategies for

lessening the impact of STS on counselors.

Still, each counselor is unique, and a self-care

approach that is helpful to one counselor may 

not be helpful to another. Exhibits 2.2-13 and

2.2-14 offer tools for self-reflection to help

counselors discover which specific self-care

activities might best suit them. The worksheet

can be used privately by counselors or by clinical supervisors as an exercise in individual supervision, group supervision, team meetings,

or trainings on counselor self-care. 

Part 2, Chapter 2—Building a Trauma-Informed Workforce 

207 
© P. Burke, 2006. This worksheet may be freely copied as long as (a) author is credited, (b) no changes 

are made, and (c) it is not sold. Permission to reprint has been granted by the author, Patricia A. Burke. 

Source: Burke, 2006. Used with permission. 

Review the questions in Exhibit 2.2-14, and

then write down specific self-care strategies in

the form (given in Exhibit 2.2-13) that you’re 

confident you will practice in both personal 

and professional realms.	 

The Comprehensive Self-Care Worksheet is a 

tool to help counselors (and clinical supervisors) develop awareness of their current coping

strategies and where in the four domains they 

need to increase their engagement in self-care

activities. Once completed, clinical supervisors 

should periodically review the plan with their

supervisees for effectiveness in preventing

and/or ameliorating secondary traumatization

and then make adjustments as needed. 

Essential Components of Self-Care 

Saakvitne and colleagues (1996) describe three

essential components, the “ABCs,” of self-care

that effectively address the negative impact of

secondary traumatization on counselors: 

1. Awareness of one’s needs, limits, feelings,

and internal/external resources. Awareness 

involves mindful/nonjudgmental attention

to one’s physical, psychological, emotional,

and spiritual needs. Such attention requires quiet time and space that supports 

self-reflection. 

2. Balance of activities at work, between

work and play, between activity and rest,

and between focusing on self and focusing

on others. Balance provides stability and

helps counselors be more grounded when

stress levels are high. 

3. Connection to oneself, to others, and to 

something greater than the self. Connection decreases isolation, increases hope,

diffuses stress, and helps counselors share

the burden of responsibility for client care.

It provides an anchor that enhances counselors’ ability to witness tremendous suffering without getting caught up in it. 

Trauma-Informed Care in Behavioral Health Services 

Exhibit 2.2-13: Comprehensive Self-Care Plan Worksheet 

Name: 

Date: 

Personal Professional/Workspace 

Physical 

Psychological/Mental 

Emotional/Relational 

Spiritual 

208 
Exhibit 2.2-14: Comprehensive Self-Care Plan Worksheet Instructions 

Use the following questions to help you engage in a self-reflective process and develop your comprehensive self-care plan. Be specific and include strategies that are accessible, acceptable, and 

appropriate to your unique circumstances. Remember to evaluate and revise your plan regularly. 

Physical 

What are non-chemical things that help my body relax? 

What supports my body to be healthy? 

Psychological/Mental 

What helps my mind relax? 

What helps me see a bigger perspective? 

What helps me break down big tasks into smaller steps? 

What helps me counteract negative self-talk? 

What helps me challenge negative beliefs? 

What helps me build my theoretical understanding of trauma and addictions? 

What helps me enhance my counseling/helping skills in working with traumatized clients? 

What helps me become more self-reflective? 

Emotional/Relational 

What helps me feel grounded and able to tolerate strong feelings? 

What helps me express my feelings in a healthy way? 

Who helps me cope in positive ways and how do they help? 

What helps me feel connected to others? 

Who are at least three people I feel safe talking with about my reactions/feelings about clients? 

How can I connect with those people on a regular basis? 

Spiritual 

What helps me find meaning in life? 

What helps me feel hopeful? 

What sustains me during difficult times? 

What connects me to something greater? 

© P. Burke, 2006. This worksheet may be freely copied as long as (a) author is credited, (b) no 

changes are made, and (c) it is not sold. Permission to reprint has been granted by the author, 

Patricia A. Burke. 

Source: Burke, 2006. Used with permission. 

Clinical supervisors can help counselors review their self-care plans through the ABCs 

by reflecting on these questions:

1.	 Has the counselor accurately identified his 

or her needs, limits, feelings, and internal 

and external resources in the four domains 

(physical, psychological/mental, emotional/relational, spiritual)? 

2.	 Has the counselor described self-care activities that provide a balance between 

work and leisure, activity and rest, and a 

focus on self and others? 

3.	 Has the counselor identified self-care activities that enhance connection to self,

others, and something greater than self (or 

a larger perspective on life)? 

Supervisors should make their own self-care

plans and review them periodically with their

clinical supervisors, a peer supervisor, or a

colleague. 

Part 2, Chapter 2—Building a Trauma-Informed Workforce 

209 
Exhibit 2.2-15: The Ethics of Self-Care 

The Green Cross Academy of Traumatology was originally established to serve a need in Oklahoma 

City following the April 19, 1995, bombing of the Alfred P. Murrah Federal Building. Below are 

adapted examples of the Academy’s code of ethics with regard to worker self-care. 

Ethical Principles of Self-Care in Practice 

These principles declare that it is unethical not to attend to your self-care as a practitioner, because 

sufficient self-care prevents harming those we serve. 

Standards of self-care guidelines: 

• Respect for the dignity and worth of self: A violation lowers your integrity and trust. 

• Responsibility of self-care: Ultimately it is your responsibility to take care of yourself—and no 

situation or person can justify neglecting this duty. 

• Self-care and duty to perform: There must be a recognition that the duty to perform as a helper 

cannot be fulfilled if there is not, at the same time, a duty to self-care. 

Standards of humane practice of self-care: 

• Universal right to wellness: Every helper, regardless of her or his role or employer, has a right to 

wellness associated with self-care. 

• Physical rest and nourishment: Every helper deserves restful sleep and physical separation from 

work that sustains them in their work role. 

• Emotional rest and nourishment: Every helper deserves emotional and spiritual renewal both in 

and outside the work context. 

• Sustenance modulation: Every helper must utilize self-restraint with regard to what and how 

much they consume (e.g., food, drink, drugs, stimulation) since improper consumption can compromise their competence as a helper. 

Commitment to self-care: 

• Make a formal, tangible commitment: Written, public, specific, measurable promises of self-care. 

• Set deadlines and goals: The self-care plan should set deadlines and goals connected to specific 

activities of self-care. 

• Generate strategies that work and follow them: Such a plan must be attainable and followed 

with great commitment and monitored by advocates of your self-care. 

Source: Green Cross Academy of Traumatology, 2010. Adapted with permission. 

Trauma-Informed Care in Behavioral Health Services 

Commitment to Self-Care 

One of the major obstacles to self-care is giving in to the endless demands of others, both

at work and at home. It is therefore essential 

for counselors with the support of clinical supervisors to become “guardians of [their]

boundaries and limits” (Saakvitne et al., 1996,

p 136). Creating a daily schedule that includes 

breaks for rest, exercise, connection with

coworkers, and other self-care activities can

support counselors in recognizing that they are

valuable individuals who are worthy of taking

the time to nourish and nurture themselves,

thus increasing commitment to self-care. Another way to support counselors in committing to self-care is for supervisors and administrators to model self-care in their own 

professional and personal lives. 

Understanding that counselor self-care is not

simply a luxury or a selfish activity, but rather,

an ethical imperative (Exhibit 2.2-15) can

foster counselors’ sense of connection to their 

own values and accountability to the people 

they serve as competent and compassionate 

caregivers. Clinical supervisors and administrators can reinforce this sense of accountability while supporting counselors by providing a 

caring, trauma-informed work environment 

210 
Part 2, Chapter 2—Building a Trauma-Informed Workforce 

that acknowledges and normalizes secondary 

traumatization and by offering reasonable resources that make it possible for counselors to

do their work and take care of themselves at 

the same time. Preventing secondary traumatization and lessening its impact on counselors 

once it occurs is not only cost-effective with

regard to decreasing staff turnover and potential discontinuity of services to clients; it is 

also the ethical responsibility of a traumainformed organization. 

211 
. 
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Technology and Trauma: Using the Web To Treat PTSD 

The role of the Internet in helping those who are experiencing posttraumatic stress disorder (PTSD) 

has expanded rapidly; there are numerous Web sites with toolkits and research publications for clinicians who treat clients with PTSD, as well as Web sites aimed at providing information and support 

for these individuals. The U.S. military has contributed to the field in developing these avenues— 

specifically, with interactive Web applications for use on home computers and smartphones. 

• PTSD Coach is a smartphone application from the U.S. Department of Veterans Affairs (VA) to 

help people experiencing PTSD learn about and manage their symptoms 

(http://www.ptsd.va.gov/public/pages/ptsdcoach.asp). 

• Afterdeployment.org is a Web site developed by the Defense Centers of Excellence project led 

by the National Center for Telehealth & Technology, with interactive workshops about PTSD, 

traumatic brain injury (TBI), anxiety, and depression, aimed at returning veterans 

(http://www.afterdeployment.org). 

• T2 Virtual PTSD Experience, also developed by the National Center for Telehealth & Technology, 

is an application to be used within the popular online game Second Life as an interactive way of 

simulating how PTSD can be acquired within a combat environment, how PTSD may present itself 

to the person experiencing it, and how to seek effective treatment 

(http://www.t2health.org/vwproj). 

Phone: 267-350-7683 

Email: info@academyofct.org 

The Academy of Cognitive Therapy, a nonprofit organization, supports continuing education and research in cognitive therapy,

provides a valuable resource in cognitive therapy for professionals and the public at large, 

Resources for Adults 

Academy of Cognitive Therapy 

http://www.academyofct.org 

260 South Broad Street 

18th Floor 

Philadelphia, PA 19102 

Appendix B—Trauma Resource List 

Appendix B—Trauma Resource List
 

Introduction 

As it would be difficult to include every organization focused on trauma, the list of resources in this appendix is not exhaustive;

consequently, this list does not include books 

or other materials concerning the vast nature 

of this topic, but rather, it concentrates solely 

on online resources accessible to the public for 

free or as part of an organization membership. The inclusion of selected resources does 

not necessarily signify endorsement by the 

Substance Abuse and Mental Health Services 

Administration (SAMHSA), U.S.

Department of Health and Human Services 

(HHS). Following these resources for adults is 

a list of resources focused on children and 

adolescents and a list of training opportunities. 

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and actively works toward the identification

and certification of clinicians skilled in 

cognitive therapy. Certification is awarded to

those individuals who, based on an objective 

evaluation, have demonstrated an advanced

level of expertise in cognitive therapy. The 

Academy includes physicians, psychologists,

social workers, and other mental health professionals from around the world. The 

Academy formed a Trauma Task Force after

September 11, 2001, to disseminate information (available on their Web site) to help

people around the world receive the best help

possible following trauma. 

Addiction Technology Transfer 

Center Network 

http://www.attcnetwork.org/index.asp

5100 Rockhill Road 

Kansas City, MO 64110

Phone: 816-235-6888 

Email: networkoffice@attcnetwork.org 

The Addiction Technology Transfer Center

(ATTC) Network serves as a resource for students and professionals to identify international 

distance education opportunities for the substance abuse treatment field and as a free marketing venue for ATTC-approved sponsors of

distance education courses.The ATTC Web 

site provides trauma-related resources that include case studies, information on working

with returning veterans who have been exposed

to trauma, and links to various publications on

PTSD and secondary traumatic stress. 

Agency for Healthcare Research 

and Quality 

http://www.innovations.ahrq.gov/index.aspx

540 Gaither Road 

Suite 2000 

Rockville, MD 20850

Phone: 301-427-1104 

The Agency for Healthcare Research and

Quality (AHRQ) is the research arm of HHS,

specializing in patient safety and quality improvement, outcomes and effectiveness of care,

clinical practice and technology assessment,

and healthcare organization and delivery systems. AHRQ also provides funding and technical assistance to health research and research 

training programs at many universities and

institutions. AHRQ’s Web site provides links 

to research publications on PTSD and to other government publications and toolkits dealing with trauma-informed care. 

The American Academy of 

Experts in Traumatic Stress 

http://www.aaets.org

203 Deer Road 

Ronkonkoma, NY 11779

Phone: 631-543-2217 

Email: info@aaets.org 

The American Academy of Experts in Traumatic Stress is a multidisciplinary network of

professionals who are committed to the advancement of intervention for survivors of 

trauma. The Academy aims to identify expertise among professionals and across disciplines and to provide meaningful standards

for those who work regularly with survivors.

The Academy is committed to fostering a

greater appreciation of the effects of common

traumatic experiences (e.g., chronic illness,

accidents, domestic violence, loss) in addition

to large-scale disasters and catastrophes. The 

group’s aim is to help all victims to become 

survivors and, ultimately, to thrive. 

American Red Cross Disaster 

Services 

http://www.redcross.org/what-wedo/disaster-relief

American Red Cross National Headquarters

2025 E Street, NW 

248 
 

 

 

 

 

Appendix B—Trauma Resource List 

Washington, DC 20006

Phone: 202-303-4498 

Red Cross disaster relief focuses on meeting

people’s immediate emergency disaster-caused

needs. When a disaster threatens or strikes,

the Red Cross provides shelter, food, and 

health and mental health services to address 

basic human needs. In addition to these services, the core of Red Cross disaster relief is 

the assistance given to individuals and families

affected by disaster to enable them to resume 

their normal daily activities independently.

Training opportunities are also provided. 

Anxiety and Depression 

Association of America 

http://www.adaa.org

8701 Georgia Avenue #412

Silver Spring, MD 20910

Phone: 240-485-1001 

The Anxiety and Depression Association of

America (ADAA) is the only national, nonprofit membership organization dedicated to

informing the public, healthcare professionals,

and legislators that anxiety disorders are real,

serious, and treatable. ADAA promotes the 

early diagnosis, treatment, and cure of anxiety 

disorders and is committed to improving the 

lives of the people who have them. The 

ADAA Web site provides information about

the symptoms of PTSD and how it can be

treated, in addition to offering a PTSD selfscreening tool. 

Association for Behavioral and 

Cognitive Therapies 

http://www.abct.org

305 7th Avenue 

16th Floor 

New York, NY 10001

Phone: 212-647-1890 

Fax: 212-647-1865 

The Association for Behavioral and Cognitive

Therapies is a professional, interdisciplinary

organization concerned with the application of

behavioral and cognitive science to understanding human behavior, developing interventions to enhance the human condition, and

promoting the appropriate use of these interventions. The association’s Web site includes 

resources for the public and for professionals 

on trauma and disaster-related problems, a

clinical referral directory, and other resources 

and training opportunities in behavioral

therapy. 

Association of Traumatic Stress 

Specialists 

http://www.atss.info

88 Pompton Avenue

Verona, NJ 07044

Phone: 973-559-9200 

Email: Admin@atss.info 

The Association of Traumatic Stress 

Specialists is an international membership

organization that offers three distinct board

certifications to qualified individuals who provide services, intervention, response, and/or

treatment in the field of traumatic stress. The 

Association is dedicated to improving the

quality of life of all individuals throughout the

world who have been affected by traumatic

events. Membership represents those who

serve survivors of natural disasters, terrorist

attacks, injuries and deaths related to serving

in the line of duty or to school and workplace 

violence; veterans; refugees; victims of crime;

Holocaust survivors; those affected and exploited by political persecution; and others 

who have experienced traumatic stress injuries. 

Center for Anxiety and Related 

Disorders 

http://www.bu.edu/card

648 Beacon Street 

6th Floor 

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Boston, MA 02215

Phone: 617-353-9610 

The Center for Anxiety and Related Disorders (CARD) at Boston University is a clinical 

and research center dedicated to advancing

knowledge and providing care for anxiety,

mood, eating, sleep, and related disorders.

CARD’s Web site offers information regarding PTSD and research publications on trauma and anxiety, in addition to linking to

toolkits from the National Child Traumatic 

Stress Network’s Adolescent Traumatic Stress 

and Substance Abuse Program. 

Center for the Study of Traumatic 

Stress 

http://www.cstsonline.org

Uniformed Services University of the Health

Sciences 

Department of Psychiatry

4301 Jones Bridge Road

Bethesda, MD 20814-4799

Phone: 301-295-2470 

Fax: 301-319-6965 

The Center for the Study of Traumatic Stress 

(CSTS) is a federally funded organization

established by the Military Health System in

1987 to address Department of Defense concerns regarding health risks and concerns resulting from the traumatic impact of the use 

of weapons of mass destruction in combat, acts 

of terrorism and hostage events, combat and

peacekeeping operations, natural disasters, and

assaults or accidents occurring in both uniformed and civilian communities. CSTS primarily serves members of the armed forces,

along with their children and families. 

Center for Culture, Trauma and 

Mental Health Disparities 

http://www.semel.ucla.edu/cctmhd

UCLA Semel Institute of Neuroscience & 

Biobehavioral Sciences 

760 Westwood Plaza 

Los Angeles, CA 90024

Phone: 310-794-9929 

The Collaborative Center for Trauma and 

Mental Health Disparities at the University of

California Los Angeles is a multiethnic and

multidisciplinary group that focuses on conducting research and providing training that

pertains to trauma in minority populations. 

Council of State Governments 

Justice Center—Mental Health 

http://csgjusticecenter.org/jc/category/mentalhealth 

100 Wall Street 

20th Floor 

New York, NY 10005

Phone: 212-482-2320 

Fax: 212-482-2344 

Email: consensusproject@csg.org 

The Consensus Project is part of the Council 

of State Governments Justice Center and 

partners with other organizations, such as

SAMHSA’s GAINS Center, working to improve outcomes for people, including juveniles,

with mental illnesses involved with the criminal justice system. The Consensus Project offers a webinar on trauma services in the 

criminal justice system and on child trauma

and juvenile justice, as well as a local programs 

database. 

Dart Center for Journalism and 

Trauma 

http://www.dartcenter.org

Columbia University

Graduate School of Journalism 

2950 Broadway

New York, NY 10027

Phone: 212-854-8056 

The Dart Center is dedicated to improving

media coverage of trauma, conflict, and 

250 
 

 

 

 

 

Appendix B—Trauma Resource List 

tragedy. The Center also addresses the consequences of such coverage for those working in

journalism and provides training and education via seminars, newsroom briefings and

consultation on trauma issues, in addition to

training for journalism educators and other

trainers. The Dart Center Web site offers fact 

sheets, publications, and DVDs on request for

use by journalists, educators, and clinicians. 

David Baldwin’s Trauma 

Information Pages 

http://www.trauma-pages.com

Phone: 541-686-2598 

Email: dvb@trauma-pages.com 

This Web site focuses primarily on emotional 

trauma and traumatic stress, including PTSD 

and dissociation, whether following individual

traumatic experience(s) or a large-scale disaster. The site’s purpose is to provide information for clinicians and researchers in the 

traumatic stress field. Specifically, the focus is 

on both clinical and research aspects of trauma

responses and their resolution. 

Disaster Technical Assistance 

Center 

http://www.samhsa.gov/dtac

9300 Lee Highway

Fairfax, VA 22031

Phone: 800-308-3515 

Fax: 703-225-2338 

SAMHSA has created the Disaster Technical 

Assistance Center (DTAC) to help States 

prepare for and respond to a wide range of

potential catastrophes—both natural and

human-caused disasters. DTAC primarily 

serves individuals and communities who are 

recovering from natural and human-caused

disasters. It works in conjunction with the

Federal Emergency Management Agency 

(FEMA) and SAMHSA’s Emergency Mental 

Health and Traumatic Stress Services Branch, 

using strengths-based, outreach-oriented principles conducted in nontraditional settings, as 

a supplement to programs already in place on

a local level. 

EMDR Institute, Inc. 

http://www.emdr.com

P.O. Box 750 

Watsonville, CA 9507

Phone: 831-761-1040 

Fax: 831-761-1204 

Email: inst@emdr.com 

Eye Movement Desensitization and Reprocessing (EMDR) is an information-processing

therapy that uses an eight-phase approach.

(See the description in Part 1, Chapter 6.) The 

Web site presents background and descriptive 

information about this approach to treatment 

and lists training opportunities, references, and

networking groups. 

The Federal Emergency 

Management Agency 

http://www.fema.gov

500 C Street SW 

Washington, DC 20472 

Phone: 202-646-2500 

The Federal Emergency Management Agency,

a formerly independent agency that became 

part of the Department of Homeland Security 

in March 2003, is tasked with responding to,

planning for, recovering from, and mitigating

against disasters. FEMA can trace its beginnings to the Congressional Act of 1803. This 

Act, generally considered the first piece of

disaster legislation, provided assistance to a

New Hampshire town following an extensive 

fire. In the century that followed, ad hoc legislation was passed more than 100 times in response to hurricanes, earthquakes, floods, and

other natural disasters. 

251 
 

 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

The International Critical Incident 

Stress Foundation, Inc. 

http://www.icisf.org

3290 Pine Orchard Lane 

Suite 106 

Ellicott City, MD 21042

Phone: 410-750-9600 

Fax: 410-750-9601 

Email: info@icisf.org 

The International Critical Incident Stress 

Foundation, Inc., is a nonprofit, openmembership foundation dedicated to the prevention and mitigation of disabling stress

through the provision of education, training,

and support services for all emergency services 

professions; continuing education and training

in emergency mental health services for psychologists, psychiatrists, social workers, and

licensed professional counselors; and consultation in the establishment of crisis and disaster 

response programs for varied organizations 

and communities worldwide. 

International Society for the 

Study of Trauma and Dissociation 

http://www.issd.org

8400 Westpark Drive

Second Floor 

McLean, VA 22102

Phone: 703-610-9037 

Fax: 703-610-0234 

Email: info@isst-d.org 

The Society is a nonprofit professional association organized for the purposes of information sharing and international networking

of clinicians and researchers; providing professional and public education; promoting research and theory about dissociation; and

promoting research and training in the identification, treatment, and prevention of dissociative disorders. The Society offers courses in its 

Dissociative Disorders Psychotherapy Training

Program. 

The International Society for 

Traumatic Stress Studies 

http://www.istss.org

111 Deer Lake Road 

Suite 100 

Deerfield, IL 60015

Phone: 847-480-9028 

Fax: 847-480-9282 

The International Society for Traumatic Stress 

Studies (ISTSS) was founded in 1985 for professionals to share information about the effects of trauma. ISTSS is dedicated to the 

discovery and dissemination of knowledge 

about policy, program, and service initiatives

that seek to reduce traumatic stressors and 

their immediate and long-term consequences.

ISTSS provides a forum for the sharing of

research, clinical strategies, public policy concerns, and theoretical formulations on trauma

in the United States and around the world. 

National Alliance on Mental 

Illness 

http://www.nami.org

3803 N. Fairfax Dr. 

Suite 100 

Arlington, VA 22203

Phone: 703-524-7600 

Fax: 703-524-9094 

The National Alliance on Mental Illness 

(NAMI) is a nonprofit advocacy group founded in 1979 to raise awareness and provide essential and free education, advocacy, and

support group programs for people living with

mental illness and their loved ones. NAMI 

operates at the local, State, and national levels, 

with each level of the organizations providing

education, information, support, and advocacy

for those with mental illness and their support

system. NAMI has developed a Trauma

Toolkit and includes a series of lectures for 

mental health professionals about trauma. 

252 
 

 

 

 

 

 

 

 

Appendix B—Trauma Resource List 

National Association of State 

Alcohol and Drug Abuse 

Directors, Inc. 

http://www.nasadad.org

1025 Connecticut Ave NW 

Suite 605 

Washington, DC 20036

Phone: 202-293-0090 

Fax: 202-293-1250 

Email: dcoffice@nasadad.org 

The National Association of State Alcohol 

and Drug Abuse Directors, Inc. (NASADAD)

is a private, not-for-profit educational, scientific, and informational organization.

NASADAD’s basic purpose is to foster and

support the development of effective alcohol 

and drug abuse prevention and treatment programs throughout every State. NASADAD

offers a policy brief with regards to trauma

and substance use/abuse in the wake of natural 

or human-made disasters. 

National Association of State 

Mental Health Program Directors 

http://www.nasmhpd.org

66 Canal Center Plaza 

Suite 302 

Alexandria, VA 22314

Phone: 703-739-9333 

Fax: 703-548-9517 

The National Association of State Mental 

Health Program Directors (NASMHPD; pronounced “NASH-pid”) is a nonprofit organization dedicated to serving the needs of the 

Nation’s public mental health system through

policy development, information dissemination, 

and technical assistance. NASMHPD represents the $23 billion public mental health

service delivery system. As a private, not-forprofit 501(c)(3) membership organization,

NASMHPD helps set the agenda and determine the direction of State mental health 

agency interests across the country, historically 

including State mental health planning, service 

delivery, and evaluation.The principal programs operated, funded, and/or regulated by 

NASMHPD members serve people who have

serious mental illnesses, developmental disabilities, and/or substance use disorders.

NASMPHD has launched a Technical 

Assistance Coordinating Center in response to

the Alternatives to Restraint and Seclusion 

State Infrastructure Grant Project, an initiative

of SAMHSA’s Center for Mental Health 

Services, designed to promote the implementation and evaluation of best practice approaches

to preventing and reducing the use of seclusion

and restraint in mental health settings. 

National Center for Injury 

Prevention and Control 

http://www.cdc.gov/injury

1600 Clifton Road 

Atlanta, GA 30333

Phone: 800-232-4636 

Email: cdcinfo@cdc.gov 

The National Center for Injury Prevention

and Control (NCIPC) was established by the

Centers for Disease Control and Prevention in 

1992. Through research, surveillance, implementation of evidence-based strategies, capacity building, and communication activities,

NCIPC works to reduce morbidity, disability,

mortality, and costs associated with injuries 

and violence. NCIPC is the lead U.S. Federal 

agency for nonoccupational injury prevention. 

National Center for PTSD 

http://www.ptsd.va.gov

810 Vermont Avenue NW 

Washington, DC 20420

Phone: 802-296-6300 

Email: ncptsd@va.gov 

The National Center for PTSD (NCPTSD) 

was created within the Department of 

253 
 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

Veterans Affairs in 1989 in response to a

Congressional mandate to address the needs 

of veterans with military-related PTSD. Its 

mission is to advance the clinical care and social welfare of America’s veterans through research, education, and training in the science,

diagnosis, and treatment of PTSD and stressrelated disorders. Its Web site is provided as an

educational resource concerning PTSD and

other enduring consequences of traumatic

stress. The NCPTSD Web site has information about instruments to measure trauma 

exposure, risk and resilience factors for PTSD,

self-report instruments, and interview schedules. Training opportunities are listed at

http://www.ptsd.va.gov/about/training/trainin 

g-programs.asp. 

National Center for Telehealth 

and Technology 

http://www.t2health.org

9933C West Hayes Street

Joint Base Lewis-McChord, WA 98431

Phone: 253-968-1914 

Fax: 253-968-4192 

Email: AskUs@t2health.org 

The National Center for Telehealth and 

Technology is a Federal agency founded by 

the Department of Defense as part of the 

Military Health System. It primarily serves 

veterans and active-duty military personnel 

who are experiencing adverse health effects 

due to TBI and PTSD, as well as military 

children who are coping with their parents’ 

deployment, through the use of technology 

(e.g., mobile phone applications, deployable 

telehealth centers). 

National Center for TraumaInformed Care 

http://www.samhsa.gov/nctic

66 Canal Center Plaza 

Suite 302 

Alexandria, VA 22314 

Phone: 866-254-4819 

Fax: 703-548-9517 

Email: NCTIC@NASMHPD.org 

The National Center for Trauma-Informed 

Care (NCTIC) is a Federal center established

by SAMHSA in 2005 to offer consultation,

technical assistance, education, outreach, and

resources to support trauma-informed care in

publicly-funded systems and programs.

NCTIC primarily serves those who are already receiving services from the behavioral 

health system and is focused on helping behavioral health services and programs to become more aware of the impact of trauma

among consumers, to adapt services to incorporate trauma-informed practices, and to help

raise awareness of practices or processes that

are more likely to retraumatize consumers. 

National Center for Victims of 

Crime 

http://www.victimsofcrime.org

2000 M Street NW 

Suite 480 

Washington, DC 20036

Phone: 202-467-8700 

Fax: 202-467-8701 

Email: webmaster@ncvc.org 

The National Center for Victims of Crime 

(NCVC) is a nonprofit organization funded

partially by Federal grants from the Department of Justice. It was founded in 1985 and 

originally known as the Sunny Von Bulow 

National Victim Advocacy Center. NCVC is a

resource center for those affected by violent

crimes and also provides training and education for behavioral health service providers. 

National Center on Domestic 

Violence, Trauma & Mental Health 

http://www.nationalcenterdvtraumamh.org/

Phone: 312-726-7020 

Fax: 312-726-7022 

254 
 

 

 

Appendix B—Trauma Resource List 

The National Center on Domestic Violence,

Trauma & Mental Health was established in 

2005 through a grant from the Family Violence Prevention and Services Program, HHS.

The Center’s mission is to promote accessible,

culturally relevant, and trauma-informed responses to domestic violence and other lifetime trauma so that survivors and their 

children can access the resources that are essential to their safety and well-being; this is

achieved by providing training and online resources to mental health and substance abuse 

treatment providers and developing policies to

improve system responses to domestic violence 

survivors and their children. 

National Center on Elder Abuse 

http://www.ncea.aoa.gov

University of California–Irvine

Program in Geriatric Medicine

101 The City Drive South, 200 Building

Orange, CA 92868

Phone: 855-500-3537 

Email: ncea-info@aoa.hhs.gov 

The National Center on Elder Abuse 

(NCEA), part of the U.S. Administration on

Aging, serves as a national resource center

dedicated to the prevention of elder mistreatment. NCEA provides information to both 

mental health professionals and the general 

public and also provides technical assistance 

and training to States and community-based

organizations. 

National Center on Family 

Homelessness 

http://www.familyhomelessness.org

200 Reservoir Street 

Suite 200 

Needham, MA 02494

Phone: 617-964-3834 

Fax: 617-244-1758 

Email: info@familyhomelessness.org 

The National Center on Family Homelessness 

(NCFH) was founded in 1988 and is a nonprofit organization that conducts research and

creates public awareness about the special 

needs of families experiencing homelessness.

NCFH primarily serves veterans who are 

homeless and their families and young mothers who are homeless with their children. 

NCFH has developed a Trauma-Informed 

Organizational Toolkit for Homeless Services. 

National Coalition Against 

Domestic Violence 

http://www.ncadv.org

1 Broadway

Suite B210 

Denver, CO 80203

Phone: 303-839-1852 

Fax: 303-831-9251 

Email: mainoffice@ncadv.org 

The National Coalition Against Domestic

Violence (NCADV) is an advocacy group

founded in 1978 and acts as a national information and referral center for the general public, media, survivors of domestic violence and

their children, and allied and member agencies

and organizations. NCADV also works to

influence legislation that would provide protection for survivors of domestic violence and 

their families and provide funding to shelters,

healthcare centers, and other organizations. 

National Council for Behavioral 

Health 

http://www.thenationalcouncil.org

1701 K Street NW 

Suite 400 

Washington, DC 20006

Phone: 202-684-7457 

Email: communications@thenationalcouncil.org 

The National Council for Behavioral Health 

is a national community behavioral health 

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Trauma-Informed Care in Behavioral Health Services 

advocacy organization, formed in 1970, to

conduct Federal advocacy activities, representing the industry on Capitol Hill and before 

Federal agencies. It also offers a national consulting service program, various publications, 

and an annual training conference. The National Council Magazine, 2011, Issue 2, focuses on trauma-informed behavioral health 

services. The National Council has offered a 

Learning Community for Adoption of

Trauma-Informed Practices, funded by

SAMHSA. 

National Institute on Drug Abuse 

http://drugabuse.gov

National Institute on Drug Abuse

National Institutes of Health 

6001 Executive Boulevard 

Room 5213, MSC 9561

Bethesda, MD 20892-9561

Phone: 301-443-1124 

Email: information@nida.nih.gov 

The National Institute on Drug Abuse’s 

(NIDA) mission is to lead the Nation in

bringing the power of science to bear on drug

abuse and addiction. NIDA’s goal is to ensure 

that science, not ideology or anecdote, forms 

the foundation for all of the Nation’s drug

abuse reduction efforts. NIDA was established 

in 1974, and in October 1992 it became part

of the National Institutes of Health (NIH), 

HHS. The Institute is organized into divisions

and offices, each of which plays an important

role in programs of drug abuse research.

NIDA has an ongoing research program on 

women’s health and sex/gender differences,

including the gathering of information on 

trauma and substance abuse. 

National Institute of Mental 

Health 

http://www.nimh.nih.gov

National Institute of Mental Health 

Science Writing, Press, and Dissemination 

Branch 

6001 Executive Boulevard 

Room 8184, MSC 9663

Bethesda, MD 20892-9663

Phone: 301-443-4513 

Fax: 301-443-4279 

Email: nimhinfo@mail.nih.gov 

The National Institute of Mental Health 

(NIMH) is one of the 27 component institutes of NIH, the Federal Government’s principal biomedical and behavioral research

agency that is part of HHS. NIMH’s mission 

is to reduce the burden of mental illness and 

behavioral disorders through research on

mind, brain, and behavior. This public health

mandate demands that NIMH use science to 

achieve better understanding, treatment, and

eventually, prevention of these disabling conditions that affect millions of Americans. 

NIMH offers publications and podcasts related to traumatic events and PTSD. 

National Registry for EvidenceBased Programs and Practices 

http://www.nrepp.samhsa.gov

Phone: 866-436-7377 

Email: nrepp@samhsa.hhs.gov 

SAMHSA’s National Registry for EvidenceBased Programs and Practices (NREPP) is a 

searchable online registry of more than 300

interventions supporting mental health promotion, substance abuse prevention, and mental health and substance abuse treatment. 

NREPP offers several interventions that address trauma and PTSD. 

National Sexual Violence 

Resource Center 

http://www.nsvrc.org

123 North Enola Drive 

Enola, PA 17025

Phone: 717-909-0710 

Fax: 717-909-0714 

256 
 

 

 

 

Appendix B—Trauma Resource List 

The National Sexual Violence Resource Center (NSVRC) was founded by the Pennsylvania Coalition Against Rape in 2000 and is

partially federally funded by grants from the

Centers for Disease Control and Prevention. 

NSVRC advocates for changes in Federal and

State legislation to further the goal of ending

sexual violence in all communities, in addition

to collecting and disseminating a wide range

of resources on sexual violence, including statistics, research, position statements, statutes,

training curricula, prevention initiatives and

program information. NSVRC does not provide direct services to survivors of sexual violence but acts as a resource to support these 

services. 

National Trauma Consortium 

http://www.nationaltraumaconsortium.org

520 Ralph Street

Sarasota, FL 34242

Phone: 941-312-9795 

The National Trauma Consortium (NTC) is a 

clearinghouse for information about trauma 

and emerging best practices in trauma treatment and services and, in addition, offers

training and consultation services. NTC also

provides resources in the form of downloadable publications and links to other organizations related to mental health and trauma. 

National Voluntary Organizations 

Active in Disasters 

http://www.nvoad.org

1501 Lee Highway

Suite 170 

Arlington, VA 22209-1109

Phone: 703-778-5088 

Fax: 703-778-5091 

Email: info@nvoad.org 

National Voluntary Organizations Active in

Disasters (NVOAD) coordinates planning

efforts by many voluntary organizations responding to disaster. Member organizations 

provide more effective service and less duplication by getting together before disasters 

strike. Once disasters occur, NVOAD or an

affiliated State VOAD encourages members 

and other voluntary agencies to convene on

site. This cooperative effort has proven to be 

the most effective way for a wide variety of

volunteers and organizations to work together

in a crisis. NVOAD’s principles are cooperation, coordination, communication, education,

mitigation, convening mechanisms, and outreach. 

Office for Victims of Crime 

Training and Technical Assistance 

Center 

https://www.ovcttac.gov/

9300 Lee Highway

Fairfax, VA 22031-6050

Phone: 866-682-8822 

TTY: 866-682-8880 

Fax: 703-279-4673 

Email: TTAC@ovcttac.org 

The Office for Victims of Crime Training and

Technical Assistance Center provides comprehensive, quality technical assistance and

training resources to victims’ service providers 

and allied professionals. Its mission is to support the development of the field by increasing

the Nation’s capacity to provide crime victims 

with skilled, capable, and sensitive assistance.

Its core functions are needs assessment, capacity building, evaluation, and reporting. 

Rape, Abuse & Incest National 

Network 

http://www.rainn.org

1220 L Street NW 

Suite 505 

Washington, DC 20005

Phone: 202-544-1034 

Email: info@rainn.org 

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The Rape, Abuse & Incest National Network 

(RAINN) is a nonprofit organization, founded in 1994, that is partially funded by a grant

from the Office for Victims of Crime, Office 

of Justice Programs, U.S. Department of Justice. RAINN provides support for survivors of

sexual assault via a telephone hotline and an

online hotline and works with the Department

of Defense (DoD) to provide a hotline for

members of the DoD community who have 

experienced sexual assault. 

SAMHSA’s Tribal Training and 

Technical Assistance Center 

http://beta.samhsa.gov/tribal-ttac

201 Corporate Drive

Suite 800 

Landover, MD 20785

Phone: 240-650-0257 

Email: TA-Request@tribaltechllc.com 

SAMHSA’s Tribal Training and Technical

Assistance Center (Tribal TTAC) is committed to providing comprehensive broad, focused, and/or intensive training and technical

assistance to federally recognized Tribes and

other American Indian and Alaska Native 

communities seeking to address and prevent

mental and substance use disorders and suicide 

while promoting mental health. The goal of

the Tribal TTAC is to use a culturally relevant,

evidence-based, holistic approach to support 

Native communities in their selfdetermination efforts through infrastructure 

development, capacity building, and program

planning and implementation. 

Sanctuary Model 

http://www.sanctuaryweb.com

Phone: 888-538-3124 

The goals of the Sanctuary Model include 

increasing the perceived sense of community/cohesiveness; the degree of social immunity 

to the spread of violence; the capacity for social learning; the making of decisions democratically and the sharing of responsibility in

solving problems and resolving conflicts; the

ability to deal with complexity; opportunities 

for all clients and staff members to experience 

a truly safe and connected community; opportunities for troubled clients to have corrective 

emotional, relational, and environmental experiences; and recovery, healing, and growth. 

Seeking Safety 

http://www.seekingsafety.org

Treatment Innovations 

28 Westbourne Road 

Newton Centre, MA 02459

Phone: 617-299-1610 

Fax: 617-701-1295 

Email: info@seekingsafety.org 

This Web site provides information about

Seeking Safety, a psychotherapeutic intervention for treating trauma, PTSD, and substance

abuse. Seeking Safety is a present-focused 

therapy to help people attain safety from both

PTSD and substance abuse. The treatment is 

also available as a book, which provides both 

client handouts and guidance for clinicians.

The site includes topics included in the treatment program, sample materials, relevant empirical studies, and supplementary articles. 

Sidran Institute 

http://www.sidran.org

P.O. Box 436 

Brooklandville, MD 21022-0436

Phone: 410-825-8888 

Fax: 410-560-0134 

Email: info@sidran.org 

The Sidran Institute is a nationally focused

nonprofit organization devoted to helping

people who have experienced traumatic life 

events through education and advocacy. The

Institute’s education and advocacy focuses on: 

258 
 

 

 

Appendix B—Trauma Resource List 

•	 The early recognition and treatment of

trauma-related stress in children. 

•	 The understanding of trauma and its longterm effect on adults. 

•	 The strategies in engaging in mutual-help

recovery for trauma survivors. 

•	 The clinical methods and practices leading

in aiding trauma victims. 

•	 The development of public policy initiatives responsive to the needs of adult and

child survivors of traumatic events. 

Substance Abuse and Mental 

Health Services Administration 

http://www.samhsa.gov

1 Choke Cherry Lane

Rockville, MD 20857

Phone: 877-726-4727 

Fax: 240-221-4292 

Email: SAMHSAInfo@samhsa.hhs.gov 

SAMHSA is the Federal agency within HHS

charged with improving the quality and availability of prevention, treatment, and rehabilitative services to reduce illness, death,

disability, and cost to society resulting from

substance abuse and mental illness. The 

Emergency Mental Health and Traumatic

Stress Services Branch, a branch of

SAMHSA’s Center for Mental Health Services, works with FEMA to provide crisis 

counseling training and technical assistance 

to State and local mental health professionals.

SAMHSA offers several publications regarding trauma and PTSD, as well as a publication focusing on creating a seclusion-free and

restraint-free environment. 

Traumatic Stress Institute 

http://www.traumaticstressinstitute.org

Klingberg Family Centers

370 Linwood Street 

New Britain, CT 06052

Phone: 860-224-9113 

The Traumatic Stress Institute (TSI) works to

increase understanding of the psychological 

impact of trauma and to help victims of violence restore meaning and wholeness to their

lives. In meeting these goals, TSI is involved in

clinical service, professional training, community education, and research. TSI offers forensic assessment and expert testimony,

professional education, training opportunities,

and publications. TSI developed the “Risking

Connections” trauma treatment program and

provides training in the use of this model. 

Tulane University Traumatology 

Institute 

http://sites.google.com/site/charlesfigley/

Home/traumatologyinstitute

Tulane School of Social Work 

6823 St. Charles Ave., Building 9 

New Orleans, LA 70118 

Phone: 800-631-8234 

Email: figley@tulane.edu 

The Traumatology Institute, founded in 1996,

brings together health and mental health professionals from a wide array of disciplines 

from throughout the United States and

around the world to develop cutting-edge research, treatment approaches, and training

programs in the field of traumatology. The 

Institute facilitates the development of

knowledge about the traumatization experience of victims, survivors, and the professionals who serve them. The Traumatology 

Institute conducts research, education, and

service activities toward reducing the deleterious effects of trauma on individuals, families,

communities, and entire societies. 

Veterans Affairs PTSD Support 

Services 

http://www.ptsdsupport.net/va.html

P.O. Box 5574 

Woodland Park, CO 80866

Email: russ@ptsdsupport.net 

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The Department of Veterans Affairs Medical 

Centers provide a network of more than 100

specialized programs for veterans with PTSD,

working closely in conjunction with the Veterans Web Site (http://www.vetcenter.va.gov) 

operated by VA’s Readjustment Counseling

Service. Each specialized PTSD program offers veterans education, evaluation, and treatment conducted by mental health

professionals from a variety of disciplines 

(such as psychiatry, psychology, social work,

counseling, and nursing). See also: National 

Center for PTSD. 

White Bison Wellbriety Training 

Institute 

http://www.whitebison.org

701 N. 20th Street 

Colorado Springs, CO 80904

Phone: 877-871-1495 

Email: info@whitebison.org 

White Bison is an American Indian nonprofit

charitable organization that focuses on offering sobriety, recovery, addictions prevention,

and wellness/Wellbriety learning resources to

the Native American community nationwide.

White Bison’s Wellbriety Training Institute 

provides training, tools, and resources for historical and intergenerational trauma to trainers and mental health professionals. 

Resources for Children 

and Adolescents 

The following section provides resources that

address the needs of children and adolescents 

who are affected by traumatic stress. 

American Academy of Child & 

Adolescent Psychiatry 

http://www.aacap.org

3615 Wisconsin Avenue NW 

Washington, DC 20016-3007 

Phone: 202-966-7300 

Fax: 202-966-2891 

The American Academy of Child & Adolescent Psychiatry (AACAP) is a national professional medical association dedicated to 

treating and improving the quality of life for

children, adolescents, and families affected by 

mental, behavioral, and developmental disorders. AACAP distributes information to 

promote an understanding of mental illnesses 

and remove the shame associated with them,

to advance efforts in prevention of mental 

illnesses, and to ensure proper treatment and

access to services for children and adolescents. 

American Professional Society on 

the Abuse of Children 

http://www.apsac.org

350 Poplar Avenue

Elmhurst, IL 60126

Phone: 630-941-1235 

Fax: 630-359-4274 

E-mail: apsac@apsac.org 

The mission of the American Professional 

Society on the Abuse of Children (APSAC) is 

to enhance the ability of professionals to respond to children and families affected by 

abuse and violence. Among other initiatives,

APSAC provides education and other sources 

of information to professionals who work in

the child maltreatment and related fields. 

Anna Institute 

http://www.theannainstitute.org

21 Ocean Street 

Rockland, ME 04841

Email: afj@gwi.net 

The Anna Institute was founded in memory 

of artist Anna Caroline Jennings; it focuses on 

educating both the public and mental health

professionals about the effects of sexual abuse 

and trauma on children. The Anna Institute’s 

Web site provides articles on incorporating 

260 
Appendix B—Trauma Resource List 

 

 

 

 

 

trauma-informed care into existing behavioral

health models, presentations on childhood

trauma and retraumatization, and handouts

for teachers at primary and secondary schools. 

Caring for Every Child’s Mental 

Health Campaign 

http://www.samhsa.gov/children

P.O. Box 2345 

Rockville, MD 20847-2345

Email: nmhic-info@samhsa.hhs.gov 

SAMHSA’s Caring for Every Child’s Mental 

Health communications campaign is a national

public information and education operation. Its

goals are to increase public awareness about the 

importance of protecting the mental health of

young people; foster the recognition that many

children have mental health problems; and

encourage caregivers to seek early, appropriate 

treatment and services. It also strives to reduce 

discrimination associated with mental health 

problems. The campaign is a technical assistance program that is part of the Comprehensive Community Mental Health Services 

Program for Children and Their Families. 

Child Study Center 

http://www.aboutourkids.org

One Park Avenue 

7th Floor 

New York, NY 10016

Phone: 212-263-6622 

Email: webmaster@aboutourkids.org 

The New York University Child Study Center

Web site offers information to parents of children and adolescents with learning, behavioral, and emotional disorders, including PTSD

and substance use disorders. An online newsletter is available. Its research initiatives advance understanding of the causes and

treatments of child mental disorders, and

these findings are integrated into clinical care

to provide state-of-the-art service. 

Child Trauma Academy 

http://www.childtrauma.org

5161 San Felipe

Suite 320 

Houston, TX 77056 

Phone: 866-943-9779 

Email: cta@childtrauma.org 

The mission of the Child Trauma Academy is 

to help improve the lives of traumatized and

maltreated children. Through education, service delivery, and program consultation, the 

academy seeks to advance systems that educate, nurture, protect, and enrich these children. 

Child Trauma Institute 

http://www.childtrauma.com 

P.O. Box 544 

Greenfield, MA 01302-0544 

Phone: 413-774-2340 

Email: cti@childtrauma.com 

The Child Trauma Institute provides training,

consultation, information, and resources for

those who work with trauma-exposed children, adolescents, and adults. The Web site has 

information for parents, publications for parents and professionals, and links to other child

trauma Web sites. 

Child Welfare Information 

Gateway 

http://www.childwelfare.gov

Children’s Bureau/ACYF

1250 Maryland Avenue SW

Eighth Floor

Washington, DC 20024

Phone: 800-394-3366 

Email: info@childwelfare.gov 

The Child Welfare Information Gateway 

(CWIG) is a service of the Children’s Bureau 

in the Administration for Children and Families, part of HHS, which provides information 

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Trauma-Informed Care in Behavioral Health Services 

to child welfare and mental health professionals about programs, research, laws and policies,

training approaches, and statistics regarding

child welfare, child abuse and neglect, and

adoption. CWIG offers educators’ toolkits for

preventing and responding to child abuse and

neglect, a function to search State statutes 

about child abuse and neglect, and logic model 

builder toolkits for program administrators. 

Child Welfare League of America 

http://www.cwla.org

1726 M Street NW 

Suite 500 

Washington DC, 20036

Phone: 202-688-4200 

Fax: 202-833-1689 

Through its member child welfare agencies,

the Child Welfare League of America develops and disseminates practice standards as 

benchmarks for high-quality services that protect children and youth; promotes high-quality 

services through training, consultation, conferences, and publications; formulates and promotes public policies that contribute to the 

well-being of children and youth; ensures that

all child welfare services are provided in a

manner that demonstrates respect for cultural 

and ethnic diversity; and promotes open exchange of data, resources, and ideas within and

across systems that serve children, youth, and

families. 

Eunice Kennedy Shriver National 

Institute of Child Health and 

Human Development 

http://www.nichd.nih.gov/Pages/index.aspx

31 Center Drive 

Building 31, Room 2A32

Bethesda, MD 20892-2425

Phone: 800-370-2943 

Established in 1962, NIH’s National Institute 

of Child Health and Human Development 

(NICHD) focuses on human development

processes from conception to later years. The

Institute implements, conducts, and supports 

laboratory research, clinical trials, epidemiological research, and other studies that explore 

health processes and the impact of disabilities,

diseases, and variations on the lives of individuals. NICHD sponsors training for scientists 

and healthcare providers to promote the goals 

of the Institute. 

National Center for Children 

Exposed to Violence 

http://www.nccev.org

Yale Child Study Center

230 South Frontage Road

P.O. Box 207900 

New Haven, CT 06520-7900 

Phone: 877-496-2238 

Email: colleen.vadala@yale.edu 

The National Center for Children Exposed to

Violence (NCCEV) seeks to increase the capacity of individuals and communities to reduce the incidence and impact of violence on

children and families; to train and support the 

professionals who provide intervention and

treatment; and to increase professional and

public awareness of the effects of violence on

children, families, communities, and society.

The Center’s Web site is a rich source of information. NCCEV is supported by grants

from the Office of Juvenile Justice and Delinquency Prevention, the Department of Justice,

SAMHSA, and the Department of Education. 

National Center on Substance 

Abuse and Child Welfare 

http://www.ncsacw.samhsa.gov

P.O. Box 2345 

Rockville, MD 20847-2345

Phone: 866-493-2758 

Email: ncsacw@cffutures.org 

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Appendix B—Trauma Resource List 

The National Center on Substance Abuse and 

Child Welfare (NCSACW) is an initiative of

HHS and is jointly funded by SAMHSA’s 

Center for Substance Abuse Treatment and 

the Administration on Children, Youth and

Families, Children’s Bureau’s Office on Child 

Abuse and Neglect. NCSACW seeks to develop and implement a comprehensive program of information gathering and

dissemination, to provide technical assistance,

and to develop knowledge that promotes effective practical, organizational, and systemic

changes at the local, State, and national levels.

Its Web site includes PowerPoint presentations, online tutorials and training, technical

assistance presentations, and additional print 

resources. 

National Child Traumatic Stress 

Network 

http://www.nctsnet.org

NCTSN—University of California, Los 

Angeles

11150 W. Olympic Boulevard

Suite 650 

Los Angeles, CA 90064

Phone: 310-235-2633 

Fax: 310-235-2612 

The National Child Traumatic Stress Network 

(NCTSN), currently comprising 54 treatment

centers nationwide, is funded by SAMHSA’s 

Center for Mental Health Services through

the Donald J. Cohen National Child Traumatic 

Stress Initiative and coordinated by Duke University and the University of California, Los 

Angeles. The purpose of this congressionally 

mandated initiative is to improve the quality,

effectiveness, provision, and availability of

therapeutic services delivered to all children

and adolescents experiencing traumatic events.

NCTSN works with SAMHSA to raise public awareness of the effects of traumatic stress 

on children and families, and with other systems of care (including the health, mental 

health, education, law enforcement, child welfare, juvenile justice, and military family service systems) to ensure that there is a

comprehensive trauma-informed continuum of

accessible care. Additionally, NCTSN offers a

list of evidence-based and promising practices. 

National Institute for Trauma and 

Loss in Children 

http://www.starrtraining.org/trauma-andchildren 

42855 Garfield Road 

Suite 111 

Clinton Township, MI 48038

Phone: 877-306-5256 

Fax: 586-263-4915 

Email: TLC@starrtraining.org 

The National Institute for Trauma and Loss 

in Children provides school professionals, crisis intervention teams, medical and mental 

health professionals, child care professionals,

and clinicians with trauma education, training,

consultation, referral services, and traumaspecific intervention programs and resource 

materials needed to help those traumatized by 

violent or nonviolent trauma-inducing

incidents. 

National Native Children’s Trauma 

Center 

http://iers.umt.edu/National_Native_Childrens

_Trauma_Center 

Institute for Educational Research and Service 

McGill Hall 026 

The University of Montana

Missoula, MT 59812-6376

Phone: 406-243-5344 

Fax: 406-243-2197 

Email: iers@mso.umt.edu 

The National Native Children’s Trauma Center 

(NNCTC) is a federally funded organization

created by SAMHSA and affiliated with the

National Child Traumatic Stress Network. It 

263 
 

 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

is run by the University of Montana. NNCTC

offers trauma interventions and trainings to

address trauma in American Indian/Alaska 

Native children, primarily through clinicians,

Tribal programs, school systems, and community agencies. 

Training Opportunities 

The following resources highlight various

training and credentialing opportunities for

behavioral health professionals interested in

gaining more education in treating and

providing services to those affected by trauma.

It is not an exhaustive list, but provides a starting place for service providers looking for further training. 

The Web site of the ISTSS has posted a directory of trauma-related academic and training

opportunities (http://www.istss.org/Learning

AboutTrauma.htm). It includes links to the 

institutions providing the programs.The Association for Traumatic Stress Specialists 

(http://www.atss.info) offers three levels of

recognition for education and experience:

•	 Certified Trauma Specialist (CTS)—

designed for counselors, clinicians, and

treatment specialists who provide intervention services or individual, group, and/or

family counseling.This certification requires 240 hours of education and training

in trauma treatment, plus 2,000 hours of

trauma counseling and intervention

experience. 

•	 Certified Trauma Responder (CTR)—

designed for those who provide immediate 

trauma interventions. It requires a minimum of 40 hours of experience on a crisis 

or critical incident response team, an associate degree or a high school diploma with

successful completion of disaster or critical

incident stress debriefing training, and 72

hours of crisis response training. 

•	 Certified Trauma Services Specialist

(CTSS)—designed for those who provide

immediate trauma intervention, crisis support, advocacy, or victim assistance. It requires 1 year of experience in a traumarelated field, plus specific training. 

Some colleges and universities, such as the 

International Trauma Studies Program at New

York University and the Center for Anxiety 

and Related Disorders at Boston University,

provide specialty trauma training for mental

health practitioners. The University of Missouri at St. Louis offers specialized training in

trauma therapy or research at its Center for

Trauma Recovery to students in its Clinical 

Psychology graduate program. The Center for

the Treatment and Study of Anxiety at the 

University of Pennsylvania provides training

for health professionals.The Department of

Counseling at the University of Nevada, Las 

Vegas offers a graduate and undergraduate 

course on Trauma and Addiction; graduate

students can receive training in trauma and

addictions as part of the Advanced Graduate

Certificate in Addiction Studies. The Medical 

University of South Carolina offers Webbased courses in trauma-focused cognitive–

behavioral therapy (TF-CBT) and in using

TF-CBT for childhood traumatic grief. Many

universities have faculty members with expertise in trauma and trauma-related subjects, so

that training can be accessed through many

graduate programs. 

The Addiction Technology Transfer Center

(ATTC) Network, a resource established in

1993 by the SAMHSA’s Center for Substance 

Abuse Treatment, is a network of 14 independent regional centers with a national office. 

One of its programs provides long-distance

education for clinicians on various topics.

Among hundreds of self-paced, self-directed,

and supervised courses available online

(http://www.attcnetwork.org/learn/education/ 

264 
 

 

Appendix B—Trauma Resource List 

dasp.asp) are Substance Abuse Treatment for

Trauma Survivors, Substance Abuse Treatment for Persons with Child Abuse and Neglect Issues, Chemical Dependency and

Posttraumatic Stress Disorder, Clinical SelfCare for Addiction Counselors and Clinical 

Supervisors, Eye Movement Desensitization

and Reprocessing, Battered Women and Addictions, and Posttraumatic Stress Disorder.

ATTC training and educational opportunities

are based on empirical research and are intended to bring science to service. Undoubtedly, more distance-learning courses in this 

specialized area of interest will be developed as 

professional attention to co-occurring disorders increases. 

SAMHSA’s Center for Mental Health Services provides training for FEMA-approved

crisis counseling programs using Stafford Act

funding. These funding resources are available 

to select agencies designated to provide crisis 

counseling in the wake of a Presidential Disaster Declaration. Other funding for trauma 

training may be found through special programs of funding for target groups, such as 

those who provide mental health services and

case management for victims of crime (e.g.,

Office for Victims of Crime in the U.S. Department of Justice; see p. 257). 

The American Red Cross provides limited

disaster mental health training. The focus of

this training is to orient licensed mental health

professionals to the Red Cross Disaster services system and their roles as volunteers. 

The National Center for Post-Traumatic 

Stress Disorder was originally created in 1989

within the U.S. Department of Veterans Affairs (VA) to address the needs of veterans 

with military-connected PTSD. Its focus has 

since broadened to include trauma in general. 

The Center provides a variety of training opportunities for both VA and non-VA mental 

health personnel, including a PTSD 101 

course developed specifically for clinicians 

who provide services to clients who have experienced trauma (see http://www.ptsd.va.gov/

professional/index.asp). 

Seeking Safety offers training in trauma,

PTSD, and co-occurring disorders to mental

health professionals on all levels, from counselors to nurses to administrators. The EMDR 

International Association (EMDRIA) provides training to clinicians for certification in

EMDR via a curriculum including instruction,

supervised practicum, and consultation;

EMDRIA additionally provides basic training

in the field, separate from the certification

process. EMDR training is also provided by

the EMDR Humanitarian Assistance Program, a nonprofit organization with a 

training-focused model to assist clinicians in

treating trauma. 

ISTSS was founded in 1985 to bring attention 

to the study, assessment, and treatment of

traumatized people (http://www.istss.org). 

ISTSS is a professional society and provides 

face-to-face training during its annual meeting, especially through the preconference institutes. The ISTSS Web site offers numerous 

video and audio trainings for continuing education credits. ISTSS and the Figley Institute 

(http://www.figleyinstitute.com) have established best practice standards. The American

Academy of Experts in Traumatic Stress provides training and certification in several different areas (http://www.aaets.org). Similarly, 

the International Society for the Study of Dissociation (http://www.issd.org) specializes in

promoting therapies for dissociative disorders.

In 2002, the Green Cross Academy of Traumatology (http://www.greencross.org) established a Commission on Accreditation of 

Traumatology Education Programs to increase 

and maintain the high standards in the education and training of traumatologists. 

265 

 

 

 

Appendix C—Historical Account of
 

Trauma 

Historically, symptoms of traumatic stress 

have been recorded in both military and civilian populations (Lasiuk & Hegadoren, 2006).

Early accounts described the effect of battle 

conditions on soldiers; “soldier’s heart” and 

“nostalgia” were the terms for traumatic stress

reactions used during the American Civil 

War. As warfare techniques and strategies 

changed, so did the depiction of soldiers’ 

traumatic stress reactions. The advent of heavy 

explosives in World War I led to the attribution of symptoms to “shell shock,” giving a 

more physiological description of the effects 

from explosions (Benedek & Ursano, 2009).

On the civilian side, the industrial revolution

gave rise to larger and more dramatic catastrophes, including industrial and railway accidents. These, as well as other disasters, are 

noted in occupational health histories, newspapers, and contemporary literature. 

Even with a more physical explanation of

traumatic stress (i.e., shell shock), a prevailing

attitude remained that the traumatic stress 

response was due to a character flaw. For instance, a soldier’s pain at that time was often

seen as a symptom of homesickness. In spite 

of the efforts of Charcot, Janet, and Freud,

who described the psychogenic origin of

symptoms as a response to psychological 

trauma (Lasiuk & Hegadoren, 2006), World

War II military recruits were screened in attempt to identify those “who were afflicted 

with moral weakness,” which would prevent

them from entering military service. 

At the same time, there were new treatment

innovations for war-related trauma during

World War II. One approach treated soldiers 

in the field for what was then called “battle 

fatigue” by allowing some time for rest before 

returning to battle. During the Korean and

Vietnam wars, approaches began to focus 

more on the use of talk therapy. It was not

until the post-Vietnam era that interest in developing treatment alternatives started to take 

hold. During this time, the U.S. Department

of Veterans Affairs (then called the Veterans 

Administration) developed group therapy for

posttraumatic stress disorder (PTSD). Beyond 

being cost-effective, the technique was well 

suited to the symptoms of the veterans and

fostered socialization and reintegration

(Greene et al., 2004). 

The publication of the American Psychiatric

Association’s (APA’s) Diagnostic and Statistical

Manual of Mental Disorders, Third Edition 

(DSM-III), in 1980 marked the introduction

of PTSD as a diagnosis, inspired by symptoms 

presented by veterans of the Vietnam War 

(Benedek & Ursano, 2009). The diagnosis in

this iteration required the identification of a 

specific stressor—a catastrophic stressor that

was outside the range of usual human experience (APA, 1980)—and classified PTSD as 

267 
 

 

Historical Approaches to Trauma Healing and Recovery 

First Generation of Approaches to Trauma Healing and Recovery 

The first generation approaches to trauma healing and recovery focused on individual and clinical 

interventions to address the symptoms of PTSD and moved toward integration of trauma effects 

into ongoing life activities. The rapidly developing recognition of additional groups with violence 

and trauma histories—beyond those with war and captivity experiences (e.g., survivors of natural 

disasters and terrorism, refugees and immigrants fleeing homeland violence and persecution)— 

presented issues and needs that incited a second generation of approaches to trauma healing and 

recovery. 

Second Generation of Approaches to Trauma Healing and Recovery 

The second generation approaches focused on psychosocial education and empowerment models 

designed to tap into self-healing forces to energize personal and social movement. These approaches 

often are based on group and peer support models, and provide both support and education on the 

management of trauma and its affects. These approaches are not designed to replace clinical or 

alternative therapies; rather, they provide a social context for care. 

Concurrent to the development of psychosocial educational empowerment approaches, we also 

learned that if the approaches are not implemented in organizations or programs that are traumainformed, they will not take root and may lose effectiveness. 

Trauma-Informed Care: A New Paradigm for Public Health Services 

Trauma-informed care is a new paradigm for organizing public mental health and human services. 

Trauma-informed care changes the opening question for those seeking services from “What is 

wrong with you?” (patient or consumer) to “What has happened to you?” (survivor). Traumainformed care is initiated by assumption that every person seeking services is a trauma survivor who 

designs his or her own path to healing, facilitated by support and mentoring from the service 

provider. 

In a trauma-informed environment, survivors are empowered to proactively set goals and to manage 

progress toward those goals. For most existing organizations or programs, that requires movement 

from a traditional “top down” hierarchical clinical model to a psychosocial empowerment partnership that embraces all possible tools and paths to healing. In a pluralistic public health system with 

many levels and types of services and treatment, this is coming to be accepted as a “sine qua non,” 

or “without which not,” for humane, dignified, cost-effective, genuinely person-centered support 

and assistance in moving forward. 

Source: Salasin, 2011, p. 18. 

Trauma-Informed Care in Behavioral Health Services 

an anxiety disorder (Lasiuk & Hegadoren,

2006). Beginning with this definition, the

body of research grew, and the scope of application began to broaden, but not without considerable debate on what constituted a trauma. 

The social revolution that began in the 1960s,

combined with the women’s movement and 

the call for more attention to diverse and disenfranchised groups, set the stage for an increase in the acknowledgement and treatment

of victims of interpersonal violence and crimerelated trauma (Figley, 2002). The introduction of rape trauma syndrome as a condition

highlighted the psychological consequences of

sexual assault and the subsequent lack of support from society and the social services system (Kramer & Green, 1997). Subsequently,

research began to focus more on interpersonal 

violence, thus leading to the identification of

risk factors and treatment approaches unique 

to this form of violence and trauma (Olff,

Langeland, Drajer, & Gersons, 2007). 

268 
 

 

 

Appendix C—Historical Account of Trauma 

With input from international and national

mental health organizations and research, the 

DSM-IV further modified the definition of 

trauma to include a broader interpretation of

the identified stressor (Andreasen, 2010).

DSM-5 has maintained the modified definition of trauma, but the criterion requires being

explicit as to whether qualifying traumatic

events were experienced directly, witnessed, or

experienced indirectly (APA, 2013b). 

Paralleling the change in DSM criteria,

cognitive–behavioral therapy for traumatic 

stress was developed along with other skillsbased approaches (Greene et al., 2004). 

Researchers, such as Foa, Resick, D’Zurilla,

and Michenbaum, added to the body of

knowledge and gave clinicians a variety of

tools; these approaches continue to develop

and show efficacy even today. There was also

renewed interest in the long- and short-term 

effects of childhood sexual abuse and domestic 

violence. Interest in documenting the effects 

of trauma expanded further, including traumatic brain injury, significant orthopedic injuries, and multiple traumas (Starr et al., 2004).

So too, the consumer movement in health care 

began. Consumers insisted on patient rights,

humane treatment, and involvement in the 

treatment process; as a result, the paternalistic

approach to health care began to change. As 

consumers set the initial stage and Federal 

agencies (e.g., the Substance Abuse and Mental Health Services Administration and its 

centers) and national organizations promoted

the need for trauma-informed policies and 

care, national studies began to demonstrate 

the prevalence of traumatic experiences. Research including the Adverse Childhood

Experiences and the Women, Co-Occurring,

and Violence studies clearly demonstrated the 

pervasive long-term impact of trauma, reinforcing the call for trauma-informed policies 

and care. (For more information on the development of trauma-informed care, see Harris 

and Fallot, 2001b, as well as Jennings, 2004.) 

269 

 

 

 

Appendix D—Screening and 


Assessment Instruments
 

This appendix provides a selected sample of available tools for screening and assessment of traumatic events and trauma-related symptoms. This is not an exhaustive list, nor does this list focus 

on screening instruments that capture a broader range of symptoms related to trauma (such as 

sleep hygiene and dissociation) or other features important in providing trauma-informed care

(e.g., resilience level, coping skill style, resource availability). For more information on a broad

range of available instruments, refer back to Part 1, Chapter 4. Many of the instruments listed

below use criteria found in the Diagnostic and Statistical Manual of Mental Disorders, Fourth 

Edition, Text Revision (DSM-IV-TR; APA, 2000), but with the release of the DSM-5 (APA, 

2013a), instruments will evolve, and new versions will be available under the same contact information. 

Screening and Assessment Measures 

• Clinician Administered PTSD Scale (CAPS) 

• Davidson Trauma Scale (DTS) 

• Distressing Event Questionnaire (DEQ) 

• Evaluation of Lifetime Stressors (ELS) 

• Impacts of Event Scale Revised (IES-R) 

• Mississippi Scale for Combat-Related PTSD (M-PTSD) 

• Penn Inventory for Posttraumatic Stress Disorder 

• Posttraumatic Diagnostic Scale (PDS) 

• PTSD Symptom Scale-Interview (PSS-I) 

• PTSD Symptom Scale: Self-Report Version (MPSS-SR) 

• Screen for Posttraumatic Stress Symptoms (SPTSS) 

• Structured Interview for PTSD (SI-PTSD) 

• Trauma Assessment for Adults (TAA) 

• Trauma Assessment for Adults (TAA)–Self Report 

• Trauma History Questionnaire (THQ) 

• Trauma Symptom Inventory (TSI) 

• Traumatic Stress Schedule 

271 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

Screening and Assessment Measures 

Clinician Administered PTSD Scale (CAPS) 

Domains:	 Posttraumatic stress disorder (PTSD), acute stress disorder (ASD) 

Timeframe:	 CAPS-Sx: Lifetime and current (past week)

CAPS-Dx: Current (past month) 

Response format:	 Other 

Format of administration:	 Structured 

Number of items:	 30 

Completion time:	 30–60 minutes 

Qualifications to administer: Administered by clinicians and clinical researchers who have a

working knowledge of PTSD and by appropriately trained

paraprofessionals 

How to obtain scale:	 Contact Danny G. Kaloupek, Ph.D. 

Cost or public domain:	 Public domain 

Psychometrics:	 Populations sampled: veterans, car accident survivors

Reliability: alpha = .94, test-retest = .90–.98

Validity: sensitivity = .85, specificity = .95 (compared with Structured Clinical Interview for DSM Disorders [SCID]), r = .91 

(with MS Scale for Combat-related PTSD) kappa = .77 against

the SCID diagnosis; item-total correlations = .49–.82; internal

consistency = .94 

Author(s):	 Dudley David Blake, Frank W. Weathers, Linda M. Nagy, Danny 

G. Kaloupe, Dennis S. Charney, and Terence M. Keane 

Contact:	 Danny G. Kaloupek, Ph.D.

National Center for PTSD 

Boston VA Medical Center, 11B

150 South Huntington Avenue

Boston, MA 02130 

Relevant citations:	 Blake, D. D. (1994). Rationale and development of the clinicianadministered PTSD scales. PTSD Research Quarterly, 5, 1–2. 

Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., 

Gusman, F. D., Charney, D. S., & Keane, T. M. (1995). The development of a clinician-administered PTSD scale. Journal of 

Traumatic Stress, 8, 75–90. 

272 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appendix D—Screening and Assessment Instruments 

Gray, M., Litz, B., Hsu, J., & Lombardo, T. (2004). Psychometric

properties of the Life Events Checklist. Assessment, 11, 330–341. 

Weathers, F. W., Keane, T. M., & Davidson, J. R. (2001). Clinician-Administered PTSD Scale: A review of the first ten years of

research. Depression and Anxiety, 13, 132–156. 

Davidson Trauma Scale (DTS) 

Domains: PTSD symptoms 

Timeframe: Current (past week) 

Response format: Self-administered 

Format of administration: Structured 

Number of items: 17 

Completion time: 10–15 minutes 

Qualifications to administer: Bachelor’s degree in psychology. Must have related field and course 

work in the use of assessment instruments or special training in the 

use of this instrument. Education/training requirements may be 

waived for those granted the right to administer tests at this level

(B) in their jurisdiction. 

How to obtain scale:	 Contact Mental Health Systems, Inc. 

Cost or public domain:	 Cost: $15.00 

Psychometrics:	 Populations sampled: rape victims, veterans, hurricane victims, miscellaneous traumas 

Reliability: alpha = .99, test-retest = .86 

Author(s):	 Jonathan R.T. Davidson 

Contact: 	 Mental Health Systems, Inc.

908 Niagara Falls Boulevard

North Tonawanda, NY, 14120-2060

800-456-3003 

Relevant citations:	 Davidson, J. R. T., Book, S. W., Colket, J. T., Tupler, L. A., Roth,

S., David, D., Hertzberg, M., Mellman, T., Beckham, J.C., Smith, 

R., Davison, R. M., Katz, R., & Feldman, M. (1997). Assessment

of a new self-rating scale for posttraumatic stress disorder.

Psychological Medicine, 27, 153–160. 

Davidson, J. R., Tharwani, H. M., & Connor, K. M. (2002).

Davidson Trauma Scale (DTS): Normative scores in the general 

population and effect sizes in placebo-controlled SSRI trials. 

Depression and Anxiety, 15, 75–78. 

273 
 

 

 

 

 

 

 

How to obtain scale: Contact Edward Kubany, Ph.D. 

Cost or public domain: Contact Edward Kubany, Ph.D. 

Psychometrics: Population sampled: veterans, battered women

Reliability: inter-item r = .93, test-retest = .95; validity: Pearson’s r 

Trauma-Informed Care in Behavioral Health Services 

Distressing Event Questionnaire (DEQ) 

Domains: Posttraumatic Stress Disorder (PTSD) for multiple events 

Timeframe: Lifetime 

Response format: Self-administered 

Format of administration: Structured 

Number of items: 35 

Completion time: 10–15 minutes 

Qualifications to administer: Contact Edward Kubany, Ph.D. 

reliability coefficient = .83 (with Penn Inventory, Pearson’s r reliability coefficient = .76 (with Beck Depression Inventory) 

Author(s):	 Edward Kubany, Mary Beth Leisen, Aaron S. Kaplan, Martin P. Kelly 

Contact:	 Edward Kubany, Ph.D.

National Center for PTSD 

Pacific Islands Division 

Department of VA

Suite 307 

Honolulu, HI 96813 

Kubany.Edward@honolulu.va.gov 

Relevant citations:	 Kubany, E. S., Leisen, M. B., Kaplan, A. S., & Kelly, M. P. (2000).

Validation of a brief measure of posttraumatic stress disorder: The 

distressing event questionnaire (DEQ). Psychological Assessment, 12,

197–209. 

Evaluation of Lifetime Stressors (ELS) 

Domains: Trauma history 

Timeframe: Lifetime 

Response format: Other 

Format of administration: Structured 

Number of items: 56 

Completion time: 10–20 minutes for screening, 1–3 hours for complete interview 

Qualifications to administer: Should be administered by trained clinicians only 

274 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appendix D—Screening and Assessment Instruments 

How to obtain scale:	 Contact Karen Krinsley, Ph.D. 

Cost or public domain:	 Public domain 

Psychometrics:	 Populations sampled: male veterans, female sexual abuse survivors 

Reliability: r = .4–1.0 

Author(s):	 Karen Krinsley, Frank W. Weathers, Elana Newman, Edward A.

Walker, Danny G. Kaloupek, Rachel Kimerling 

Relevant citations:	 Corcoran, C. B., Green, B. L., Goodman, L. A., & Krinsley, K. E. 

(2000). Conceptual and methodological issues in trauma history 

assessment. In A. Y. Shalev, R. Yehuda, & A. C. McFarlane (Eds.), 

International handbook of human response to trauma (pp. 22–232). 

Dordrecht, Netherlands: Kluwer Academic Publishers. 

Krinsley, K. (1996). Psychometric review of the Evaluation of Lifetime Stressors (ELS) Questionnaire and Interview. In B. H. 

Stamm (Ed.), Measurement of stress, trauma, and adaptation (pp. 

160–162). Lutherville, MD: Sidran Press. 

Impact of Event Scale Revised (IES-R) 

Domains: PTSD for a single event 

Timeframe: Current (past week) 

Response format: Self-administered 

Format of administration: Structured 

Number of items: 22 

Completion time: 5–10 minutes for screening 

Qualifications to administer: None 

How to obtain scale: http://consultgerirn.org/uploads/File/trythis/try_this_19.pdf 

Cost or public domain: Public domain 

Psychometrics: Populations sampled: earthquake survivors, emergency disaster

workers, Vietnam veterans, violence and sexual assault victims 

Reliability: alpha = .79–.92, test-retest = .89–.94, Pearson’s r reliability coefficient = .74–.87 

Author(s):	 Daniel Weiss and Charles R. Marmar 

Relevant citations:	 Sundin, E. C. & Horowitz, M. J. (2002). Impact of Event Scale:

Psychometric properties. British Journal of Psychiatry, 180, 205–209. 

Weiss, D. S. & Marmar, C. R. (1996).The Impact of Event ScaleRevised. In J. Wilson & T. M. Keane (Eds.), Assessing psychological 

trauma and PTSD (pp. 399–411). New York: Guilford Press. (Includes measure in its entirety.) 

275 
 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

Mississippi Scale for Combat-Related PTSD (M-PTSD) 

Domains: PTSD for multiple events 

Timeframe: Contact National Center for PTSD at ncptsd@ncptsd.org 

Response format: Self-administered 

Format of administration: Structured 

Number of items: 35 

Completion time: 10–15 minutes 

Qualifications to administer: Contact National Center for PTSD at ncptsd@va.gov 

How to obtain scale: To order the scale contact the National Center for PTSD 

Cost or public domain: Free (ncptsd@va.gov) 

Psychometrics: Population sampled: veterans

Reliability: inter-item r = .94, test-retest = .97

Validity: sensitivity = .93, specificity = .89 

Author(s): Terence M. Keane 

Contact:	 National Center for PTSD (116D)

VA Medical Center 

215 N. Main St. 

White River Junction, VT 05009

http://www.ptsd.va.gov/ 

Relevant citations:	 Engdahl, B. & Eberly, R. (1994). Assessing PTSD among veterans 

exposed to war trauma 40–50 years ago. NCP Clinical Quarterly, 4, 

13–14. 

Keane, T. M., Caddell, J. M., & Taylor, K. L. (1988). Mississippi 

Scale for Combat-Related Posttraumatic Stress Disorder: Three 

studies in reliability and validity. Journal of Consulting and Clinical 

Psychology, 56, 85–90. 

Penn Inventory for Posttraumatic Stress Disorder 

Domains: PTSD for multiple events 

Timeframe: Current (past week) 

Response format: Self-administered 

Format of administration: Structured 

Number of items: 26 

Completion time: 5–15 minutes 

276 
 

 

 

 

 

 

 

 

 

 

 

 

Appendix D—Screening and Assessment Instruments 

Qualifications to administer: Contact Melvyn Hammarberg, Ph.D. 

How to obtain scale:	 Contact Melvyn Hammarberg, Ph.D. 

Cost or public domain:	 Public domain 

Psychometrics:	 Population sampled: veterans, oil-rig disaster survivors

Reliability: alpha = .94, test-retest = .96 

Author(s):	 Melvyn Hammarberg 

Contact: 	 Melvyn Hammarberg, Ph.D.

Department of Anthropology

University of Pennsylvania

325 University Museum

33rd and Spruce Street

Philadelphia, PA 19104-6398 

Relevant citations:	 Hammarberg, M. (1996). Psychometric review of the Penn Interview for Post Traumatic Stress Disorder. In B. H, Stamm (Ed.),

Measurement of stress, trauma, and adaptation (pp. 231–235). Lutherville, MD: Sidran Press. (Includes measure in its entirety.) 

Steel, J. L., Dunlavy, A. C., Stillman, J., & Pape, H. C. (2011). 

Measuring depression and PTSD after trauma: Common scales 

and checklists. Injury, 42, 288–300. 

Posttraumatic Diagnostic Scale (PDS) 

Domains:	 DSM-IV PTSD symptom clusters 

Timeframe:	 Current (past month) 

Response format:	 Self-administered 

Format of administration:	 Structured 

Number of items:	 49 

Completion time:	 10–15 minutes 

Qualifications to administer: Bachelor’s degree in psychology. Must have related field and course 

work in the use of assessment instruments or special training in the 

use of this instrument. 

How to obtain scale:	 Contact National Computer Systems (NCS) 

Cost or public domain:	 Cost: $15.00 

Psychometrics:	 Population sampled: accident/fire, disaster, assault, sexual assault,

sexual abuse, major illness

Reliability: alpha = .92, test-retest = .83

Validity: sensitivity = .89, specificity = .75 

277 
 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

Author(s):	 Edna B. Foa, Ph.D. 

Contact: 	 National Computer Systems (NCS)

5605 Green Circle Drive 

Minnetonka, MN 55343 

Relevant citations:	 Foa, E. (1996). Post-traumatic Diagnostic Scale manual. 

Minneapolis, MN: National Computer Systems. 

Foa, E., Cashman, L., Jaycox, L., & Perry, K. (1997). The validation 

of a self-report measure of PTSD: The Post-traumatic Diagnostic

Scale (PDS). Psychological Assessment, 9, 445–451. 

Steel, J. L., Dunlavy, A. C., Stillman, J., & Pape, H. C. (2011). 

Measuring depression and PTSD after trauma: Common scales 

and checklists. Injury, 42, 288–300. 

PTSD Symptom Scale-Interview (PSS-I) 

Domains:	 PTSD single event 

Timeframe:	 Current (past 2 weeks) 

Response format:	 Other 

Format of administration:	 Structured 

Number of items:	 17 

Completion time:	 20 minutes 

Qualifications to administer: Can be administered by a master’s level interviewer after a few 

hours of training. 

How to obtain scale:	 Contact Edna B. Foa, Ph.D. 

Cost or public domain:	 Public domain 

Psychometrics:	 Population sampled: female sexual assault victims, female assault

victims 

Reliability: alpha = .85, test-retest = .80; validity: sensitivity = .88,

specificity = .96 (compared with SCID); Pearson’s r reliability coefficient = .48–.80 (with Impact of Events intrusion and avoidance,

State portion of State-Trait Anxiety Inventory, and MPSS-SR) 

Author(s):	 Edna B. Foa and Gregory A. Leskin 

Contact:	 Edna B. Foa, Ph.D.

Medical College of Pennsylvania

Department of Psychiatry

3200 Henry Avenue

Philadelphia, PA 19129-1137 

278 
 

 

 

 

 

 

 

 

 

Appendix D—Screening and Assessment Instruments 

Relevant citations:	 Foa, E. B., Riggs, D. S., Dancu, C. V., & Rothbaum, B. O. (1993).

Reliability and validity of a brief instrument for assessing posttraumatic stress disorder. Journal of Traumatic Stress, 6, 459–474. 

Foa, E. & Tolin, D. F. (2005). Comparison of the PTSD Symptom 

Scale-Interview Version and the clinician administered PTSD 

Scale. Journal of Traumatic Stress, 13, 181–191. 

Leskin, G. A. (1999). Screening for trauma and PTSD in a primary care clinic. NC-PTSD Clinical Quarterly, 8, 68–69. 

PTSD Symptom Scale: Self-Report Version (MPSS-SR) 

Domains:	 PTSD for multiple or unknown events 

Timeframe:	 Current (past 2 weeks) 

Response format:	 Self-administered 

Format of administration:	 Structured 

Number of items:	 17 

Completion time:	 10–15 minutes 

Qualifications to administer: Contact Sherry Falsetti, Ph.D. 

How to obtain scale:	 Contact Sherry Falsetti, Ph.D. 

Cost or public domain:	 Public domain 

Psychometrics:	 Reliability: alpha = .96–.97

Validity: sensitivity = .89, specificity = .65 

Author(s):	 Sherry Falsetti, Patricia A. Resick, Heidi S. Resnick, Dean G. 

Kilpatrick 

Contact:	 Sherry Falsetti, Ph.D.

University of Illinois 

College of Medicine

Department of Family and Community Medicine

1601 Parkview Avenue 

Rockford, IL 61107-1897 

Relevant citations:	 Bonin, M. F., Norton, G. R., Asmundson, G. J., Dicurzio, S., & 

Pidlubney, S. (2000). Drinking away the hurt: The nature and

prevalence of PTSD in substance abuse patients attending a community-based treatment program. Journal of Behavior Therapy and 

Experimental Psychiatry, 31, 55–66. 

Coffey, S. F., Dansky, B. S., Falsetti, S. A., Saladin, M. E., & Brady,

K. T. (1998). Screening for PTSD in a substance abuse sample: 

279 
 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

Psychometric properties of a modified version of the PTSD Symptom Scale Self-Report. Journal of Traumatic Stress, 11, 393–399. 

Falsetti, S. A., Resnick, H. S., Resick, P. A., & Kilpatrick, D. (1993).

The Modified PTSD Symptom Scale: A brief self-report measure of

post-traumatic stress disorder. The Behavioral Therapist, 16, 161–162. 

Screen for Posttraumatic Stress Symptoms (SPTSS) 

Domains: PTSD for multiple or unknown events 

Timeframe: Current (past 2 weeks) 

Response format: Self-administered 

Format of administration: Structured 

Number of items: 17 

Completion time: 5 minutes 

Qualifications to administer: Contact Eve Carlson, Ph.D. 

How to obtain scale: Contact Eve Carlson, Ph.D. 

Cost or public domain: Public domain 

Psychometrics: Population sampled: psychiatric inpatients

Reliability: split half reliability = .91, test-retest = .82 

Author(s):	 Eve Carlson, Ph.D. 

Contact:	 Eve Carlson, Ph.D.

National Center for PTSD (352-117-MP)

Palo Alto Health Care System

795 Willow Road 

Menlo Park, CA 94025 

Relevant citations:	 Carlson, E. (2001). Psychometric study of a brief screen for PTSD:

Assessing the impact of multiple traumatic events. Assessment, 8,

431–441. 

Structured Interview for PTSD (SI-PTSD) 

Domains: PTSD single event 

Timeframe: Current (past 4 weeks) 

Response format: Other 

Format of administration: Structured 

Number of items: 17 

280 
 

 

 

 

 

 

 

 

 

Appendix D—Screening and Assessment Instruments 

Completion time:	 20–30 minutes 

Qualifications to administer: Can be administered by mental health professionals or by 

paraprofessionals after some training. 

How to obtain scale:	 Contact Jonathan Davidson, M.D. 

Cost or public domain:	 Public domain 

Psychometrics:	 Population sampled: veterans

Reliability: alpha = .94, test-retest = .71, intraclass r = .97

Validity: sensitivity = .96, specificity = .80 (compared with SCID), 

Pearson’s r reliability coefficient = .61 (with IES), Pearson’s r reliability coefficient = .51 (with Hamilton Anxiety Scale) 

Author(s):	 Jonathan Davidson 

Contact: 	 Jonathan Davidson, M.D.

Department of Psychiatry

Box 3812 

Duke University Medical Center

Durham, NC 27710-3812 

Relevant citations:	 Davidson, J. R. T., Kudler, H. S., & Smith, R. D. (1990). Assessment and pharmacotherapy of posttraumatic stress disorder. In J. E. 

L. Giller (Ed.), Biological assessment and treatment of post-traumatic 

stress disorder (pp. 205–221). Washington, DC: American Psychiatric Press. (Includes measure in its entirety.) 

Steel, J. L., Dunlavy, A. C., Stillman, J., & Pape, H. C. (2011). 

Measuring depression and PTSD after trauma: Common scales 

and checklists. Injury, 42, 288–300. 

Trauma Assessment for Adults (TAA) 

Domains: Trauma history 

Timeframe: Lifetime 

Response format: Other 

Format of administration: Structured 

Number of items: 13 

Completion time: 10–15 minutes 

Qualifications to administer: None specified 

How to obtain scale: Contact Heidi Resnick, Ph.D. 

Cost or public domain: Public domain 

281 
 

 

 

 

 

 

 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

Psychometrics:	 Populations sampled: adult mental health center clients; face validity established; feasible; validity established via archival records 

Author(s):	 Connie L. Best, John R. Freedy, Sherry A. Falsetti, Dean G. 

Kilpatrick, Heidi S. Resnick 

Relevant citations:	 Cusack, K. J., Frueh, B. C., & Brady, K. T. (2004). Trauma history

screening in a community mental health center. Psychiatric Services, 

55, 157–162. 

Resnick, H. S. (1996). Psychometric review of Trauma Assessment for

Adults (TAA). In B. H. Stamm (Ed.), Measurement of stress, trauma, 

and adaptation (pp. 362–365). Lutherville, MD: Sidran Press. 

Trauma Assessment for Adults (TAA)–Self Report 

Domains: Trauma history 

Timeframe: Lifetime 

Response format: Self-administered 

Format of administration: Structured 

Number of items: 17 

Completion time: 10–15 minutes 

Qualifications to administer: None specified 

How to obtain scale: Contact Heidi Resnick, Ph.D. 

Cost or public domain: Public domain 

Psychometrics: None to date 

Author(s): Connie L. Best, John R. Freedy, Sherry A. Falsetti, Dean G. 

Kilpatrick, Heidi S. Resnick 

Relevant citations:	 Resnick, H. S., Falsetti, S. A., Kilpatrick, D. G., & Freedy, J. R. 

(1996). Assessment of rape and other civilian trauma-related posttraumatic stress disorder: Emphasis on assessment of potentially 

traumatic events. In T. W. Miller (Ed.), Stressful life events (pp. 

231–266). Madison, WI: International Universities Press. 

Trauma History Questionnaire (THQ) 

Domains: Trauma history 

Timeframe: Lifetime 

Response format: Self-administered 

Format of administration: Structured 

282 
 

 

 

 

 

 

 

 

Appendix D—Screening and Assessment Instruments 

Number of items:	 24 

Completion time:	 5–15 minutes 

Qualifications to administer: Contact Bonnie L. Green, Ph.D. 

How to obtain scale:	 Contact Bonnie L. Green, Ph.D. 

Cost or public domain:	 Public domain 

Psychometrics:	 Populations sampled: psychiatric outpatients, college students,

women with breast cancer 

Reliability: r = 0.7–0.9, intraclass = .76 

Author(s):	 Bonnie L. Green 

Relevant citations:	 Hooper, L., Stockton, P., Krupnick, J., & Green, B., (2011). Development, use, and psychometric properties of the Trauma History 

Questionnaire. Journal of Loss and Trauma, 16, 258–283. 

Muesser, K. T., Salyers, M. P., Rosenberg, S. D., Ford, J. D., Fox, 

L., & Carty, P. (2001). Psychometric evaluation of trauma and

posttraumatic stress disorder assessments in persons with severe 

mental illness. Psychological Assessment, 13, 110–117. 

Norris, F. H. & Hamblen, J. L. (2004). Standardized self-report

measures of civilian trauma and PTSD. In J. P. Wilson, T. M. 

Keane & T. Martin (Eds.), Assessing psychological trauma and PTSD

(pp. 63–102). New York: Guilford Press. 

Trauma Symptom Inventory (TSI) 

Domains: Trauma-related symptoms 

Timeframe: Current (last 6 months) 

Response format: Self-administered 

Format of administration: Structured 

Number of items: 100 

Completion time: 20 minutes 

Qualifications to administer: Bachelor’s degree in psychology. Must have related field and courses in the use of assessment instruments or special training in the 

use of this instrument. 

How to obtain scale:	 Contact Psychological Assessment Resources 

Cost or public domain:	 Cost: $15.00 

Psychometrics:	 Population sampled: general population

Reliability: alpha = .84–.87 

283 
 

 

 

 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

Author(s):	 John Briere 

Contact: 	 Psychological Assessment Resources

Box 998 

Odessa, FL 33556 

Relevant citations:	 Briere, J. (1996). Psychometric review of Trauma Symptom Inventory (TSI). In B. H. Stamm (Ed.), Measurement of stress, trauma, 

and adaptation (pp. 381–383). Lutherville, MD: Sidran Press. 

Briere, J. (1995). Trauma Symptom Inventory professional manual.

Odessa, FL: Psychological Assessment Resources. 

Orsillo, S. M. (2001). Measures for acute stress disorder and posttraumatic stress disorder. In M. M. Antony & S. M. Orsillo (Eds.),

Practitioner’s guide to empirically based measures of anxiety (pp. 255– 

307). New York: KluwerAcademic/Plenum. 

Traumatic Stress Schedule 

Domains: Trauma history 

Timeframe: Current (but author suggests any period) 

Response format: Other 

Format of administration: Semi-structured 

Number of items: 10 (with 12 probes) 

Completion time: 5–30 minutes 

Qualifications to administer: Can be administered by lay interviewer with training 

How to obtain scale: Contact Fran Norris, Ph.D. 

Cost or public domain: Public domain 

Psychometrics: Reliability: test-retest = .88, frequency of events equal to National 

Women’s Study PTSD Module 

Author(s):	 Fran Norris 

Relevant citations:	 Norris, F. H. (1990). Screening for traumatic stress: A scale of use 

in the general population. Journal of Applied Social Psychology, 20,

1704–1718. (Includes measure in its entirety.)
 

Norris, F. H. & Hamblen, J. L. (2004). Standardized self-report


measures of civilian trauma and PTSD. In J. P. Wilson, T. M. 


Keane & T. Martin (Eds.), Assessing psychological trauma and PTSD


(pp. 63–102). New York: Guilford Press.
 

284 
 

 

Appendix E—Consumer Materials 

The following are samples of available consumer materials relating to trauma-informed care and 

traumatic stress. There is a plethora of consumer information available to meet the immediate 

and long-term needs of consumers of behavioral health services affected by trauma. In order to

not waste effort creating new materials for your client’s concerns, it is advisable to explore current

science-informed resources. In most cases, consumer materials are already available and easily 

accessible for free. 

AfterDeployment.org (2010). Just the Facts: Resilience. Available: 

http://afterdeployment.org/sites/default/files/pdfs/client-handouts/resilience-understanding.pdf

This Web site provides resources to address symptoms related to traumatic stress in addition to other postdeployment adjustment issues.This site provides information and

handouts on resilience, triggers, and other trauma-related topics. It is appropriate for service members as well as civilians. 

Blanch, A., Filson, B., & Penny, D. (2012). Engaging Women in Trauma-Informed Peer Support: A 

Guidebook. Available: http://www.nasmhpd.org/publications/engagingwomen.aspx

This draft technical assistance guide was created by the National Center for TraumaInformed Care (NCTIC) and developed under contract with the National Association

of State Mental Health Program Directors. This publication is designed to help make 

trauma-informed peer support available to women who are trauma survivors and who receive or have received behavioral health services. It is a resource for peers providing support in these or other settings who want to learn how to use trauma-informed principles 

in supporting women or in the peer support groups. It has been a resource used in the delivery of technical assistance through NCTIC. 

Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J., Steinberg, A., et al. (2006). Appendix E:

Handouts. Psychological First Aid: Field Operations Guide. Available: 

http://www.ptsd.va.gov/professional/manuals/manual-pdf/pfa/PFA_Appx_E_handouts.pdf

Developed jointly with the National Child Traumatic Stress Network and the National

Center for PTSD, this curriculum provides a science-informed approach to psychological

first aid for response workers. The goals of this module are to assist survivors in the 

immediate aftermath of disaster and/or terrorism, reduce initial distress, and foster shortand long-term adaptive functioning. This link provides specific survivor-oriented

material, such as strategies in seeking and giving support, education on common

immediate reactions, and parental tips for children across developmental stages. 

285 
 

 

 

Trauma-Informed Care in Behavioral Health Services 

Center for Mental Health Services (2002). Dealing with the Effects of Trauma-A Self-Help Guide.

Available: http://store.samhsa.gov/shin/content//SMA-3717/SMA-3717.pdf

This self-help guide gives practical information and tools to address and manage symptoms and other consequences of traumatic stress. It provides education on a variety of

topics, including trauma-related symptoms, advice on the key ingredients of quality care,

barriers to recovery, and practical strategies to enhance recovery and manage difficult

emotions. 

Center for Mental Health Services, Substance Abuse and Mental Health Services Administration (2005). Roadmap to Seclusion and Restraint Free Mental Health Services. Available: 

http://store.samhsa.gov/product/Roadmap-to-Seclusion-and-Restraint-Free-Mental-HealthServices-CD-/SMA06-4055

This curriculum concerns the elimination of seclusion and restraint. It provides numerous 

handouts for consumers as well as staff. Several consumer handouts include common reactions to trauma, a trauma screening tool, and strategies to de-escalate agitation and distress. 

Mead, S. (2008). Intentional Peer Support: An Alternative Approach. Sherry Mead Consulting.

Available: http://www.intentionalpeersupport.org/apps/webstore/products/show/3408520

This interactive workbook is designed for individuals who are in peer support roles and

those who use peer support services. It provides goals, tasks, competencies, and skills associated with peer support relationships and guidelines for first interviews. 

Najavits, L. M. (2002). Seeking Safety: A Treatment Manual for PTSD and Substance Abuse. New 

York: Guilford Press. 

This evidence-based practice for individuals who have a history of trauma and a substance use disorder provides not only guidelines for clinicians but handouts for individuals. The consumer materials include information on PTSD and substance abuse and their 

interrelationship, key principles of the Seeking Safety program, coping skills to support

safety, and grounding exercises. For additional information and resources, go to

http://www.seekingsafety.org. 

National Center for PTSD, U.S. Department of Veterans Affairs (2010). Understanding PTSD. 

Available: http://www.ptsd.va.gov/public/understanding_ptsd/booklet.pdf

This booklet provides consumer information on posttraumatic stress, common traumatic 

stress symptoms, effective treatments, and resources. The National Center for PTSD also

provides additional professional and public resources specific to trauma for veterans and

civilians. 

Sidran Institute (2012). Healing Self-Injury. Available: http://healingselfinjury.org/about.html

This Web site provides numerous resources for consumers and professionals to understand self-inflicted violence. It offers publication links, archived newsletters, and a current

blog focused on self-harm. 

286 
 

 

 

 

 

Appendix F—Organizational 

Assessment for TraumaInformed Care 

The following two resources are organizational assessments, which represent a key strategy in

developing or re-evaluating trauma-informed services. The first assessment, presented by the 

University of South Florida, College of Behavioral and Community Sciences (2012), is designed

for staff or key stakeholders. The second assessment comes from the Trauma-Informed Organizational Toolkit for Homeless Services (Guarino, Soares, Konnath, Clervil & Bassuk, 2009) and is a

consumer version. There are several other assessment tools available, including Fallot and Harris’s 

Creating Cultures of Trauma-Informed Care (CCTIC): A Self Assessment and Planning Protocol

(2009). 

Staff or Key Stakeholder Organizational Assessment Tool

University of South Florida, College of Behavioral and Community Sciences (2012). Creating 

Trauma-Informed Care Environments: An Organizational Self-Assessment. Available: 

http://www.cfbhn.org/assets/TIC/youthresidentialself%20assess%20Fillable%20FORM%20%28

2%29.pdf 

Consumer Version: Organizational Assessment Tool

Guarino, K., Soares, P., Konnath, K., Clervil, R., & Bassuk, E. (2009). Trauma-Informed 

Organizational Toolkit for Homeless Services. Rockville, MD: Center for Mental Health Services,

Substance Abuse and Mental Health Services Administration, and the Daniels Fund, the 

National Child Traumatic Stress Network, and the W.K. Kellogg Foundation. See: pp. 82–93.

Available: http://www.familyhomelessness.org/media/90.pdf 

287 

 

 

Appendix G—SAMHSA Resource 


Panel 

John Bailey

Special Expert

Office of Policy, Planning, and Budget

Office of the Administrator 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Shirley Beckett, NCAC II

Certification Administrator 

National Association of Alcohol and Drug

Abuse Counselors 

Washington, DC 

Danny Brom, Ph.D.

Director 

The Israel Center for the Treatment of 

Psychotrauma

Latner Institute for the Study of Social

Psychiatry and Psychotherapy

Israel 

Ling Chin, M.D.

Chief, Clinical Science

Center for the Clinical Trials Network 

National Institute on Drug Abuse 

National Institutes of Health 

Bethesda, MD 

Carol Coley, M.S., USPHS

Senior Program Management Officer

Division of State and Community 

Assistance 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Christina Currier 

Public Health Analyst

Office of Evaluation, Scientific Analysis and

Synthesis

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Marlene EchoHawk, Ph.D.

Health Science Administrator 

Division of Health 

Indian Health Service 

U.S. Department of Health and Human

Services 

Rockville, MD 

Jill Shepard Erickson, M.S.W., ACSW

Center for Mental Health Services 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

289 
 

 

 

Trauma-Informed Care in Behavioral Health Services 

Angela M. Gonzalez, Ph.D., CDR,

USPHS 

Special Programs Development BranchRefugee Mental Health Program

Division of Prevention, Traumatic Stress,

and Special Programs

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Jacqueline Hendrickson, M.S.W.,

LCSW-C 

Public Health Advisor 

Division of Pharmacologic Therapies

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Michael Hilton, Ph.D.

Health Science Administrator 

Division of Clinical and Prevention 

Research 

National Institute of Alcohol Abuse and 

Alcoholism 

National Institutes of Health 

Bethesda, MD 

Kenneth J. Hoffman, M.D., M.P.H.

Medical Director 

TRICARE Management Activity

Military Health System-Population Health

Programs

Department of Defense, Health Affairs

Falls Church, VA 

Kirk E. James, M.D.

Special Expert

Systems Improvement Branch

Division of Services Improvement

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Hendree E. Jones, Ph.D.

Assistant Professor 

Department of Psychiatry and Behavioral 

Sciences 

Johns Hopkins University Center

Baltimore, MD 

Cindy Kleppinger, M.D.

Center for the Clinical Trials Network 

National Institute on Drug Abuse

National Institutes of Health 

Bethesda, MD 

David Liu, M.D.

Center for the Clinical Trials Network 

National Institute on Drug Abuse

National Institutes of Health 

Bethesda, MD 

Richard E. Lopez, J.D., Ph.D.

Social Science Analyst

Co-Occurring and Homeless Branch

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Sue Martone, M.P.A.

Public Health Advisor 

Office of Disease Prevention and Health 

Promotion 

U.S. Department of Health and Human

Services 

Washington, DC 

Dee S. Owens, M.P.A.

Director 

Alcohol-Drug Information Center

Indiana University

Bloomington, IN 

290 
 

 

 

Appendix G—Resource Panel 

Harold I. Perl, Ph.D.

Chief, Health Services Research Branch

Division of Clinical and Prevention 

Research 

National Institute of Alcohol Abuse and 

Alcoholism 

National Institutes of Health 

Bethesda, MD 

Melissa V. Rael, USPHS

Senior Program Management Officer

Division of State and Community 

Assistance 

Co-Occurring and Homeless Branch

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Lawrence D. Rickards, Ph.D.

Co-Occurring Disorders Program Manager

Homeless Programs Branch

Division of Knowledge Development and

Systems Change

Center for Mental Health Services 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Cecilia Rivera-Casale, Ph.D.

Senior Project Officer

Center for Mental Health Services 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Terrence Schomburg, Ph.D.

Team Leader 

Division of State and Community 

Assistance 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Richard T. Suchinsky, M.D.

Associate Chief for Addictive Disorders and 

Psychiatric Rehabilitation

Mental Health and Behavioral Sciences 

Services 

Department of Veterans Affairs

Washington, DC 

Beth A. Weinman, M.A.

Coordinator 

National Drug Abuse Programs

Correctional Programs Division-Services 

Branch 

U.S. Department of Justice

Washington, DC 

Penelope P. Ziegler, M.D.

Head, Treatment Section

American Academy of Addiction Psychiatry

Williamsburg, VA 

291 

 

. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appendix H—Field Reviewers
 

Carol Ackley 

Owner/Director 

River Ridge Treatment Center

Burnsville, MN 

Rosie Anderson-Harper, M.A. 

Mental Health Manager

Division of Alcohol and Drug Abuse 

Missouri Department of Mental Health

Jefferson City, MO 

Reba Architzel 

Director 

Federal Relations and Policy Analysis 

New York State Office of Alcoholism and 

Substance Abuse Services 

Albany, NY 

Larry L. Ashley, Ed.S., M.A.

Addictions Specialist

Department of Counseling

University of Nevada, Las Vegas

Las Vegas, NV 

G.T. (Gigi) Belanger

Public Health Advisor 

Homeless Programs Branch

Center for Mental Health Services 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Charles H. Bombardier, Ph.D.

Associate Professor 

Department of Rehabilitation Medicine

Harborview Medical Center 

University of Washington School of

Medicine 

Seattle, WA 

Patricia T. Bowman 

Probation Counselor 

Fairfax Alcohol Safety Action Program

Fairfax, VA 

Patricia Allen Bradford, LISW, LMFT,

CTS 

Program Manager 

Health Care for Homeless Veterans 

Columbia, SC 

Kathy Brock

Director 

Polytechnic University Counseling Center

Brooklyn, NY 

Vivian B. Brown, Ph.D.

Chief Executive Officer 

Mental Health and Social Services Centers 

for Innovation in Health 

PROTOTYPES 

Culver City, CA 

293 
 

 

 

 

 

 

 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

Wilma J. Calvert, R.N., Ph.D.

Post-Doctoral Fellow 

Department of Psychiatry 

Washington University School of Medicine

St. Louis, MO 

Jerome F.X. Carroll, Ph.D. 

Consultant in private practice

Chair, Columbia University’s Drugs & 

Society Seminar

Brooklyn, NY 

Steven J. Chen, Ph.D.

Associate Director 

Division of Substance Abuse and Mental 

Health 

Utah Department of Human Services 

Salt Lake City, UT 

Colleen Clark, M.A., Ph.D.

Research Assistant Professor 

Licensed Clinical Psychologist

Triad Women’s Project

University of South Florida

Tampa, FL 

R.T. Codd, III., Ed.S.

Certified Member of the Academy of

Cognitive Therapy 

Director/Owner 

Cognitive–Behavioral Therapy Center of

Western North Carolina 

Asheville, NC 

Carol Coley, M.S.

Senior Program Management Advisor

Division of State and Community 

Assistance 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Carol J. Colleran, CAP, ICADC

Director of Primary Programs 

Center of Recovery for Older Adults 

Hanley-Hazelden Center

West Palm Beach, FL 

Stephanie S. Covington, M.S.W., Ph.D.

Co-Director 

Center for Gender and Justice 

Institute for Relational Development

La Jolla, CA 

David A. Deitch, Ph.D.

Professor of Clinical Psychiatry 

Director, CCARTA 

Department of Clinical Psychiatry 

University of California, San Diego

La Jolla, CA 

Gail D. Dixon, M.A., CAPP 

NIDA Project Manager 

Southern Coast Addiction Technology 

Transfer Center 

Tallahassee, FL 

Jill Shepard Erickson, M.S.W., ACSW

Public Health Advisor 

Child and Family Branch

Center for Mental Health Services 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Phil Erickson 

Substance Abuse Program Manager

Loudoun County Community Services 

Board 

Leesburg, VA 

Kathleen J. Farkas, Ph.D., LISW 

Mandel School of Applied Social Sciences 

Case Western Reserve University 

Cleveland, OH 

294 
 

 

 

 

 

 

 

 

 

 

 

 

Appendix H—Field Reviewers 

Norma B. Finkelstein, M.S.W., Ph.D.

Executive Director 

W.E.L.L. Project

Institute for Health and Recovery 

Cambridge, MA 

Jerry P. Flanzer, D.S.W., LCSW, CAC

Chief 

Services Research Branch 

National Institute on Drug Abuse 

National Institutes of Health 

Bethesda, MD 

Judith Ford, M.A., MFT

Director of Women’s Services 

Community Services and Hospitals 

Connecticut Department of Mental Health

and Addiction Services 

Hartford, CT 

Julian D. Ford, Ph.D.

Associate Professor 

Department of Psychiatry 

University of Connecticut Health Center

Farmington, CT 

Matthew Friedman, M.D., Ph.D.

Professor of Psychiatry and Pharmacology 

Executive Director, National Center for

PTSD 

Dartmouth Medical School 

VA Medical Center 

White River Junction, VT 

John Galea, M.A.

Deputy Director, New York City Relations 

New York State Office of Alcoholism and 

Substance Abuse Services 

New York, NY 

Angela M. Gonzalez, Ph.D., CAPT.,

USPHS 

Scientist Officer 

Special Programs Development BranchRefugee Mental Health Program 

Division of Prevention, Traumatic Stress,

and Special Programs

Center for Mental Health Services 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Maya D. Hennessey 

Women’s Specialist

Supervisor, Quality Assurance, Technical 

Assistance & Training

Office of Special Programs 

Division of Substance Abuse 

Illinois Department of Human Services and

Substance Abuse 

Chicago, IL 

Michael W. Herring, LCSW 

Licensed Clinical Social Worker 

Wayne Psychiatric Associates, P.A.

Goldsboro, NC 

Nancy J. Hirzel

Clinic Director 

Adult Services Division 

Jefferson Addictive Disorders Clinic 

Jefferson Parish Human Services Authority

Metairie, LA 

Robert Holden, M.A.

Program Director 

Partners in Drug Abuse Rehabilitation

Counseling (PIDARC)

Washington, DC 

Kay M. Johnson

Crime Victims Treatment Center - HIV 

Project

St. Luke’s Roosevelt Hospital Center

New York, NY 

295 
 

 

 

 

 

 

 

 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

Kimberly A. Johnson, M.A., NCAC II 

Director 

Augusta Mental Health Complex

Maine Office of Substance Abuse 

Augusta, ME 

Sharon D. Johnson, M.S.W., M.P.E.,

Ph.D. 

Assistant Professor 

Department of Social Work 

University of Missouri-St. Louis

St. Louis, MO 

Lorene Lake, M.A., Ed.D.

Executive Director 

Chrysalis House, Inc.

Crownsville, MD 

Michael S. Levy, Ph.D.

Director of Clinical Treatment Services 

CAB Health and Recovery Services 

Danvers, MA 

T.K. Logan, Ph.D.

Associate Professor 

Center on Drug & Alcohol Research

Department of Behavioral Science 

University of Kentucky 

Lexington, KY 

James J. Manlandro, D.O., FAOAAM, 

FACOFP 

Medical Director 

Family Addiction Treatment Services, Inc.

Somers Point, NJ 

Rozanne Marel, Ph.D.

Head of Epidemiology & Needs 

Assessment 

New York State Office of Alcoholism and 

Substance Abuse Services 

New York, NY 

Pamela Martin, Ph.D.

Director 

Behavioral Health Services Division 

New Mexico Department of Health

Santa Fe, NM 

Ruby J. Martinez, Ph.D., R.N., CS

Assistant Professor 

School of Nursing

University of Colorado Health Sciences 

Center 

Denver, CO 

Sue Martone, M.P.A.

Public Health Advisor 

Office of Disease Prevention and Health 

Promotion 

U.S. Department of Health and Human

Services 

Washington, DC 

Beth Marty, M.S., LPC

Clinical Program Manager

WYSTAR 

Sheridan, WY 

Lisa A. Melchior, Ph.D.

Vice President 

The Measurement Group, LLC 

Culver City, CA 

Candace Merritt 

Social Worker 

Veterans Administration Medical Center 

Denver, CO 

Pamela A. Mumby, C.N.S., F.N.P., M.S.N.

Adult Psychiatric Nurse Practitioner

Substance Abuse Treatment Program 

Veterans Administration Medical Center 

Denver, CO 

Briana S. Nelson-Goff, Ph.D.

Associate Professor 

Family Studies and Human Service 

Kansas State University 

Manhattan, KS 

Sarah Niemeyer

Clinical Director 

Amethyst, Inc.

Columbus, OH 

296 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appendix H—Field Reviewers 

Thomas A. Peltz, M.Ed.

Therapist/Licensed Mental Health

Counselor 

Certified Addiction Specialist

Private Practice 

Beverly Farms, MA 

Karen Pressman, M.S.W., CADAC, 

LACDI 

Director, Planning and Development

Bureau of Substance Abuse Services 

Massachusetts Department of Public Health

Boston, MA 

Melissa V. Rael, USPHS

Senior Program Management Officer 

Co-Occurring and Homeless Branch

Division of State and Community 

Assistance 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Lawrence D. Rickards, Ph.D.

Public Health Advisor 

Center for Mental Health Services 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Alice F. Roeling

OAD Inpatient Facility Manager

The Springs of Recovery Adolescent

Program

Greenwall Springs, LA 

James Rowan, M.A. 

Program Manager 

Case Management and Offender Services 

Arapahoe House, Inc.

Thornton, CO 

JoAnn Y. Sacks, Ph.D. 

Deputy Director, CIRP

National Development and Research

Institutes, Inc.

New York, NY 

Darren C. Skinner, M.S.W., Ph.D., LSW 

Division Director 

Co-Occurring Program

Gaudenzia, Inc.

Philadelphia, PA 

Mickey J.W. Smith, M.S.W.

Senior Policy Associate, Behavioral Health

Program, Policy & Practice Unit

Division of Professional Development &

Advocacy

National Association of Social Workers 

Washington, DC 

Richard T. Suchinsky, M.D.

Associate Chief for Addictive Disorders and 

Psychiatric Rehabilitation

Mental Health and Behavioral Sciences 

Services 

Department of Veterans Affairs 

Washington, DC 

Wilbur Woodis, M.A.

Management Analyst

Office of Clinical and Preventive Services 

Division of Behavioral Health 

Indian Health Service 

Office of Public Health 

U.S. Department of Health and Human

Services 

Rockville, MD 

297 

 

Charles H. Bombardier, Ph.D. 

Associate Professor 

Department of Rehabilitation Medicine

Harborview Medical Center 

University of Washington School of

Medicine 

Seattle, WA

Disability Workgroup 

Carol S. D’Agostino, CSW, CASAC

Director 

Geriatric Addictions Program

LIFESPAN of Greater Rochester, Inc.

Rochester, NY

Aging Workgroup 

Thomas L. Geraty, M.S.W., Ph.D.,

LICSW 

Private Practice 

Jamaica Plain, MA

LGBT Workgroup 

Wayne Lee Mitchell, M.D. 

Indian Health Service 

Phoenix, AZ

Aging Workgroup 

Ann S. Yabusaki, M.Ed., M.A., Ph.D. 

Substance Abuse Director 

Psychologist 

Substance Abuse Programs and Training

Coalition for a Drug-Free Hawaii 

Kaneohe, HI 

Asian and Pacific Islanders Workgroup and

Aging Workgroup 

Appendix I: Cultural Competency 

and Diversity Network 

Participants 

299 
 

 

Trauma-Informed Care in Behavioral Health Services 

Appendix J: Acknowledgments 

Numerous people contributed to the development of this Treatment Improvement Protocol 

(TIP), including the TIP Consensus Panel (p. vii), the Knowledge Application Program (KAP)

Expert Panel and Federal Government Participants (p. ix), SAMHSA Resource Panel (see 

Appendix G), TIP Field Reviewers (Appendix H), and the KAP Cultural Competency and

Diversity Network participants (Appendix I). 

This publication was produced under KAP, a Joint Venture of The CDM Group, Inc. (CDM),

and JBS International, Inc. ( JBS), under contract numbers 270-99-7072, 270-04-7049, and 270­

09-0307 for the Substance Abuse and Mental Health Services Administration, Center for

Substance Abuse Treatment. 

CDM KAP personnel included Rose M. Urban, M.S.W., J.D., LCSW, LCAS, KAP Executive 

Deputy Project Director; Jessica L. Culotta, M.A., KAP Managing Project Co-Director; Susan

Kimner, former Managing Project Co-Director; Elizabeth Marsh, former KAP Deputy Project

Director; Claudia Blackburn, M.S., Psy.D., Expert Content Director; Sheldon Weinberg, KAP 

Senior Researcher/Applied Psychologist; Bruce Carruth, Ph.D., Expert Content Director;

Raquel Witkin, M.S., former Deputy Project Manager; Janet G. Humphrey, M.A., former

Editor/Writer; Virgie D. Paul, M.L.S., Librarian; Angela T. Fiastro, KAP Junior Editor; Sonja

Easley and Elizabeth Plevyak, former Editorial Assistants; and Elizabeth Pratt, Ph.D., Carol 

Schober, Psy.D., M.S.N., and Patricia A. Burke, M.S.W., LCSW, BCD, C-CATODSW, CCS, 

contributing authors. Special thanks to Stephanie Perry, M.D., for providing a content review of

the TIP, and to John P. Allen, Ph.D., for writing draft material and contributing information on 

combat stress. 

300 
. 

 

 

 

 

 

 

 

 

 

Index 

A 

AA (Alcoholics Anonymous), 178, 188, 190


ACE (adverse childhood experiences), 8, 42–


43, 47, 64, 65


acute stress disorder (ASD), 37, 61, 75, 77–80,
 

78–79, 80, 141
 

adaptation to traumatic experience, symptoms 

and behaviors as, 13–14

Addiction and Trauma Recovery Integrated 


Model (ATRIUM), 148


Addressing Suicidal Thoughts and Behaviors in


Substance Abuse Treatment (Treatment Improvement Protocol [TIP] 50), 72, 94, 101,
 

134
 

ADHD (attention deficit hyperactivity disorder), misdiagnosed, 102


administration and administrators. See also
 

organizational investment in trauma-


informed services; trauma-informed workforce
 

avoidance of trauma issues, dangers of, 18
 

demonstrating commitment to TIC, 29


information for, xv, xvi, 4


NCTIC self-assessment package, 29
 

quality improvement steps, 164
 

staff reactions to implementation of TIC,


managing, 162
 

strengths-focused perspective, encouraging, 28
 

training staff, 181
 

adolescents and trauma. See children and
 

trauma
 

adverse childhood experiences (ACEs), 8, 42–


43, 47, 64, 65


Adverse Childhood Experiences Study, 8, 42,


75, 94


Afghanistan War, 8


African Americans, 40, 56


age, as factor in experience of trauma, 56, 74


alcohol abuse. See substance abuse 

Alcohol and Other Drug Screening of Hospitalized Trauma Patients (TIP 16), 38


Alcoholics Anonymous (AA), 178, 188, 190
 

American Red Cross, 139
 

amnesia and memory recovery, 129


antisocial personality disorder, misdiagnosed,


102
 

anxiety/mood disorders, misdiagnosed, 102


ASD (acute stress disorder), 37, 61, 75, 77–80,
 

78–79, 80, 141
 

assessment. See screening and assessment

ataques de nervios, 103


ATRIUM (Addiction and Trauma Recovery


Integrated Model), 148


attention deficit hyperactivity disorder


(ADHD), misdiagnosed, 102


avoidance behaviors of clients/consumers, 73–


74
 

balance, teaching, 120


clinician/administrator handling of trauma and, 18
 

as diagnostic criterion, 78
 

prior psychological trauma, clients with


history of, 54–55
 

301 
 

 

 

 

 

 

 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

recovery from trauma as goal and, 20–21,


31
 

as screening and assessment obstacle, 99–


100
 

somatization and, 64


avoidance behaviors of providers and administrators, 18, 100


awareness of trauma, promoting, 12–13
 

B
 

balance, 120, 120–121
 

Bangladesh, disaster subculture in, 132


basic necessities for immediate trauma victims,


140
 

Beck Depression Inventory II and Beck Anxiety Inventory, 101, 105
 

behavioral health, defined, xvi


Behavioral Health Services for People Who Are


Homeless (TIP 55-R), 57


behavioral health services providers and counselors. See also clinical supervisors and clinical supervision; intervention, prevention,


and treatment; organizational investment in


trauma-informed services; trauma-


informed workforce; trauma-specific treatment
 

avoidance behaviors of, 18, 100
 

biology of trauma and, 65
 

collaboration between, 21


collaboration with clients, 23–24


CSR, understanding, 77
 

delayed trauma responses, dealing with,


84
 

first responders, group trauma experienced by, 38–39


flashbacks and triggers, managing, 68
 

gender of, 134–135


impact of personal trauma on, 20
 

importance and usefulness of trauma-


informed practice for, 8, 9
 

individual trauma, working with clients


who have experienced, 37
 

information for, xv, 4


NCTIC guidelines for, 11
 

retraumatization, avoiding, 45, 114
 

screening and assessment advice for, 86,


94
 

screening and assessment avoided by, 100
 

self-care, promoting, 29–31, 31, 205–211,
 

206–210
 

self-injurious clients, working with, 72
 

strengths-focused perspective, encouraging, 28
 

STS experienced by. See secondary traumatic stress
 

suicide of clients, provider response to, 20,


200, 207
 

behavioral reactions to trauma, 70–74, 71, 72
 

bereavement and grief, 125
 

Beyond Trauma program, 149


biofeedback, 143
 

biology of trauma, 65
 

bisexuality and trauma, 56–57


blame, assigning, 49–50, 50
 

borderline personality disorder, misdiagnosed,


102
 

boundaries and boundary-crossing, 187–190,


188, 189, 190


breathing retraining and breathing exercises,

143, 144


burnout, 195, 196, 199, 200, 202, 203, 204
 

C 

California, repeated natural disasters in, 47


Cambodia, Khmer Rouge regime in, 40


captivity and trauma, 43
 

cascading trauma, 47


case studies
 

ASD (Sheila), 80
 

boundary confusion and STS (Denise),


190
 

clinical supervision (Arlene), 192
 

co-occurring PTSD and substance abuse 


(Maria), 88
 

control, choice, and autonomy of clients,


supporting (Mina), 23
 

core assumptions and beliefs, disruption


of (Sonja), 53–54
 

empowerment (Abby), 124
 

hyperarousal (Kimi), 65
 

302 
 

 

 

 

 

 

 

 

 

Index 

individual and contextual responses to


trauma (Marisol), 17
 

intentionality of cause of trauma (Frank),


50
 

losses associated with trauma (Rasheed),

48
 

natural or human-caused trauma (Quecreek Mine flood and Greensburg tornado), 36
 

normalization of symptoms (Hector), 117
 

numbing (Sadhana), 64
 

provider's personal trauma ( Jane), 20
 

psychoeducation (Linda), 116
 

PTSD (Michael), 81
 

reenactments (Marco), 71
 

safe environment, creating (Mike), 19,


19–20
 

self-care by counselors (Carla), 206
 

self-examination of stressful experiences,


46
 

sleep disturbances (Selena), 122
 

STS (Denise; Gui), 190, 200


subclinical trauma-related symptoms 


(Frank), 76
 

training in TIC (Larry), 178
 

causes of trauma, need to designate, 49–50, 50
 

CBT (cognitive behavioral therapies), 142,


145, 148, 149


Center for Mental Health Services (CMHS),


170
 

Chernobyl (1986), 40


children and trauma
 

age, as factor in experience of trauma, 56,


74
 

developmental traumas, 42, 42–43, 74, 75
 

emotional dysregulation, 61


families, impact of trauma on, 12


homelessness, 57


individual nature of response to trauma,


15
 

interpersonal and social relationships, 74


IPV, 41, 42
 

neglect, 42
 

repeated or sustained trauma, 46
 

Screening and Assessing Adolescents for Substance Use Disorders (TIP 31), 102


self-harming behaviors, 70, 71


specialized interventions required for, 5


Substance Abuse Treatment for Persons With
 

Child Abuse and Neglect Issues (TIP 36),
 

5, 43


CISD (critical incident stress debriefing),


141–142, 200–204


clients/consumers. See also avoidance behaviors
 

of clients/consumers; impact of trauma


boundaries and boundary-crossing, 187–


190, 188, 189, 190


collaboration between providers and, 23–


24
 

confidentiality, right to, 184, 185
 

control, choice, and autonomy, supporting,


21–22, 23, 97
 

defined, xvi


definition of trauma survivor, xix


engagement in treatment, 127
 

familiarity with trauma-informed services, 24–25


importance of engaging, 9


individual experience of trauma, 7, 14–17,


15, 16, 17


in screening and assessment setting, 96–


99, 98
 

Clinical Supervision and Professional Development of the Substance Abuse Counselor (TIP 


52), 188, 191


clinical supervisors and clinical supervision,


191–193
 

boundary confusion, recognizing, 188
 

case study (Arlene), 192
 

EBT and, 191
 

ethical responsibilities, 185


psychometric measures, use of, 204


psychotherapy versus supervision, 205
 

religion and spirituality, 207
 

screening procedures, 93


self-care and, 207, 209
 

staff training and, 181
 

STS and, 194, 195, 198, 204, 205
 

303 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

CMHS (Center for Mental Health Services),


170
 

co-occurring disorders, 85–89


defined, xvii, 85
 

integrated models designed to treat trauma and, 147–150

IPV and substance abuse, 41–42

mental disorders and trauma, 4, 10, 46–

47, 55, 86, 102


National Comorbidity Studies, 8, 42


physical disorders and trauma, 4, 64


physical injury and substance abuse, 38–


39
 

prevalence of trauma and, 8
 

refugee trauma and, 44


screening and assessment process and,


101–102
 

sleep disturbances, PTSD, and substance 


abuse, 88–89


substance abuse and trauma, 4, 10, 46–47,


73, 86–89, 87, 88, 89, 102
 

Substance Abuse Treatment for Persons With
 

Co-Occurring Disorders (TIP 42), 55,


72, 86, 101, 102, 103, 148, 182


Women, Co-Occurring Disorders and 


Violence Study, 8, 148, 152, 153


cognitive behavioral therapies (CBT), 142,


145, 148, 149


cognitive processing therapy (CPT), 142–143,


145
 

cognitive reactions to trauma, 66, 66–70, 67,
 

68, 69, 102
 

cognitive triad of traumatic stress, 67
 

collaboration
 

between agencies and providers, 21


between clients and providers, 23–24


Combat Exposure Scale, 106


combat stress reaction (CSR), 39, 75–77, 77
 

community/organizational factors, 15, 16
 

community trauma, 36, 39, 39–40
 

competencies of trauma-informed workforce,


181–182, 183–184, 191


complex trauma and complex traumatic stress,


xvii, 85
 

Composite International Diagnostic Interview, 84


Concurrent Prolonged Exposure (COPE), 149


Concurrent Treatment of PTSD and Cocaine
 

Dependence (CTPCD), 149


confidentiality, client right to, 184, 185
 

consumers. See clients/consumers


contextual models for individual experience of


trauma, 7, 14–17, 15, 16, 17


continuing education for trauma-informed


workforce, 180–81


control, choice, and autonomy of clients, supporting, 21–22, 23, 97
 

COPE (Concurrent Prolonged Exposure), 149


core assumptions and beliefs, disruption of,


51–52, 53–54, 63, 67
 

countertransference, 150, 184, 191, 196, 198
 

couples therapy, 153


CPT (cognitive processing therapy), 142–43,


145
 

critical incident stress debriefing (CISD),


141–42, 200–204


CSR (combat stress reaction), 39, 75–77, 77
 

CTPCD (Concurrent Treatment of PTSD


and Cocaine Dependence), 149


cultural issues
 

community trauma, 36, 39, 39–40
 

definition of cultural responsiveness/cultural competence, xvii, 132
 

historical trauma, 40


Improving Cultural Competence (planned


TIP), 27, 52, 104, 132, 164, 168


meaning attached to trauma, 52


for organizational investment in trauma-


informed services, 167–69


PTSD, 84, 85, 133
 

race and ethnicity as factor in experience


of trauma, 56
 

reestablishment of family, cultural, and


communities ties post-trauma, 52
 

resilience and, 56
 

in screening and assessment process, 96–


97, 100–101, 103, 103–104
 

sociocultural approach to trauma, 14, 15,


16, 17, 26, 26–27, 27
 

304 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Index 

sociocultural factors in experience of


trauma, 15, 16, 52, 55–57


treatment services sensitive to, 131–133,


132, 133, 134
 

D 

Davidson Trauma Scale (DTS), 108


DBT (dialectical behavior therapy), 142, 145,


146, 153


delayed trauma responses, 83–84, 84
 

delusions, 66
 

Department of Health and Human Services 


(HHS), xi, xiii, 132


Department of Housing and Urban Development (HUD), 57


Department of Veterans Affairs (VA) National Center on PTSD, 115


depersonalization, 69


derealization, 69


desensitization, 120, 144


destabilization, managing, 126
 

developmental factors in experience of trauma,


15, 16


developmental traumas, 42, 42–43, 74, 75
 

diagnosis


criteria for, 78
 

misdiagnosis and underdiagnosis, 102–


103
 

PTSD, 81–83, 82–83, 85


Diagnostic and Statistical Manual of Mental


Disorders (DSM) V and other various editions, xix, 16, 59, 75, 78–79, 82–83, 84, 85,


101, 104


dialectical behavior therapy (DBT), 142, 145,


146, 153


DID (dissociative identity disorder), 69, 71


direct versus indirect experience of trauma,

50–51 

disaster plans, 166–167

disaster response agencies, 139
 

disaster subcultures, 132


Disaster Technical Assistance Center Web
 

site, 139
 

dissociation, 69, 69–70, 78, 79, 102


dissociative identity disorder (DID), 69, 71
 

domestic violence. See intimate partner violence 

drug abuse. See substance abuse 

drug therapy, 154–155

DSM (Diagnostic and Statistical Manual of

Mental Disorders) V and other various editions, xix, 16, 59, 75, 78–79, 82–83, 84, 85,
 

101, 104


DTS (Davidson Trauma Scale), 108


dual relationships with clients, 189
 

dysregulation, emotional, 61–63
 

E
 

EBP (evidence-based practices), xvii, 139, 160,


169, 191
 

EMDR (eye movement desensitization and


reprocessing), 144, 144–145
 

EMDR Institute, 145


emergency response agencies, 139
 

emergency rooms (ERs), treatment of trauma


in, 37


emerging or promising practices, xvii, 153–155


emotional distress, somatic ailments masking,


64
 

emotional reactions to trauma, 61–64, 62, 64


emotional responses to screening and assessment process, 97–99


empowerment, 124, 124–125
 

engagement of client in treatment, 127
 

ERs (emergency rooms), treatment of trauma


in, 37


ethics
 

of self-care, 210
 

of treating traumatized clients, 182, 185–
 

189, 185–190, 190
 

ethnicity and race as factor in experience of


trauma, 56
 

evaluations and feedback
 

organizational investment in trauma-


informed services, 170–171


screening and assessment, 99


evidence-based practices (EBP), xvii, 139, 160,


169, 191
 

existential reactions to trauma, 51–52, 53–54,
 

63
 

305 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

expected versus unexpected trauma, 49


exposure therapy, 143–144

Exxon Valdez oil spill (1989), 39
 

eye movement desensitization and reprocessing (EMDR), 144, 144–145 

F
 

families and trauma, 12, 52, 74, 97, 133
 

family therapy, 153


Federal Emergency Management Agency 


(FEMA), 139
 

feedback and evaluations
 

organizational investment in trauma-


informed services, 170–171


screening and assessment, 99


feeling different from others, 67–68


FEMA (Federal Emergency Management


Agency), 139
 

first aid, psychological, 140–141, 141
 

first responders, group trauma experienced by,


38–39
 

flashbacks, 68, 68–69
 

forgiveness, 129–131


future, changes in beliefs about, 60, 67
 

G 

gender. See also women and trauma
 

as factor in experience of trauma, 55


prevalence of ASD and PTSD, 79–80, 89
 

of provider, 134–135


substance abuse and, 135


treatment of trauma and, 133–135


gender identity and trauma, 56–57, 135


Green Cross Academy of Traumatology, 210
 

Greensburg tornado (Kansas, 2007), 36
 

grief and bereavement, 125
 

grounding techniques, 98
 

group trauma, 36, 38–39

A Guide to Substance Abuse Services for Primary


Care Clinicians (TIP 24), 102
 

guilt, 66
 

H
 

Haitian earthquake (2010), 40


hallucinations, 66
 

Health and Human Services Department


(HHS), xi, xiii, 132


healthcare administrators. See administration 

and administrators 

healthcare providers. See behavioral health 

services providers and counselors

HHS (Department of Health and Human


Services), xi, xiii, 132


hiring and recruitment of trauma-informed 


workforce, 174–176, 175
 

historical trauma, 40, 51, 52, 133


history of trauma, establishing, 105, 106, 107,


108
 

Holocaust, 40


homelessness and trauma, 57


homosexuality and trauma, 56–57, 135


Housing and Urban Development Department (HUD), 57


human-caused versus natural trauma, 34–36,


35, 36


Hurricane Katrina (2005), 40–41, 49, 51, 99


Hurricane Rita (2005), 51


Hutu people, Rwanda, 40


hyperarousal, 65, 65–66, 78
 

I
 

ICD (International Statistical Classification of


Diseases and Related Health Problems), 84,


85
 

idealization, 66
 

impact of trauma, 59–89. See also avoidance 

behaviors of clients/consumers; cooccurring disorders; posttraumatic stress 

disorder 

adaptation to traumatic experience, symptoms 

and behaviors as, 13–14

ASD, 37, 61, 75, 77–80, 78–79, 80


behavioral reactions, 70–74, 71, 72


clients' trauma affecting behavioral health


services providers and counselors, 13


cognitive reactions, 66, 66–70, 67, 68, 69, 102
 

complex trauma and complex traumatic stress,


xvii, 85


core assumptions and beliefs, disruption of,


51–52, 53–54, 63, 67
 

306 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Index 

definition of trauma survivor, xix

developmental effects, 74, 75 

emotional reactions, 61–64, 62, 64 

on families, 12

future, changes in beliefs about, 60, 67

individual experience of, 7, 14–17, 15, 16, 

17 

individual nature of, 7, 14–17, 15, 16, 17, 

52–55 

isolated versus pervasive, 49

losses associated with trauma, 47–48, 58 

numbing, 63–64, 64 

personal trauma affecting behavioral

health services providers and counselors, 20 

physical reactions, 62, 64–66, 65 

resilient responses, 70 

sequence and types of trauma reactions,

60–61, 62–63 

social and interpersonal relationships, 74

socio-ecological model for, 14–16, 15, 16 

sociocultural factors in, 15, 16, 52 

STS, 30 

subclinical symptoms, 59, 61, 75–77, 76 

temporary versus long-term, 7

in TIC framework, 60 

Improving Cultural Competence (planned TIP), 

27, 52, 104, 132, 164, 168

indirect versus direct experience of trauma,

50–51 

individual interpretation of trauma, 51

individual nature of experience of trauma, 7, 

14–17, 15, 16, 17, 52–55 

individual trauma (as type), 36–38, 37 

institutional trauma-informed framework. See 

organizational investment in traumainformed services 

Integrated CBT, 149

integrated models designed to treat trauma

and co-occurring disorders, 147–150

intentionality of cause of trauma, 49–50, 50 

International Society for Traumatic Stress 

Studies, 180 

International Statistical Classification of Diseases and Related Health Problems (ICD),

84, 85 

interpersonal and social relationships, trauma

affecting, 74

interpersonal factors, 15, 16

interpersonal trauma, 41–43, 42 

interpretation of trauma, 51

intervention, prevention, and treatment, 11–

32, 111–135. See also trauma-specific treatment 

adaptation to traumatic experience, recognizing symptoms and behaviors as,

13–14 

ASD, 80


assessments throughout treatment period,


95 

awareness and understanding of trauma,

promoting, 12–13

balance, teaching, 120, 120–121 

co-occurring PTSD and substance abuse,

87–88 

collaborative relationships with clients,

creating, 23–24

connections between trauma and health 

issues, establishing, 119, 119–120 

control, choice, and autonomy of clients,

supporting, 21–22, 23, 97 

cultural issues, 131–133, 132, 133, 134 

desensitization, 120, 144

empowerment, supporting, 124, 124–125 

engagement of client in, 127 

familiarization of client with traumainformed services, 24–25

forgiveness, 129–131

gender issues, 133–135

goals and objectives of, 111

grief and bereavement, acknowledging,

125 

in immediate aftermath of trauma, 132

individual nature of trauma experience,

understanding, 14–17, 15, 16, 17

legal issues arising during, 129, 131 

length of, 128–129

memory issues, 129, 130 

307 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

NCTIC guidelines, 11
 

normalization of symptoms, 25, 117
 

organizational and administrative commitment to TIC, demonstrating, 29


peer support, providing, 116, 116–117,
 

117
 

psychoeducation, providing, 114–116,

115, 116


recovery, as goal of, 20–21


recovery, possibility of, 31–32


referrals for trauma-specific services, 135


resilience, building, 121
 

retraumatization, minimizing risks of, 17–


19, 18, 113–114, 114
 

safe environment, creating, 19, 19–20,
 

112–113, 113
 

secondary trauma, addressing, 29–31, 30,


31
 

sexual orientation and, 135


sleep disturbances, 121–122, 122
 

stability, monitoring and facilitating, 126
 

strengths-focused perspective, encouraging, 27–28, 28
 

in TIC framework, 112
 

timing and pacing of, 127–128, 128
 

trauma-resistant skills, fostering, 28–29


triggers, identifying and managing, 118,


118–119, 119
 

trust, building, 123
 

universal routine trauma screenings, 25–


26, 86, 91, 167


intimate partner violence (IPV)


ATRIUM, 148


children and, 41, 42
 

as interpersonal trauma, 41–42


as repeated or sustained trauma, 46


substance abuse and, 41–42


Substance Abuse Treatment and Domestic
 

Violence (TIP 25), 5, 42


Women, Co-Occurring Disorders and 


Violence Study, 8
 

Intimate Partner Violence Screening Tool,


106, 108
 

intrusive thoughts and memories, 66
 

IPV. See intimate partner violence
 

Iraq War, 8


isolated versus pervasive effects of trauma, 49


Israel, disaster subculture in, 132
 

J
 

Japanese trauma concepts, 103
 

Jews, historical trauma of, 40
 

K
 

Khmer Rouge, Cambodia, 40
 

L 

language issues in screening and assessment

process, 96–97, 100–101


Latin American trauma concepts, 103
 

"leaves floating in a stream" mindfulness practice, 154
 

legal issues arising during treatment, 129, 131
 

lesbians and trauma, 56–57, 135


LGBT clients and trauma, 56–57, 135


linguistic barriers, 96–97


losses associated with trauma, 47–48, 58
 

M 

Managing Depressive Symptoms in Substance


Abuse Clients During Early Recovery (TIP 


48), 101


mass trauma, 36, 38, 40–41


meaning attached to trauma


core assumptions and beliefs, disruption


of, 51–52, 53–54, 63, 67
 

cultural meaning, 52


psychological meaning, 51


medications, 154–155 

memory


ATRIUM, 148


intrusive thoughts and memories, 66
 

managing traumatic memories, 130
 

TIR approach, 147


of trauma, 129
 

traumatic memory recovery, 129


mental disorders. See also posttraumatic stress 

disorder 

ASD, 37, 61, 75, 77–80, 78–79, 80
 

CMHS, 170
 

308 
 

 

 

 

 

 

 

 

 

 

 

Index 

co-occurrence with trauma, 4, 10, 46–47,

55, 86, 102


CSR, 39, 75–77, 77
 

DID, 69, 71


families of trauma members and, 12


importance of addressing traumatic background to, 21


individual history of, 55


integrated models designed to treat trauma and co-occurring disorders, 147–


150
 

Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery (TIP 48), 101


misdiagnosis of, 102–103

program curriculum for seclusion-free 

and restraint-free services, 166
 

PTSD and, 10, 55, 86


refugees experiencing, 44


screening and assessment process and,


101
 

Mental Health Screening Form-III, 101, 105
 

military personnel. See also posttraumatic stress 


disorder
 

CSR, 39, 75–77, 77
 

group trauma experience by, 39


isolated versus pervasive effects of trauma


on, 49


prior mental disorders, 55


Reintegration-Related Behavioral Health

Issues in Veterans and Military Families

(planned TIP), 5, 38, 47, 76


repeated or sustained trauma experienced


by, 46, 47


training to reduce traumatic impact, 49


mindfulness interventions, 153–154, 154
 

Minneapolis bridge collapse, 35


misdiagnosis, 102–103


mission statements, 162, 162–163
 

Mississippi Riber floods, 1993, 140
 

mood/anxiety disorders, misdiagnosed, 102


motivational interviewing, 180
 

N
 

narrative therapy, 145
 

National Center for PTSD, 106, 108, 138–139


National Center for Trauma-Informed Care 


(NCTIC), 11, 29, 175
 

National Center on PTSD, Department of


Veterans Affairs (VA), 115


National Child Traumatic Stress Network,


xvii, 56, 75, 141
 

National Comorbidity Studies, 8, 42


National Epidemiologic Survey on Alcohol 


and Related Conditions, 8


National Institutes of Health (NIH), 84


National Registry of Evidence-Based Programs and Practices (NREPP), 139, 144,


145, 147, 148, 150, 152, 169
 

Native Americans, 39, 40, 52, 84, 133
 

natural versus human-caused trauma, 34–36,


35, 36


NCTIC (National Center for TraumaInformed Care), 11, 29, 175
 

neglect of children, 42
 

nervios, 103


neurobiological development and early childhood trauma, 75
 

NIH (National Institutes of Health), 84


normalization of symptoms, 25, 117
 

NREPP (National Registry of Evidence-


Based Programs and Practices), 139, 144,


145, 147, 148, 150, 152, 169
 

numbing, 63–64, 64
 

O
 

OBSERVATIONS coping strategy, 118, 119


Oklahoma City bombing (1995), 73, 130–131,


210
 

organizational/community factors, 15, 16


organizational investment in trauma-informed


services, 159–171


advantages of, 9


assigning key staff members to facilitate,


163
 

culturally responsive principles, applying,


167–169
 

defined, 161
 

demonstrating commitment to, 29, 161–


162
 

309 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

disaster plan, developing, 166–167


EBP, use of, 160, 169


feedback and evaluations, 170–171


implementation plan, developing, 164–


165, 165


oversight committees, 163–164


peer-support environment, importance of,


169–170, 170
 

policies and procedures, developing, 166


quality improvement steps, 164
 

retraumatization, avoiding, 166


safe environment, creating, 171
 

self-assessments, 164


staff reactions to implementation, managing, 162
 

stages of, 160–161


strategic planning, use of TIC principles 


in, 162


in TIC framework, 160
 

universal routine trauma screenings, 167


vision, mission, and value statements, 162,


162–163 

oversight committees, 163–164 

P
 

parallel, single, or sequential trauma-specific 


treatment, 142
 

past-focused trauma-specific treatment, 137–


138
 

PC-PTSD (Primary Care PTSD) Screen, 108
 

peer support, 116, 116–117, 117, 169–170,
 

170
 

period of time in history as factor, 15, 16
 

personal space, 96


pervasive versus isolated effects of trauma, 49


pharmacological therapy, 154–155


physical disorders


biology of trauma, 65
 

co-occurrence with trauma, 4, 64


hyperarousal, 65, 65–66
 

as impact of trauma, 62, 64–66, 65
 

neurobiological development and early 


childhood trauma, 75
 

sleep disturbances, 66


somatic complaints, 64
 

physical injury as cause of trauma, 37, 37–38 

PILOTS database, National Center for

PTSD, 138–139


political terror and war, 43, 43–44, 44
 

post-trauma disruption, 51


posttraumatic stress disorder (PTSD), 80–85.


See also trauma-specific treatment

ASD and, 79–80

biology of trauma and, 65


case study (Michael), 81
 

childhood abuse leading to, 43


complex trauma and complex traumatic

stress, 85


CSR and, 76


CTPCD and COPE, 149


culture and, 84, 85, 133
 

delayed onset of, 83–84, 84
 

families and trauma, 12


gender and, 55, 133


homelessness and, 57


hyperarousal, 65, 65–66 

from individual trauma, 36, 37


mental disorders and, 10, 55, 86


misdiagnosis and underdiagnosis, 102–

103
 

physical disorders as symptomatic of, 64,


65
 

from physical injuries, 37
 

refugees suffering, 44


screening and assessment, 95, 104, 105,


108, 108–110, 109
 

sleep disturbances, 88–89

somatic disorders, 64


STS compared, 193, 199


substance abuse and, 10, 73, 83, 87, 87–
 

89, 88, 89, 95, 101, 102
 

Substance Dependence PTSD Therapy,

150
 

subthreshold symptoms, 59, 61, 75–77


susceptibility to, 81, 87


symptoms and diagnosis, 81–83, 82–83, 

85
 

powerlessness, 12-Step concept of, 179
 

pregnant women and trauma, 15


prescription drug therapy, 154–155
 

310 
 

 

 

 

 

 

 

 

 

 

 

Index 

present-focused trauma-specific treatment,

137–138 

prevention. See intervention, prevention, and 

treatment
 

Primary Care PTSD (PC-PTSD) Screen, 108
 

prior mental disorder, 55


prior psychological trauma, 54–55


promising practices, xvii, 153–155


ProQOL Scale, 199–200, 201, 202, 203, 204
 

providers. See behavioral health services providers and counselors
 

psychoeducation, 114–116, 115, 116


psychological first aid, 140–141, 141
 

psychological meaning attached to trauma, 51


psychotherapy versus clinical supervision, 205
 

PTSD. See posttraumatic stress disorder


PTSD Checklist, 108–110, 109
 

Q


quality improvement steps, 164
 

Quecreek Mine flood (Pennsylvania, 2002), 36
 

R
 

race and ethnicity as factor in experience of


trauma, 56
 

recovery


defined, xviii, 31


Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery (TIP 48), 101


possibility of, 31–32


as primary goal of TIC, 20–21


responsibility for, 50


STS in counselors in, 195
 

recruitment and hiring of trauma-informed 

workforce, 174–176, 175
 

reenactments, 70, 71
 

referrals for trauma-specific services, 135


refugees, 43–44, 44
 

Reintegration-Related Behavioral Health Issues 


in Veterans and Military Families (planned 

TIP), 5, 38, 47, 76


relaxation training, 143
 

religion and spirituality, 51–52, 84, 207
 

repeated, sustained, or single trauma, 46–47
 

resilience
 

defined, xviii


individual history of, 55


mass trauma and, 41


race, ethnicity, and culture affecting, 56
 

reestablishment of family, cultural, and


communities ties post-trauma, 52
 

as response to trauma, 70
 

screening and assessment for, 110
 

strengths-focused perspective, encouraging, 27–28, 28
 

trauma-resistant skills, fostering, 28–29


treatments aimed at building, 121
 

retention and turnover of trauma-informed 

workforce, 176, 176–177 

retraumatization
 

advantages of TIC for reducing risk of, 9


avoidance of trauma issues by providers 


leading to, 18
 

awareness and understanding of trauma 


as means of avoiding, 12


defined, xviii


mass trauma and, 40–41


minimizing risks of, 17–19, 18
 

organizational investment in trauma-


informed services to avoid, 166


provider techniques for avoiding, 45
 

safe environment, establishing, 113


as system-oriented traumatic experience,


45–46
 

as treatment goal, 17–19, 18, 113–114,
 

114
 

risk and protective factors model for STS,


194–197
 

Rwanda, genocide in, 40
 

S
 

safe environment, creating, 19, 19–20, 96,
 

112–113, 113, 171, 180, 189


safety, affect modulation, grieving, and emancipation (SAGE), 171
 

SAMHSA. See Substance Abuse and Mental 


Health Services Administration
 

sanctuary model, 171
 

311 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

Schedules for Clinical Assessment in Neuropsychiatry, 84


Screening and Assessing Adolescents for Substance


Use Disorders (TIP 31), 102


screening and assessment, 91–110

advantages of TIC for purposes of, 9


advice for behavioral care providers on, 94
 

Alcohol and Other Drug Screening of Hospitalized Trauma Patients (TIP 16), 38
 

avoided by providers, 100
 

co-occurring disorders, 101–102

concept of assessment, 93–94

concept of screening, 92–93

cultural issues in, 96–97, 100–101, 103,


103–104 

emotional responses, dealing with, 97–99

expectations, clarifying, 96


feedback on, 99


grounding techniques, 98
 

history of trauma, establishing, 105, 106,


107, 108


instruments, choosing, 104, 104–106, 105
 

interviews versus paper-and-pencil selfassessments, 94, 97–98 

language issues, 96–97, 100–101

legal implications of, 99


misdiagnosis and underdiagnosis, 102–

103
 

obstacles and challenges, 99–103, 100,


101
 

physical and emotional setting for, 95–99,

98
 

for PTSD, 95, 104, 105, 108, 108–110,
 

109
 

for resilience, 110
 

Simple Screening Instruments for Outreach

for Alcohol and Other Drug Abuse and

Infectious Diseases (TIP 11), 102


of substance abusers, 95


for suicidality, 93, 94, 101, 110
 

in TIC framework, 92
 

timing of, 94–95

training and tools, 86
 

for trauma-related symptoms and disorders, 106–110 

treatment, ongoing assessments during,

95
 

universal trauma screening, 25–26, 86, 91,


167
 

secondary traumatic stress (STS), 193–205


awareness of, 13


boundary confusion and, 190
 

burnout, 195, 196, 199, 200, 202, 203,
 

204
 

case studies (Denise; Gui), 190, 200
 

CISD, 200–204


clinical supervisors and, 194, 195, 198,


204, 205


defined, xviii, 194
 

direct versus indirect experience of trauma, 50–51


in families, 12


impact of, 30
 

interpersonal and social relationships affected by trauma, 74


military personnel experiencing, 39


prevalence of, 193–194


prevention, 197–198, 198
 

ProQOL Scale, 199–200, 201, 202, 203,
 

204
 

PTSD compared, 193, 199


recovery, counselors in, 195
 

risk and protective factors model of understanding, 194–197


in screening and assessment, 96


signs of, 199
 

socio-ecological model of, 29–31, 31
 

staff training in, 181
 

trauma histories, listening to, 96


treatment, 29–31, 31, 200–205
 

Seeking Safety treatment model, 149–150, 180
 

S.E.L.F., 115–116


self-assessments, organizational, 164


self-care by providers, 29–31, 31, 205–211,
 

206–210
 

self-examination of stressful experiences, 46
 

self-harming and self-destructive behavior,


70–73, 72
 

self-image, changes in, 13, 24, 43, 63
 

self-medication, 21, 63, 73, 87
 

312 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Index 

September 11, 2001, 8, 46, 49, 70, 73, 140


sequential, single, or parallel trauma-specific 


treatment, 142
 

sexual contact with clients, 189
 

sexual orientation and trauma, 56–57, 135


Simple Screening Instruments for Outreach for


Alcohol and Other Drug Abuse and Infectious 


Diseases (TIP 11), 102


single, repeated, or sustained trauma, 46–47

single, sequential, or parallel trauma-specific 


treatment, 142
 

SIT (stress inoculation training), 146, 146–
 

147, 147
 

Skills training in affective and interpersonal 


regulation (STAIR), 145–146, 146
 

SLE (Stressful Life Experiences) screening,


106, 107
 

sleep disturbances, 66, 78, 88–89, 121–122,
 

122
 

social and interpersonal relationships, trauma 


affecting, 74


societal factors, 15, 16


socio-ecological model, 14–16, 15, 16


sociocultural approach to trauma, 14, 15, 16,
 

17, 26, 26–27, 27
 

sociocultural factors in experience of trauma,


15, 16, 52, 55–57


somatic complaints, 64


South African Truth and Reconciliation
 

Commissions, 130


SPAN, 108
 

Stages of Change model of addiction treatment, 179
 

STAIR (Skills training in affective and interpersonal regulation), 145–146, 146
 

Stalinist purges, 52, 133
 

state and local government disaster response 


information, 34
 

strategic planning, use of TIC principles in,


162
 

strengths-focused perspective on trauma


treatment, 27–28, 28
 

stress inoculation training (SIT), 146, 146–
 

147, 147
 

Stressful Life Experiences (SLE) screening,


106, 107
 

STS. See secondary traumatic stress


subclinical trauma-related symptoms, 59, 61,


75–77, 76
 

Subjective Units of Distress Scale (SUDS),


120
 

substance abuse
 

co-occurrence with trauma, 4, 10, 46–47,


73, 86–89, 87, 88, 89, 102
 

defined, xviii–xix


gender and, 135


as impact of trauma, 73


importance of addressing traumatic background to, 21


integrated models designed to treat trauma and co-occurring disorders, 147–


150
 

IPV and, 41–42


physical injury and, 38–39


PTSD and, 10, 73, 83, 87, 87–89, 88, 89,
 

95, 101, 102
 

by refugees, 44


screening and assessment process and, 95,


101
 

self-harming behaviors and, 70, 71


as self-medication, 21, 63, 73, 87


sleep disturbances and PTSD, 88–89


as trauma in and of itself, 101
 

Substance Abuse and Mental Health Services 


Administration (SAMHSA)


CMHS, 170


Disaster Technical Assistance Center
 

Web site, 139
 

mission of, xiii


NREPP, 139, 144, 145, 147, 148, 150,


152, 169
 

September 11, 2001, study of impact of,


73
 

state and local government disaster response information, 34
 

Strategic Initiative #2, 5


Women, Co-Occurring Disorders and 


Violence Study, 8, 148, 152, 153
 

313 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

Substance Abuse Treatment: Addressing the Specific Needs of Women (TIP 51), 5, 102, 134


Substance Abuse Treatment and Domestic Violence (TIP 25), 5, 42


Substance Abuse Treatment for Persons With
 

Child Abuse and Neglect Issues (TIP 36), 5,
 

43
 

Substance Abuse Treatment for Persons With Co-


Occurring Disorders (TIP 42), 55, 72, 86,


101, 102, 103, 148, 182


Substance Dependence PTSD Therapy, 150


SUDS (Subjective Units of Distress Scale),


120
 

suicidality and suicidal thoughts


Addressing Suicidal Thoughts and Behaviors 


in Substance Abuse Treatment (TIP 50),
 

72, 94, 101, 134


as impact of trauma, 36, 43, 53, 62, 70,


71, 72, 81, 89


organizational commitment to TIC and, 


167
 

provider response to client suicide, 20,


200, 207
 

screening and assessment, 93, 94, 101,


110
 

timing and pacing of treatment and, 128
 

trauma-informed workforce and, 180, 187


trauma-specific services, 143, 144, 150


supervisors, clinical. See clinical supervisors 

and clinical supervision

survivor guilt, 66
 

survivors of trauma, xix. See also clients/consumers; impact of trauma

sustained, repeated, or single trauma, 46–47

susto, 103
 

symptoms. See impact of trauma 

T 

Taijin kyofusho, 103


TARGET (Trauma Affect Regulation: Guide 

for Education and Therapy), 151, 151–152 

THQ (Trauma History Questionnaire), 97–98

TIC. See trauma-informed care 

TIR (traumatic incidence reduction) approach,


147
 

torture and trauma, 43
 

training in TIC, 177–181, 178, 179–180, 181


transference and countertransference, 150,


184, 191, 196, 198
 

transsexuals and trauma, 56–57, 135


trauma, 33–57. See also impact of trauma; retraumatization
 

awareness, in TIC framework, 34
 

biology of, 65
 

cascading, 47


characteristics of, 46–52


community, 36, 39, 39–40
 

core assumptions and beliefs disrupted by,


51–52, 53–54, 63, 67
 

cultural meaning attached to, 52


defined, xix, 7


developmental, 42, 42–43
 

direct versus indirect experience of, 50–51


expected versus unexpected, 49


group, 36, 38–39


historical, 40, 51, 52, 133


individual, 36–38, 37
 

individual nature of experience of, 7, 14–


17, 15, 16, 17, 52–55
 

intentionality of cause of, 49–50, 50
 

interpersonal, 41–43, 42
 

isolated versus pervasive effects of, 49


losses associated with, 47–48, 58
 

mass, 36, 38, 40–41


natural versus human-caused, 34–36, 35,


36
 

political terror and war leading to, 43, 43–
 

44, 44
 

post-trauma disruption, 51


prevalence of, 8


psychological meaning attached to, 51


single, repeated, or sustained, 46–47


sociocultural factors in experience of, 15,


16, 52, 55–57


time available for processing, 47


types of, 33–46


Trauma Affect Regulation: Guide for Education

and Therapy (TARGET), 151, 151–152
 

trauma centers, 37
 

trauma champions, 176
 

314 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Index 

Trauma History Questionnaire (THQ), 97–98

trauma-informed care (TIC), xvi–xvi, 3–32

co-occurring disorders, 85–89. See also cooccurring disorders

definitions pertinent to, xvi–xix, 7

framework for, 6 

goals and purposes of TIP addressing, 4–

6 

impact of trauma, 59–89. See also impact 

of trauma 

intervention, prevention, and treatment

principles, 11–32, 111–135. See also intervention, prevention, and treatment

organizational investment in, 159–171.

See also organizational investment in

trauma-informed services 

rationale for, 8–9

recent focus on, 7–8

scope, intended audience, and target population, 4, 5

screening and assessment, 91–110. See also 

screening and assessment

specific trauma services, 137–155. See also 

trauma-specific treatment

understanding trauma, 33–57. See also 

trauma 

workforce and, 173–211. See also behavioral health services providers and

counselors; trauma-informed workforce 

trauma-informed workforce, 173–211. See also
 

behavioral health services providers and counselors; clinical supervisors and clinical supervision; secondary traumatic stress


administrative management of staff reactions to TIC implementation, 162
 

advantages of, 9


assigning key staff members to facilitate 


TIC, 163


boundaries and boundary-crossing, 187–


190, 188, 189, 190


burnout, 195, 196, 199, 200, 202, 203,
 

204
 

common clinical errors made by, 179–180
 

competencies of, 181–182, 183–184, 191
 

continuing education, 180–181
 

ethical issues, 182, 185–189, 185–190,
 

190
 

organizational and administrative commitment to TIC, demonstrating, 29


peer-support environment, creating, 169–


170, 170
 

recruitment, hiring, retention, and turnover, 174–177, 175, 176


responsibilities of, 182–183


self-care, promoting, 29–31, 31, 205–211,
 

206–210
 

in TIC framework, 174
 

training, 177–181, 178, 179–180, 181
 

Trauma Recovery and Empowerment Model


(TREM), 152
 

trauma-specific treatment, 137–155


ATRIUM, 148


Beyond Trauma program, 149


biofeedback, 143
 

breathing retraining and breathing exercises, 143, 144


CBT, 142, 145, 148, 149


choice of treatment model, 155


CISD, 140, 141, 141–142
 

COPE, 149


couples therapy, 153


CPT, 142–143, 145


CTPCD, 149


DBT, 142, 145, 146, 153


defined, xix


EMDR, 144, 144–145
 

exposure therapy, 143–144


family therapy, 153


first 48 hours after traumatic event, interventions aimed at, 139–142, 140, 141


integrated models designed to treat trauma and co-occurring disorders, 147–


150
 

mindfulness interventions, 153–154, 154
 

narrative therapy, 145
 

pharmacological therapy, 154–155


present- or past-focused, 137–138


referrals for, 135


relaxation training, 143
 

Seeking Safety, 149–150
 

315 
 

 

 

 

 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

single, sequential, or parallel, 142
 

SIT, 146, 146–147, 147
 

STAIR, 145–146, 146
 

Substance Dependence PTSD Therapy,


150
 

TARGET, 151, 151–152
 

in TIC framework, 138
 

TIR approach, 147


TREM, 152
 

Triad Women's Project, 153


trauma survivors, xix. See also clients/consumers; impact of trauma

traumatic incidence reduction (TIR) approach, 147


traumatic memory recovery, 129


treatment. See intervention, prevention, and
 

treatment 

TREM (Trauma Recovery and Empowerment Model), 152
 

Triad Women's Project, 153


triggers, 68, 68–69, 118, 118–119, 119
 

trust, building, 123
 

Truth and Reconciliation Commissions, South


Africa, 130


TSF (12-Step Facilitation) protocol, 179
 

tsunami, Indian Ocean (2005), 40


turnover and retention of trauma-informed 


workforce, 176, 176–177
 

12-Step programs, 121, 145, 178, 179, 188,
 

189
 

U
 

underdiagnosis, 102–103


unexpected versus expected trauma, 49


universal trauma screening, 25–26, 86, 91, 167


U.S. Department of Health and Human Services (HHS), xi, xiii, 132


U.S. Department of Housing and Urban Development (HUD), 57


U.S. Department of Veterans Affairs (VA)


National Center on PTSD, 115


Using Technology-Based Therapeutic Tools in


Behavioral Health Services (planned TIP),
 

153
 

V
 

VA (Veterans Affairs) National Center on


PTSD, 115


value statements, 162, 162–163
 

Veterans Affairs (VA) National Center on


PTSD, 115


Vietnamese refugees, 44
 

Virginia Polytechnic Institute shootings


(2007), 39


vision statements, 162, 162–163
 

W
 

war and political terror, 43, 43–44, 44
 

WHO (World Health Organization), 84


women and trauma. See also intimate partner
 

violence
 

ATRIUM, 148


Beyond Trauma program, 149


co-occurring disorders and trauma, 8, 10
 

experience of trauma, gender as factor in,


55
 

homelessness, 57


pregnant women, 15


prevalence of ASD and PTSD, 79–80,


89, 133
 

substance abuse and, 135


Substance Abuse Treatment: Addressing the


Specific Needs of Women (TIP 51), 5,
 

102, 134


treatment of trauma, gender as factor in,

133–35
 

TREM, 152


Triad Women's Project, 153


Women, Co-Occurring Disorders and Violence Study, 8, 148, 152, 153


World Health Organization (WHO), 84


World Refugee Survey, 43


World Trade Center attacks (9/11, 2001), 8,


46, 49, 70, 73, 140
 

Y 

youth and trauma. See children and trauma 

316 
 

 

 

 

 

 

 

 

 

 

 

Treatment Improvement Protocols (TIPs) are the products of a systematic and innovative process that 

brings together clinicians, researchers, program managers, policymakers, and other Federal and nonFederal experts to reach consensus on state-of-the-art treatment practices. TIPs are developed under the

Substance Abuse and Mental Health Services Administration’s Knowledge Application Program (KAP) 

to improve the treatment capabilities of the Nation’s alcohol and drug abuse treatment service system. 

A Quick Guide clearly and concisely presents the primary information from a TIP in a pocket-sized

booklet. Each Quick Guide is divided into sections to help readers quickly locate relevant material. Some

contain glossaries of terms or lists of resources. Page numbers from the original TIP are referenced so

providers can refer back to the source document for more information. 

Also based on TIPs, KAP Keys are handy, durable tools. Keys may include assessment or screening instruments, checklists, and summaries of treatment phases. Printed on coated paper, each KAP Keys set is

fastened together with a key ring and can be kept within a treatment provider’s reach and consulted frequently.The Keys allow you, the busy clinician or program administrator, to locate information easily and

to use this information to enhance treatment services. 

Publications may be ordered or downloaded for free at http://store.samhsa.gov.To order over the phone,

please call 1-877-SAMHSA-7 (1-877-726-4727) (English and Español). 

TIP 1	 State Methadone Treatment Guidelines— 

Replaced by TIP 43 

TIP 2	 Pregnant, Substance-Using Women— 

Replaced by TIP 51 

TIP 3	 Screening and Assessment of Alcohol- and

Other Drug-Abusing Adolescents—Replaced 

by TIP 31 

TIP 4	 Guidelines for the Treatment of Alcoholand Other Drug-Abusing Adolescents— 

Replaced by TIP 32 

TIP 5	 Improving Treatment for Drug-Exposed 

Infants 

TIP 6	 Screening for Infectious Diseases Among

Substance Abusers—Archived 

TIP 7	 Screening and Assessment for Alcohol and

Other Drug Abuse Among Adults in the 

Criminal Justice System—Replaced by TIP 44 

TIP 8	 Intensive Outpatient Treatment for Alcohol

and Other Drug Abuse—Replaced by TIPs 46 

and 47 

TIP 9	 Assessment and Treatment of Patients With 

Coexisting Mental Illness and Alcohol and

Other Drug Abuse—Replaced by TIP 42 

TIP 10 Assessment and Treatment of CocaineAbusing Methadone-Maintained Patients— 

Replaced by TIP 43 

TIP 11 Simple Screening Instruments for Outreach

for Alcohol and Other Drug Abuse and

Infectious Diseases—Replaced by TIP 53 

TIP 12 Combining Substance Abuse Treatment

With Intermediate Sanctions for Adults in 

the Criminal Justice System—Replaced by 

TIP 44 

TIP 13 Role and Current Status of Patient 

Placement Criteria in the Treatment of 

Substance Use Disorders 

Quick Guide for Clinicians

Quick Guide for Administrators

KAP Keys for Clinicians 

TIP 14 Developing State Outcomes Monitoring

Systems for Alcohol and Other Drug Abuse 

Treatment 

TIP 15 Treatment for HIV-Infected Alcohol and 

Other Drug Abusers—Replaced by TIP 37 

317 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Trauma-Informed Care in Behavioral Health Services 

TIP 16 Alcohol and Other Drug Screening of

Hospitalized Trauma Patients

Quick Guide for Clinicians


KAP Keys for Clinicians
 

TIP 17 Planning for Alcohol and Other Drug Abuse 

Treatment for Adults in the Criminal Justice 

System—Replaced by TIP 44 

TIP 18 The Tuberculosis Epidemic: Legal and

Ethical Issues for Alcohol and Other Drug

Abuse Treatment Providers—Archived 

TIP 19 Detoxification From Alcohol and Other 

Drugs—Replaced by TIP 45 

TIP 20 Matching Treatment to Patient Needs in

Opioid Substitution Therapy—Replaced by 

TIP 43 

TIP 21 Combining Alcohol and Other Drug Abuse 

Treatment With Diversion for Juveniles in 

the Justice System

Quick Guide for Clinicians and

Administrators 

TIP 22 LAAM in the Treatment of Opiate 

Addiction—Replaced by TIP 43 

TIP 23 Treatment Drug Courts: Integrating

Substance Abuse Treatment With Legal

Case Processing

Quick Guide for Administrators 

TIP 24 A Guide to Substance Abuse Services for 

Primary Care Clinicians

Concise Desk Reference Guide 

Quick Guide for Clinicians

KAP Keys for Clinicians 

TIP 25 Substance Abuse Treatment and Domestic 

Violence 

Linking Substance Abuse Treatment and

Domestic Violence Services: A Guide for 

Treatment Providers 

Linking Substance Abuse Treatment and

Domestic Violence Services: A Guide for 

Administrators 

Quick Guide for Clinicians

KAP Keys for Clinicians 

TIP 26 Substance Abuse Among Older Adults

Substance Abuse Among Older Adults: A

Guide for Treatment Providers 

Substance Abuse Among Older Adults: A

Guide for Social Service Providers 

Substance Abuse Among Older Adults:

Physician’s Guide 

Quick Guide for Clinicians

KAP Keys for Clinicians 

TIP 27 Comprehensive Case Management for 

Substance Abuse Treatment 

Case Management for Substance Abuse 

Treatment: A Guide for Treatment Providers 

Case Management for Substance Abuse 

Treatment: A Guide for Administrators 

Quick Guide for Clinicians

Quick Guide for Administrators 

TIP 28 Naltrexone and Alcoholism Treatment— 

Replaced by TIP 49 

TIP 29 Substance Use Disorder Treatment for 

People With Physical and Cognitive 

Disabilities 

Quick Guide for Clinicians

Quick Guide for Administrators

KAP Keys for Clinicians 

TIP 30 Continuity of Offender Treatment for 

Substance Use Disorders From Institution to 

Community

Quick Guide for Clinicians


KAP Keys for Clinicians
 

TIP 31 Screening and Assessing Adolescents for 

Substance Use Disorders 

See companion products for TIP 32. 

TIP 32 Treatment of Adolescents With Substance 

Use Disorders 

Quick Guide for Clinicians


KAP Keys for Clinicians
 

TIP 33 Treatment for Stimulant Use Disorders 

Quick Guide for Clinicians


KAP Keys for Clinicians
 

TIP 34 Brief Interventions and Brief Therapies for 

Substance Abuse 

Quick Guide for Clinicians


KAP Keys for Clinicians


TIP 35 Enhancing Motivation for Change in 

Substance Abuse Treatment 

Quick Guide for Clinicians


KAP Keys for Clinicians
 

TIP 36 Substance Abuse Treatment for Persons 

With Child Abuse and Neglect Issues

Quick Guide for Clinicians

KAP Keys for Clinicians

Helping Yourself Heal: A Recovering Woman’s 

Guide to Coping With Childhood Abuse 

Issues 

Also available in Spanish

Helping Yourself Heal: A Recovering Man’s 

Guide to Coping With the Effects of

Childhood Abuse 

Also available in Spanish 

318 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TIP 37 Substance Abuse Treatment for Persons 

With HIV/AIDS

Quick Guide for Clinicians

KAP Keys for Clinicians

Drugs, Alcohol, and HIV/AIDS: A Consumer 

Guide 

Also available in Spanish

Drugs, Alcohol, and HIV/AIDS: A Consumer 

Guide for African Americans 

TIP 38 Integrating Substance Abuse Treatment and

Vocational Services 

Quick Guide for Clinicians

Quick Guide for Administrators

KAP Keys for Clinicians 

TIP 39 Substance Abuse Treatment and Family

Therapy

Quick Guide for Clinicians

Quick Guide for Administrators

Family Therapy Can Help: For People in

Recovery From Mental Illness or Addiction 

TIP 40 Clinical Guidelines for the Use of 

Buprenorphine in the Treatment of Opioid

Addiction 

Quick Guide for Physicians


KAP Keys for Physicians
 

TIP 41 Substance Abuse Treatment: Group Therapy

Quick Guide for Clinicians 

TIP 42 Substance Abuse Treatment for Persons With 

Co-Occurring Disorders

Quick Guide for Clinicians

Quick Guide for Administrators

KAP Keys for Clinicians 

TIP 43 Medication-Assisted Treatment for Opioid

Addiction in Opioid Treatment Programs

Quick Guide for Clinicians


KAP Keys for Clinicians
 

TIP 44 Substance Abuse Treatment for Adults in the 

Criminal Justice System

Quick Guide for Clinicians


KAP Keys for Clinicians
 

TIP 45 Detoxification and Substance Abuse 

Treatment 

Quick Guide for Clinicians

Quick Guide for Administrators

KAP Keys for Clinicians 

TIP 46 Substance Abuse: Administrative Issues in 

Outpatient Treatment

Quick Guide for Administrators 

TIP 47 Substance Abuse: Clinical Issues in 

Outpatient Treatment

Quick Guide for Clinicians


KAP Keys for Clinicians
 

TIP 48 Managing Depressive Symptoms in

Substance Abuse Clients During Early

Recovery 

TIP 49 Incorporating Alcohol Pharmacotherapies

Into Medical Practice 

Quick Guide for Counselors


Quick Guide for Physicians


KAP Keys for Clinicians
 

TIP 50 Addressing Suicidal Thoughts and Behaviors

in Substance Abuse Treatment 

Quick Guide for Clinicians

Quick Guide for Administrators 

TIP 51 Substance Abuse Treatment: Addressing the 

Specific Needs of Women 

Quick Guide for Clinicians

Quick Guide for Administrators 

TIP 52 Clinical Supervision and Professional 

Development of the Substance Abuse 

Counselor 

Quick Guide for Clinical Supervisors

Quick Guide for Administrators 

TIP 53 Addressing Viral Hepatitis in People With

Substance Use Disorders 

Quick Guide for Clinicians and

Administrators 

KAP Keys for Clinicians 

TIP 54 Managing Chronic Pain in Adults With or in

Recovery From Substance Use Disorders 

Quick Guide for Clinicians

KAP Keys for Clinicians

You Can Manage Your Chronic Pain To Live a

Good Life: A Guide for People in Recovery

From Mental Illness or Addiction 

TIP 55-R Behavioral Health Services for People Who

Are Homeless 

TIP 56 Addressing the Specific Behavioral Health

Needs of Men 

TIP 57 Trauma-Informed Care in Behavioral Health 

Services 

319 

HHS Publication No. (SMA) 14-4816

First Printed 2014 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment