Over the past decade, focus has been placed on utilizing evidence-based practices for substance abuse treatment. Evidence-based practices are supported by carefully-designed research studies which demonstrate the effectiveness of those interventions over other interventions or no treatment at all. While identification of best practices is largely based on behavioral outcomes such as program retention and reductions in recidivism and substance abuse, consumer perceptions are also important in determining the effectiveness of interventions (Elliott, Bjelajac, Fallot, Markoff, & Reed, 2005). Satisfied consumers are more likely to fully engage in and comply with treatment protocols, particularly when those protocols are difficult to follow. Consumer satisfaction with treatment has also been associated with positive behavioral outcomes (Zhang, Gerstein, & Friedmann, 2008), while understanding consumer satisfaction allows treatment providers to make adjustments to interventions to better meet client needs (Crosier, Scott & Steinfeld, 2012).
This article looks at consumer perceptions of trauma-informed care within substance abuse treatment programs. Trauma-informed care is an important and growing model for providing substance abuse treatment, as many clients also have histories of trauma which need to be addressed in order to obtain and maintain positive long-term outcomes.
Providing Trauma-Informed Services
Addressing trauma within substance abuse treatment programs has become increasingly common, an important development given the high co-occurrence of substance abuse and trauma (Brown, Harris, & Fallot, 2013; Wu, Schairer, Dellor, & Grella, 2010). The co-occurrence of trauma and substance abuse has been attributed to a variety of factors, including client efforts to control anxiety through substance use, self-medication to avoid the experience of trauma-related symptoms, avoidance of negative affective states through substance use, and the increased exposure of adults with substance abuse disorders to “high risk” environments (Douglas et al., 2010; Dvorak, Arens, Kuvaas, Williams, & Kilwein, 2013; Stewart & Conrod, 2008).
Studies show that clients who receive treatment for both trauma and substance abuse are retained in substance abuse treatment longer than are clients who receive treatment for substance abuse alone, and that they are also more likely to show reductions in both substance abuse and trauma-related symptoms (Amaro et al., 2007; Gatz et al., 2007; Mangrum, Spence, & Lopez, 2006; Sacks, McKendrick, & Banks, 2008).
Providing interventions that address substance abuse and trauma requires a reconsideration of how substance abuse treatment is provided at all levels of service delivery. To provide trauma-informed care, agencies need to engage in a thorough client assessment process and provide specialized interventions, both of which require staff training. A description of these types of services, and consumer perceptions of these services, follows.
Assessment of Trauma
In order to determine the extent of trauma experienced by clients, a thorough assessment needs to be conducted; that is, clients need to be asked about a range of potentially traumatic experiences. While this assessment is necessary, it also may bring up troubling issues for clients. Unless clients feel safe, they are likely to underreport prior abuse or other traumatizing experiences. Thus, staff members need to be trained to talk about trauma in a clinically sensitive manner. Counselors who have experienced trauma themselves may be particularly vulnerable to the experience of vicarious trauma after exploring those issues with their clients (Baird & Kracen, 2006; Jenkins, Mitchell, Baird, Whitfield, & Meyer, 2011). As substance abuse treatment programs increase their use of trauma-informed care, training in this process will become a necessity.
There are several standardized measures that can be used to determine a client’s history of trauma. It is important to note that these instruments ask about different types of potentially traumatic experiences, thus depending on the assessment one uses, one may have a different understandings of their clients’ needs. For example, the Adverse Childhood Experiences (ACE) scale (Felitti et al., 1998), was developed as part of an epidemiologic study of the influences of stressful and traumatic childhood experiences on health and behavioral outcomes later in life. The scale has questions about exposure to ten forms of trauma before the age of eighteen:
- Physical abuse
- Emotional abuse
- Sexual abuse
- Household substance abuse
- Incarcerated household member
- Household mental illness
- Violent treatment of a female caregiver
- Emotional neglect
- Physical neglect
- Parental separation or divorce
High scores on this scale have been associated with negative biological and psychological outcomes including alcoholism, depression, smoking, sexually transmitted diseases, and cancer (Brown et al., 2010; Chapman et al., 2004; Douglas et al., 2010.)
Another assessment, the Trauma History Screen (THS; Carlson et al., 2011), includes items on fourteen potentially traumatic experiences across one’s lifetime. The experiences are:
- A really bad car, boat, train or airplane accident
- A really bad accident at work or home
- A hurricane, flood, earthquake, tornado or fire
- Hit or kicked hard enough to injure as a child
- Hit or kicked hard enough to injure as an adult
- Forced or made to have sexual contact as a child
- Forced or made to have sexual contact as an adult
- Attacked with a gun, knife or other weapon
- During military service, seeing something horrible or being badly scared
- Sudden death of a close family member or friend
- Seeing someone die suddenly or get badly hurt or killed
- Some other sudden event that made you feel very scared, helpless or horrified
- Sudden move or loss of home and possessions
- Suddenly abandoned by spouse, partner, parent or family
Participants are asked whether or not they had experienced that particular event, and if so, how many times it happened, the age at which it happened, and the intensity and psychological impact of the experience. The measure has been used with homeless veterans, hospital trauma patients, college students, and a community sample (Carlson et al., 2011).
These two assessments capture notably different types of trauma beyond sexual and physical abuse, and reflect various types of adversity individuals can experience. Regardless of which instrument is used, a key element is that the question of “What happened to you?” is asked, as opposed to the question clients sometimes hear, “What is wrong with you?” Finally, if questions about trauma are not asked by the clinician, they are not likely to be brought up by the client, missing what could be an important piece of the puzzle for helping clients recover.
Symptoms associated with traumatic distress, while associated with the intensity of traumatic experiences, can significantly vary across individuals both as a function of that person’s perception of the severity of the trauma and their coping skills at the time of the traumatic experience as well as since it occurred. Thus, in addition to determining the trauma clients have experienced it is necessary to separately assess the severity of their trauma symptoms. Standardized measurement for this includes the Trauma Symptom Inventory (TSI; Briere, Elliott, Harris, & Cotman, 1995). On this scale, respondents rate their experience of one hundred posttraumatic stress symptoms on a four-point scale. Items form ten clinical scales, which in turn comprise three summary scales:
- Trauma (composed of intrusive experiences, defensive avoidance, dissociation, and impaired self-reference clinical scales)
- Self (composed of impaired self-reference, sexual concerns, dysfunctional sexual behavior, and anger/irritability clinical scales)
- Dysphoria (composed of anger/irritability, depression, and anxious arousal clinical scales)
In sum, while many clients who enter substance abuse treatment have experienced trauma, there is variation in the types of trauma they have experienced and the extent to which these experiences have resulted in psychological distress and symptoms that need to be addressed.
There are numerous ways that substance abuse treatment programs can integrate interventions for substance abuse and trauma. Van Dam, Vedel, Ehring, and Emmelkamp (2013) describe integrated programs as being trauma-focused or non-trauma-focused; trauma-focused interventions address the trauma memory itself, while non-trauma-focused therapies help the client cope with present-oriented problems that result as a function of the trauma. More commonly, treatment programs do the latter. For example, Seeking Safety (Najavits, 2001; Najavits, Weiss, Shaw, & Muenz, 1998), is a program designed to help clients see the relationship between trauma and substance abuse and develop coping skills for both. The Seeking Safety curriculum can be used in both group and individual formats. Topics covered include grounding, asking for help, setting boundaries in relationships, and creating meaning. Other evidence-based programs include the Trauma Recovery and Empowerment Model (Harris, 1998), the Addiction and Trauma Recovery Integration Model (Miller & Guidry, 2001), Beyond Trauma (Covington, 2003), and Triad (Herman, 1992a, 1992b).
To help guide integration efforts, Elliott et al. (2005) proposed ten principles for the development of trauma-informed treatment. These include recognition of the impact of violence and victimization on clients, making recovery from trauma symptoms a primary goal, minimizing possibilities of retraumatization, emphasizing strengths, and creating an atmosphere that provides a sense of safety. Elliott et al. also note that to be considered a trauma-informed agency, all staff—from the person at the front desk to the counseling staff—need to engage in behaviors which reflect these principles. Staff members are expected to behave in a trauma-sensitive manner in all of their interactions with clients.
Despite the challenges of providing integrated interventions for substance abuse and trauma symptoms within substance abuse treatment programs, consumer perceptions of these interventions are generally positive. Studies find that consumers who receive integrated treatment for trauma symptoms and substance abuse disorders from a single provider are more satisfied than are those who receive non-integrated services (Clark et al., 2008; Schulte, Meier, & Stirling, 2011). Evaluations of Seeking Safety, for example, show high levels of consumer satisfaction, strong working alliances, and high retention (Zlotnick, Najavits, Rohsenow, & Johnson, 2003).
Sanford, Donahue, and Cosden (2014) studied consumer satisfaction with trauma-informed care provided as part of a drug treatment court, a program that provided a treatment alternative to incarceration for nonviolent offenders with a need for drug treatment. They conducted consumer interviews with 153 adults—51 men and 102 women—who were receiving trauma-informed assessments and interventions as part of an enhanced drug treatment court funded by the Substance Abuse and Mental Health Services Administration (SAMHSA). It was hypothesized that consumers would generally be positive about the trauma-informed interventions, but that participants who had experienced more trauma and had greater traumatic distress would be best matched to those interventions and most satisfied.
Satisfaction with treatment was measured through the Consumer Perception of Care (CPC; Clark et al., 2008). The CPC is a twenty-six-item measure developed to assess satisfaction with integrated trauma and substance abuse interventions on four scales:
- Service Integration, which describes treating clients as a whole person and providing them with a safe and comfortable environment
- Choice in Services, which describes clients’ perception of their choice in services, providers, and ability to complain without retribution
- Trauma-Informed Assessment, which asks about assessment of sexual and physical abuse histories
- Respect for Cultural Identity, which has items on providers’ respect for and sensitivity to clients’ values and beliefs
Number of traumatic experiences was measured by the ACE scale and level of distress on the TSI. The results found that participants were generally satisfied with the trauma assessments and interventions they received. As predicted, the number of traumatic experiences they reported and their level of distress were significantly associated with satisfaction with the program’s trauma-related assessments and integrated interventions for trauma and substance abuse. That is, clients who reported more anxiety, depression, and other symptoms associated with trauma were more supportive of the use of trauma assessments and interventions as part of the program.
There are differences in how men and women perceive the treatment-focused interventions. In a meta-analysis examining data from nineteen studies, Tolin and Foa (2006) found that women reported a higher severity of trauma symptoms than did men. Some of these differences may reflect differences in the types of trauma experienced by men and women—specifically the higher rates of sexual assault reported by women (Tolin & Foa, 2006)—but it may also be due to the tendency for men to underreport these problems. This latter interpretation is supported by studies which find that men are less comfortable disclosing or talking about abuse than are women (Sable, Danis, Mauzy, & Gallagher, 2006; Sorsoli, Kia-Keating, & Grossman, 2008; Teram, Stalker, Hovey, Schachter, & Lasiuk, 2006;. This discomfort has been attributed to the greater stigma experienced by men than for women for reporting abuse, the tendency of others to underplay the significance of abuse toward men, and concerns that others will now think the male victim may become an abuser. Confounding this problem is evidence that treatment providers also find it more challenging to talk to men about abuse (Lab, Feigenbaum, & De Silva, 2000; Teram et al., 2006).
Similarly, Sanford et al. (2014) found that men were less satisfied than women with the process of assessing trauma. In that study, clinically-trained staff members had conducted assessments of the client’s history of trauma on the ACE scale and their experience of traumatic distress on the TSI. Still, gender differences were noted, with men reporting fewer traumatic experiences and trauma-symptoms and less satisfaction with trauma assessment.
While research is just beginning to look at client perspectives on trauma-informed care, initial evidence is that consumers are supportive of this approach, with clients who report more trauma also reporting greater satisfaction. Gender norms and related social stigma around violating these norms may make some men feel more uncomfortable discussing their traumatic experiences than women. It also may be difficult for some providers to ask about trauma, particularly if it brings up their own history of trauma or if they do not feel trained to do this effectively. Nevertheless, trauma assessment is a crucial aspect of trauma-informed treatment. More work is needed to develop methods for talking with clients about trauma that is sensitive to their differences as a function of gender, ethnicity, sexual orientation, and history of trauma, and to develop models for staff training to do this work safely and effectively.
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Editor’s Note: This article was adapted from an article by the same authors previously published in the Journal of Substance Abuse Treatment (JSAT). This article has been adapted as part of Counselor’s memorandum of agreement with JSAT. The following citation provides the original source of the article:
Sanford, A., Donahue, M., & Cosden, M. (2014). Consumer perceptions of trauma assessment and intervention in substance abuse treatment. Journal of Substance Abuse Treatment, 47(3), 233–8.