Trauma and Justice Strategic Initiative: Trauma Informed Care

& Trauma Specific ServicesLarke Nahme Huang, Ph.D.Lead, Trauma and Justice SI

Administrator’s Office of Policy Planning and Innovation

ATCC Annual Grantee MeetingBethesda, MD February 28, 2012

SAMHSA’S STRATEGIC INITIATIVES

AIM: Improving the Nation’s Behavioral Health (1-4)AIM: Transforming Health Care in America (5-6)AIM: Achieving Excellence in Operations (7-8)

1. Prevention

2. Trauma and Justice

3. Military Families

4. Recovery Support

5. Health Reform

6. Health Information Technology

7. Data, Outcomes &

Quality

8. Public Awareness &

Support

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SAMHSA’s Trauma and Justice Strategic Initiative

Rationale:• Emerging understanding of the central role of trauma in

mental and substance use disorders• High rates of trauma/trauma histories among people with BH

problems and among people in Justice SystemPurpose:• To create trauma-informed systems to implement prevention

and treatment interventions and to reduce the incidence of trauma and its impact on the behavioral health of individuals and communities

• To better address the needs of person with mental and substance use disorders involved with, or at-risk of involvement with, the criminal and juvenile justice systems.

Intersection of Criminal Justice and Behavioral Health Issues

• 1982-2007: population of U.S. prisons and jails nearly quadrupled from 612,000 2.3M

• ~1 in 5 has diagnosable serious mental illness, many with co-occurring alcohol and drug abuse problems.

• Most common reason for incarceration in jails is substance use-related crimes; drug offenders 20% of State inmates (38% African American/ 20% Hispanic)

• 14.5% of male and 31.0% of female inmates recently admitted to jail have a serious mental illness (Steadman, 2009)

• The GAINS Center estimates ~ 800,000 persons with serious mental illness are admitted annually to U.S. jails. Among these admissions, 72% also meet criteria for co-occurring SU disorder

• ~ 700,000 adults released each year -> reentry issues

Intersection of Criminal Justice and Behavioral Health

• Substance abuse or dependence rates of prisoners >four times general population

• Bureau of Justice Statistics (2004) estimated 53% of State and 45% of Federal prisoners met DSM criteria for drug abuse or dependence

• ~ Three-quarters of State, Federal, and jail inmates meet criteria for either MH or SU problems, contributing to higher corrections costs

• >41 percent State prisoners, 28 percent Federal prisoners, and 48 percent jail inmates meet criteria for having both

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Youth, Juvenile Justice and Behavioral Health

• A survey of juvenile detainees in 2000 found that about 56 percent of the boys and 40 percent of the girls tested positive for drug use at the time of their arrest (NIDA)

• Youth in juvenile justice have high rates of M/SUDs• Prevalence rates as high as 66 percent; 95 percent

experiencing functional impairment

Reported Prevalence of Trauma in Behavioral Health

• Majority of adults and children in inpatient psychiatric and substance use disorder treatment settings have trauma histories (Lipschitz et al, 1999; Suarez, 2008; Gillece, 2010)

• 43% to 80% of individuals in psychiatric hospitals have experienced physical or sexual abuse

• 51%-90% public mental health clients exposed to trauma (Goodman et al, 1997; Mueser et al, 2004)

• 2/3 adults in SUD treatment report child abuse and neglect (SAMHSA, CSAT, 2000)

• Survey of adolescents in SU treatment > 70% had history of trauma exposure (Suarez, 2008)

Trauma and Youth

Among U.S. Youth:• 60% exposed to violence within past year• 8% report lifetime prevalence of sexual assault• 17% report physical assault• 39% report witnessing violence• Childhood traumas potentially explain 32% of psychiatric

disorders in adulthood» Archives of General Psychiatry, Feb 2010, NCRS-R Study

Justice, Trauma and Behavioral Health Issues

• About ¼ of state prisoners (27%) and jail inmates (24%) with mental health problem reported past physical or sexual abuse

• 2003 OJJDP survey of youth in residential tx 70% have past traumatic experience with 30% physical and/or sexual abuse (Sedlak & McPherson, 2010)

• Overrepresentation of youth and adults of color in the justice system (CDF: Cradle to Prison Pipeline)

What do we mean by Trauma?

• Event(s)– Exposure to violence, victimization including sexual,

physical abuse, severe neglect, loss, domestic violence, witnessing of violence, disasters

• Experience– Intense fear of/ threat to physical or psychological safety

and integrity, helplessness; intense emotional pain and distress

• Effects– Stress that overwhelms capacity to cope and manifests in

physical, psychological, and neuro-physiological responses

What do we mean by Trauma-Specific Interventions?

• Focus directly on the sequelae/effects of trauma and facilitate recovery

• Individual/ Family or Group-specific• Evidence-supported Clinical Interventions

– Trauma-Focus Cognitive Behavioral Treatment– Trauma Recovery and Empowerment Model (TREM)– Seeking Safety– Trauma Affect Regulation: Guidelines for Education and

Therapy for Adolescents (TARGET)

What do we mean by Trauma-Informed Care (Salasin)

• Systemic, organizational approach to care• Paradigm for organizing mental health and human

services; “operating system” or “service delivery platform”

• Value-based change with Core Principles• Builds on unique perspective of people with lived

experiences of trauma• Transferable to other service sectors; growing consensus

that being trauma-informed can occur in many different settings

Core Values of Trauma-Informed Care (Fallot and Harris, 2001)

• Safety: How safe, physically and emotionally, is the organization setting? (for staff and clients)

• Trustworthiness: Are relationships consistent, open, transparent and honest?

• Choice: How is the consumer’s experience of choice supported?

• Collaboration: How does shared decision-making and a balance of power occur in the organization?

• Empowerment: How does the organization maximize recognition and validation of one’s strengths

Trauma Informed Care Systems(NCTSN/NCTIC)

• Recognize the pervasiveness of trauma• Takes into account individual or community trauma

history in order to promote recovery and growth• Provides trauma-specific treatments• Involves strong partnerships, cross system and

working relationships with families and consumer/survivors

• Specific training and tools• Trauma-informed Policy

What do we mean by Trauma-Informed Care in the Justice System? (GAINS Center)

• Align Trauma-informed opportunities for change at each of the 5-Intercept points:1. Law Enforcement (Crisis intervention training, avoid re-

traumatizing, e.g., de-escalation; strip searches)2. Initial Detention/Court Hearings (screen for trauma; gather

trauma histories; what happened to you?)3. Jails/Courts (avoid re-traumatizing behaviors; demeaning,

disempowering; personnel training on trauma; provide trauma-specific tx )

4. Reentry (ensure trauma-informed peer support, transition planning with trauma interventions)

5. Community Corrections (trauma training for parole and probation officers; link with community trauma services/supports))

3 Final Points

• Cost Study• Re-offending Study• Pending Opportunities in Affordable Care Act

(Health Reform)

Cost of CJ Involvement Among Persons with SMI in One-State Study (Swanson et al, 2011)

• Costs of CJ involvement among adults with schizophrenia and bipolar disorder in State’s public MH and Addiction services agencies

• N= 25,133 service recipients 6,904 w/ CJ involvement• CJ-involved higher overall costs than non-CJ• Total system costs for CJ-I ~ $49,000/person; non CJ-I ~

$25,000/person (doubled costs)• CJ-I: $338M; non-CJ-I: $446M• Dept MH/SA: had largest (61%) costs over 4 State agencies

(~$476M of $784M over two years- 2006,, 2007)• Jail Diversion cost amounted to small fraction of cost of

arrest/incarceration; thus potential for significant cost offset if prevent CJ-I

Serious Youth Offender Study: Substance Abuse And Reoffending (Schubert & Mulvey, 2011)

• N= 1,354 felony youth offenders, Phoenix and Philadelphia• 8 year study (21,000 interviews)• Mental health disorder alone does not affect time in gainful

activity (school/work) and re-offending• Substance use disorder significantly contributes to re-arrest

over 6 years and less time in gainful activity• No benefit from longer lengths of institutional stay to rate of

re-arrest • Institutional environments matter: more positive institutional

experience associated with 35%-49% reduction of system involvement in the next year

• Dimensions of environment: caring adult, safety, fairness and low harshness

In 2014: 32 MILLION MORE AMERICANS WILL BE COVERED

4-6 mil

Commercia

l

In

sura

nce

Medicaid

6-10 Million with M/SUDs

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ACA & JUSTICE INVOLVED POPULATIONS

Coverage expansion means individuals reentering communities from jails and prisons (generally have not had health coverage in past) will now have more opportunity for coverage

CJ population w/ comparatively high rates of M/SUDs = opportunity to coordinate new health coverage w/other efforts to ↑ successful transitions

Addressing BH needs can ↓ recidivism and ↓ expenditures in CJ system while ↑ public health and safety outcomes

SAMHSA and partners working to develop standards and improve coordination around coverage expansions

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