Trauma Issues with Specific Populations: Adolescents & Transition Age Youth

WORKSHOP Michael Dennis, Ph.D. and Janet C. Titus, Ph.D.

Chestnut Health Systems, Normal, IL

Presentation at Substance Abuse and Mental Health Services Administration’s Pre- Conference Training Session, Trauma-Informed Care: An Essential Element of Recovery Training. Hollywood, FL, June 18, 2011

2

Acknowledgements and Contact Information

• Analysis performed with support from SAMHSA contrac t no. 270-07-0191 using data from SAMHSA/CSAT GAIN Data set from 182 grantees (17534, 16386, 16400, 16414, 16904, 16915, 16928, 16939, 16961, 16984, 16992, 17046, 17070, 17071, 17334, 17433, 17434, 17446, 17475, 17476, 17484, 17486, 17490, 17517, 17523, 17534, 17535, 17547, 17589, 17604, 17605, 17638, 17646, 17648, 17673, 17702, 17719, 17724, 17728, 17742, 17744, 17751, 17755, 17761, 17763, 17765, 17769, 17775, 17779, 17786, 17788, 17812, 17817, 17821, 17825, 17830, 17831, 17847, 17864, 18406, 18587, 18671, 18723, 18735, 18849, 19313, 19323, 19942, 20084, 20085, 20086, 20100, 20117, 20200, 20300, 20400, 20759, 20781, 20798, 20806, 20827, 20828, 20847, 20848, 20849, 20852, 20865, 20870, 20910, 20921, 20941, 21551, 21580, 21585, 21597, 21624, 21632, 21682, 21688, 21705, 21714, 21774, 21788, 21815, 21874, 21883, 21890, 21892, 21948, 30100, 30200, 30300, 30400, 30500, 30600, 30700, 31000, 31100, 31200, 110000, 130000, 140000, 150000, 160000, 190000, 200000, 210000, 220000, 230000, 240000, 250000, 260000, 270000, 280000, 290000, 300000, 310000, 320000, 330000, 340000, 350000, 360000, 370000, 380000, 390000, 400000, 410000, 420000, 430000, 440000, 450000, 460000, 470000, 480000, 500000, 510000, 520000, 540000, 570000, 580000, 590000, 600000, 610000, 620000, 630000, 640000, 655372, 655373, 655374, 660000, 670000, 680000,, 690000, 700000, 820000, 830000, 840000, 850000, 860000, 870000, 880000, 910000, 920000)

• Dr. Liza Suárez and the Adolescent Trauma and Substance Abuse Committee of the National Child Traumatic Stress Network (NCTSN)

• Opinions are those of the author and not official positions of the government• Available from www.chestnut.org/li/posters • Please direct comments to Michael Dennis, Chestnut Health Systems, 448 Wylie

Drive, Normal, IL 61761, 309-451-7801, mdennis@chestnut.org .

3

Goals of Afternoon Breakout

1. To compare the effectiveness of several evidence based approaches to adolescent treatment in terms of changes in victimization, trauma, emotional problems, substance use, abuse & dependence, HIV risk behaviors and crime

2. To review some of the promising trauma-informed or integrated treatments for co-occurring trauma and substance abuse

4

Change Over Time in Selected NOMS Outcomes

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Intake 3 Month 6 Month 9 Month 12 Month

No HealthProblems

No MentalHealth Problems

No FamilyProblems

Abstinence

No IllegalActivity

VocationallyEngaged (PastMo.)Housed

Source: CSAT 2010 SA Dataset Subset to Adolescents and Young Adults (n=24,091)

5

Change in Selected NOMS Outcomes by Severity of Victimization

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Intake LastWave

Intake LastWave

Intake LastWave

No Health Problems

No Mental HealthProblems

No Family Problems

Abstinence

No Illegal Activity

VocationallyEngaged (Past Mo.)

Housed

Low Severity Mod Severity High Severity

Source: CSAT 2010 SA Dataset Subset to Adolescents and Young Adults (n=24,091)

On average higher trauma associated with being

worse at intake but also more change

6

Which general outpatient approaches address co-occurring trauma issues?

Nine Treatment Outpatient Approaches •Seven Challenges (Schwebel, 2004) (n=114)•Chestnut Health Systems (CHS; Godley et al. 2002) Treatment (n=192)•Adolescent Community Reinforcement Approach (A-CRA; Godley et al., 2001) -CYT/AAFT (n=2144) and -Other (n=276)•Multi-Systemic Therapy (MST; Henggeler et al., 1998) (n=85)•Multi-Dimensional Family Therapy (MDFT; Liddle, 2002) (n=258)•Motivational Enhancement Therapy-Cognitive Behavior Therapy (METCBT; Sampl & Kadden, 2001)-CYT/EAT (n=5262) and -Other (n=878) •Family Support Network (FSN; Hamilton et al., 2001) (n=369)

6

7

Two sets of outcomes

• Mental Health• Emotional Problems Scale • Days of Traumatic Memories• Days of Victimization • Other Outcomes• Substance Problems Scale • Substance Frequency Scale • Illegal Activities Scale • HIV Risk Change Index • Average Across

7

8

Change (post-pre) in Effect Size for Emotional Problems by Type of Treatment

-0.5

4

-0.4

3

-0.4

5 -0.3

9

-0.3

7

-0.3

7

-0.3

4 -0.2

9

-0.2

9

-0.1

8

-0.2

8

-0.1

9

-0.3

2

-0.1

9

-0.1

5

-0.2

1 -0.1

3 -0.0

8

-0.0

8

-0.0

9

-0.1

4

-0.2

2

-0.0

4

-0.1

3

-0.1

2 -0.0

8

-0.1

6

-0.80

-0.60

-0.40

-0.20

0.00

0.20

SevenChallenges

(n=114)

CHSTreatment(n=192)

A-CRA-CYT/AAFT

(n=2144) MST(n=85)

MDFT(n=258)

METCBT-CYT/EAT(n=5262)

METCBT-Other

(n=878) FSN

(n=369)

A-CRA-Other

(n=276)

Cha

nge

Eff

ect S

ize

d ((

mea

n fo

llow

-up

- m

ean

inta

ke)/

std

dev

. int

ake)

Emotional Problem Scale Days of traumatic memories Days of victimization

Four best on mental health outcomes include 7 challenges,

CHS, A-CRA, & MST

9

Change (post-pre) in Effect Size for Core Treatment Outcomes by Type of Treatment

-0.5

4

-0.4

3

-0.4

5 -0.3

9

-0.3

7

-0.3

7

-0.3

4 -0.2

9

-0.2

9

-0.6

2

-0.6

5

-0.4

3

-0.4

5

-0.5

0

-0.3

8 -0.3

3

-0.4

7

-0.3

6-0.3

0

-0.3

7

-0.4

2

-0.4

3 -0.3

8 -0.3

3 -0.2

6

-0.5

1

-0.4

8

-0.1

5 -0.1

1

-0.2

8

-0.3

9

-0.3

8

-0.1

7

-0.1

9

-0.2

9 -0.2

3

0.00 0.

04

-0.2

3

-0.3

8

-0.1

8 -0.1

1

-0.1

7

-0.3

0

-0.1

8

-0.3

2

-0.3

0

-0.3

6

-0.4

1 -0.3

6

-0.2

7

-0.2

6

-0.3

7 -0.3

1

-0.80

-0.60

-0.40

-0.20

0.00

0.20

SevenChallenges

(n=114)

CHSTreatment(n=192)

A-CRA-CYT/AAFT

(n=2144) MST(n=85)

MDFT(n=258)

METCBT-CYT/EAT(n=5262)

METCBT-Other

(n=878) FSN

(n=369)

A-CRA-Other

(n=276)

Cha

nge

Eff

ect S

ize

d ((

mea

n fo

llow

-up

- m

ean

inta

ke)/

std

dev

. int

ake)

Emotional Problem Scale Substance Problem Scale Substance Frequency Scale

HIV Risk Scale Illegal Activity Scale Average

Four best on treatment outcomes include A-CRA, MST, MDFT, & FSN

10

Summary of Findings • All programs reduced mental health / trauma problems with 4

doing particularly well: 7 challenges, CHS, A-CRA, & MST• All programs reduced general outcomes on average, with 4

doing particularly well: A-CRA, MST, MDFT, FSN– All more assertive/family/systemic programs – All have formal training, quality assurance,

monitoring & technical assistance• Where we could break in two (A-CRA & MET/CBT), programs

with more training, quality assurance, monitoring and technical assistance did better than those with less• A-CRA with a mix of BA/MA did as well as MST which targets

MA level therapists and family therapists that are often in short supply• While it is not as effective, the shortest & least expensive

(MET/CBT5) still has positive effects 10

11

Both Trauma and Substance Use Follow Classical Conditioning Models

Original SignalOriginal SignalTrigger/ReminderTrigger/Reminder

Emotional/Physical Emotional/Physical ReactionReaction

Craving, drug seekingCraving, drug seekinganxiety, guilt, shameanxiety, guilt, shame

Pain, anxiety, anger,Pain, anxiety, anger,anxiety, guilt, sadnessanxiety, guilt, sadness

Bad coping/Bad coping/Avoidant response orAvoidant response or

Seeking reliefSeeking relief

Substance useSubstance use

12

12Photo courtesy of the NIDA Web site. From A Slide Teaching Packet: The Brain and the Actions of Cocaine, Opiates, and Marijuana.

pain

Adolescent Brain Development Occurs from the Inside to Out and from Back to Front

The two main reasons for continued use are to seek pleasure and to avoid physical or psychological pain

13

Characteristics of Individuals with Traumatic Stress and Substance Abuse

• Emotional and behavioral dysregulation• Coping deficits• Family strain• Environmental stress• Academic & vocational difficulties• Health problems• Involvement with multiple service systems (legal

system, social services, mental health, substance abuse, special education)

14

Trauma Exposure vs. PTSD

• Lifetime exposure to trauma is common.• Only a fraction of trauma-exposed individuals will go on to

develop PTSD or a sub-clinical variation of it (complex trauma response, DESNOS, partial PTSD).

• Strongest risks for exposure turning into PTSD…– Unexpected death of someone close– Sexual assault or physical assault that involved fearing for own

life– If they do not get help right away or are not believed

• As demonstrated earlier, trauma associated with a wide range of consequences

• PTSD is just a subset

15

Posttraumatic Stress Disorder

– A set of characteristic symptoms that can develop when a PAST trauma overwhelms the person’s ability to cope

– Re-Experiencing the traumatic event through intrusive thoughts or dreams of the event, or intense psychological distress when exposed to reminders of the event

– Avoidance of thoughts, feelings, images, or locations that remind one of or are associated with the traumatic event

– Increased arousal such as hyper-vigilance, irritability, exaggerated startle response, and sleeping difficulties

Child maltreatment often does not meet criteria for PTSD because it happened multiple ways or times and is often on going.

16

The Whole is Greater than the Sum of its Parts…

• The presence of traumatic stress or PTSD greatly complicates the recovery process in individuals with substance use disorders.

• Exposure to trauma or trauma triggers has been shown to increase drug cravings and relapse in people with co-occurring trauma and substance abuse.

• When substance abuse and traumatic stress are treated separately, individuals with co-occurring disorders are more likely to relapse and revert to previous maladaptive coping strategies..

17

Common Components of Trauma-Informed Care

• Cognitive restructuring such as recognizing, challenging, and correcting negative cognitions

• Emotion regulation skills such as the identification, expression, and modulation of negative affect like anxiety and panic

• Stress management skills such as relaxation and positive self-talk

• Gradual exposure to achieve desensitization to trauma reminders while practicing relaxation

Adapted from Cohen, Mannarino, Zhitova, & Capone (2003)

18

Some Specific Models of Trauma Informed Care for Adolescents and Emerging Adults

• Cognitive Behavioral Intervention for Trauma in Schools (CBITS)

• Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS)

• Integrated Care for Adolescents Struggling with Traumatic Stress and Substance Abuse (I-CARE)

• Trauma Recovery and Empowerment Model (TREM)

• Seeking Safety

19

Cognitive Behavioral Intervention for Trauma in Schools (CBITS)

• CBITS is a skills-based group intervention aimed at relieving symptoms of PTSD, depression, and anxiety among children exposed to trauma.

• Skills are learned through use of drawings and talking in both group and individual sessions.

• Skills are reinforced by completing assignments and participating in activities.

• There are parent and teacher education sessions as well.

20

CBITS Facts

• Population – girls & boys, 10-15 yrs, exposed to trauma AND suffering moderate symptoms; diverse groups

• Sessions – 10 weekly group sessions (5-8 youths), 1-3 individual (exposure), 2 parent, 1 teacher

• Setting - school• Components – 6 cognitive behavioral skills

– Education on reactions to trauma– Relaxation training– Cognitive therapy– Exposure to trauma reminders– Stress or trauma exposure– Social problem-solving

21

Support for CBITS

Quasi-experiment with control group (Kataoka et al., 2003)

• Latino immigrant children exposed to community violence• Children in the CBITS group had significantly greater improvement in PTSD

and depressive symptoms compared to those on a wait-list at 3 months.

Randomized controlled trial (Stein, Jaycox, Wong, Tu, Elliott & Fink, 2003)

• Largely Latino 6th graders exposed to community violence.• Children in the CBITS group had significantly greater improvement in PTSD

and depressive symptoms compared to those on a wait-list at 3 months.• Parents of the children in the CBITS group reported significant

improvements in functioning.• Improvements in symptoms and functioning continued to be seen at 6

months.

22

Implementing CBITS

• Staff - ideal person has prior training and experience with mental health and CBT.

• CBITS manual available from http://www.sopriswest.com– Jaycox, L. (2003). CBITS: Cognitive-Behavioral Intervention for Trauma

in Schools. New York: Sopris West.• Training available – contact Dr. Audra Langley (alangley@mednet.ucla.edu)

– trainees read background materials and the manual and watch a training video prior to training, attend a 2-day training, receive ongoing supervision from a local clinician with expertise in CBT

– www.cbitsprogram.org.• More info on CBITS

– Contact Sheryl Kataoka (skataoka@ucla.edu)

23

Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS)

• SPARCS is a skills-based group intervention for chronically traumatized adolescents who may still be living with ongoing stress and are experiencing problems in several areas of functioning:– Emotional and behavioral regulation– Attention/Consciousness– Self-perception– Interpersonal relationships– Somatization and physical health problems– Systems of meaning

24

Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS)

• SPARCS’ components are based on three empirically validated interventions.– Dialectical Behavior Therapy for Adolescents (mindfulness and interpersonal skills)– Trauma Adaptive Recovery Group Education and Therapy (TARGET) (problem solving skills)– UCLA Trauma/Grief Program (enhancing social support and planning for future)

• Cognitive-behavioral, present-focused, strength-based• Overall goals (the “4 C’s”)

– Cultivate awareness– Cope more effectively– Connect with others– Create meaning

25

SPARCS Facts

• Population – girls & boys, 12-19 yrs, who have problems in functioning related to chronic interpersonal trauma

• Sessions – 16 weekly 1 hour group sessions (6-10 youths)• Setting – outpatient clinics, schools, group homes, boarding

schools, residential treatment, foster care programs• Components (Core Skills)

– Mindfulness– Problem Solving– Meaning-making– Relationship building and communication skills– Distress Tolerance– Psychoeducation on stress and trauma

26

Support for SPARCS

Quasi-experiment with comparison group (Lyons et al., in press)

• Adolescents in foster care who received were half as likely to run away and a fourth as likely to experience treatment disruptions (e.g., arrests, hospitalization) than those assigned to a standard care intervention.

Pilot study (Habib & Ross, 2006)

• Adolescent girls in a 22 session SPARCS group showed significant improvement in overall functioning on level of behavioral dysfunction, interpersonal relationships, and interpersonal coping (support seeking behavior).

27

Implementing SPARCS

• Staff – prior training and experience in counseling• SPARCS manual available from treatment developers (Dr. Ruth

DeRosa)– DeRosa, R., Habib, M., Pelcovitz, D., Rathus, J., Sonnenklar, J., Ford, J., et

al. (2006). Structured Psychotherapy for Adolescents Responding to Chronic Stress. Unpublished manual.

• Training available http://sparcstraining.com/index.php

– Initial two day training, later two day training, frequent consultations– Learning Collaborative

• More info on SPARCS– Dr. Victor Labruna (vlabruna@nshs.edu)– Dr. Mandy Habib (mhabib@nshs.edu)

28

Integrated Care for Adolescents Struggling with Traumatic Stress and Substance Abuse (I-CARE)

• I-CARE is a community-based program for youths who are having difficulties regulating emotions resulting from traumatic experiences and environmental stress and who are also having problems with substance abuse.

• Acknowledges the role of the social ecology on youth and family functioning.

• The intervention provides a framework for coordinating care.

• Following assessment, a multidisciplinary team chooses from a series of interventions based on the youth’s needs.

29

Integrated Care for Adolescents Struggling with Traumatic Stress and Substance Abuse (I-CARE)

• I-CARE is based on Trauma Systems Therapy (TST), which is based on several approaches:

• Systems-of-Care approach (overall framework)• Multisystemic Therapy (MST) (home-based services)• Dialectical Behavior Therapy (emotional regulation skills training)• Trauma Focused Cognitive Behavioral Therapy (cognitive processing skills training)• Psychopharmacology

• I-CARE was previously known as Trauma Systems Therapy – Substance Abuse (TST-SA)

30

I-CARE Facts

• Population – girls & boys, 13-17 yrs, with co-occurring trauma and substance abuse who are having problems with emotional regulation in an environment that cannot contain it.

• Sessions – length of treatment is variable, can last from 3 to 9 months depending on severity of youth’s situation; individual and parent/family components

• Setting – community-based program - delivered in clinic, at home, in the social environment

31

Ready Set Go Building alliance and enhancing motivation, Psychoeducation, Troubleshooting Practical Barriers, Treatment Planning

Stabilization on Stabilization on SiteSite

Home Based Care, Family Communication, Behavior Management, Community Integration Strategies

Services Advocacy Connecting the youth and family with needed resources

PsychopharmacologPsychopharmacologyy

Coordinated psychiatric evaluation and medication management

Emotion Regulation Psychoeducation and Skill Building (Affect Management, Competency building, Emotion Identification and Acceptance)

Cognitive Cognitive ProcessingProcessing

Cognitive Restructuring, Exposure to the Trauma Narrative

Meaning Making Enacting meaning, future orientation, relapse prevention

I-CARE Modules

32

Support for I-CARE

TST open trial (Saxe, Ellis, Fogler, Hansen, & Sorkin, 2005)

– trauma symptoms, emotional and behavioral regulation – More stable social environment – Transitioning from more intensive to less intensive phases of

treatment

Dissemination: Ulster County Program Evaluation– trauma symptoms, family stability– hospitalization rates and length of hospital stay– length for need of services

TST controlled trial (preliminary findings)– Reduced drop out rates (10/10 vs. 1/10 retention after 3 months)

33

Implementing I-CARE

• Staff – M.A. level counselors; staff with less formal training can deliver components in collaboration with counselors

• Materials– I-CARE manual available from treatment developer, Dr. Liza Suárez

(lsuarez@psych.uic.edu)– Adolescent and parent workbook, assessments

• Training available– Two days basic training– Weekly conference call– One day follow-up training at 6 months

• More info on I-CARE– Contact Dr. Suárez

34

Trauma Recovery and Empowerment (TREM)

• TREM is a comprehensive group intervention for women survivors of physical, sexual, and/or emotional abuse who may use substances and for whom traditional recovery work has been unavailable or ineffective.

• Draws on cognitive restructuring, skill-building, and psychoeducational techniques

• Teaches techniques for self-soothing, boundary maintenance, and current problem solving

• Emphasizes development of coping skills and social support.

35

TREM Facts

• Population – women trauma survivors with substance abuse and/or mental health problems; a men’s group and an adolescent girls’ group have been implemented; 18-25, 26-55 yrs; diverse ethnic groups

• Sessions – 24 to 29 to 33 weekly group sessions (6-8 members), 75 minutes per session, over a 9 month period

• Setting – substance abuse and mental health programs (residential and non-residential), correctional institutions, welfare-to-work programs, homeless shelters

36

TREM Components

Empowerment – learn strategies for… – Self-comfort and accurate self-monitoring– Setting physical and emotional boundaries– Increasing self-esteem

Trauma Education– Explore and reframe the connection between their experiences

of abuse and consequences of abuse (other current difficulties), including substance use, mental health symptoms, interpersonal problems

– Provided with tools and skills with which they can combat the repercussions of trauma

37

TREM Components

Advanced Trauma Recovery– Explore practical coping, problem solving, and skill-building strategies – Topics include communication style, decision-making, managing out-of-control feelings,

developing safer relationshipsTREM addresses substance abuse throughout the intervention. Skills such as self-awareness, self-soothing, emotional modulation, development of safe and mutual relationships, and consistent problem solving are aimed at active substance abuse treatment and relapse prevention.

38

Support for TREM

Quasi-experimental studies (Amaro et. al., n.d.; Fallot, McHugo, & Harris, 2005; Toussaint, VanDeMark, Bornemann, & Graber, 2007)

Severity of problems related to substance abuse– TREM participants showed significantly greater decreases in drug addiction

severity at 6- and 12-month follow-ups than those receiving usual care; significant improvements in alcohol addiction severity

– Mean alcohol and drug problem severity scores decreased from baseline to 1-year follow-up, relative to recipients of alternative care

Psychological problems/symptoms– TREM participants showed significantly reduced symptoms of psychological

problems 1 year after the intervention

Trauma symptoms– At 12-month follow-up, trauma symptoms were significantly reduced among

TREM participants compared with recipients of alternative care.

39

Implementing TREM

• Female co-leaders (male leaders in men’s group)• TREM manual available from Community Connections or

in bookstores– Harris, M. (1998). Trauma Recovery and Empowerment: A

Clinician’s Guide for working with women in groups. New York: The Free Press.

• Training available from developers, designed for 2 trainers and up to 40 participants

• More info on TREMRebecca Wolfson Berley, M.S.W.

rwolfson@communityconnectionsdc.org www.communityconnectionsdc.org

40

Seeking Safety

• Seeking Safety is a present-focused therapy designed to promote safety and recovery for individuals with PTSD and substance abuse as well as those who have trauma histories but who do not meet clinical criteria for PTSD.

• Based on 5 key principles:– Safety is the primary goal– Work on PTSD/trauma and substance abuse at the same time– Focus on ideals to counteract the loss of ideals from the experiences of

PTSD/trauma and substance abuse– Address cognitive, behavioral, interpersonal, and case management

areas of client functioning– Focus on clinician processes (e.g., helping clinicians work with

countertransference issues)

41

Seeking Safety Facts

• Population – adults and adolescents (male and female) with PTSD/trauma and substance abuse disorders

• Sessions – 25 weekly 50-90 minute sessions (or twice weekly), group or individual formats

• Setting – substance abuse treatment (OP, residential), correctional facilities, health and mental health centers

42

Seeking Safety Components

• There are 25 components roughly equally divided between cognitive, behavioral, and interpersonal domains. Below is a sample of topics:

Safety Recovery thinkingTaking back your power Creating meaningGrounding Community resourcesWhen substances control you Setting boundaries in relationshipsAsking for help Coping with triggersSelf-nurturing Healing from anger

43

Seeking Safety Components

No exposure – considered later stage of treatment– risk of painful memories triggering

substance use in misguided attempt to cope– could trigger others if in group format

44

Support for Seeking Safety

• Evidence base of published studies - 6 pilot studies, 4 randomized controlled trials (RCTs), 1 controlled nonrandomized trial, 2 multisite controlled trials, and 1 dissemination study

• Populations - men, women, veterans, adolescents, homeless, and criminal justice

• All outcome studies evidenced positive outcomes (decreased trauma symptoms, decreased substance abuse, improvements in other areas such as HIV risk, suicidal symptoms, problem solving, social functioning, and sense of meaning).

• In the controlled trials, Seeking Safety typically outperformed the comparison condition.

45

Implementing Seeking Safety

• Seeking Safety has been implemented by counselors (M.A. level, B.A. level, case managers), social workers, and psychologists

• Seeking Safety manual– Najavits, L.M. (2002). Seeking Safety: A Treatment Manual for

PTSD and Substance Abuse. New York: Guildford.• Training

– Individualized to specific needs of clinic– Via videos, on-site, existing training, telephone consultation

• More info on Seek Safety– Contact Lisa Najavits (info@seekingsafety.org)– http://www.seekingsafety.org

46

Information on Other Models

National Child Traumatic Stress Network http://www.nctsn.org

National Center for Trauma-Informed Care http://www.samhsa.gov/nctic/

Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services – 2008 Update http://www.theannainstitute.org/Models%20for%20Developing%20Traums-Report%201-09-09%20_FINAL_.pdf