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Trauma and Justice Strategic
Initiative: Trauma Informed Care
& Trauma Specific Services
Larke Nahme Huang, Ph.D.
Lead, Trauma and Justice SI
Administrator’s Office of Policy Planning and Innovation
ATCC Annual Grantee Meeting
Bethesda, MD February 28, 2012
SAMHSA’S STRATEGIC INITIATIVES
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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
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 System
Purpose:
• 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 cooccurring alcohol and drug abuse problems.
• Most common reason for incarceration in jails is substance userelated 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
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• 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
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 TraumaSpecific 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 TraumaInformed 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 retraumatizing, 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 traumaspecific 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
19
4-6
mil
6-10 Million with M/SUDs
ACA & JUSTICE INVOLVED POPULATIONS
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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