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Factors Related to the Delivery of Trauma Services in Outpatient Treatment Programs



In recent years there has been growing recognition of the role of trauma in substance abuse treatment; however, only 20% of outpatient treatment programs report offering trauma services. We conducted a secondary analysis of the 2012 National Survey of Substance Abuse Treatment Services (N-SSATS) and explore how demographic, population served, and organization variables distinguish those programs that offer trauma services from those that do not. In this article, we present the findings, which revealed that organizational structure, process, and population served variables were the most important predictors of trauma services. Implications for social work practice in the addictions are discussed.
Journal of Social Work Practice in the Addictions, 15:114–129, 2015
Copyright © Taylor & Francis Group, LLC
ISSN: 1533-256X print/1533-2578 online
DOI: 10.1080/1533256X.2014.996230
Factors Related to the Delivery of Trauma
Services in Outpatient Treatment Programs
Professor, National Catholic School of Social Service, The Catholic University
of America, Washington, DC, USA
Director, Center for Behavioral Health Statistics and Quality, Substance Abuse
and Mental Health Services Administration, Rockville, Maryland, USA
Project Director, Center for Behavioral Health Statistics and Quality, Substance
Abuse and Mental Health Services Administration, Rockville, Maryland, USA
In recent years there has been growing recognition of the role
of trauma in substance abuse treatment; however, only 20% of
outpatient treatment programs report offering trauma services.
We conducted a secondary analysis of the 2012 National Survey
of Substance Abuse Treatment Services (N-SSATS) and explore how
demographic, population served, and organization variables dis-
tinguish those programs that offer trauma services from those that
do not. In this article, we present the findings, which revealed that
organizational structure, process, and population served variables
were the most important predictors of trauma services. Implications
for social work practice in the addictions are discussed.
KEYWORDS organization process, organization structure, outpa-
tient programs, populations served, trauma services
In recent years there has been an increased recognition of the impact of
trauma on substance use disorders and the need to include trauma ser-
vices for those enrolled in substance abuse treatment programs (Substance
Received September 17, 2014; revised November 12, 2014; accepted December 4, 2014.
Address correspondence to Joseph J. Shields, National Catholic School of Social Service,
The Catholic University of America, Shahan Hall, 620 Michigan Ave., N.E., Washington, DC
20064, USA. E-mail:
Delivery of Trauma Services in Outpatient Treatment 115
Abuse and Mental Health Services Administration [SAMHSA], 2014). Data
from both epidemiological public health surveys and studies of clients and
treatment programs document a relationship between exposure to trau-
matic events and increases in substance use suggesting that such exposure
might put individuals at increased risk for the development of substance
use disorders (Davidson, Hughes, Blazer, & George, 1991; Farley, Golding,
Young, Mulligan, & Minkoff, 2004; Fetzner, McMillan, Sareen, & Asmundson,
2011; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). National pop-
ulation estimates suggest that the majority of individuals seeking substance
abuse treatment receive services in outpatient settings (SAMHSA, 2013b). Yet,
results from the National Survey of Substance Abuse Treatment Services (N-
SSATS), the national survey of all known substance abuse treatment facilities,
reveal that only approximately 20% of outpatient treatment programs report
specifically offering trauma-related services to their clients (SAMHSA, 2013a).
This percentage is similar to the findings reported by Capezza and Najavits
(2012), who found that 21.3% of all reporting treatment programs offered
trauma services always or often.
Given this documented need, why is it that the majority of treat-
ment providers are not explicitly incorporating trauma services into their
treatment practice? Rogers’s (2003) work on the diffusion of innovative tech-
nologies in organizations has served as the foundation for a growing body
of research looking at the adoption of evidence-based technologies across
a number of service settings. In the substance abuse treatment literature
a number of studies have examined organizational factors that relate to
the adoption of pharmacotherapy interventions (Abraham & Roman, 2010;
Ducharme, Knudsen, Roman, & Johnson, 2007), contingency management
(Bride, Abraham, & Roman, 2011), other treatment innovations (Knudsen &
Roman, 2004; Simpson, 2002), and comprehensive services (Delany, Shields,
& Roberts, 2009). Bride et al. (2011) noted that there are relatively few studies
that focus on the adoption of psychosocial innovations in outpatient treat-
ment settings. The purpose of this study is to address the gap in research on
psychosocial interventions for trauma by examining selected demographic
variables, types of populations served, and organizational variables associ-
ated with the adoption of trauma services in outpatient substance abuse
treatment facilities.
Trauma Services
Innovations in the development of trauma services emerged out of a long
history within the helping professions that sought to understand and address
psychological trauma. Within the last two decades, the trauma-informed care
116 J. J. Shields et al.
paradigm has emerged to describe approaches to address trauma from an
organizational and systemic perspective (SAMHSA, 2014).
From as early as 440 BC, literature demonstrates an awareness of the
psychological sequelae resulting from exposure to traumatic events and
evolving treatment efforts (Crocq & Crocq, 2000; Van der Kolk, 2007).
The current paradigm for understanding and addressing these sequelae is
captured by the 1980 inclusion of the diagnosis of posttraumatic stress disor-
der (PTSD) in the Diagnostic and Statistical Manual of Mental Disorders
(3rd ed. [DSM–III]; American Psychiatric Association, 1980). As research
has progressed, revisions to the diagnosis have been made. Over the
years, researchers, health and mental health professionals, and practition-
ers seeking to understand trauma developed and tested numerous specific
treatments for trauma. Studies have shown success with treatments such as
cognitive-behavioral therapy (CBT), prolonged exposure therapy (PE), stress
inoculation therapy (SIT), and eye movement desensitization and reprocess-
ing (EMDR; SAMHSA, 2014). As these treatments emerged to alleviate the
debilitating effects of trauma, researchers also were assessing the role the
overall organizational structure and treatment systems play in the healing and
recovery process (Harris & Fallot, 2001). For example, in their book, Using
Trauma Theory to Design Service Systems, Harris and Fallot (2001) articulate
the important role treatment systems play in preventing the retraumatization
of clients.
Populations Served
The research literature indicates that members of specific cultural and ethnic
racial groups have higher rates of trauma exposure. For example, Roberts,
Gilman, Breslau, Breslau, and Koenen (2011) found that African American
men were significantly more likely than White men to have been violently
assaulted. In the same study, African American men were significantly more
likely than White men to have PTSD at some point in their lives. There is
also research evidence that suggests that Latinos have higher rates of PTSD
than African Americans and Whites (Pole, Gone, & Kulkarni, 2008).
The research evidence indicates that men are more likely than women
to experience a traumatic event (Olf, Langeland, Draijer, & Gersons, 2007).
However, women are more likely than men to experience intimate partner
violence and sexual assault (Pratchett, Pelcovitz, & Yehuda, 2010). There is
also evidence that women exposed to trauma tend to develop prolonged
PTSD (Holbrook, Hoyt, Stein, & Sieber, 2002).
Besides these ethnic, racial, and gender differences in trauma exposure,
there is evidence that people with other unique characteristics or experiences
have high rates of exposure to trauma. These include people with cogni-
tive or physical disabilities (Petersilia, 2001), homeless people (Greenberg &
Delivery of Trauma Services in Outpatient Treatment 117
Rosenheck, 2010), veterans (Kimerling et al., 2010), older people (Truman,
2011), and refugees (Nickerson, Bryant, Silove, & Steel, 2011).
These findings highlight the need for substance abuse treatment
providers to have a thorough understanding of the unique needs of the
clients they serve. For example, programs that serve large numbers of women
should be attuned to issues of intimate partner violence and sexual assault,
whereas programs that serve veterans and refugees need to have an under-
standing of the effects of exposure to combat and war in designing treatment
Organizational Variables
In response to the research to practice gap (Lamb, Greenlick, & McCarty,
1998), a significant number of addiction health services research studies
have focused on factors that can help explain the resistance to the adop-
tion of evidence-based treatment practices that most treatment facilities
exhibit (Roman & Johnson, 2002). To understand how treatment programs
adopt innovative practices, researchers have conducted case studies of the
technology transfer in individual treatment programs (Liddle et al., 2002;
Martin, Herie, Turner, & Cunningham, 1998). Studies have also focused
on the characteristics of the clinical workforce (Ball et al., 2002; Forman,
Bovasso, & Woody, 2001: Knudsen, Ducharme, Roman, & Link, 2005).
Other researchers have focused on organizational structures and processes
to understand the adoption of treatment innovations (Rosenheck, 2001;
Simpson, 2002). In attempting to understand the organizational charac-
teristics related to the adoption of naltrexone in private substance abuse
treatment programs, Roman and Johnson (2002) studied factors such as own-
ership, size, leadership, and caseload characteristics. In a similar study on
the adoption of buprenorphine in treatment programs, Knudsen, Ducharme,
and Roman (2006) studied organizational factors such as ownership, size,
accreditation, and staffing characteristics. In a study on the adoption of
psychosocial innovations (e.g., contingency management), Bride, Abraham,
and Roman (2010) studied structural factors such as ownership, size, and
To further the understanding of organizational processes and the adop-
tion of innovation in treatment programs Knudsen and Roman (2004)
introduced the concept of absorptive capacity, defined as the ability of an
organization to access and effectively use information. The concept has been
used by organizational theorists to explain the adoption of new technologies
and services in a variety of industries (Knudsen & Roman, 2004). They stated,
“organizations with greater information processing and application capabil-
ities are more likely to use innovations” (Knudsen & Roman, 2004,p.51).
They then model the relationship between absorptive capacity and the use
118 J. J. Shields et al.
of treatment innovations by focusing on workforce professionalism, envi-
ronmental scanning, and the collection of satisfaction data. Although these
are clearly important dimensions of absorptive capacity, other factors such
as internal and external case review practices, as well as periodic utilization
review, are important learning strategies for treatment facilities.
The research literature indicates the importance of including organiza-
tional structure and process variables, as well as variables related to client
characteristics and populations served, in developing models explaining the
adoption of treatment innovations for substance abuse treatment programs.
In this study we use data derived from a national survey of substance
abuse treatment facilities to assess the extent to which selected demographic
variables, population served variables, and organizational structure and pro-
cess variables predict the extent to which treatment programs incorporate
trauma-informed services into practice.
Data Source
This study employed a secondary analysis of the 2012 N-SSATS. The N-
SSATS is an annual survey conducted by SAMHSA of all known substance
abuse treatment programs in the United States and its jurisdictions (SAMHSA,
2013a). The survey collects data about facility characteristics, number of
clients served, types of services provided, and the availability of programs
for specific populations. No information is obtained directly from clients. The
surveys were sent to the facilities administrators and were completed by the
administrators or their designees.
In 2012 the N-SSATS collected data from a total of 14,311 substance
abuse treatment facilities. For this study, we selected only those facilities that
offered substance abuse treatment services and those whose primary focus
was substance abuse treatment. This eliminated programs that only provided
intake or referral services, and those that provided only detoxification ser-
vices. It also eliminated those programs whose primary focus was mental
health services or general health care. We further pared down the sample by
selecting only those programs that were either regular or intensive outpatient
treatment programs. This eliminated the hospital inpatient programs, residen-
tial programs, and methadone programs. We also eliminated those programs
not located in the 50 states or the District of Columbia. This process resulted
in a final sample of 4,762 facilities or 33% of the original data set.
Delivery of Trauma Services in Outpatient Treatment 119
The questionnaire included a list of therapeutic approaches that are used
in substance abuse treatment. The respondents were asked to rate each
in terms how often the approach was used in their facility. For this
analysis we selected the “trauma-related counseling” item and coded the
responses so that never, rarely, or sometimes equaled 0 and always or often
equaled 1.
Two demographic characteristics were included in the analysis. Region of the
country was categorized as the Northeast, Midwest, South, and West. The
second variable was a measure of urbanicity. The location of each facility
was rated on a 6-point scale from least urban to most urban. The rating scale
was developed by the National Center on Health Statistics and is commonly
used in national health surveys (Ingram & Franco, 2013).
The questionnaire asked the respondents to report on the types of clients
accepted into treatment and whether the facility offered specifically designed
programs for the population. For this analysis we selected six groups that
often present themselves in treatment with trauma-related issues. These
groups included adolescents, people with cooccurring mental and substance
use disorders, criminal justice clients, adult women, pregnant women, and
veterans. Organizations that reported having programs for these groups were
scored 1 and those that did not have programs were scored 0.
The organizational variables that were included in this study were own-
ership, size, financing characteristics, accreditation, and absorptive capacity.
Ownership was a dichotomous variable that contrasted not-for-profit facilities
with for-profit facilities. Organizational size was measured by the total num-
ber of clients who received intensive or regular outpatient services during
March 2012. The distribution was recoded into five quintiles. Three financ-
ing variables were included in the analysis: Did the facility use a sliding
fee scale? Did the facility offer treatment at no charge to clients? Did the
facility receive any government funding or grants? The responses to these
three items were coded so that yes equaled 1 and no equaled 0. Two
accreditation measures were included in the analysis: whether the facility
was accredited by the Joint Commission on the Accreditation of Health Care
120 J. J. Shields et al.
Organizations (JCAHCO), and whether the facility was accredited by the
Council on Accreditation (COA).
Absorptive capacity, defined as an organization’s capacity to access and
effectively use information (Knudsen & Roman, 2004), was measured by the
responses to whether or not the following practices were part of the stan-
dard operating procedures of the facility: (a) required continuing education
for staff, (b) conducted periodic drug testing of clients, (c) regularly sched-
uled case reviews with a supervisor, (d) conducted case reviews by a quality
review committee, (e) conducted outcome follow-up of discharged clients,
(f) conducted periodic utilization review, and (g) conducted client satisfac-
tion surveys. Each of these practices was scored 1 if the facility reported
yes for the procedure and 0 if the facility reported no. This resulted in an
additive scale ranging from 0 to 7.
All statistical analyses were conducted using IBM SPSS software (version
21.0). For the descriptive analysis we conducted cross-tabulations on the
dependent variable (trauma services) with each of the demographic, popu-
lation served, and organizational variables. The chi-square test (p<.05) was
used to test for significant relationships between variables.
To determine if any of the independent variables were collinear, a zero-
order correlation analysis was conducted on the interrelationships of all of
the independent variables (not shown because of space considerations).
None of the relationships exceeded r=.50, indicating that multicolinearity
was not an issue.
For the multivariate analysis we conducted a step-wise binary logistic
regression. In this analysis we regressed the dichotomous dependent variable
(trauma services) on the demographic variables (Step 1), on the population
served variables (Step 2), and then on the organizational variables (Step 3).
This allowed us to assess the relative influence of each set of variables in
predicting trauma services.
The results of the descriptive analyses are contained in Table 1. The findings
indicate that overall approximately one fifth (19.6%) of outpatient substance
abuse treatment programs provide trauma services. Region of the country
was statistically significant, showing that fewer programs in the Midwest
offered trauma services. There were no differences between urban and rural
areas in the provision of trauma services.
All of the population served variables were significantly related to the
provision of trauma services, with the strongest being veterans (34.6%),
Delivery of Trauma Services in Outpatient Treatment 121
TABLE 1 Characteristics of Outpatient Substance Abuse Treatment Facilities by the
Availability of Trauma Services
Trauma services
Never or rarely Always or often
Facility characteristics N%N%
Total 3,828 80.4 934 19.6
Northeast 817 79.4 212 20.6
Midwest 934 83.0 191 17.0
South 1,008 80.8 240 19.2
West 1,069 78.6 291 21.4
Rural 1,924 80.9 454 19.1
Urban 1,904 79.9 480 20.1
Populations served
Adolescents1,081 78.1 304 21.9
Cooccurring conditions938 69.5 411 30.5
Criminal justice906 77.2 268 27.8
Adult women1,225 71.0 500 29.0
Pregnant women552 72.6 208 27.4
Vete rans 149 65.4 79 34.6
Not-for-profit 2,094 75.7 671 24.3
For profit 1,734 86.8 263 13.2
Small 1,546 79.4 401 20.6
Medium 721 79.6 185 20.4
Large 1,561 81.8 348 18.2
Uses sliding fee2,315 77.5 674 22.5
Offers free treatment1,527 74.7 518 25.3
Receives government funds1,918 75.0 638 25.0
JCAHCO573 77.4 167 22.8
COA 149 77.2 44 22.8
Absorptive capacity
Low 852 89.8 97 10.2
High 2,976 78.0 837 22.0
Note: JCAHCO =Joint Commission on the Accreditation of Health Care Organizations; COA =Council
on Accreditation.
people with cooccurring conditions (30.5%), adult women (29.0%), and
pregnant women (27.4%).
The organizational variables that were significantly related to the provi-
sion of trauma services included ownership, financing, accreditation, and
absorptive capacity. Not-for-profit agencies were more likely to provide
trauma services (24.3% vs. 13.2%). Programs that used a sliding fee (22.5%),
offered free treatment (25.3%), and received government funds (25.0%) were
all more likely to provide trauma services. The facilities that reported being
122 J. J. Shields et al.
TABLE 2 Logistic Regression of Trauma Services on Demographic, Populations Served, and
Organizational Characteristics
Step 1 Step 2 Step 3
Northeast .951 .759.649
Midwest .773.796.613
South .898 .907 .812
Urbanicity 1.0481.047 1.062
Populations served
Adolescents 1.084 .963
Cooccurring 1.9271.844
Criminal justice .847 .809
Adult women 2.0241.836
Pregnant women 1.031 1.065
Veterans 1.3881.434
Organizational characteristics
Ownership .766
Size .858
Sliding fee 1.146
Free treatment 1.286
Government funds 1.593
JCAHCO 1.310
COA 1.095
Absorptive capacity 1.488
Constant .220.136.013
Model chi-square 12.571230.059462.269
Nagelkerke R2.004 .075 .147
Note: OR =odds ratio; JCAHCO =Joint Commission on the Accreditation of Health Care Organizations;
COA =Council on Accreditation.
aFor region the reference category is West.
accredited by JCAHCO were more likely to provide trauma services (22.6%).
Being accredited by COA was not significantly related to the provision of
trauma services. Absorptive capacity was significantly related to the provi-
sion of trauma services; those that were high on absorptive capacity were
more than twice as likely to provide trauma services (22.0% vs. 10.2%).
Table 2 contains the findings from the step-wise logistic regression
analysis. On the first step, the demographic variables of region of the coun-
try and urbanicity were entered. The findings show that programs in the
Midwest and those in more rural locations were less likely to offer trauma
services. Although the model is statistically significant (χ2=12.571), it is not
particularly strong (Nagelkerke R2=.004).
The second step included the demographic variables and the population
served variables. The model is statistically significant (χ2=230.089) and
explains approximately 7.5% of the variation in trauma services. The findings
show that facilities that have programs dedicated to serving adult women
Delivery of Trauma Services in Outpatient Treatment 123
are more than twice as likely to provide trauma services (OR =2.024).
The findings also show that facilities with programs specifically for people
with cooccurring disorders (OR =1.927) and programs for veterans (OR =
1.388) are also more likely to provide trauma services.
The final step in the analysis included adding the organizational vari-
ables. This step was statistically significant (χ2=462.269) and explains 14.7%
of the variation in the provision of trauma services. The findings show that
not-for-profit facilities are 24% more likely to provide trauma services (OR =
.766) and that smaller programs are 15% more likely to provide trauma ser-
vices (OR =.858). Facilities that offer free services are about 1.3 times more
likely and those that accept government funds are 1.6 times more likely
to provide trauma services. Facilities that are accredited by JCAHCO are
1.3 times more likely to provide trauma services. The findings related to
absorptive capacity are quite strong: For every unit increase in absorptive
capacity, there is a 48.8% increase in the probability of providing trauma
care. Those facilities that score the highest on absorptive capacity are approx-
imately 3.5 times more likely to provide trauma services than those that score
at the lowest level of absorptive capacity.
Overall the findings from the final model confirmed most of the findings
from the preliminary analyses. Facilities located in the West as compared
to the Midwest and Northeast and those located in more urban areas
are more likely to provide trauma services. Also, facilities that offer pro-
grams specifically for people with cooccurring conditions, women, and
veterans are more likely to provide trauma-related services. Facilities that
provide programs for criminal justice clients are less likely to provide trauma
There is convincing evidence of the cooccurrence of substance use disor-
ders and trauma among treatment populations. In fact, 62% of substance
abuse treatment facilities provide brief mental screenings that can be used to
identify individuals in need of trauma services (SAMHSA Office of Applied
Studies, 2010). However, only 19.7% of treatment facilities indicate that they
“always” or “often” provide trauma services. It remains unclear why there is
such low adoption of trauma services given the past two decades of research
showing the high correlation between substance use disorders and trauma
histories. Bride et al. (2011) noted that research on innovations in treatment
for substance use disorders indicates that the adoption of such practices are
often partially implemented focusing on specific subpopulations within the
facility. This would seem to be supported by the results of this study that
found programs that serve veterans, people with cooccurring disorders, and
women were much more likely to provide trauma services.
124 J. J. Shields et al.
Dass-Brailsford and Myrick (2010) identified a number of barriers that
might limit the integration of trauma and substance abuse services. These
include barriers at the clinical, organizational, and screening and assess-
ment levels. Among the clinical barriers, the authors noted that clinicians
might lack awareness of the role of trauma in the substance abuse treatment
population and thus could fail to regularly screen or inadequately screen
for trauma or PTSD (Ouimette, Brown, & Najavits, 1998; Read, Bollinger, &
Sharkansky, 2003). Likewise, individuals seeking treatment might minimize
symptoms to increase chances for treatment entry or to guard against other
perceived discrimination. Finally, theoretical and philosophical approaches
might view the substance use as the primary problem to be addressed and
maintain that mental health issues such as trauma or PTSD should not be
addressed until after abstinence is achieved (Brown, 2000).
From an organizational perspective, one possible explanation for the
low level of adoption is the dearth of research about which models of
integrated trauma treatment are most effective (Dass-Brailsford & Myrick,
2010). As a result, to recognize intervention services with a strong evi-
dence base that can be implemented within a specific program or practice
setting requires significant skills in terms of assessing cost, training require-
ments, fit with program and provider orientation, the setting, and the service
population (SAMHSA, 2014). Organizations with limited resources and low
absorptive capacity might not identify a need or a benefit in adopting trauma
services or adopting a trauma-informed approach to care.
Another possible explanation for failure to adopt trauma services in
outpatient substance abuse treatment might have to do with the pro-
gram’s organizational philosophy. Essentially, if the norms and values of
the program establish the substance use disorder as the paramount problem,
whether or not this view is endorsed by the clinical staff, abstinence could be
viewed as the main clinical goal with cooccurring trauma issues as secondary
(Harris & Fallot, 2001). If and when abstinence is achieved, the program
could begin to address trauma as a recovery maintenance intervention or it
might refer to a mental health facility.
The results also help provide additional insight into the way programs
might have chosen to adopt trauma services. In this study, organizations that
served individuals with cooccurring disorders, adult women, and veterans,
who are often identified in the mainstream media as requiring PTSD treat-
ment, were more likely to adopt trauma services. This could be a reflexive
response by organizations that serve specific populations or, in some cases,
a more proactive organizational strategy to develop services to target these
specific populations. Consistent with previous research on characteristics of
treatment, financing and accreditation were found to influence the adoption
of trauma services. Programs that offered free treatment, received govern-
ment funding, and met JCAHCO accreditation standards were more likely
to provide trauma services. Here, the population served and organizational
Delivery of Trauma Services in Outpatient Treatment 125
characteristics might be the prime influence on the values and norms of
these organizations, which in turn could influence the receptivity of the orga-
nization and staff to adopt trauma services to meet the needs of the client
population (Rogers, 2003).
Consistent with our expectations, organizations that regularly gathered
and utilized information to assess program effectiveness were about one
and a half times more likely to adopt trauma services than those that did
not. One explanation is that organizations that have stronger communication
ties with other organizations are exposed to more information regarding
trauma, PTSD, and the cooccurrence of substance use disorders. As a result,
these programs might be making treatment decisions based on information
gathered from other substance abuse treatment agencies. Thus, increased
absorptive capacity, defined as the ability of an organization to access and
effectively use information, enhances the buy-in and cooperation of both
management and clinical staff and could enhance overall implementation of
services to address trauma and PTSD among their clients.
In evaluating the results of this study, its limitations must be kept in mind.
First, the information on organizational characteristics and services is based
on self-report and is by its nature subject to reporting error. Second, the N-
SSATS is a point-prevalence survey so certain characteristics such as facility
size represent a snapshot of outpatient treatment facilities on a specific ref-
erence date rather than an annual average. Although the survey attempts to
capture information from all known treatment facilities, it is voluntary, and
does not adjust for the 7% facility nonresponse. Further, as noted earlier, the
information about trauma services is limited to reported frequency of use
and does not provide information on additional principles involved in many
multidimensional definitions of trauma-informed care, the reasons for adopt-
ing or implementing models, or the extent of the populations that receive
trauma services. Further research on the level of integration of trauma ser-
vices into standard practice, including the level of training and sustained
supervision, would help to illuminate the impact on values, norms, and
implementation within treatment settings. Research that focuses on identify-
ing the trauma-informed care models or elements of models that work best
across a variety of organizational types is needed to help inform treatment
programs’ planning and strategies for implementation. Also, because the
study was a secondary analysis of data, we were limited to what was asked in
the original study. For example, factors related to workforce education and
credentials (Knudsen & Roman, 2004), as well as caseload characteristics
(Roman & Johnson, 2002), have been shown to be related to the adoption
of innovations. We were not able to access data on these crucial factors.
126 J. J. Shields et al.
Research that examines the administrative decisions that influence the moti-
vation for offering trauma services in substance abuse treatment programs
can lead to a better understanding of the role that absorptive capacity plays
in identifying, adopting, and implementing innovative treatment protocols.
It is important that new treatments not be implemented for implementation’s
sake, but that the decisions to adopt innovative services reflect the norms
and values of the social work profession. This is clearly relevant for the
implementation of trauma services.
Another area that warrants attention is the training of social work prac-
titioners and managers who are on the front lines of treatment. Delany and
colleagues (2009) noted that in the last two decades there has been increased
attention to accountability in service organizations, resulting in increased
emphasis on less intensive services and the adoption of interventions with
a strong evidence base. This trend has not diminished under the Patient
Portability and Affordable Care Act (ACA). The training of social workers
to become trauma-informed providers of substance abuse treatment is crit-
ical for the further development of innovations in treatment. This training
of social workers in trauma-informed care has the potential for positively
impacting the program philosophies, and thus the treatment procedures of
substance abuse treatment programs.
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... SUD organizations' engagement with TIC appears limited. Though current rates may be higher, data from the National Survey of Substance Abuse Treatment Services (NSSTS) indicate that in 2012, 20% of US SUD treatment facilities addressed trauma "always or often" (Shields et al., 2015). Addressing trauma is associated with provision of specialized services for co-occurring disorders and specialized services for women and military veterans (Shields et al., 2015), suggesting adoption may be driven by client needs. ...
... Though current rates may be higher, data from the National Survey of Substance Abuse Treatment Services (NSSTS) indicate that in 2012, 20% of US SUD treatment facilities addressed trauma "always or often" (Shields et al., 2015). Addressing trauma is associated with provision of specialized services for co-occurring disorders and specialized services for women and military veterans (Shields et al., 2015), suggesting adoption may be driven by client needs. NSSTS data do not allow for distinction between organizations using TIC and a trauma services approach. ...
... Proponents of integrated trauma and SUD intervention note multiple barriers (Shields et al., 2015). Clinicians may perceive co-occurring PTSD and SUD as more difficult to treat than either issue individually (Najavits, 2002) or be uncertain about which to address first (Back et al., 2009, Blakey & Bowers, 2014. ...
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Purpose Intimate partner violence (IPV) and substance use disorder (SUD) frequently co-occur and are rarely addressed together despite evidence indicating benefits of combined interventions. Both are linked to trauma. Scholars have theorized attention to trauma may facilitate engagement with IPV and SUD but have not studied this potential empirically. Methods Using service system level quantitative data on organizations focused on IPV or SUD (n = 281) in a midwestern city in the United States and semi-structured interviews with policymakers, funders, and practitioners in both areas (n = 27), this paper uses grounded theory to explore whether attention to trauma facilitates attention to IPV and SUD. Results While quantitative data suggest addressing trauma and both IPV and SUD are associated at the service system level, analysis of interview data indicates greater complexity. Despite consensus on trauma-informed care’s potential, competing understandings of temporality (when trauma occurs in relation to IPV or SUD), different liabilities associated with addressing trauma, and different intervention approaches combine to limit engagement by both IPV and SUD organizations. Rather than adopting trauma-informed care, both types of organizations more typically engage trauma selectively, offering discrete services rather than holistic intervention. Findings have implications for addressing co-occurring IPV, SUD, and trauma and for practice, policy, education, and research. Conclusions There is need for greater consensus about what it means to address trauma, increased investments in practitioner education and training around intersections of IPV, SUD, and trauma, and additional supports to incentivize movement from a trauma services approach towards meaningful implementation of trauma-informed care.
... When a jurisdiction does decide to implement traumafocused screening, a crucial factor to consider early in the process is what will happen after adolescents complete the trauma-focused screening. Although this may seem like a task to tackle farther along in the implementation process, an evaluation of the accessibility of trauma-focused and other mental health services within the JLS and the local community as early as possible is fundamental, as there is a shortage of providers trained in evidence-based treatments for posttraumatic stress (Shields et al., 2015). Critically, screening should only occur if the information "leads to specific actions" (Dierkhising & Branson, 2016); yet, if there are not clear procedures in place to ensure that the adolescent is linked to assessment and/or treatment referrals when appropriate, screening for traumatic event exposure and posttraumatic stress symptoms may yield little benefit for adolescents. ...
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Adolescents involved in the juvenile legal system (JLS) report high rates of traumatic event exposure and posttraumatic stress symptoms. Due to such elevated rates of exposure to potentially traumatic events and posttraumatic stress, it has been recommended that adolescents involved in the JLS receive access to trauma-focused screening upon each contact with the system. Implementing trauma-focused screening within the JLS raises several considerations for systems who have yet to implement this evidence-based practice. This article applies the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework to discuss important decisions and potential ethical issues that arise when trauma-focused screening is implemented within the JLS, from the initial planning stages, to implementation, to long-term sustainment. This article discusses decision points that JLS leadership and administrators must consider when determining whether to implement trauma-focused screening or in the initial stages of implementation, as well as several practical suggestions for individual practitioners who work within the JLS, including clinical and non-clinical staff.
... Across all three jurisdictions, there remained no introduction of trauma-informed care or mention of trauma-specific training for African-American populations signaling a need for more culturally relevant policies. Shields et al. (2015) concluded that treatment could impact the trauma recovery process through the role of organizational structure. Organizational policies determine how organizations serve clients with baseline standards that should be implemented across settings. ...
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African-Americans have a greater likelihood to experience psychological distress as compared to other racial populations; however, they are less likely to seek mental health treatment. Their prolonged and cumulative experiences of racism and discrimination create barriers to treatment services, which negatively impact mental health treatment outcomes. Research suggests that there is a need for more culturally competent treatment to strengthen treatment outcomes within African-American communities. Social work field education coins itself as the pedagogy of social work education. It becomes the role of social work field education to prepare new practitioners to address the unique needs of vulnerable populations and begin to bridge the gap in current inequities in mental health treatment. A content analysis was conducted to examine policies, specifically related to outpatient treatment regulations. Policy documents were collected from Maryland, Virginia, and the District of Columbia and surveyed according to appropriateness and effectiveness in providing mental health services to African-Americans. The results showed an emphasis on licensing requirements for treatment facilities and standard treatment practices. There was a deficiency in requirements for training across all three jurisdictions, with little emphasis made for culturally competent training. Recommendations were made to strengthen organizational policies by conceptualizing practices to be more inclusive of race-based issues and trauma-informed care.
... This suggests that programs that address parental trauma may be a promising way to prevent parental substance use and ACEs. Research has demonstrated a consistent relationship between trauma and substance use (Shields et al., 2015;Wolf et al., 2015) and that integrating trauma-informed care into substance use treatment may be a promising approach for addressing substance use issues and preventing ACEs (Brown et al., 2013). Additional research is needed to demonstrate the effectiveness of integrating traumainformed care on addressing substance use and preventing ACEs using rigorous evaluation designs (e.g., randomized control trials and quasi-experimental designs). ...
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The opioid crisis is a significant challenge for health and human service systems that serve children, youth, and families across the United States. Between 2000 and 2017, the number of foster care entries, a type of adverse childhood experience (ACE), attributable to parental drug use increased by 147%. Nevertheless, there is variation in the burden of opioid overdose and foster care rates across the U.S., suggesting community supports and systems to support families affected by substance use also vary. This qualitative study sampled communities experiencing high and low rates of overdose mortality and foster care entries (i.e., a qualitative comparison group) to better understand what might protect some counties from high overdose mortality and foster care entries. The sample included six counties from three states that were selected based on their rates of opioid overdose mortality and foster care entries. Using purposive sampling within counties, interview and discussion group participants included multi-sector community partners, parents whose children had been removed due to parental substance use, and caregivers caring for children who had been removed from their homes. Across all counties, prevention was not front-of-mind. Yet, participants from communities experiencing high rates of overdose mortality and foster care entries identified several factors that might help lessen exposure to substance use and ACEs including more community-based prevention services for children and youth. Both parents and caregivers across all communities also described the need for additional supports and services. Participants also described the impact of COVID-19 on services, including greater utilization of mental health and substance use treatment services and the challenges with engaging children and youth on virtual platforms. The implications for prevention are discussed, including the need to encourage primary prevention programs in communities.
... Another question for future research is where youth offenders should receive treatment. Many communities face a shortage of mental health providers, particularly those trained in evidencebased treatments for posttraumatic stress (Courtois & Gold, 2009;Shields, Delany, & Smith, 2015; U.S. Department of Health and Human Services, 2015). One study found that probation officers working in counties with a shortage of mental health providers were significantly less likely to refer youth on their caseload for treatment (Wasserman et al., 2008). ...
Social workers along with other practitioners and researchers in the substance misuse treatment field have long recognized the connection between substance use and interpersonal violence. However, fewer than 40% percent of outpatient treatment programs report offering groups or programs specially designed to meet the needs of clients who experienced interpersonal violence. We conducted a secondary analysis of the 2017 National Survey of Substance Abuse Treatment Services (N-SSATS) to explore how demographic, population served, and organizational variables distinguished those programs that offered programs or groups specifically tailored for clients who have experienced interpersonal violence from those programs that did not. In this article, we present findings which revealed that programs that served individuals at substantial risk and programs that provided counseling and trauma and anger management services were more likely to provide specifically designed interpersonal violence programs or groups. Implications for social work practice in the addictions are discussed.
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Rates of violence and abuse perpetrated on people with developmental disabilities (e.g., mental retardation, autism) appear significantly higher than for people without these disabilities. Few of these crimes get reported to police, and even fewer are prosecuted because officials hesitate to pursue cases that rely onthe testimony of a personwith a developmental disability. The author offers several conceptual models to explain their differential victimization risk, including routine activities theory, dependency-stress model, cultural stereotyping, and victim-learned compliance. This article summarizes the research evidence on crimes against children and adults with developmental disabilities. It is divided into four sections. The first section describes the nature and extent of crimes against individuals with developmental disabilities. The second reviews the literature onrisk factors associated with their victimization. The third discusses the manner in which justice agencies respond to these crimes. The final section enumerates what research and policy initiatives might address the problem.
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This report details the National Center for Health Statistics' (NCHS) development of the 2006 NCHS Urban-Rural Classification Scheme for Counties and provides some examples of how the scheme can be used to describe differences in health measures by urbanization level. The 2006 NCHS urban-rural classification scheme classifies all U.S. counties and county-equivalents into six levels--four for metropolitan counties and two for nonmetropolitan counties. The Office of Management and Budget's delineation of metropolitan and nonmetropolitan counties forms the foundation of the scheme. The NCHS scheme also uses the cut points of the U.S. Department of Agriculture Rural-Urban Continuum Codes to subdivide the metropolitan counties based on the population of their metropolitan statistical area (MSA): large, for MSA population of 1 million or more; medium, for MSA population of 250,000-999,999; and small, for MSA population below 250,000. Large metro counties were further separated into large central and large fringe metro categories using classification rules developed by NCHS. Nonmetropolitan counties were assigned to two levels based on the Office of Management and Budget's designated micropolitan or noncore status. The 2006 scheme was applied to data from the National Vital Statistics System (NVSS) and the National Health Interview Survey (NHIS) to illustrate its ability to capture health differences by urbanization level. Application of the 2006 NCHS scheme to NVSS and NHIS data shows that it identifies important health disparities among communities, most notably those for inner city and suburban communities. The design of the NCHS Urban-Rural Classification Scheme for Counties makes it particularly well-suited for assessing and monitoring health differences across the full urbanization continuum.
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To identify sources of race/ethnic differences related to post-traumatic stress disorder (PTSD), we compared trauma exposure, risk for PTSD among those exposed to trauma, and treatment-seeking among Whites, Blacks, Hispanics and Asians in the US general population. Data from structured diagnostic interviews with 34 653 adult respondents to the 2004-2005 wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were analysed. The lifetime prevalence of PTSD was highest among Blacks (8.7%), intermediate among Hispanics and Whites (7.0% and 7.4%) and lowest among Asians (4.0%). Differences in risk for trauma varied by type of event. Whites were more likely than the other groups to have any trauma, to learn of a trauma to someone close, and to learn of an unexpected death, but Blacks and Hispanics had higher risk of child maltreatment, chiefly witnessing domestic violence, and Asians, Black men, and Hispanic women had higher risk of war-related events than Whites. Among those exposed to trauma, PTSD risk was slightly higher among Blacks [adjusted odds ratio (aOR) 1.22] and lower among Asians (aOR 0.67) compared with Whites, after adjustment for characteristics of trauma exposure. All minority groups were less likely to seek treatment for PTSD than Whites (aOR range: 0.39-0.61), and fewer than half of minorities with PTSD sought treatment (range: 32.7-42.0%). When PTSD affects US race/ethnic minorities, it is usually untreated. Large disparities in treatment indicate a need for investment in accessible and culturally sensitive treatment options.
Background: Data were obtained on the general population epidemiology of DSM-III-R posttraumatic stress disorder (PTSD), including information on estimated lifetime prevalence, the kinds of traumas most often associated with PTSD, sociodemographic correlates, the comorbidity of PTSD with other lifetime psychiatric disorders, and the duration of an index episode.Methods: Modified versions of the DSM-III-R PTSD module from the Diagnostic Interview Schedule and of the Composite International Diagnostic Interview were administered to a representative national sample of 5877 persons aged 15 to 54 years in the part II subsample of the National Comorbidity Survey.Results: The estimated lifetime prevalence of PTSD is 7.8%. Prevalence is elevated among women and the previously married. The traumas most commonly associated with PTSD are combat exposure and witnessing among men and rape and sexual molestation among women. Posttraumatic stress disorder is strongly comorbid with other lifetime DSM-III-R disorders. Survival analysis shows that more than one third of people with an index episode of PTSD fail to recover even after many years.Conclusions: Posttraumatic stress disorder is more prevalent than previously believed, and is often persistent. Progress in estimating age-at-onset distributions, cohort effects, and the conditional probabilities of PTSD from different types of trauma will require future epidemiologic studies to assess PTSD for all lifetime traumas rather than for only a small number of retrospectively reported "most serious" traumas.
The present study examines six-month treatment outcomes for substance use disordered (SUD) female patients with a comorbid diagnosis of Post-Traumatic Stress Disorder (PTSD). Patients completed a baseline assessment while receiving inpatient substance use treatment and were reinterviewed six-months post-treatment. Approximately one-half the women had relapsed on alcohol and/or drugs during the follow-up period. One-quarter had remitted from PTSD at follow-up. Logistic regressions showed that baseline severity of PTSD reexperiencing symptoms is a significant predictor of both alcohol/drug relapse and PTSD status (remitted/unremitted). No baseline measure of substance use emerged as a significant predictor of PTSD remitted/unremitted status at follow-up. Our results suggest that treatment targeting comorbid PTSD might result in improved outcomes for both disorders.
Mental health practitioners are becoming increasingly aware that they are encountering a large number of men and women who are survivors of sexual and physical abuse. An understanding of trauma, its sequelae, and the impact that it has in shaping a consumer's response to subsequent experience is essential for providers working in the human services field, regardless of whether they are asked to deliver specific services intended to address the effects of abuse. This book identifies the essential elements necessary for a system to begin to integrate an understanding about trauma into its core service programs. The basic philosophy of trauma-informed practice is examined across several specific service components: assessment and screening, inpatient treatment, residential services, addictions programming, and case management. The modifications necessary to transform a current system into a trauma-informed system and the approaches that may become contraindicated are identified. The changing roles of consumers and providers in a trauma-informed system are also discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Because ethnoracial minorities are a growing part of the U.S. population yet are underrepresented in the psychopathology literature, we reviewed the evidence for differences in prevalence and treatment of posttraumatic stress disorder (PTSD) in African Americans, Latino Americans, Asian and Pacific Islander Americans, and American Indians. With respect to prevalence, Latinos were most consistently found to have higher PTSD rates than their European American counterparts. Other groups also showed differences that were mostly explained by differences in trauma exposure. Many prevalence rates were varied by subgroup within the larger ethnoracial group, thereby limiting broad generalizations about group differences. Regarding service utilization, some studies of veterans found lower utilization among some minority groups, but community-based epidemiological studies following a traumatic event found no differences. Finally, in terms of treatment, the literature contained many recommendations for culturally sensitive interventions but little empirical evidence supporting or refuting such treatments. Taken together, the literature hints at many important sources of ethnoracial variation but raises more questions than it has answered. The article ends with recommendations to advance work in this important area.
Trauma-informed treatment increasingly is recognized as an important component of service delivery. This study examined differences in treatment-related characteristics of facilities that offer moderate or high levels of trauma-informed counseling versus those that offer no or low levels of such counseling. Responses from 13,223 substance abuse treatment facilities surveyed in 2009 by the National Survey of Substance Abuse Treatment Services (NSSATS) were used. A majority (66.6%) of facilities reported using trauma counseling sometimes or always or often. Facilities that provided moderate or high levels of trauma counseling were more likely to provide additional treatment services, such as disease testing and specialized group therapy, as well as child care, employment counseling, and other ancillary services. A majority of facilities reported provision of trauma counseling. Additional training and resources may be needed for programs that reported low rates of trauma counseling.