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Enhancing Trauma-Informed Approaches in Behavioral Healthcare

August 11, 2017 - 01:30

Behavioral health service providers increasingly view trauma as an important element that must be addressed in providing effective services for mental and substance use disorders. Trauma may occur as a result of violence, abuse, neglect, loss, disaster, war and other emotionally harmful experiences. Left unaddressed, it may lead to long lasting effects that can compromise a person’s behavioral, emotional, cognitive, and physical health.

SAMHSA, through its Strategic Initiative on Trauma and Justice, has been a leader in identifying and supporting ways that service systems can become more attuned to trauma-related issues and skilled in responding to them.  Efforts include public education to raise awareness, prevention and early identification efforts, technical assistance for developing trauma-informed service environments, and trauma-specific treatment.

SAMHSA’s work in this area was strongly influenced by two seminal research studies:

Two of SAMHSA’s key efforts to address trauma are the National Child Traumatic Stress Network and the National Center for Trauma-Informed Care.

National Child Traumatic Stress Network

The National Child Traumatic Stress Network (NCTSN) is a nationwide network of researchers, intervention developers and service providers whose objective is to improve the access to and quality of services for children and families exposed to trauma. The NCTSN was established by Congress in 2000 under the Children’s Health Act that provides funding through the National Child Traumatic Stress Initiative (NCTSI). The NCTSI also supports a National Child Trauma Coordinating Center to manage the network, grants to intervention developers and grants for community service providers, as well as learning collaboratives in trauma-specific areas.

How NCTSN Works

As the network grantees and members work to address the needs of children and families, they also benefit from collaboration with one another. Treatment and Service Adaptation (TSA), centers run by universities and medical centers, develop evidence-based practices for which they then provide training throughout the network. Community Treatment and Services Centers of frontline and community organizations work together and also benefit from the TSA training.

The NCTSN facilitates the formation of collaborative workgroups or committees guided by strategic plans for specific areas such as child welfare, sexual abuse, trafficking, medical trauma, community trauma, and traumatic experiences of refugees and immigrants. These workgroups give grantees and members the opportunity to work together to advance practices with a specific topic in mind.

The NCTSN also hosts a Learning Center that offers free, open-forum training for providers and others supporting children who have experienced traumatic events. The trainings are self-paced and flexible, and CEUs are available for providers. This resource also includes podcasts, content on specific populations, and clinical training. Through the Learning Center and additional training events delivered by grantees, the NCTSN provides training to more than 200,000 participants annually.

National Center for Trauma-Informed Care and Alternatives to Seclusion and Restraint

SAMHSA’s National Center for Trauma-Informed Care and Alternatives to Seclusion and Restraint (NCTIC) focuses on reducing the use of seclusion and restraint through trauma-informed culture change in publicly funded organizations, systems, and communities. It provides training, technical assistance, and consultation to increase understanding and responsiveness to trauma in behavioral health, offering on-site and virtual support, as well as Virtual Learning Communities, webinars, and online tools.

NCTIC stresses the importance of involving trauma survivors and service recipients in all aspects of its work and in trauma-informed culture change, from conceptualization to implementation and evaluation.

In addition to providing technical assistance, facilitating collaboration, and awarding grants to continue this work, SAMHSA recently initiated an effort to train all agency staff in ways to understand and integrate a trauma-informed approach in SAMHSA grants, contracts, and program and policy development.


 Resources On SAMHSA’s YouTube Channel SAMHSA Blog

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Learning Center Brings Research to Practice

August 7, 2017 - 04:30

SAMHSA recently launched an updated Learning Center within the National Registry of Evidence-based Programs and Practices (NREPP). The redesigned Learning Center provides practical support for developing and using evidence-based programs and practices to improve the behavioral health of clients, family members, and the community.


NREPP is an evidence-based repository and review system designed to improve access to information on evaluated interventions and reduce the lag time between creation of scientific knowledge and its practical application in the field. It has served as a centralized resource for the behavioral health community since 1997.

Resources in the NREPP Learning Center are organized in five thematic areas:

Evidence-Based Practice or Program (EBP) Development – This area of the Learning Center provides guidance for service providers who want to develop and potentially submit a program for inclusion in the NREPP registry.  The section discusses the development of a program, the evidence-based practice selection process, ways to adapt the program for a particular organizational culture or population, and ways to avoid evaluation pitfalls.

Program Implementation – Providers encounter challenges when trying to integrate new approaches into a program. This “how to” section offers strategies, tips, and stories of what others in the field do to support decisions and initiate change.

Program Sustainability – Sustaining a program can be just as challenging as initiating one. This area of the Learning Center outlines strategies to support success and offers stories of providers who used innovative approaches to integrate new practices, improve outcomes, and enhance longevity. Sustainability frameworks, tools, and resources are also available for providers to think through their own program approaches.

Behavioral Health Topics – This section provides summaries of evidence on the promotion of mental health and treatment, substance use (reduction, prevention, and treatment), and behavioral health issues regarding special populations. These papers cover a wide range of topics including motivational interviewing, mental health and drug courts, school-based bullying and violence prevention, and screening for posttraumatic stress disorder, to name a few.

Emerging Evidence in Culture-based Practices –This section provides examples of less common approaches used to assess the effectiveness of culture-centered practices for underserved populations.  Research methods for emerging evidence are included, as well as case studies and videos. The focus during the first round of this work has been on programs and practices developed within and for American Indian and Alaskan Native communities.

“As we pursued this study with the tribal nations in question, particularly the Navajo, they felt very strongly that their tribal ceremonies, their traditional healing rituals were absolutely critical and previously unrecognized outside of the Nation itself in enabling these Navajo combat veterans to address posttraumatic stress disorder in their lives.” – Spero Manson from the “Bridging Different Ways of Knowing” video featured in NREPP’s Learning Center.

NREPP Senior Advisor Carter Roeber discussed the inclusion of the section on emerging evidence in culture-based practices.

“We decided to include emerging evidence in the Learning Center for two reasons,” he said.  “First, an emerging evidence section enables us to give voice to SAMHSA stakeholders who have been providing underserved populations with important, localized, culturally appropriate care that – for practical and ethical reasons – has not been evaluated for inclusion the Registry. Second, and more generally, the field recognized that the Learning Center needed to reflect multiple views and encourage communities and practitioners to use a full range of evidence to adapt programs to ensure they fit their specific populations and communities.”

A Resource Library offers a glossary and video presentations from experts about bringing research to practice. It also contains a list of the expert panel members who inform the NREPP Learning Center.

SAMHSA collaborated with the Centers for Disease Control and Prevention, Agency for Health Research and Quality, and the National Institutes of Health to update the NREPP Learning Center.



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Pain Management and Opioid Use with Veterans and Service Members

June 12, 2017 - 03:00

Military service brings a risk for serious injury, and with it, the possibility of severe or chronic pain. Such pain may be treated with prescription medication – sometimes opioids – which carry a risk for overuse or misuse. SAMHSA has been working with the U.S. Department of Defense (DoD) and the U.S. Department of Veterans Affairs (VA) to enhance informed prescribing practices and prevent misuse that can result in overdose or even death.

Controlling Pain

Injuries incurred during military service can be complex and the management of chronic pain requires attention. According to Friedhelm Sandbrink, M.D., VA’s Acting National Program Director for Pain Management, up to 75 percent of older veterans experience chronic pain. Prevalence of severe pain is strikingly more common in veterans than in the general population, particularly in younger veterans and in veterans who served during recent conflicts. Complicating matters even more are co-occurring disorders experienced by veterans, such as posttraumatic stress disorder and traumatic brain injury, for which additional psychotropic medications may be prescribed. Medication interaction is an important consideration.

“The challenge for those prescribing medications in the military and in the VA is to find the right balance to get the pain under control and to keep the patient safe,” said Dr. Sandbrink. “We want to ensure that patients are finding relief and taking medications as prescribed, and that we are aware of other sedating medications or alcohol use that could increase the risk of overdose.” He added, “in order to find the right balance, we nowadays rely less on medication and make much greater use of other approaches, including behavioral therapies, physical therapy and integrative health modalities, and emphasize physical and mental function.”

Providers outside the military systems and VA are accessed by more than half of those who serve, so they also need to be aware of population-specific guidance for veterans and service members. This is particularly true for members of the National Guard and Reserve, whose home communities may not include military supports.

The High Risk Of Relapse – For individuals in recovery from a substance use disorder who relapse, the risk of overdose is greatest. Tolerance of a drug during sobriety decreases, so if a person resumes at the same dosage as before recovery, that use can be lethal. For this reason, it is important to educate family members on the possibilities of misuse and how to respond.

The DoD currently has a pilot project called Building Healthy Military Communities that addresses the unique needs of geographically dispersed service members and their families that may affect readiness, resiliency, and wellbeing. SAMHSA also supports this work to address the mental health needs of service members and their families in communities throughout the U.S.

Interagency Task Force

The DoD, VA, and HHS participate in the Interagency Task Force on Military and Veterans Mental Health, created in 2013 to ensure that veterans, service members, and their families can access the services and supports that they need. SAMHSA represents the U.S. Department of Health and Human Services on this Task Force. Through this partnership, SAMHSA provides a number of resources to DoD and VA providers, including:

 SAMHSA and Veterans Affairs in Action

Dr. Karen Drexler, M.D., the National Mental Health Program Director for Substance Use Disorders in the VA, explained that, “SAMHSA resources and trainings are excellent. We are currently using many SAMHSA resources such as the PCSS-MAT and PCSS-O to educate Veterans, their families and clinicians about the best approaches to care.”

SAMHSA has been instrumental in training the prescribing workforce in the military to limit the length of opioid and other pain medication use, recognize the signs of misuse, be aware of treatment options, and understand DEA waivers to prescribe Buprenorphine (medication-assisted treatment to help people reduce or quit their use of opiates, such as pain relievers like morphine). SAMHSA uses evidence-based practices to develop these trainings that have substantially reduced dosages to stay within the recommended ranges and have encouraged providers to limit opioid use to three months.

“SAMHSA’s contribution on the Task Force has led to some specific advancements that support military service members, veterans, and their families,” said Cicely Burrows-McElwain, SAMHSA’s Military and Veteran Affairs Liaison. “In addition to reviewing the clinical practice guidelines, SAMHSA also worked with the other agencies to relay and report prescription drug information to Prescription Drug Monitoring Programs which helps to prevent over prescribing and overmedicating.”

The VA also worked to eliminate the co-pay on drugs like naloxone that are used if someone overdoses, making it much more accessible to patients and their families.

Dr. Drexler’s experience with SAMHSA’s trainings and work on the Task Force has changed the way she thinks about treatment. She explained that she had a patient with multiple medical problems that increase the risk for overdose such as sleep apnea and emphysema who was stable on medication-assisted treatment for opioid use disorder, but life stressors led him to relapse to benzodiazepine use. “Every time he came in, he was intoxicated, so we couldn’t have a meaningful discussion about treatment and I was especially concerned about overdose because he lived alone.”

The SAMHSA training encourages providers to think creatively about care and who to involve in overdose prevention and education. As a result, Dr. Drexler reached out to her patient’s sister and shared information learned in the SAMHSA training and prescribed a naloxone rescue kit. Educating his sister helped her to assist in limiting his access to illicit pills.  “My very next visit with him, he was alert, and I was able to have a meaningful talk with him about recovery and safety.”

“The federal coordination made it possible to look at risks and safety concerns across an entire spectrum of federal efforts,” said A. Kathryn Power, M.A., Executive Lead for SAMHSA on the Interagency Task Force. “The coordination, weekly communication, and measured positive outcomes all point to better care for military service members and veterans. That has been, and continues to be, our driving force.”

Although advancements have been made to better equip treatment providers with information and training to prevent circumstances that could lead to addiction, opioid misuse continues to be a serious public health concern. Providers in the DoD and VA continue their efforts to address pain and limit opioid use, while discussing potential associated risks with military service members, veterans, and their families. SAMHSA’s work with the Task Force, and work done to support states across the country through the SMVF TA Center,  will ensure that the support, resources, and training to improve care and prevent substance use disorders is accessible no matter where military service members and veterans go for care.

Daniel and Stephanie Keegan’s Story

Daniel Keegan, a soldier in the 82nd Airborne and son of Stephanie Keegan (in above image) who works with a number of advocacy groups to raise awareness. Daniel struggled with opioid addiction and overdosed two weeks before the start of his treatment in the VA. Stephanie calls this her “joy” picture because of his smile and the cup he is holding – it was the last image taken before he passed away.

“My son Daniel was a soldier for nearly eight years, deploying to Afghanistan twice. He came home from his second deployment with a serious case of PTSD and quickly became addicted, as a means of self-medicating. Daniel wanted to get well so that he could help the struggling veterans following in his footsteps. I promised him that if we lost him, I would take up the fight in his place. I will continue on this mission until my last breath.” – Stephanie Keegan


The Voice Awards 2017 – A Focus on Veterans

The Voice Awards will take place on August 16, 2017 at UCLA’s Royce Hall. The annual event recognizes individuals in recovery who have promoted family involvement in recovery, have led efforts to reduce the negative attitudes and misperceptions of behavioral health conditions, and have had a positive influence where they live and work. This year, special consideration will be given to leaders who are working to ensure that America’s military and veteran communities have access to the mental health and substance use treatment and services they deserve.



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“Making Each Day Count” for Prevention Week

May 22, 2017 - 10:00

Pictured at the Prevention Week 2017 Kickoff Event from SAMHSA are Frances M. Harding, Director of the Center for Substance Abuse Prevention and Kana Enomoto, Acting Deputy Assistant Secretary for Mental Health and Substance Use; Angie Goff, News Anchor for NBC4 in Washington, DC; Peter Konwerski, Vice Provost and Dean of Student Affairs, The George Washington University.

The 2017 observance of Prevention Week focused on the theme, “Making Each Day Count.” The annual observance raises awareness and promotes action on substance use and mental health. In addition to a kick-off event in Washington, DC, communities around the country participated in events and educational outreach and celebrated achievements made to prevent behavioral health issues. Participants also shared their prevention efforts on social media using #PreventionPower and #NPW2017 in their posts. Each day of Prevention Week had a prevention focus, including youth tobacco use, underage drinking and alcohol misuse, prescription and opioid drug misuse, illicit drug use and youth marijuana use, suicide, and mental health and wellness.

Prevention resources on all of these topics and more can be found at

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Spotlights on Six Trauma-Informed Resilient Communities

May 16, 2017 - 10:00

Establishing and integrating a trauma-informed approach to addressing mental and substance use disorders is important not only for individuals, but for communities as well. To further this goal, SAMHSA recently published Spotlight: Building Resilient and Trauma-Informed Communities, a series that highlights efforts underway in six different cities across the United States to build trauma-informed, resilient communities.

SAMHSA defines a trauma-informed approach as one where people realize the prevalence of trauma, recognize the impact and responses to trauma, and resist practices that could cause more harm.

The Spotlight Series

Following are some examples of trauma-informed community programs from the Spotlights.

Kansas City

Molly Ticknor, Director of Mental Health Services with Kansas City Public Schools, holding a “Power Plan” that teachers and student create in trauma-informed schools to keep them in tune with their own self-care.

In Kansas City, MO, advocates for trauma-informed care organized Trauma Matters KC (TMKC), bringing together 40 organizations to address social and economic challenges. The Spotlight describes their collective action to build resilience and to address special needs. For example, in the Kansas City Trauma Sensitive Schools, children and teachers create their own self-care plans as a tool for managing stress or distress during the day.

Spotlight: Kansas City: One of the most striking aspects of TMKC is the breadth of community involvement. At any monthly meeting you might find a landscape architect whose designs promote resilience, a judge who runs a trauma-informed court, an author or journalist who wants to learn more, a sports coach concerned about the young people on his team, or a community planner considering implications for urban development.

Tarpon Springs

Another Spotlight looks at the strides made in Tarpon Springs, FL. After learning about Adverse Childhood Experiences (ACE), Tarpon Springs former commissioner and vicemayor Robin Saenger initiated a community effort called Peace4Tarpon (P4T). This effort gathered city officials, professionals, and city residents into a group that coordinated multiple trauma-informed activities including a library-sponsored community education day, and a public “peace flags” event in which businesses and residents donated a wide variety of efforts and materials.

Building on the P4T effort, the Pinellas Ex-Offender Reentry Program (PERC) Clinical Director, Denise Hughes Conlon, added ACE assessment into PERC evaluations and found surprisingly high scores for childhood trauma among this population. In response, she incorporated the Seeking Safety curriculum into PERC’s substance abuse treatment program.

Spotlight: Tarpon Springs: “If one person or agency expresses a need, chances are good that someone else will meet it.”


The Porch Light Program in Philadelphia uses art as a public health strategy, strengthening community engagement, promoting behavioral health recovery, and addressing social and economic factors such as poverty, racism, violence, and resource disparities. People with behavioral health concerns and intellectual disabilities work side-by-side with service providers, local funders, academics, and local artists to create public art in neighborhoods across the city. The process improves morale, builds connections, and heals communities by exploring health related issues.

Spotlight: Philadelphia: “Relationships forged during the process often lead to ongoing activities. In one neighborhood, the collaboration led to a yearly conference to address community concerns.”

“The effects of traumatic events place a heavy burden on individuals, families and communities and create challenges for public institutions and service systems,” said Larke Huang, Ph.D., SAMHSA’s Trauma and Justice Strategic Initiative Lead and Director of the Office of Behavioral Health Equity. “We hope these spotlights will motivate other cities and regions to consider how they can take similar steps in their communities.”

SAMHSA offers many resources for addressing trauma, including SAMHSA’s National Center for Trauma-Informed Care, a technical assistance center, which provides training and support to organizations throughout the United States. Additional resources are provided below.

Learn more about SAMHSA’s 6 Principles of a Trauma-Informed Approach in the Spotlight Introduction.


Resources On SAMHSA’s YouTube Channel Related SAMHSA Blogs

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Olympians Phelps and Schmitt Join with SAMHSA to Promote Children’s Mental Health

May 16, 2017 - 07:30

Olympic medalists Michael Phelps and Allison Schmitt served as honorary chairs for SAMHSA’s National Children’s Mental Health Awareness Day event on May 4. Both have experienced depression and eventually found help. Health and Human Services Secretary Thomas E. Price, M.D., presented both Michael and Allison with SAMHSA Special Recognition Awards for their support of children, youth, and young adults with mental and substance use disorders.

Allison Schmitt, SAMHSA Acting Deputy Assistant Secretary Kana Enomoto, Health Resources and Services Administration Administrator George Sigounas, Health and Human Services Secretary Tom Price, and Michael Phelps at Awareness Day event.

During the event, Michael explained why partnering with SAMHSA, was so important. “I want to be able to get out in front and talk and say – look, I’ve done these great things in the pool, but I’m also a human, just like other people in the world that are going through the exact same struggle.”

His remarks were echoed by Allison who described the special recognition award from SAMHSA as the most meaningful award of her life. Allison spoke of the importance of reaching out for help – something that was not easy for her. “I was battling depression – and my 17-year-old cousin was also battling depression, and we didn’t know it. She lost her life one week after her 17th birthday to suicide. She was in such a dark place, and so isolated, and felt so alone inside,” said Allison.

The two talked about the “red flag” of isolation and said that isolation can be a warning sign to others that something is not right.

Allison described a time when she returned to her home and chose to park in an unusual spot, so her college roommates would not realize she was there. She went to her room and cried in her closet – isolating herself from her friends or anyone else who could help. Michael had a similar experience when, in the depths of his depression, he stayed in his room for days, wondering if life was worth continuing. They both sought treatment and now support each other.

“Allison and Michael demonstrate that reaching out for help is a sign of strength and self-awareness,” said Paolo Delvecchio, M.S.W., Director of SAMHSA’s Center for Mental Health Services. “They provide a living example of resilience and recovery by sharing their stories publicly and supporting each other.”

This year marks the 12th year of SAMHSA’s National Children’s Mental Health Awareness Day. Each year more than 1,100 communities across the country and 160 national organization and federal programs conduct Awareness Day activities. New collaborating organizations this year included American Academy of Family Physicians, American Diabetes Association, Association of State and Territorial Health Officials, the President’s Council on Physical Fitness and the Medical Reserve Corps.

Awareness Day 2017: “Partnering for Help and Hope” focused on the importance of addressing physical, mental, emotional, and behavioral health needs when providing services and supports for children, youth, and young adults.

During the event, SAMHSA released reports combining 2005 to 2014 data showing that major depressive episodes were more common among adolescents ages 12 to 17 with asthma (11.4 percent) or diabetes (14.3 percent), than among adolescents without asthma (8.8 percent) or diabetes (9.0 percent). In addition, adolescent girls who were overweight or obese were more likely to have experienced a major depressive episode in the past year than those who were a healthy weight (20.5 percent vs. 17.4 percent).

To view the webcast of the national event, go to

“We commend Michael Phelps and Allison Schmitt for having the courage to speak out about their mental health challenges. Their honesty and candor have shown countless Americans quietly struggling with mental illness that seeking help is a sign not of weakness, but of strength,” said Health and Human Services Secretary Tom Price, M.D.


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Self-Care for Providers During Change and Stress

May 3, 2017 - 09:00

People working in health care recognize stress as something that can compromise the wellness of the people they serve. However, health care workers may neglect their own wellness and not realize that an even a greater challenge is to manage their own stress. Long hours, large workloads, and exposure to the physical and psychological trauma of others can contribute to provider stress, burnout, and diminished well-being. Maintaining good self-care is especially important to avoid the toll that stressful challenges take on mood, behavior, physical health, and patient care.

Significant events such as a job change, the loss of a family member, an empty nest, divorce, or even age-related biological changes can decrease the ability to cope with daily stressors. This is amplified during times when a community is affected by disaster or disease, which often presents service providers with additional challenges to maintaining their own health and well-being while helping others. Therefore, it is essential that healthcare workers adopt and maintain healthy lifestyles and employ self-care strategies during times of stress.

Stress can cause headaches, fatigue, sexual disinterest, stomach problems, and sleep disturbance. It can decrease energy, make a person more irritable, and lead to feelings of depression or anger. Stress can also decrease an individual’s efficiency, quality of interpersonal interactions, and lead to serious changes in behavior such as isolation, substance use, and changes in eating and exercise habits.

Self-Care Strategies

Providers can learn to recognize their own need for self-care by learning the common causes of stress and how stress impacts them as individuals. SAMHSA offers many resources on resilience, protective factors, and self-care strategies to lessen the effects of stress. Some of the recommended strategies include:

  • Follow a healthy lifestyle. Eat healthy foods and limit alcohol intake. Don’t smoke or use addictive substances. Exercise regularly. Consistently practice good sleep habits. And make time for rest and relaxation.
  • Make wellness part of everyday life. Address emotional and general health to improve personal resilience and manage stress. This may include exercise, time by yourself, or mindfulness exercises.
  • Connect with friends and family. Relationships and social networks that provide support, friendship, love, and hope are essential to one’s well-being. At work, if case load or other work issues are creating stress, connect with a supportive colleague or workplace mentor to think through helpful strategies.
  • Schedule annual checkups and health screenings. Take care of the basics to ensure your best health in the event of any adversity and to help manage stress.
  • Seek support from a support group or mental health professional. If stress is starting to affect your mood, behavior, or physical health, it may be helpful to talk with a physician or counselor to talk through strategies to help balance.

Carlton Speight, public health advisor with SAMHSA’s Center for Mental Health Services, provides additional perspective. “If providers take the steps to build resilience through wellness practices and healthy supportive relationships, they will be better equipped to manage adversity. A little thought, intention, and time are key before a crisis arises.”

Resources On SAMHSA’s YouTube Channel

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