Substance use disorder (SUD) providers are increasingly building trauma therapy into their practices, offering screenings and specific treatments to address trauma and improve patient outcomes.
Including these services may make providers more attractive partners for health plans. Still, providers may be missing a wide swath of their patient base who need trauma care.
Research has linked traumatic experiences with an increased likelihood of developing SUDs. Trauma in early life, like violence, abuse, or neglect, is particularly likely to lead to the development of an SUD.
“When we think about the movement in the healthcare field, and in our society in general, from viewing substance use and alcoholism as a character flaw to the idea that it’s a health condition, it’s a disease, and a disease that we now know is often related to trauma history,” Dr. Steven Pratt, senior medical director for the employer segment within Magellan Healthcare, told Behavioral Health Business.
Frisco, Texas-based Magellan Healthcare is a subsidiary of Magellan Health, a health plan and provider of behavioral health and other services.
What is trauma-informed SUD care?
The Substance Abuse and Mental Health Services Administration (SAMHSA) has a specific definition of trauma, although in practice, clinicians may use their discretion to identify trauma in a patient.
SAMHSA defines trauma as the “three Es,” which include an event or series of events, the experience of those events, and long-lasting adverse effects of those events on a person’s functioning and mental, physical, social, emotional or spiritual well-being.
While SAMHSA’s three Es are among the best definitions of trauma, Dr. Benjamin Israel, a psychiatrist, psychotherapist, researcher and assistant professor at the University of Maryland School of Medicine, said they are not perfect. He added “a teaspoon or two of thoughtful discretion” when identifying trauma in a patient.
When offering trauma-informed care, providers need to make sure they are not re-traumatizing patients. To avoid doing so, providers practice six principles developed by the Centers of Disease Control and Prevention (CDC) and SAMHSA.
The six pillars of trauma-informed care, according to the CDC, are safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment and choice, cultural, and historical and gender issues.
SUD providers often practice a number of different trauma therapies as part of a trauma-informed approach.
One treatment called EMDR, which refers to eye movement desensitization and reprocessing, is a virtual exposure technique that helps patients heal from trauma by moving their eyes in a specific way while processing traumatic memories.
Accelerated Resolution Therapy (ART) is another psychotherapy approach to trauma that involves replacing negative mental images of traumatic events with positive images. ART can provide relief in as little as a single session.
Mindfulness and grounding can also build skills to help a person tolerate the emotions associated with trauma.
But providing trauma-informed care goes beyond the six pillars, the three E’s and offering treatments for trauma.
“Trauma-informed care is more than trauma treatment,” Frances Myers-Routt, clinical director at River Oaks Treatment Center, an American Addictions Centers facility, told BHB. “Trauma informed care is an entire approach.”
River Oaks is a 162-bed SUD American Addictions Centers treatment facility in Tampa, Florida that offers inpatient and outpatient services for primary substance use and secondary mental health and medical issues. The facility has specific tracks for veterans, LGBTQ patients and professionals seeking to reinstate professional licenses.
American Addictions Centers provides inpatient and outpatient SUD treatment in 12 facilities across eight states. The provider named new co-CEOs in December 2023.
In practice, trauma-informed care means providers must maintain constant attention, caring awareness, sensitivity and even a cultural change, according to the CDC.
Every level of an organization needs to receive training in trauma, Myers-Routt said.
“We have an inpatient program, so we have nurses and doctors, but we also have housekeepers and dietary staff and receptionists,” Myers-Routt said. “Everyone has to understand the approach that you would use with somebody, a calm, direct approach. Helping people to come to whatever it is that they need to come to in a way that’s collaborative. Being transparent with people about why you may ask or do something that you’re going to do.”
One of the most essential principles of trauma-informed care is to approach people without judgment or assumptions and to address people collaboratively, Myers-Routt said.
Benefits of a trauma-informed approach
Offering trauma-informed care can improve patient outcomes. Unrecognized and untreated trauma, meanwhile, can lead to poor engagement in treatment, a higher chance of dropping out of treatment and greater risk of relapse, according to SAMHSA.
“Clients’ behavior will be less predictable, and client responses to treatment will be less predictable,” Myers-Routt said.
Offering trauma-informed services can potentially give providers a leg up in negotiating with insurance providers. Magellan prefers to partner with SUD providers with a trauma-informed approach, Pratt said.
“We are strong advocates for assessing for trauma and incorporating interventions addressing trauma into treatment,” Pratt said. “We tend to try to select the better providers to be in our network. It’s more common than not to have them address trauma as a part of their treatment program.”
Where trauma-informed care is heading
While a trauma-informed approach can vastly improve patient outcomes and experience, providers can do more to improve current approaches to trauma, according to a recently published critical review co-authored by Israel.
The long-standing approach to trauma treatment starts with safety and symptom stabilization. Israel’s article found that incorporating harm reduction principles through a phase of treatment before stabilization “unequivocally improve[s] outcomes and save[s] lives.”
The practice of harm reduction involves minimizing the adverse health, social and legal impacts of drug use. The pre-stabilization phase suggested by Israel aims to engage and retain people with both opioid use disorder (OUD) and trauma in treatment through increased screening and psycho-education about trauma in OUD clinics.
“We need to meet people where they are,” Israel said. “And evidence-based treatments for trauma are generally not [radically different from] a traditional therapy frame. So, what that looks like is integrating psychotherapy with a harm reduction model. … That looks like a healthcare system that places primacy on relationships between human beings. That means being welcomed and treated with dignity from the time you walk through the front door.”
River Oaks previously only screened for trauma among clients who told clinicians on their first visit that they had experienced or witnessed trauma. When the clinic began to screen all clients for trauma, the number of patients who qualified for trauma treatment “shot up significantly.”
“In the field, I think people are counting on a client being able to articulate to a provider that they need trauma treatment because they’ve had a traumatic event, only to find out that many people have these symptoms and cannot even articulate what it is,” Myers-Routt said.
Pratt suggests integrating screening for trauma into primary care practices.
“I think that we need to get to the point where we’re doing that kind of screening for trauma just as much as we are for depression,” he said.
While most SUD providers do treat trauma for patients who can articulate their trauma, the industry does not currently do enough to provide trauma-informed care to all patients who need it, Myers-Routt said.
“The pervasiveness of trauma symptoms really requires that all clients should be evaluated and treated,” she said.
