Charlie Health Curriculum: Why Trauma-Informed Care Works

Clients with trauma often experience worse clinical outcomes when placed in the general mental health curriculum. These cohorts, while effective for the treatment of general mental health care, are often not designed to address the specific needs of clients with trauma. Charlie Health offers client-focused care through a specialized trauma-informed and trauma-specific curriculum in an effort to prevent retraumatization and encourage equitable gains for those in the trauma cohort. Our primary goal is to improve outcomes for clients with trauma by addressing their specific needs.

What is trauma and why is it significant?

Trauma is a potential response to situations that overwhelm the individual’s natural ability to cope. Because the experience of trauma is extremely individualized, almost anything perceived by the individual as possibly threatening or dangerous can trigger a trauma response.

Adverse Childhood Experiences (ACEs) refer to potentially traumatic events that occur before the age of 18. Examples of ACEs include neglect, violence, abuse, and household challenges with stability, mental health, and/or substance use. These problems can continue into adolescence and adulthood, with ACEs being linked to chronic mental health issues, unstable relationships, and substance abuse problems later on in life.

Additionally, exposure to trauma can lead to other chronic health conditions, such as:

• Cardiovascular disease
• Hypertension
• Weight gain
• Stroke

These are just a few of the short-term and long-term effects of trauma on an individual’s mental and physical well-being. Often, the severity of trauma is categorized into one of three types of trauma: 

• Acute trauma is a singular traumatic event with a definitive start and end. An example of acute trauma would be a natural disaster or serious injury.
• Chronic trauma is characterized by multiple traumatic events, usually over a prolonged period of time. This trauma can continue for weeks, months, or even years. An example of chronic trauma would be an abusive relationship or bullying over time.  
• Complex trauma is a chronic trauma with long-term physical and emotional effects. Examples of complex trauma include sexual harassment or sexual abuse, prolonged neglect, homelessness or housing instability, and lack of secure attachment to caregivers. 

When exposure to a traumatic event is severe enough to develop into a mental disorder, it is called post-traumatic stress disorder (PTSD). PTSD is a mental disorder that can be developed after exposure to a traumatic event. PTSD symptoms are characterized by disturbing thoughts, feelings, or dreams, mental or physical distress due to trauma-related cues, and an increase in the fight-or-flight response system. 

It is important to note that survivors of prolonged, complex trauma may experience what is known as “complex post-traumatic stress disorder” (C-PTSD). C-PTSD includes all the symptoms of PTSD, but those with C-PTSD may also experience issues with emotional regulation, relationships, and dissociation.

Exposure to traumatic events has been shown to be the highest individual predictor in the improvement and deterioration of clinical outcomes in inpatient youth. Those with exposure to various types of trauma were less likely to make improvements with a general care curriculum, as compared to those with lesser or no exposure to trauma, according to current research. This makes addressing the effects of trauma important for the delivery of clinical care to clients with trauma.

Understanding the specific needs of clients with trauma has led to revamping the methods used to treat trauma for the purpose of addressing the limitations of historic mental healthcare. This awareness has resulted in the creation of trauma-informed and trauma-specific care. 

The trauma curriculum at Charlie Health

Trauma-informed and trauma-specific mental health care addresses the effects of trauma by intentionally and properly meeting the needs of clients with trauma. It takes into consideration not only the client’s individual needs but also how the organization’s practices might affect the clinical outcomes of clients with trauma in their care. 

Trauma-informed care is the understanding of trauma and its complexity, which allows a clinical team to respond appropriately to their clients’ needs. The top priority of trauma-informed care is to cultivate an environment grounded in empowerment, safety, and understanding aimed at enhancing clinical outcomes and averting re-traumatization.

Meanwhile, trauma-specific care refers to evidence-based treatment and interventions for addressing trauma, traumatic events, and/or any co-occurring disorders associated with trauma. These evidence-based interventions are used to treat trauma in a clinical setting.

A curriculum that utilizes trauma-specific care, such as trauma-focused CBT (TF-CBT), has been found to significantly reduce trauma symptomatology, depression, and general mental health in clients with trauma as compared to those in the “therapy-as-usual” or TAU group. Additionally, significantly fewer participants in the TF-CBT group met the diagnostic criteria for PTSD when tested post-treatment compared to the TAU group. 

The importance of trauma-informed and trauma-specific care in curriculum for clients with trauma is evident, as it leads to better clinical outcomes post-treatment by providing a safe, empowering environment while providing the tools needed to process trauma and its impacts on an individual’s mental health and daily functionality.

The Substance Abuse and Mental Health Administration (SAMHSA) believes that six principles must be abided to provide a successful trauma-informed care experience:

• 1. Safety 
• 2. Trustworthiness and transparency 
• 3. Peer support 
• 4. Collaboration and mutuality 
• 5. Empowerment, voice, and choice 
• 6. Cultural, historical, and gender issues

Charlie Health identifies and sorts clients into specialty cohorts depending on their self-identified needs using information taken from their initial Biopsychosocial assessment (BPS), which is conducted at intake.

Once a client is identified as having trauma or trauma-related needs, they are placed into one of the trauma cohorts at Charlie Health. While all of Charlie Health’s programming is trauma-informed, trauma cohorts have a specific curriculum designed to best treat the needs of trauma-having clients.

The trauma curriculum at Charlie Health is broken into three different hours, ensuring each hour offers the client a different experience:

First hour: Relationally-focused therapy

Relationally-focused therapy is experienced for one-hour by every Charlie Health client. Relationally-focused therapy helps create a meaningful connection to others in group therapy and interpersonal relationships, through a person-centered, trauma-informed lens.

Second hour: Trauma-focused CBT

Trauma-focused cognitive behavioral therapy (TF-CBT) focuses on understanding the brain’s response to trauma. It helps clients learn how to cope with their specific triggers and establish healthy relationships by learning how to set healthy boundaries. 

Third hour: Creative, expressive, and contemplative Arts

Creative, expressive, and contemplative arts therapy allows for clients to decompress, re-engage, and view their treatment from a different perspective. Clients are tasked with exploring themselves and their situation through various mediums, like art therapy, yoga therapy, and others.

Additionally, Charlie Health offers a unique intensive outpatient experience with Care Coaches. Care Coaches are employees who are present during group sessions as peers to talk to if a client ever wants 1:1 support. Clients are encouraged to specify what identity Care Coach they would like to talk with, creating a relationship built on empowerment through self-advocacy and safety. With these implementations, the Care Coaches and clients work collaboratively and transparently on improving the client’s experience and clinical outcomes. 

Trauma client outcomes at Charlie Health

Charlie Health’s dedication to providing trauma-informed and trauma-specific care creates equal opportunities for clients with trauma. Because Charlie Health identifies clients with trauma early on in treatment through a biopsychosocial assessment (BPS), there is reason to expect similar outcomes as both clients with trauma and non-clients with trauma receive equitable care. 

At the beginning and end of treatment, clients receive an intake and discharge assessment. Specifically, these surveys screen for anxiety, depression, and well-being through the GAD-7 questionnaire, the PHQ-9 questionnaire, and the WHO-5 wellness questionnaire, respectively. These assessments help measure anxiety and depression severity and a client’s overall well-being through a series of targeted questions. 

Using information collected from these questionnaires, data was sampled from 2,969 Charlie Health clients. All of these clients completed treatment and provided both an intake survey and discharge survey at the start and end of treatment. 

Of the sampled 2,969 clients, 377 clients were placed into the trauma cohort (12.7%), and 2,592 clients were placed into non-trauma cohorts (87.3%).

At intake, clients placed in the trauma cohort at Charlie Health expressed:

• Moderate anxiety (x = 13.30) according to the average GAD-7 score.
• Severe depression (x = 15.66) according to the average PHQ-9 score.
• A low well-being score, averaging at 21.51/100 points on the WHO-5. For reference, the higher the reported well-being score, the better the client’s well-being.

Comparatively, non-trauma cohort clients at Charlie Health expressed:

• Moderate anxiety (x = 11.43) according to the average GAD-7 score.
• Moderate depression (x = 13.77) according to the average PHQ-9 score.

Based on the data provided at intake, clients with trauma have higher anxiety (13.3 > 11.43) and depression scores (15.66 > 13.77) than non-clients with trauma. Despite both groups having moderate anxiety at intake, clients with trauma have clinically and statistically significantly worse depression scores (severe versus moderate depression) than their non-trauma client cohorts. 

These average intake scores were then compared to clients’ discharge scores to evaluate the efficacy of Charlie Health’s trauma cohort curriculum. With Charlie Health’s attentiveness to developing a trauma curriculum built on evidenced-based care, the expectation is that clients in the trauma cohort will experience similar, positive outcomes as clients in Charlie Health’s non-trauma cohorts.

When comparing intake and discharge outcomes for anxiety, measured through GAD-7 scores, it can be observed:

• Both clients with trauma and non-trauma clients at Charlie Health experienced a significant reduction in anxiety symptoms. 
• From intake to discharge, both clients in the trauma cohort and clients in non-trauma cohorts were able to, on average, move out of the clinical threshold for moderate anxiety (GAD-7 Sum Score between 10-14; 11.43 for non-trauma clients, 13.30 for clients with trauma) into mild anxiety post-treatment on GAD-7 (GAD-7 Sum Score between 5-9; 6.32 for non-trauma clients, 7.34 for clients with trauma).

These results indicate that both clients with trauma and non-clients with trauma experienced positive outcomes and decreased anxiety symptoms at discharge.

A similar trend can be observed for the depression scores of clients with trauma and non-clients with trauma at intake and discharge:

• At intake, non-trauma clients start with moderate depression (PHQ-9 Sum Score between 10-14, 13.77), while the clients with trauma, on average, start with moderately severe depression (PHQ-9 Sum Score between 15-19, 15.66). 
• Trauma clients and non-trauma clients’ scored on average in the mild depression range at discharge (PHQ-9 Sum Score between 5-9 ; 7.72 for non-trauma clients and 7.92 for clients with trauma at discharge). 

These results indicate that both clients with trauma and non-clients with trauma experienced positive outcomes regarding depression pre- and post-treatment at Charlie Health. Additionally, trauma clients were able to move from the clinical threshold of severe depression to mild depression.

Regarding the WHO-5, which measures a client’s overall well-being, clients with trauma improved on average by 27 points on the WHO-5 scale from intake to discharge. This would mean that a client’s perceived well-being can be expected to double from their initial intake score of 21.51 points. 

From the initial intake score of 21.51 points on average, clients with trauma are observed to experience much higher well-being after treatment at Charlie Health, as indicated by the average discharge survey score of 48.26/100 points. 

These results are consistent with clients with trauma experiences with Charlie Health. They are both clinically and statistically significant, indicating that clients with trauma can expect higher levels of well-being as a result of receiving trauma-informed and trauma-specific treatment at Charlie Health.

The role of trauma-informed and trauma-specific care in client outcomes

Trauma-informed and trauma-specific care has been demonstrated to ensure positive outcomes for clients with trauma in clinical settings. With exposure to trauma being the highest predictor of mental health outcomes, it is increasingly important to address the effects of trauma on mental health. Charlie Health emphasizes trauma-informed and trauma-specific care, as it recognizes how trauma can negatively impact clinical outcomes if left untreated or unaddressed.