Developing TraumaInformed Systems of Care for Women in Substance Abuse Treatment

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Developing Trauma-Informed Systems of Care for
Women in Substance Abuse Treatment

• Norma Finkelstein Ph.D.
• Institute for Health and Recovery
• normafinkelstein_at_healthrecovery.org
• Womens Health Addiction, Trauma and Hope
• Princeton, New Jersey
• October 5, 2007

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I Drank to Their Diseases
They pretended that there was nothing wrong,
Their lies stole my trust. The said that they
were normal. I felt insane. They said, We love
you, I was alone. I used alcohol to kill the
pain. It made me a liar. I drank to feel
normal, I became insane. I cried, Please love
me! I was still alone. Katherine,
age 40
(Source Evans and Sullivan, Treating Addicted
Survivors of Trauma, 1995, p. 1)
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Trauma Definition

• Extreme stress that overwhelms a persons ability
  to cope
• The subjective experience of a threat to life,
  bodily integrity or sanity
• A normal response to an abnormal event that
  results in a disruption of equilibrium

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• TRAUMATIC EVENTS ARE EXTRAORDINARY, not because
  they occur rarely, but rather because they
  overwhelm the ordinary human adaptations to life.
  Unlike commonplace misfortunes, traumatic events
  generally involve threats to life or bodily
  integrity, or a close personal encounter with
  violence or death. They confront human beings
  with the extremities of helplessness and terror,
  and evoke the responses of catastrophe. The
  common denominator of trauma is a feeling of
  intense fear, helplessness, loss of control, and
  threat of annihilation. (Judith Herman,
  MD, Trauma and Recovery, 1992)

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Going Out of My Mind

• Thats a victim thing you ask yourself, Am I
  just crazy? Did I make all this up? Somehow it
  might be easier to accept that youre crazy and
  you made it all up than to admit that it happened
  and how awful it was.

Teri Hatcher, star of TV show Desperate
Housewives, and survivor of child sexual abuse by
her uncle. (Source Janet Yassen, VOV Program,
Cambridge Hospital, 2006)
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Traumatic Events

• Physical Assault
• Sexual Abuse including sex work
• Emotional/ Psychological Abuse
• Domestic Violence
• War/Genocide
• Accidents
• Natural or Man-Made Disaster

• Witnessing abuse/violence
• Living in dangerous environment
• Experienced as an adult or child
• Occurred over time or one incident or time
  limited

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Interpersonal Violence

• Interpersonal Violence physical/sexual abuse
  is not like natural disasters, car accidents,
  etc.
• Human-fostered violence against another human
  being
• Causes extreme disconnection from other human
  beings

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Why Trauma Matters

• A significant proportion of men and women
  entering services for substance use disorders
  have histories of trauma (Brems, 2004 Clark,
  2001 Farley, 2004 Medrano, 1999 Moncrieff,
  1996 Rice, 2001).
• Women in community samples report a lifetime
  history of physical sexual abuse ranging from
  36 to 51, while women with substance abuse
  problems report a lifetime history ranging from
  55 to 99
• (Najavits et al., 1997).

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• Women in methadone treatment
• 75 report lifetime history of physical and/or
  sexual abuse
• 33 report abuse in past year
• 50 report abuse as children
• 33 report witnessing abuse of mother (El-Bassel
  et al., (2004)
• Women who were both physically and sexually
  abused in childhood were six times more likely to
  abuse alcohol then non abused women.
• (Bensley, Eenwyk, and Simmons, 2000)

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• 50 of substance abusing women in treatment had
  experienced rape or incest (Woodhouse, 1990)
• Rate of childhood sexual abuse among female
  substance abusers is twice that of general
  population (Simpson and Miller, 2002)
• African American women with histories of
  childhood sexual abuse were addicted to more
  substances, admitted to hospital or ER more often
  for substance-related health issues, attended
  more substance abuse treatment programs. (Young
  and Boyd, 2000)

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Co-occurrence of Substance Abuse Domestic
Violence

• Research Institute on Addictions (1997)
• 80of women with substance abuse disorders had
  been the victim of domestic violence
• Brookhoff, et al. (1997)
• 42 of victims of domestic violence contacting
  the police had used alcohol or other drugs on the
  day of the assault

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Adverse Childhood EventsACE Study

• Kaiser Permanente (Felitti) CDC (Anda)
• Large-scale epidemiological study of influence of
  stressful/traumatic childhood experiences
• Interviewed over 17, 000 people
• Compares adverse childhood experiences against
  adult health status

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ACE Study

• Scoring system usedone point for each category
  of Adverse Childhood Experiences (ACE) before 18
• ACEs not only common, but effects were
  cumulative
• Compared to persons with ACE score of 0, those
  with ACE score of 4 or more were 2x more likely
  to be smokers, 12x more likely to have attempted
  suicide, 2x more likely to be alcoholic and 10x
  more likely to have injected street drugs

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Adverse Childhood Experiences

• Recurrent and severe physical abuse
• Recurrent and severe emotional abuse
• Sexual abuse
• Growing up in household with
• Alcohol or drug user
• Member being imprisoned
• Mentally ill, chronically depressed, or
  institutionalized member
• Mother being treated violently
• Both biological parents absent
• Emotional or physical abuse
  (Fellitti, 1998)

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ACE Study

• Controlling for other adverse childhood events
• Women with a history of childhood sexual abuse
  were 60 more likely to have alcohol problems and
  70 more likely to have used illegal drugs.
• Men with a history of childhood sexual abuse were
  30 more likely to have alcohol problems and 60
  more likely to have used illegal drugs.
• (Dube et al. (2005)

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Messina and Grella (2006)
Number of childhood traumatic events associated
with

• Prostitution
• Eating Disorders
• Mental Health disorders
• STIs
• Alcohol problems
• Early onset of criminal behavior

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Trauma-Informed Treatment is Important for
Substance Abuse Because

• Substance use increases after trauma
• Women with substance use disorders and trauma
  histories appear to have worse treatment outcomes
  (when treated in traditional treatment programs)
• A woman with both trauma and substance abuse may
  have a variety of other problems such as poverty,
  homelessness, increased risk for HIV

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• Impact of Trauma

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Impact of Trauma Physiological

• Changes in neurobiology and physical health that
  can dysregulate emotions and distort thinking,
  perceptions and behavior
• The Body Keeps the Score
• (Bessel van der Kolk, MD
  1999, p.214)
• Emotional Memory May Be Forever
• (Le Doux, et al 1991,
  p.24)

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• A century of study of traumatic memories shows
  that 1) they generally remain unaffected by other
  life experiences 2) they may return, triggered
  by reminders at any time during a persons life,
  with the same vividness as if the subject were
  having the experience all over again and 3) these
  memories are primarily sensory and emotional,
  frequently leaving victims in a state of
  speechless terror, in which they may be unable to
  articulate precisely what they are feeling and
  thinking. (Bessel van der Kolk, et al
  1996, p.565)

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Impact of Trauma Cognitive

• Amnesia
• Blocking
• Flashbacks
• Dissociation
• Confusion
• Difficulty concentrating

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Impact of TraumaFeelings Numb or Overwhelmed

• Fear, terror
• Anger, revenge, hate
• Frustration
• Guilt or self-blame (legitimate, illegitimate,
  survivor)
• Shame, humiliation
• Grief or sorrow

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Impact of Trauma Beliefs

• About self
• About other people
• About the world

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Impact of Trauma Skill Deficits

• Self-awareness
• Self-protection
• Self-soothing/emotional modulation
• Relational mutuality/empathy/authenticity
• Accurate labeling of self and others
• A sense of agency
• Purpose and meaning

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Impact of TraumaRelational Disconnection

• Centrality of relationships for women
• trauma affects view of self as well as
  participation in relationships.

• Core experience of trauma is disconnection and
  disempowerment
• Pathways to healing through connection and
  empowerment

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Mental Health Problems

• PTSD
• Other anxiety disorders
• Depression, suicidality
• Eating disorders
• Self-harm

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PTSD

• Approximately 1/3 who experience significant
  trauma will develop symptoms of PTSD
• 35-59 of women in substance abuse treatment have
  PTSD
• (Najavits, 2002)

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PTSD Symptoms

• Hyperarousal/persistent expectation of danger/
  hypervigilance
• Irritability/outbursts
• Impaired concentration
• Exaggerated startle response
• Intrusion
• Reliving eventhallucinations, flashbacks
• Constriction numbing/persistent avoidance
• Avoids thoughts, feelings, people, places,
  activities
• Detachment
• Diminished interest
• Sense of foreshortened future (Herman,
  Trauma and Recovery, 1992)

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• Trauma-Informed Services

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• The impact of violence/trauma on both men and
  women is inadequately understood and addressed by
  service providers.
• Less than half of the women with interpersonal
  trauma and co-morbidity will receive treatment
  that addresses their trauma history and
  co-occurring conditions. (Timko
  Moos, 2002)

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• I am an incest survivor never dealt with it.
  Left treatment, did drugs. The most important
  thing is to integrate services. Im a slicer
  before no place would take me if I say Ive
  been sexually abused they boot youI thought here
  we go again. Substance abuse identified
  youre welcomeneed to work all 3 areasothers
  throw you out because they are afraid.
  (WELL Project, 2005)

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Substance Abuse Treatment Programs Often Fail to
Adequately Deal with Trauma. Why?

• Lack of research/knowledge dissemination
  training
• Trauma not seen as central/critical to recovery
• Uncovering trauma would destabilize
  symptomsneed to stabilize mental health/
  substance abuseOpening a Pandoras Box
• A belief that trauma work requires more
  sophisticated clinical skills

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Failure to understand and address trauma can
lead to

• Failure to engage in treatment services (Farley,
  2004)
• Increase in symptoms (eating disorders,
  self-harm)
• Increase in management problems
• Retraumatization (Harris and Fallot, 2001)
• Increase in relapse
• Withdrawal from service relationship
• Poor treatment outcomes (Easton et al 2000
  Ouimette et al 1999)

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Trauma-Informed Services

• Trauma-informed services are based on an
  understanding of the impact of violence and
  victimization.
• All treatment for substance abuse/co-occurring
  disorders should be trauma-informed.

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Trauma-Informed vs. Trauma-Competent Treatment

• Trauma-informed basic training/education to all
  stafffrom secretaries to high level
  administratorsunderstanding of trauma permeates
  every aspect of treatment milieu and
  interventions.
• Trauma-competent treatment educating fewer,
  carefully selected staff/clinicians to conduct
  actual trauma treatment
  (Fallot Harris, 2001 Najavits, 2006)

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Assumption 1Trauma is Central and Pervasive

• Central to the development of mental health and
  addiction problems
• Impacts MANY aspects of a persons life

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Assumption 2Universal Precautions

• A client should not have to disclose trauma to
  receive trauma-informed servicestreat everyone
  as a potential trauma survivor.

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Assumption 3Symptoms and Behaviors

• Are often attempts to cope with the trauma

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Assumption 4Goal of Services

• Is to return a sense of autonomy and control to
  the victim

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Principles of Trauma-informed Services

• Trauma-informed services recognize the impact of
  violence and victimization on development and
  coping strategies.
• 2. Trauma-informed services identify recovery
  from trauma as a primary goal.

(Source Elliott, D, Bjelajac, P, Fallot, R,
Markoff, L, Reed, BG, J of Community Psychology,
2005, pp 461-477)
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Principles of Trauma-informed Services

• Trauma-informed services employ an
  empowerment model
• Collaborative relationship between provider and
  consumer
• Focus on strengths
• Build skills
• Trauma-informed services strive to maximize a
  womans choice and control over her recovery

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Principles of Trauma-Informed Services

• Trauma-informed services are based in a
  relational collaboration.
• Since the violation often occurred in
  relationship, healing must occur by changing
  relational context
• From abusive to nurturing
• From unresponsive to empathic
• From lies and denial to authenticity
• From controlling to empowering

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Principles of Trauma-Informed Services

• Trauma-informed services create an atmosphere
  that is respectful of survivors need for safety,
  respect and acceptance.
• 7. Trauma-informed services emphasize womens
  strengths, highlighting adaptations over symptoms
  and resilience over pathology.

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Principles of Trauma-Informed Services

• The goal of trauma-informed services is to
  minimize the possibilities of retraumatization.
• Reduce triggering situations
• Identify triggers for individual consumers
• Trauma-informed services strive to be culturally
  competent and to understand each woman in the
  context of her life experiences and cultural
  background.

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Principles of Trauma-Informed Services

• Trauma-informed agencies solicit consumer input
  and involve consumers in designing and evaluating
  services.

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SAMHSAs Women with Co-Occurring Disorders and
Violence Study
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SAMHSAS Women, Co-occurring Disorders and
Violence Study (WCDVS)(1998 2003)

• Phase 1
• 2 years, 14 sites
• Design of new Trauma Integrated Service System
• Selection of most promising trauma interventions
• Development of Cross-site protocols
• Phase 2
• 3 years, 9 sites
• Implementation of Cross-site study comparing
  integrated trauma-informed and trauma-specific
  services to services as usual

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Sample Sizes Across Program Sites by Condition
(N2,729)
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Baseline Demographic Characteristics by Program
Site
Boston Consortium of Services
Franklin Co. Womens Research Project
The W.E.L.L. Project
PROTOTYPES SCC
DC Trauma Collaboration Study
Triad Womens Project
New Directions for Families
Portal Project
Allies
Total
Hispanic ethnicity was measured independent of
race Not all percentages total to 100, as
excluded from the totals were subjects for whom
data were missing Category includes subjects
who identified two or more races
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Participants in the Study

• 2,729 women were enrolled in the study
• All are 18 or older with histories of mental
  health and substance abuse services use and
  histories of physical or sexual abuse
• Average age (both groups) is about 26. Age ranges
  from 18 to 76
• 54 were Caucasian, 18 Hispanic/Latina, 29
  African American
• 87 were mothers
• 50 had completed high school

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Primary Outcomes Measures

• Outcomes Measures
• Substance Abuse Addiction Severity Index
• Alcohol Composite (ASI-A)
• Drug Abuse Composite (ASI-D)
• Mental Health Brief Symptom Inventory
• Global Severity Index (GSI)
• Trauma Post Traumatic Diagnostic Scale
• Post Traumatic Symptom Scale (PSS)

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Outcomes

• At 6 monthsall women improved on all 4 major
  outcomes (alcohol and drug use, mental health,
  and trauma symptoms)
• Women in integrated condition did better than
  women in usual care when provided with integrated
  counseling
• At 12 months, women in the intervention group
  maintained their improvement in drug use outcomes
  and continued to improve in mental health and
  trauma outcomes

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WCDVS Showed

• Can start trauma treatment integrated with
  substance abuse mental health treatment from
  the beginningdoes not hurt but helps the
  recovery process
• The importance of developing trauma specific
  treatment models that address substance abuse and
  co-occurring disorders

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• Trauma-Specific Group Services
• Used in WCDVS

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Trauma Specific Interventions

• Services designed specifically to address
  violence, trauma, and related symptoms and
  reactions.
• Increase skills and strategies that allow
  survivors to manage their trauma symptoms and
  reactions with minimal disruption to their daily
  obligations and quality of life, and eventually
  to reduce or eliminate debilitating symptoms and
  prevent further traumatization and violence.

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Trauma-Specific Curricula

• Utilized in WCDVS
• Maxine Harris Trauma Recovery
  Empowerment (TREM)
• Lisa Najavits Seeking Safety
• Dusty Miller Addiction Trauma Recovery
  Integration Model (ATRIUM)
• Clark Fearday TRIAD

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Other Models Utilized in Substance Abuse
Treatment

• Stephanie CovingtonHelping Women Recover
  Beyond Trauma
• Julian FordTrauma Adaptive Recovery Group
  Education Therapy for Persons in Recovery from
  Addiction (TARGET-AR)

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Common Features

• Stage 1
• Cognitive-behavioral
• Teach coping skills
• Group curricula, but could be utilized in
  individual sessions
• Can be co-facilitated by a professional a peer

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Stages of Trauma Recovery Treatment Aims

• Stage One ESTABLISHING SAFETY
• Securing safety
• Stabilizing symptoms
• Fostering self-care
• Stage Two REMEMBRANCE MOURNING
• Reconstructing the trauma
• Transforming traumatic memory
• Stage Three RECONNECTION
• Reconciliation with self
• Reconnection with others
• Resolving the trauma (Herman, Trauma
  and Recovery)

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Stage I Recovery

• Focus upon establishing both physical
  psychological safety
• Increasing understanding of links between trauma
  substance abuse
• Teaching coping skills
• (Herman, Trauma and Recovery)

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Seeking Safety

• Najavits, L.M. (2002). Seeking Safety A
  treatment manual for PTSD and substance abuse.
  New York Guilford Press.
• Integrates safety and recovery
• Stresses accessing other community supports
• 25 topics, including Safety, When substances
  control you, Grounding
• Session format
• Check in
• Quotation
• Relating topic to womens lives
• Closing
• 80 safe coping skills

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ATRIUMAddiction Trauma Recovery Integrated
Model

• Miller, D. Guidry, L. (2001). Addictions and
  Trauma Recovery Healing the body, mind, and
  spirit. New York WW. Norton Co.
• Addresses mental, physical spiritual health
• Creating sacred connections to the world beyond
  the self
• 12 sessions, including self-harm, relationship
  changes, spiritual disconnections

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TRIAD

• Clark, C. Fearday, F. (Eds.) (2003). Triad
  womens project Group facilitators manual.
  Tampa, FL Louis de la Parte Florida Mental
  Health Institute, University of South Florida.
• Promotes survival, recovery empowerment
• 16 sessions, divided into 4 phases
• Mindfulness
• Interpersonal effectiveness skills
• Emotional regulation
• Distress tolerance
• Has been modified for use in jails

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TREMTrauma Recovery and Empowerment

• Harris, M. The Community Connections Trauma
  Work Group (1998). Trauma Recovery and
  Empowerment A clinicians guide for working with
  women in groups. NY Free Press.
• Current problematic behaviors and symptoms may
  have originated as legitimate and courageous
  attempts to cope with or defend against trauma
• 33 topics, divided into four categories
• Empowerment (11 sessions)
• Trauma Recovery (10 sessions)
• Advanced Trauma Recovery Issues (9 sessions)
• Closing Rituals (3 sessions)

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Helping Women Recover

• Covington, S.S. (1999). Helping Women Recover A
  program for treating addiction. San Francisco
  Jossey-Bass.
• Integrates expressive arts
• Accompanying journal
• 17 sessions, divided into four modules
• Self
• Relationships
• Sexuality
• Spirituality

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TARGET-ARTrauma Adaptive Recovery Group
Education and Therapy for Persons in Addiction
Recovery

• Ford, J.D., Mahoney, K., Russo, E., Kasimer, N.,
  MacDonald, M. (2003). Trauma Adaptive Recovery
  Group Education and Therapy (TARGET) Revised
  composite 9 session leader and participant guide.
  Farmington, CT University of Connecticut Health
  Center.
• Cognitive-behavioral
• Present-focused
• Systematic skills training
• Designed to be brief treatment

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Choosing a Curriculum

• Research, evaluation studies
• Program values and treatment philosophy
• Curriculum length and format
• Group facilitators expertise
• Adaptations for specific populations
• Cost, training, setting

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Integrating the Curriculum into Substance Abuse
Treatment

• Pilot-testing the curriculum
• Training for staff and supervisors
• Ongoing supervision and support for the new
  practice
• Monitoring of fidelity

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SAMHSAs WCDVS Childrens Subset Study
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WCDVS Childrens Subset Study

• 4 of the 9 WCDVS womens study sites
• Development/implementation of standardized,
  strengths-based intervention
• Outcome evaluation of children (ages 5-10)
• Interviews conducted with mothers/caregivers
• Generate empirical knowledge re effectiveness of
  trauma-informed, age-specific intervention models
• Identify models of care that will prevent or
  reduce intergenerational perpetuation of violence

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WCDVS Childrens Study Sites
Women Embracing Life Living (WELL) Project
Allies Project
New Directions for Families
Prototypes
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Core Intervention Components

• Clinical AssessmentMother Child
• Resource/Service Coordination and Advocacy
• Skills/ResiliencyBuilding Group

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Primary Goals of the Group Intervention

• Learn self-protection skills
• Develop skill in self-soothing
• Enhance interpersonal relationships
• Strengthen self-esteem and self identity

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Characteristics of Children

• Average age7.28 years
• In legal custody of mother74.3
• Involved in child welfare system39
• Experiencing emotional or behavioral problems
  67.5
• Parent convicted of a crime79.8
• Parent treated for substance abuse98

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OutcomesN253 Baseline, 209 (6 months), 217 (12
months)

• 6 months post-baseline, mothers overall
  treatment outcome played a stronger role in
  childrens outcomes than involvement in
  intervention if mother did better, children did
  better.
• However, children enrolled in intervention showed
  general improvement regardless of mothers
  outcome.
• 12 months post-baseline, participation in
  intervention led to sustained positive
  improvement regardless of mothers outcome, with
  younger children showing a greater degree of
  positive change than older children.

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Lessons Learned

• Children can be the motivator for women to seek
  treatment
• Treatment of the woman offers an opportunity to
  provide services to the children
• Traumatic childhood experiences influence the
  ability to parent
• Victimization of children triggers memories in
  the parent
• Motherhood is both a major source of identity and
  self-worth, and a source of shame and guilt

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Lessons Learned

• Extreme guilt and shame must be addressed in
  order to build healthy parenting relationships
• The support of a parent who has experienced
  similar challenges is critical to overcome fear
  and guilt
• Must have well developed working relationships
  with child welfare agencies

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Consumer Quote

• It was not until I became a part of the Women,
  Co-Occurring Disorders Violence Study that I
  became trauma informed. I remember realizing one
  day, what perfect sense this all makes. I was
  able to finally fit the pieces of the puzzle
  together. Being a survivor was the reason I drank
  used drugs. Post Traumatic Stress Disorder had
  set in, the drinking and using suppressed my
  true feelings. I am among one of the lucky few.
  So many of us have not solved the puzzle
  survivors, providers.
• One of the most important things I have learned
  is how to keep myself safe. The word Safety never
  came up in treatment. I now realize how much
  jeopardy I put myself in when I was using
  substances, not caring what time of the night it
  was, not caring that the guy just came into the
  room waving a gun, just give me another hit. We
  continue to put ourselves in situations that can
  retraumatize us on a daily basis. Learning how
  important safety is to my recovery process has
  changed my outlook.