Treating Women with Cooccurring Conditions

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Treating Women with Co-occurring Conditions

• Presented at the 4th Annual Arizona Substance
  Abuse Conference Addressing Substance Abuse in
  Critical Populations A Call to Action, Phoenix,
  AZ, April 2009.
• Supported by NIDA Grant RO1 DA08637, CSAT Grant
  KD1TI12539, La Frontera Center, Inc.

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Pat Penn, PhDErin Overstreet, MABrenda Morris,
RSSLa Frontera Center, Inc., Tucson,
AZwww.lafrontera.org ppenn_at_lafrontera.org
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Basis of Presentation

• Seven focus groups with clients with CC, and
  counselors
• A study comparing treatment based upon SMART or
  12-Step methods
• NIDA Clinical Trials Network Seeking Safety
• Years of agency co-occurring treatment
• Other literature

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Agenda

• Introduction
• Co-occurring treatment principles
• Women with CC focus group
• Brendas story
• Seeking Safety
• SMART Recovery
• Questions

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Co-occurring ConditionsSome Facts

• Half of people with one have the other
• Women men, equal prevalence
• Have more severe symptoms
• Treatment may take longer, cost more
• Have other problems legal, social, health,
  financial, housing
• Often receive fragmented treatment

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Principles of Co-Occurring Conditions (CC)
Treatment

• Integrated treatment
• Stage-wise treatment
• Engagement interventions
• Motivational counseling
• Active treatment
• Relapse prevention interventions
• Longer term treatment available
• Drake et al., 2004 26 Controlled Studies

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What CC Clients Want

• Positive, upbeat environment
• Nonjudgmental, non-confrontational
• Listen to, affirm, support client
• Work with clients strengths, goals
• Connection with at least one staff
• Support from other clients
• Structure
• Brooks Penn, 2003 Brooks et al., 2007

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What CC Clients Want (cont.)

• Integrated treatment
• Harm reduction model
• Teach a variety of recovery tools
• Assistance with health issues
• Other support services
• Good long-term follow-through
• Services available long-term

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Client Quotes

• In some cases agencies dont even know each
  other exist.
• I think getting the help with the mental health
  is harder because when you come in and you say I
  have this problem, that problem, next problem,
  they say, well do you drink or use drugs? They
  respond well, yeah, okay, youre a drug addict
  and thats that, and thats where they put you.

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Women with CC Facts

• More severely affected
• Become addicted sooner
• Abuse is a risk factor for CC, and women have
  more abuse/trauma
• At greater risk for further victimization
• Afuwape, 2003

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Women with CC Facts

• Tend to seek treatment (Tx) later
• If have children tend to avoid Tx
• Have more adverse health effects
• May have more financial issues
• Women in prison about half have CC

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What Women with CC Want Our Focus Group

• Integrated Tx CC is the expectation
• Relaxed, friendly atmosphere
• Warm, engaging, supportive staff
• Client-directed Tx
• Better system coordination
• Medication management groups
• Help with finances and health care
• Penn, Brooks Worsham 2002

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What Women Want Elements for Women

• Women only groups
• Groups addressing parenting, loss of parent
  roll, domestic violence, other womens issues
• Individual therapy available initially
• Child care
• More help with advocacy, eg., CPS

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Quotes by Women

• it was literally that they listen and wrote
  down what you wanted and we sat there and derived
  how we can help you get tht goal
• I wouldnt trade my team now for nothing. They
  listen to me, stand by me, go to court with me.

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• Brendas
• Story

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Co-occurring ConditionsNow What?
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Treatment ModelsWe Like and Use

• Seeking Safety
• Lisa Najavits, PhD (2002)
• www.seekingsafety.org
• SMART Recovery
• Self Management Recovery Training
• www.smartrecovery.org

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Seeking Safety

• Seeking Safety - a therapy for co-occurring
  trauma/posttraumatic stress disorder (PTSD) and
  substance abuse
• Developed by Lisa Najavitz, PhD
• Originally designed for women

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About Seeking Safety

• Stabilizing/Grounding A present focused
  therapy to help people attain safety from PTSD
  and substance abuse.
• Flexible Can be conducted in group or individual
  format for women, men or mixed gender using all
  or fewer topics, variety of settings and
  providers.

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Key Principles of Seeking Safety

• Stability is the goal for first-stage treatment
• Integrated Treatment
• A focus on ideals to counteract the loss of
  ideals in both PTSD and SA

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Key Principles (cont.)

• Four Content Areas
• Behavioral
• Cognitive
• Interpersonal
• Case Management

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Key Principles (cont.)

• Attend to Therapist Process
• Focus on skills training group process
• Balance praise accountability
• Manage countertransference
• Attend to self-care

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Additional Features

• Prepares clients to use other treatments
• Emphasizes optimism, self-efficacy
• Makes the treatment engaging quotations,
  everyday language

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Additional Features

• Trauma details not part of group therapy
• Harm reduction model
• Gives clients control wherever possible
  empowerment

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Seeking Safety Topics

• Cognitive Topics
• Taking Back Your Power
• Compassion
• When Substances Control You
• Creating Meaning
• Discovery
• Integrating the Split Self
• Recovery Thinking

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Seeking Safety Topics

• Interpersonal Topics
• Honesty
• Asking for Help
• Setting Boundaries in Relationships
• Getting Support
• Healthy Relationships
• Community Relationships

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Seeking Safety Topics

• Behavioral Topics
• Taking Good Care of Yourself
• Commitment
• Respecting Your Time
• Coping with Triggers
• Self-Nurturing
• Red and Green Flags
• Detaching from the Emotional Pain (Grounding)

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Seeking Safety Topics

• Other Topics
• Introduction/Case Management
• Safety
• Life Choices
• Termination

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Why Choose Seeking Safety

• Demonstrated efficacy
• Treatment works for a wide range of clientele
• Treatment is relatively brief
• Focus on strengths and building positive coping
  skills rather than on reprocessing the trauma

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Why Choose Seeking Safety (cont.)

• Very Flexible
• Necessary in community treatment
• Open enrollment possible
• Topic order can be varied
• Clients can choose topics
• Topics can be repeated

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What Clients Have Said

• Noted improvements in overall self-esteem
• Greater confidence coping with PTSD and SA
  triggers
• Said they felt safe in group
• Topics and handouts were very useful

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Client quotes

• This is my favorite group
• I have learned a lot of tools
• I have used a lot of the tools outside of group
• I would like to go through the series again as a
  refresher

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Observations from Facilitators

• Many clients seem to feel relaxed in the
  emotionally managed atmosphere
• Most clients leave group in a positive, upbeat
  mood
• Clients refer to the tools they are learning when
  outside of group

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Mock Meeting

• Think of a person that might benefit
• from Seeking Safety, and get ready to participate!

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GroundingDetaching From Emotional Pain

• Check-in with everyone
• No feeling is finalRainer Maria Rilke
• How does this relate to your life in recovery?
• Scale 1-10 (1not anxious, 10very anxious)
• Write down your number

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GroundingDetaching From Emotional Pain

• Grounding a set of simple strategies to detach
  from drug cravings, self-harm, anger, sadness
• Focus the external world rather than inward
• Physical
• Mental
• Soothing

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GroundingDetaching From Emotional Pain

• Physical grounding session
• Re-rate yourself on a 1-10 scale
• Discuss how you experienced the grounding
• Practice, practice, practice!!!

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• Questions?

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SMART Recovery

• Non-profit self-help program,1994
• Derived from Albert Ellis REBT
• Originally Rational Recovery
• Alternative/addition to 12-Step

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SMART Resources

• Community self help groups
• User-friendly, inexpensive support materials
• Annual trainings
• Online meetings, information, support
• Professional advisors

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Characteristics of SMART

• Encourages people to use what works
• Meetings led by trained facilitators
• Meetings use discussion and cross talk
• Cognitive/behavioral methods
• Appropriate for self-help, group individual
  treatment

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SMART 4-Point Program

• 1 Enhancing and maintaining motivation to
  abstain
• 2 Coping with urges
• 3 Problem solving (managing thoughts, feelings
  behaviors)
• 4 Lifestyle balance (balancing momentary
  enduring satisfactions)

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SMART Tools Include

• Cognitive Restructuring ABCs
• Building Motivation CBAs
• Exchange Vocabulary
• Imagery/mental rehearsal
• Brainstorming, role playing
• Homework, personal incentives

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Our Co-Occurring Treatment Study

• Public agency treatment for CC
• IOP modality 6 months
• Compared SMART and 12-Step - alternate
  assignment
• ASI, Lehman QOL other measures
• 112 Participants
• Brooks Penn, 2003

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Outcomes for Both Groups12 Month Follow-up

• Alcohol use reduced
• Drug use remained low
• Increased life satisfaction
• Equally effective for women, minorities, variety
  of diagnoses

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Additional Outcomes for SMART

• Increased employment
• Improved health status
• Psych status better during the program
• SMART applied to more issues

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SMART Outcomes Clients Liked It

• Fewer client complaints
• 25 higher completion rate
• Higher client satisfaction
• Courtesy and respect from staff
• Program structure met needs
• Total scores higher

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Our SMART CCFocus Groups

• Two focus groups were conducted
• Clients (n12)
• Counselors (n8)
• All had experience with both 12-Step SMART
  Recovery self-help
• All participants from a community agency
• Penn, et al., 2005

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Focus Group Results

• Positive to negative comment ratio
• 12-Step 0.3 to 1
• SMART 16 to 1

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Focus Group Themes Clients re. SMART

• Tools are taught and practiced
• Wide applicability of tools
• Treats the whole person
• Harm reduction approach
• Respectful method no labeling
• Builds self confidence
• Feels safe with facilitators

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Client Comments

• SMART gave me pride. It showed me how to get
  self-worth. It was basically building me up in
  order to be receptive to everything else.
• Cognitive therapy has been good More of a
  positive outlook, the way I talk and the things I
  do.
• I will never again say that Im an alcoholic or
  addict thats a very small portion of what I am.
  So thats what I love about SMART. We dont have
  to self-deprecate.

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Focus Group Themes Counselors re. SMART

• Agreed with clients re. strengths
• Useful for persons with CC
• Works for early stages of recovery
• Helps some clients be able to use 12-Step programs

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Counselor Comments

• I was introduced to people with CC who were
  not real open to 12-Step but benefiting from
  SMART.
• SMART is not just sitting around saying my
  experience is this and that. It is tools.
• SMART does not come from a place of expecting
  abstinenceit is just more doable.
• It is simple to grasp.

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Are there additional implicationsfor these
results?
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• 90 of the substance abuse treatment in the US is
  
• 12-Step based!

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• SMART
• Demonstration

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How We Use SMART

• IOP, ADMIRE Plus
• Residential treatment
• Outpatient groups
• Community self-help groups
• Train staff at other agencies, corrections
• No refinement to SMART needed!

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ConclusionWhy SMART Recovery?

• Uses best practices for CC
• Is an integrated approach
• Builds motivation and skills
• Can be used with all change stages
• Is engaging
• Can be used in treatment and self-help aftercare

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Why SMART? (cont.)

• Women, and men, like it
• Is person-centered
• Teaches useful tools
• Led by a trained facilitator
• Respectful methods used
• Builds self-confidence
• Is fun

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Why SMART? (cont.)

• Feasible for community treatment
• Designed for open enrollment groups
• Useful for diverse clients, problems
• Is easy, inexpensive to learn and use
• Uses typical CBT methods (which have much
  evidence support in general), and makes them
  practical

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More Treatment Suggestions for Women

• Use creative therapies art, singing, drama,
  music
• Teach physical health care
• Provide safety training
• Have female staff
• Promote bonding w/ women
• Arrange for daily needs

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Conclusions

• Women with CC desire the best practices for CC
• Women have some unique treatment needs
• Evidence-supported practices exist

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Questions?

• "I think the key is for women not to set any
  limits.
• Martina Navratilova

SB JM