TraumaInformed Substance Abuse Treatment

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Trauma-Informed Substance Abuse Treatment

• Community Connections 2008

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Scope of the Problem

• Lifetime history of trauma among women substance
  abusers ranges from 55-99 as compared to 36 for
  women in the general population
• 66 of individuals in inpatient substance abuse
  programs report a history of physical or sexual
  abuse

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Scope of Problem (2)

• Women with child abuse histories are at 4 times
  the risk for psychiatric disorders and 3 times
  the risk for substance use disorders
• Women who abuse drugs are more likely to be
  victims of trauma than women who do not

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Scope of Problem (3)

• Female detainees report
• 15 had a current diagnosable severe mental
  illness
• 60 had a current diagnosable substance abuse
  disorder
• 33.5 met diagnostic criteria for PTSD because of
  rape or other violent assault

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Adverse Childhood Experiences(www.ACEstudy.org)
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Scope of the Problem (5)

• Physically abused boys are more likely to become
  substance abusers (Malinosky-Rummel and Hansen,
  1993)

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Exploring the Connections

• Family Addiction and Violence
• Transgenerational Violence
• Emotional and Relational Sequelae of Trauma for
  Which Substances Become the Coping Strategy of
  Choice
• The Context of Addiction and the Predisposition
  to Victimization

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Family Addiction and Violence

• 65 of incest offenders were drinking at the time
  of the abuse
• 30-84 of child abuse and neglect cases occur in
  families where drug or alcohol abuse is present
• Abusers use alcohol or drugs to make victims more
  compliant

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Family Addiction and Violence (2)

• 25-80 of males who assault their partners were
  drinking at the time
• Of women enrolled in drug treatment who reported
  being the recipient of abuse by their partner,
  21 of them reported being the perpetrator of
  violence against their own children.

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Emotional and Relational Sequelae of Trauma

• The use of drugs to elevate mood
• Alcohol, cocaine, amphetamines
• The use of drugs to calm agitation
• Opiates, alcohol, marijuana
• The use of drugs to dull memories
• Opiates, alcohol
• The use of drugs to stimulate feelings
• Amphetamines, cocaine, PCP

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The Context of Addiction

• Dangerous networks and violent partners
• Sex trade work
• In one study, 60 of substance abusing women
  reported having been raped at some point in their
  lives
• In a study conducted at Community Connections,
  30 of women reported an incident of sexual or
  physical violence in the preceding month
• Critical judgment and decision making skills
  become impaired as a result of use

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The Context of Addiction (2)

• The risk of assault increases because substance
  abusing females are
• impaired in their inability to detect predators
• more likely to engage in high risk behaviors
• more likely to appear vulnerable and easy to
  attack

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The Context of Addiction (3)

• The cycle of abuse and substance use
• 1997 2 year 3 phase longitudinal study of 3000
  women Journal of Consulting and Clinical
  Psychology, Kilpatrick et al.
• Drug use increases the chance of an assault which
  in turn increases the use of drugs
• History of assault increases the incidence of
  drug use which in turn increases the chance of a
  second or additional assault

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Treatment Approaches

• Sequential Treatment
• Parallel Treatment
• Integrated Treatment

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Integrated Treatment

• Trauma, addictions, and mental health problems,
  when they co-occur in a single individual, are
  addressed by a single system and at least in part
  by a single, unified intervention

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Integrated Treatment (2)

• Assumptions
• the problems of trauma, substance abuse, and
  mental health interact complexly and causally
  within a single individual
• approaches to recovery must be whole person
  approaches
• value is placed on individual, family, and
  community empowerment

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An Integrated Treatment Approach

• Integrative Explanations
• Content Modules
• Dual Recovery Skills
• Program Milieu
• Ancillary Services
• Contraindicated Approaches

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Integrative Explanations

• Primary trauma is a stressor that may trigger
  substance use and the development of psychiatric
  symptoms
• Trauma sequelae (flashbacks, nightmares) are
  stressors that may trigger substance use. These
  sequelae may also result in a psychiatric
  diagnosis
• Substance use and certain psychiatric symptoms
  may have evolved as coping strategies at a time
  when options were limited

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Content Modules

• Drug and alcohol education
• triggers to use
• consequences of use
• alternative behaviors
• relapse prevention
• Trauma Recovery and Empowerment
• 33 sessions focusing on abuse and the skills to
  cope with the aftermath

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Content Modules (2)

• Domestic Violence
• understanding the patterns of abuse and
  reconciliation in relationships
• making a plan for your safety and the safety of
  your children
• Parenting
• How trauma affects your ability to parent
• Losses associated with partial-parenting

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Dual Recovery Skills

• Self-awareness
• Self-protection
• Self-soothing
• Emotional modulation
• Relational mutuality
• Consistent problem solving
• Judgment and decision-making
• Accurate labeling of self and others
• Sense of agency and initiative

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Program Milieu

• Empowerment and strengths-based
• Relationship focused
• Nurturing peer environment
• Availability of female staff to provide services
  and to serve as role models
• Availability of same sexed groups

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Ancillary Services

• Health care
• HIV education and treatment
• Vocational/educational assessment and assistance
  with placement
• Housing opportunities and residential services
• Child care and services for children

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Contraindicated Approaches

• Shaming techniques
• name calling
• Scarlet Letter techniques
• relapse as failure
• Intrusive monitoring
• strip searches
• body cavity searches
• urine screens with male staff
• Premature self-disclosure

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Contraindicated Approaches (2)

• Excessive confrontation
• encounter groups
• hot seat activities
• Stripping away all defenses in order to make a
  women more vulnerable
• Moral inventories that encourage women to assume
  more than their share of responsibility for past
  abuses
• Forced treatment
• Exclusive emphasis on surrender to a higher power
  with no recognition of personal power

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Guidelines for Practice

• Universal screening
• Understanding the role of violence and abuse in
  peoples lives
• Appreciating the power of trauma dynamics

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Guidelines for Practice (2)

• Avoiding re-traumatization
• Policy and procedure review
• Clear and public policy for investigating abuse
  charges
• Absence of shaming and excessive confrontation
• No forced disclosure
• Accurate assessment of blame and responsibility
• Consumer involvement at all levels of service
  delivery
• Respect for consumer preferences

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Trauma-Informed Addictions Treatment

• A 20 Session Psycho-Educational
• Group Intervention Designed to
• Address Substance Abuse Issues within a
  Trauma-Informed Perspective

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Rationale

• Violence and victimization are linked to patterns
  of substance use in multiple and complex ways
• Histories of sexual and physical abuse increase
  the likelihood that consumers will abuse
  substances and once established, a life of
  addiction increases the chances of further
  victimization
• Trauma-informed understanding not intended to
  justify addiction, merely to put it in context

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Philosophy

• Room to incorporate other theoretical models
• Strengths-based model, confrontation light
• Emphasis on education

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Group Format

• Icebreaker
• Questions
• Exercise
• Ending Ritual

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Session Topics

• Introduction to the Group
• Understanding Your Family History of Addiction,
  SA and Violence (1) and (2)
• Understanding the Role of Behavioral and
  Emotional Triggers in Patterns of SA
• The Emotional Consequences of Abuse
  Understanding Anger, Impulsivity and Rage

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Session Topics (2)

• The Emotional Consequences of Abuse
  Understanding Anxiety, Fearfulness and Paranoia
• The Emotional Consequences of Abuse
  Understanding Depression and Suicidality
• The Emotional Consequences of Abuse
  Understanding Numbing, Dissociation and Boredom
• The Interpersonal Consequences of Abuse
  Loneliness, Isolation and Withdrawal
• The Interpersonal Consequences of Abuse
  Excessive Dependency, Poor Judgment and Failures
  to Set Limits

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Small Group Exercise

• Substance Abuse and
• Trauma Vignettes

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Stacy

• Stacy is a 30 year old woman who is addicted to
  crack cocaine. According to her intake, Stacy
  said she has been drinking since 10 years old and
  using drugs since she was 13 years old. She
  started with marijuana and graduated to the
  harder stuff. Crack has been her drug of choice
  for the past 8 years. She has been in treatment
  three times previously. She was able to stay
  clean for a year after one treatment program.
• She has had two jobs working in fast food
  restaurants, neither lasted long. Otherwise she
  denied any work history.

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Stacy (2)

• When asked how she was able to support her habit
  she said by doing this and that. When
  questioned further she said that sometimes she
  traded sex for drugs. She is currently on
  probation for an assault charge. She stated that
  the assault was not her fault and that people
  just keep gettin in her face.
• She said her parents were addicts and that things
  were pretty crazy when she was a kid. She said
  there were a lot of people coming and going from
  their house. When asked if she was ever abused,
  she said it was rough when she was growing up.
  But that even as a kid, she could take care of
  herself.

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Stacy (3)

• When asked if she was ever abused as an adult,
  she said no one better mess with her and that she
  could give as good as she got.
• Stacy reported having three kids. The first
  child was born when she was 14 years old and the
  father was one of her dads friends. That child
  went to foster care years ago and she thinks he
  was adopted. Her other kids are 9 and 10 years
  old. Her aunt is raising them and she sees them
  sometimes.
• When asked if she had ever been hospitalized,
  Stacy said she had a couple of overdoses. The
  hospital tried to say they were suicide attempts,
  but she said that was a crazy idea.

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Teresa

• Teresa is a 50 year old woman addicted to
  alcohol. She has been separated from her husband
  for 6 months and she reports that the depression
  has gotten worse since then. She thinks she has
  been depressed all her life, but knows that it
  has been worse since the separation. She reports
  that she isolates herself in her bedroom for days
  at a time. Her 14 and 10 year old children are
  supportive and would pretty much take care of
  themselves. She has a 24 year old son who would
  buy the groceries and runs other errands for her.

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Teresa (2)

• She states that she is very sad about the end of
  her marriage. She said that it was a very good
  marriage. Even though he had cheated on her
  several times, she always forgave him. She
  realized if she had been a better wife, this
  wouldnt have happened. When asked if he had
  ever abused her, she said that he hit her
  sometimes and would yell at her when she did
  irritating things. But she added that every
  marriage had its ups and downs. She grew up
  watching her dad hit her mom. That is just what
  happens in marriages.

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Teresa (3)

• She reluctantly admitted that an uncle and a
  neighbor sexually abused her. She told her mom
  about it, but was told not to tell her father.
  Her mom said it would just make him angry.
• She has been unemployed for 3 years. She reported
  that she started taking a computer class, but
  dropped out because it was too difficult. She
  cant really turn to family and friends for
  emotional or monetary support because she hasnt
  talked to them in a while.

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Marilyn

• Marilyn is a 22 year old addicted to marijuana
  and alcohol. She has two children, ages 3 and 5.
  She has been unemployed for a year but recently
  she got a job where her sister is working as a
  dancer. She didnt like dancing at first and
  had to drink a lot just to get herself to do it.
  But now she is okay with it. Besides, she had to
  get a job if she was going to get her kids back.
  
• Her mom reported her to Child Protective Services
  four months ago. Her mom told them that she was
  neglecting the children and that Marilyns
  boyfriend had sexually abused them. Marilyn
  thought that the accusation about the sexual
  abuse was especially ironic since when

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Marilyn (2)

• Marilyn was sexually abused as a kid her mom
  didnt believe her. And after the rape kit came
  back her mom told her that she must have asked
  for it.
• After the sexual abuse Marilyn started getting in
  trouble at school, hanging out with a rough
  crowd, drinking and doing drugs, and not coming
  home. When she was arrested for shoplifting and
  her mom told the police to take her back to jail.
  Her mom said she couldnt do anything for
  Marilyn. She said Marilyn was a bad seed and
  nobody could save her. When she was sixteen and
  called her mom to tell her she was pregnant and
  to ask if she could move back home, her mom said
  that she

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Marilyn (3)

• always knew Marilyn was a slut and a whore.
  Her mom said that she had made her bed and now
  she could lie in it.
• Marilyn is complaining that she is losing periods
  of time. She doesnt know what is happening but
  she is also forgetting lots of stuff. She has
  had a thing about cleanliness for a long time,
  but lately it has been worse. She is taking at
  least 4 showers a day and washing her hands all
  the time. She also has had problems sleeping.
  She has been experiencing a lot of nightmares.

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Darlene

• Darlene is a 40 year old woman who is addicted to
  heroin. She was recently released from federal
  prison after serving three years for forging and
  passing bad checks. She stayed clean while she
  was in prison and is struggling to stay clean now
  that she is out. Before prison she was a teacher
  and a day-care provider. She cannot go back to
  either of those professions because she now has a
  felony on her record. She is hoping to get a job
  as a home health aide.

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Darlene (2)

• Darlene was incested for years as a child. The
  family covered it up and when she became pregnant
  with her fathers child, the child was given to
  her aunt and raised as her cousin. Her
  ex-husband was physically and emotionally abusive
  to her. He has custody of their children now and
  she worries that he will abuse them also.
• She said that she presently has a male friend in
  her life that is quite good to her. She is a
  diabetic and he has been cooking healthy meals
  for her. She said for once her blood sugar is
  below 150. He has been very

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Darlene (3)

• dependable but she doesnt believe it is
  going to last. She cuts herself and he has seen
  the scars all over her body. She doesnt want to
  tell him why she cuts because then he will think
  she is a freak. She has had three serious
  suicide attempts and says she thinks about
  suicide almost daily. She knows she is
  depressed, but doesnt believe medication will be
  helpful. She is not willing to stop cutting.
  She says it is a part of her.

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Session Topics (3)

• The Behavioral Consequences of Abuse The Life of
  Addiction and Putting Yourself at Risk
• Re-Victimization Becoming Your Own Abuser
• Re-Victimization Re-Creating the Relationship of
  Abuse
• Re-Victimization Re-Creating the Feelings of
  Abuse
• Empowering Yourself

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Session Topics (4)

• Designing a Plan for When Things Go Wrong
• Building and Re-Building Relationships
• Achieving Balance in Your Life
• Recapturing the Dream and Envisioning a Future
• Saying Good-Bye

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Consumer Feedback

• Link between SA and trauma not covered in AA/NA
  or traditional SA groups
• Safety of format
• Skill building, alternate coping strategies
• Deep Trauma