TraumaInformed Practices for Treating CoOccurring Disorders

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Trauma-Informed Practices for Treating
Co-Occurring Disorders
Plenary Panel Norma Finkelstein, PhDInstitute
for Health and Recovery Roger Fallot,
PhDCommunity Connections Lisa Russell, PhDETR
Associates Vivian B. Brown, PhDPROTOTYPES Gloria
GonzalesFamily Ties
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Overview on Trauma-Informed Practices
Norma Finkelstein, PhD Institute for Health and
Recovery
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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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Co-occurrence of Substance Abuse Domestic
Violence

• Research Institute on Addictions (1997)
• 80 of women with substance use 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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Special Issues for Victims of Violence Who Have
Co-Occuring Disorders

• The presence of both alcohol and drug use
  domestic violence increases the severity of
  injuries lethality rates (Mackey, 1992)
• Perpetrators may pose risk to partners by
• Introducing partner to drugs
• Forcing or coercing partner use
• Isolating partner from help
• Coercing partner to engage in illegal acts
• Using withholding drugs as a threat
• Using legal history as a threat
• Blaming abuse on partner use

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History of Abuse Mental Illness

• Muesser et al., 1998
• 90 of public mental health clients have
  histories of trauma
• most with multiple instances
• Kessler et al, 1995
• 34-53 report childhood physical or sexual abuse
• 43-81 report some type of victimization

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Domestic Violence Mental Health Problems

• On average, over half of women seen in a range
  of mental health settings are either currently
  experiencing or have experienced abuse by an
  intimate partner.

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Prostitution Trauma

• 99 report at least one traumatic event
• 93 report multiple traumas
• 53 report 6 or more traumatic events
• 75 report child sexual abuse
• 26 report child sexual abuse before age 6
• 81 raped as adults
• 81 physically assaulted as adults
• (Roxburgh, Degenhardt, Copeland 2006)

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Adverse Childhood ExperiencesACE 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 used one 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
  experiences
• 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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Impacts of Trauma

• Physiological Changes in neurobiology and
  physical health
• Cognitive Flashbacks, dissociation
• Feelings Feeling numb or overhwhelmed
• Beliefs About self, other people, the world
• Skill Deficits Self-protection, self-soothing
• Mental Health PTSD, Substance Abuse
• Relational Disconnection

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Pathways of Co-Occurrence
Trauma Sequelae Mental Health Problems
Self- Medication
(Begin Anywhere)
Addiction
Lack of Self-Care
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What Makes Impact More Severe?

• Trauma Characteristics
• Interpersonal violence
• Perpetrator is known/trusted
• Recurrent
• Degree of exposure
• Response of social environment

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What Makes Impact More Severe?

• Person Characteristics
• Age
• Prior coping skills
• Prior trauma history
• Chronic stressors
• Current stressors

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

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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 symptoms
  need to stabilize mental health/ substance
  abuse Opening 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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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.

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Trauma-Informed Services Changes in
Understanding and Changes in Practice

• Roger D. Fallot, Ph.D.
• Community Connections
• Conference on Co-Occurring Disorders
• Long Beach, California
• February 8, 2008

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What are Trauma-Informed Services?

• Trauma-informed vs. trauma-specific
• Characteristics of trauma-informed services
• Incorporate knowledge about traumaprevalence,
  impact, and recoveryin all aspects of service
  delivery
• Hospitable and engaging for survivors
• Minimize revictimization
• Facilitate recovery and empowerment

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Why Trauma-Informed Services?

• Trauma is pervasive
• Traumas impact is broad and diverse
• Traumas impact is deep and life-shaping
• Trauma, especially interpersonal violence, is
  often self-perpetuating
• Trauma is insidious and differentially affects
  the more vulnerable
• Trauma affects how people approach services
• The service system has often been retraumatizing

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A Repetitive Cycle of Risk
Homelessness
Incarceration
Violence and Trauma
Substance Abuse
Mental Health Problems
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Comparing Traditional and Trauma-Informed
Paradigms

• Understanding of Trauma
• Understanding of the Consumer/Survivor
• Understanding of Services
• Understanding of the Service Relationship

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A Culture Shift The Core Principles of a
Trauma-Informed System of Care

• Safety Ensuring physical and emotional safety
• Trustworthiness Maximizing trustworthiness,
  making tasks clear, and maintaining appropriate
  boundaries
• Choice Prioritizing consumer choice and control
• Collaboration Maximizing collaboration and
  sharing of power with consumers
• Empowerment Prioritizing consumer empowerment
  and skill-building

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A Culture Shift Scope of Change in a Distressed
System

• Involves all aspects of program activities,
  setting, and atmosphere (more than implementing
  new services)
• Involves all groups administrators, supervisors,
  line staff, consumers, families (more than direct
  service providers)
• Involves making change into a new routine, a new
  way of thinking and acting (more than new
  information)

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Protocol for Developing a Trauma-Informed Service
System

• Services-level changes
• Service procedures and settings
• Formal service policies
• Trauma screening, assessment, and service
  planning
• Systems-level/administrative changes
• Administrative support for program-wide
  trauma-informed services
• Trauma training and education
• Human resources practices

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Trauma-Informed Services Qualitative Pilot
Outcomes

• Consumers report greater safety, trust, and
  engagement in services more collaboration with
  providers emphasis on empowerment, recovery, and
  healing
• Providers report greater collaboration with
  consumers enhanced skills and sense of efficacy
  more support from agency
• Administrators report more collaboration within
  and outside agency enhanced staff morale fewer
  negative events and more effective services

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Conclusion

• What we know about trauma, its impact, and the
  process of recovery calls for trauma-informed
  service approaches
• A trauma-informed approach involves fundamental
  shifts in thinking and practice at all
  programmatic levels
• Trauma-informed services offer the possibility of
  enhanced collaboration for all participants in
  the human service system

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Trauma-Specific Group Services

• Lisa Russell, Ph.D.
• ETR Associates
• lisar_at_etr.org

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Traumatic-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 and eventually to reduce or eliminate
  debilitating symptoms and prevent further
  traumatization and violence.

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Trauma-Specific Curricula Used in Substance Abuse
Treatment Settings

• Maxine HarrisTrauma Recovery Empowerment
  (TREM)
• Lisa NajavitsSeeking Safety
• Dusty MillerAddiction Trauma Recovery
  Integration Model (ATRIUM)
• Clark FeardayTRIAD
• 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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Features in Common

• Stages of trauma recovery
• Cognitive behavioral
• Coping skills
• Group orientation, adaptable for individual
  sessions
• Can be co-facilitated by a professional and 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 One Establishing Safety

• 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 and 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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Considerations for Choosing a Curriculum

• Evidence of effectiveness
• Fit with client characteristics
• 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
• Adapting, if necessary, based on pilot results
  (Trying evidence-based adaptations first.)
• Training for staff and supervisors
• Ongoing supervision and support for the new
  practice
• Monitoring of fidelity

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Outcomes from the Women with Co-Occurring
Disorders and Violence/Trauma Study

• CENTERS FOR INNOVATION IN
• HEALTH, MENTAL HEALTH AND SOCIAL SERVICES

Vivian B. Brown, Ph.D.
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SAMHSAs Women with Co-Occurring Disorders and
Violence Study
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The 9 National Program Sites
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Sample Sizes Across Program Sites by Condition
(N2,729)
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Baseline Demographic Characteristics by Program
Site Hispanic Ethnicity
Triad Womens Project
New Directions for Families
DC Trauma Collaboration Study
Boston Consortium of Services
Franklin Co. Womens Research Project
The W.E.L.L. Project
PROTOTYPES SCC
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 are18 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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The 6-Month Outcome Components

• Intent-to-treat design
• 2,006 women (1,023 in intervention condition, 983
  in comparison condition) were interviewed 6
  months after initial enrollment re outcomes plus
  services received and other elements
• Four outcome measures mental health symptoms,
  alcohol use, other drug use, and trauma-related
  symptoms
• Women in both intervention and comparison
  conditions had decreased symptoms in all four
  areas at 6 months

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Differences between Intervention and Comparison
Conditions

• On two of four measures (post-traumatic symptoms
  and drug use severity), women in the intervention
  programs showed significantly greater improvement
  than those in usual care
• On mental health status, differences almost reach
  significance
• Effect sizes are small, but present

Morrissey, J.P. et al. (2005) Journal of
Substance Abuse Treatment
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6-Month Data on All Sites

• On drug use problem severity (ASI-D), 49 of the
  intervention women and 36 of the comparison
  women reported no drug use or drug-related
  problems at 6 months
• On alcohol use problem severity (ASI-A), 52 of
  intervention and 40 of comparison women reported
  no use or related problems at 6 months

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The 12-Month Outcome Components

• 2,026 women were interviewed 12 months after
  initial enrollment re outcomes plus services
  received and other elements
• Four outcome measures mental health symptoms,
  alcohol use, other drug use, and trauma-related
  symptoms
• Women in both intervention and comparison
  conditions had decreased symptoms in all four
  areas at 12 months

Morrissey, J.P. et al. (2005) Psychiatric Services
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Differences between Intervention and Comparison
Conditions

• The 12-month effect sizes for mental health and
  post traumatic symptoms show statistically
  significant improvements for women in the
  intervention condition relative to those in the
  comparison condition
• The two substance use severity outcomes show no
  additional improvement over the corresponding
  values at 6 months

Morrissey, J.P. et al. (2005) Psychiatric Services
68
Program-Level Differences

• There is considerable variation across sites
• Sites were compared on eight program
  characteristics
• Integrated counseling was positively related to
  three of the four outcomes measured across sites

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Program Differences (continued)

• Integrated counseling defined as receiving all
  three types of services in individual and/or
  group counseling reported in three-month
  interview
• Number of core services provided were not
  associated with improved outcomes, unless
  integrated counseling was present

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Costs

• Controlling for baseline use, there are no
  significant differences in total costs between
  participants in the intervention condition and
  those in the usual care comparison
• This is true from a governmental or Medicaid
  reimbursement perspective

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Some Key Learnings

• Providing complex sets of integrated services is
  feasible, including attention to trauma in
  systemic ways
• Collaborations between those with lived
  experience and researchers increases the quality
  of the research (and probably the services)

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Learnings (continued)

• Women with these complicated sets of issues can
  reduce their problems
• Integrated counseling of mental health, substance
  abuse, and violence issues in a trauma-informed
  context appears to be more effective and no more
  costly than services as usual