Women and Concurrent Disorders

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  • 1. Women and Concurrent Disorders(Addiction and Mental Health)Women in Mind ConferenceNovember 2, 2012 Marilyn Herie PhD, RSW Director, TEACH Project, Centre for Addiction and Mental Health Director, Collaborative Program in Addiction Studies, University of Toronto Assistant Professor (Status Only) Factor‐Inwentash Faculty of Social Work, U of T
  • 2. Disclosure of Potential for Conflict of Interest for: Dr. Marilyn Herie• I do not have an affiliation (financial or otherwise) with a pharmaceutical,  medical device or communications organization; therefore cannot identify  any conflict of interest.   • I do not intend to make therapeutic recommendations for medications that  have not received regulatory approval (i.e., “off‐label” use of medication).
  • 3. 1. A feature that resonated for me2. A question I want to think through3. A seed I could plant now
  • 4. Learning ObjectivesAt the end of this session, you will be able to:1. Identify specific risk factors and presenting  issues among women with concurrent  disorders2. Critique emerging research and treatment  implications3. Access woman‐centred treatment tools and  additional resources
  • 5. Marusha• 45 y/o, divorced, 2 daughters• Employed part‐time as a cashier• Trauma history – never sought  treatment (she and sister sexually  abused by father)• Concerned about alcohol use (5‐7  drinks/day)• Prescribed benzodiazepines for  anxiety PRN• Past suicide attempt 5 years  previously – denies current ideation
  • 6. March 2011 Academy Award Nominees’ SWAGBAGS contained a pack of Swarovski-bedazzled electronic cigarettes (retail value = $100)(promotional value = much more, to associate celebrity with product)
  • 7. “Bruised, battered, belittled and bewildered, buffeted by societal attitudes and stereotypes are the women who end up in the offices of [helping professionals].” (Harrison, 1997)
  • 8. Recovery and the Life Cycle of the Individual, Family and CommunityWhite, W. Journal of Substance Abuse Treatment, 33, 2007
  • 9. A binary construct?
  • 10. A continuum of severityNo SevereProblems Problems
  • 11. http://www.samhsa.gov/samhsa_news/volumexii_5/article4.htm
  • 12. Who has the authority to define  recovery? Defining who is and who is not in recovery may also  dictate: • Who is seen as socially redeemed and who remains  stigmatized • Who is hired and who is fired • Who remains free and who goes to jail • Who remains in a marriage and who is divorced • Who retains and who loses custody of their children • Who receives and who is denied government  benefitsWhite, W. Journal of Substance Abuse Treatment, 33, 2007
  • 13. Recovery can be… • Return to health following trauma or illness • Assisted or unassisted (“natural recovery”) • A process, not an event (“recovery career”,  “treatment career”) • Sometimes characterized by quantum or  transformational change Principles of recovery are nested within concepts of community, national, global healthWhite, W. Journal of Substance Abuse Treatment, 33, 2007
  • 14. 5 CD Subgroups (1) Stress, Trauma & Substance Use Disorders (2) Anxiety Disorders & Substance Use Disorders (3) Mood Disorders & Substance Use Disorders (4) Psychosis & Substance Use Disorders (5) Impulsivity & Substance Use DisordersSubstance Abuse in Canada: Concurrent Disorders Report (CCSA, 2010)http://www.ccsa.ca/2010%20CCSA%20Documents/ccsa-011811-2010.pdf 21
  • 15. Examples ofConcurrent Disorders Substance: Mental health: 1.  Alcohol use  & PTSD2.  Opioids & Depression3.  Cannabis use  & Schizophrenia 22
  • 16. Why is it important to understand CD?1. Drug use can trigger mental health problems 2. Drug use may worsen symptoms of existing  mental illness3. Substance use, intoxication and withdrawal from  substances can mimic symptoms of mental  health disorders4. Substance use may mask mental illness that  already exists 23
  • 17. Why is CD Important? (cont’d)People with CD (treated or untreated) are at  higher risk for: – Double or multiple layers of stigma – Homelessness – Suicide – Family violence – Victimization – Child abuse/neglect – HIV infection – Incarceration/legal problems – Re‐hospitalization 24
  • 18. CD Etiological Models 25
  • 19. CD Etiological Models ASSESSING THE  MODEL EXAMPLE RELATIONSHIP (1) Secondary SUD •Self‐medication of  •Does SU relieve MH  Substance use is a  panic  attack symptoms  symptoms (e.g.  coping response for  with alcohol anxiety)?  mental health symptoms •Crack cocaine used to  escape memories of  •Is anxiety WORSE  trauma during abstinence? 2) Secondary MHD •Cocaine‐induced  •Did SU precede MH?  Mental health symptoms  depression •Does MH improve  are a result of chronic or  •Cannabis‐induced  during abstinence? excessive substance use,  psychosis •Does SU worsen MH? or withdrawal 26http://knowledgex.camh.net/amhspecialists/Screening_Assessment/screening/treating_cd_intro/Pages/treating_cd_relationship.aspx
  • 20. CD Etiological Models ASSESSING THE  MODEL EXAMPLE RELATIONSHIP (3) Common Factor •A traumatic event  •How are the issues  Mental health and  leads to PTSD and  linked, and what are  substance use problems  substance use possible precipitating  develop from a common  •Genetic vulnerability  factors/events?  underlying factor for psychosis and  substance dependence 4) Bi‐directional Models •Alcohol dependence  •Did SU precede MH?  One problem may  increases possibility of  •Does MH improve  increase likelihood of  job loss, increasing  during abstinence? developing problems in  possibility for  •Does SU worsen MH? the other area depression 27http://knowledgex.camh.net/amhspecialists/Screening_Assessment/screening/treating_cd_intro/Pages/treating_cd_relationship.aspx
  • 21. The Influence of Sex and Gender • Prevalence, course and burden of mental  illness • Different pathways to substance abuse • Different risk factors for substance abuse • Different barriers to treatment  • Different support needs • Differences in drug use, relapse predictors,  frequency and mode of useSAMHSA, Addressing the needs of women and girls: Developing core competencies formental health and substance abuse service professionals, 2011
  • 22. Women with Concurrent SMI and  SUD • More likely to seek help in mental health and  outpatient settings • Poorer occupational skills • Serious physical health problems • 11% of all adult women have SMI • 6% SUD • 2% bothNSDUH Report, Women with co-occurring SMI and SUD, 2004
  • 23. SUD Only vs CDNSDUH Report, Women with co-occurring SMI and SUD, 2004
  • 24. What’s the Impact of CD?  • Poorer prognosis  • Poor retention in treatment • Different needs in treatment: – e.g. harm‐reduction – longer duration – flexibility – greater focus on engagement – need for medical management 31Health Canada Best Practices: Concurrent Mental Health and Substance Use Disorders (2002)
  • 25. Recovery Orientation • Maintain optimism re: outcomes • Recognize and respect avenues of staff/client  collaboration and sharing • Respect resilience of women, girls and their  families • Women with CD can be effective and caring  mothers, family members and contributing  members of the community with appropriate  services and supportSAMHSA, Addressing the needs of women and girls: Developing core competencies formental health and substance abuse service professionals, 2011
  • 26. Three Complementary Approaches 1. Public health approach – Environmental factors, risk and resilience, role of culture,  socialization and gender – Foundational to core competencies 2. Trauma‐informed care – Women more likely than men to experience interpersonal trauma 3. Recovery‐oriented system of care – Varying types and levels of services needed at different times (e.g.,  diabetes, heart disease) – Reflection of gender differences: women have access to fewer  economic resources, greater vulnerability to violence, more family  responsibilitiesSAMHSA, Addressing the needs of women and girls: Developing core competencies formental health and substance abuse service professionals, 2011
  • 27. Old & New CD Models of Care Get Addictions Tx Parallel Get MH tx at Addiction = at mental health services + ServicesSequential And the other = Treat one… then One team provides*Integrated = mental health AND addiction treatment within the same setting 34
  • 28. Integrated Treatment1. Goal is consistency – Consistent explanations and treatment plan  (rather than a contradictory set of messages  from different providers)2. Both diagnoses are considered ‘primary’3. ‘No Wrong Door’ Approach 35
  • 29. “Every door is the right door”
  • 30. 12 Considerations to Guide Care 1. Sex and gender 7. Relational/cultural context  2. Heterogenity among  is key women 8. Developmental stages  3. Vulnerability to violence  have attendant risks and  and trauma opportunities 4. Risk of physical health &  9. Family‐centred approach medical problems 10. Cross‐sectoral 5. Impact of social  collaboration to  expectations/ messages accommodate multiple  6. Common experiences of  needs/roles staff/clients 11. Special issues re: criminal  justice involvement 12. Impact of stigma &  stereotypes on recoverySAMHSA, Addressing the needs of women and girls: Developing core competencies formental health and substance abuse service professionals, 2011
  • 31. What do you see as essential core competencies in working with women with concurrent disorders?
  • 32. Core Competency Domains 1. Sex and gender differences 2. Relational approaches in working with  women and girls 3. Family‐centred needs 4. Special considerations during pregnancy 5. Women’s health and health care 6. Interprofessional collaboration 7. Trauma‐informed careSAMHSA, Addressing the needs of women and girls: Developing core competencies formental health and substance abuse service professionals, 2011
  • 33. Brief Screening
  • 34. Why is Screening Important?• The prevalence of concurrent disorders is high • You can best help clients when you have  comprehensive information about their problems  (screening is the 1st step)• Health Canada recommends that ALL people  seeking help from mental health or substance use  services be screened for co‐occurring disorders 41
  • 35. Screening:  Asking A Few Direct QuestionsQuestions about substance use:• “Have you ever had any problems related to your use  of alcohol or drugs?”• “Has a relative, friend, doctor or other health worker  been concerned about your drinking or other drug use,  or suggested cutting down?”• “Have you ever said to another person, “No, I don’t  have an alcohol or drug problem ,when around the  same time, you questioned yourself and FELT, “Maybe I  DO have  a problem?” If answer ‘yes’ to any of the above, further assessment is warranted. (Health Canada, 2002) 42
  • 36. Alcohol Screening Tools• TWEAK• T‐ACE  Followed by a comprehensive assessment if indicated May also want to complete a safety plan with the  client
  • 37. TWEAK TEST T Tolerance: How many drinks does it take to make you feel  high?  (Record number of drinks) W Worry: Have close friends or relatives worried or   complained about  your  drinking in the past year? E Eye‐Opener: Do you sometimes have a drink in the morning  when you first get up? A Amnesia (Blackouts): Has a friend or family  member ever  told you about things  you said or did while you were drinking that you could not remember? K(C) Cut Down: Do you sometimes feel the need to cut down on  your  drinking?Russell et al. (1994)
  • 38. TWEAK ScoringThe “tolerance” question scores 2 points if a person reports  it takes 3 or more drinks to feel the effects of alcohol.  The “worry” question scores 2 points for a positive (“yes”) response.  Each of the last three questions scores 1 point for a positive (“yes”) response.  A Total score of 2 or more points indicates the woman is likely to have a drinking problem.
  • 39. T-ACE• A measurement tool of four questions that are significant identifiers of risk drinking (i.e., alcohol intake sufficient to potentially damage the embryo/fetus).• The T-ACE is completed at intake. The T-ACE score has a range of 0-5. The value of each answer to the four questions is totalled to determine the final T-ACE score.• A total score of 2 or greater indicates potential risk for the purposes of Pregnancy Outreach Program identification of prenatal risk.
  • 40. T‐ACE Questions Sokol (1988)1. How many drinks does it take to make you feel high? (Tolerance)(0) < 2 drinks (1) > 2 drinks2. Have people annoyed you by criticizing your drinking? (Annoyance)(0) No (1) Yes3. Have you felt you ought to cut down on your drinking? (Cut Down) (0) No (1) Yes4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? (Eye Opener) (0) No (1) Yes Total Score = _____
  • 41. Screening:  Asking A Few Direct QuestionsQuestions about mental health: • “Have you ever been given a mental health diagnosis  by a qualified mental health professional?”• “Have you ever been hospitalized for a mental  health–related illness?”• “Have you ever harmed yourself or thought about  harming yourself, but not as a direct result of alcohol  or other drug use?” If answer ‘yes’ to any of the above, further assessment is warranted. 48Health Canada, 2002
  • 42. Trauma Assessment:  ‘Less is More’• Destabilization may occur if clients are asked for too  much detail• The assessor must serve as gatekeeper and limit  information to safe bounds• At intake, ask only specific information needed for  the purposes of screening or assessment• A ‘Checklist’ may provide more privacy
  • 43. http://knowledgex.camh.net/amhspecialists/Screening_Assessment/screening/screen_CD_youth/Pages/GSS.aspx
  • 44. Factors to consider…• Is the client/caller intoxicated? • Has she been taking psychoactive medications or  other drugs?• Is the client voicing suicidal ideation?• Substance use is disinhibiting and can lead to  impulsivity = RISK FACTOR• Are there medical safety risks?  51
  • 45. Flexible Goal Choice(1) Abstinence:  ‐cold‐turkey ‐tapering down ‐medically‐assisted (e.g. benzodiazepines) ‐outpatient vs. inpatient ‐forever goal vs. temporary experiment(2) Reduction goal: e.g. Controlled drinking (not everyone is a candidate) “See Low‐Risk Drinking Guidelines”: Frequency: Alternate drinking days with abstinent days  Have one hour in between alcoholic drinks(3) The ‘no‐change’ goal: Agreement to at least monitor and discuss substance use*Remember: goals are not static and neither is motivation… 52
  • 46. Cross‐Cutting Issues
  • 47. Cross‐Cutting IssuesAlcohol useSuicidalityPersonality disordersMood/Anxiety disordersPsychotic disordersEating disorders PTSD
  • 48. Alcohol Use
  • 49. .0554http://caaneo.ca/about/blog/?page_id=30
  • 50. .0875http://caaneo.ca/about/blog/?page_id=30
  • 51. •Tolerance•Cross‐tolerance•Potentiation
  • 52. 11% of all breast cancers ACETADEHYDE damages genetic material in cells, and causes cells to grow too quicklyhttp://www.drugabuse.gov/publications/teaching-packets/brain-actions-cocaine- opiates-marijuana/section-ii-introduction-to-reward-system/2-reward-pathw
  • 53. Moderate drinking can…• Reduce/inhibit build up of fat in arteries and  raise HDL (“good”) cholesterol• Prevent clotting – guards against stroke and  heart attack• Keep blood pressure in check
  • 54. Smoking + Drinking POTENTIATES cancer- causing properties of each substancePotentially Potentiallyreduced risk of increased riskheart disease of cancer
  • 55. Women: 10 drinks per week 2 drinks per day Men: 15 drinks per week 3 drinks per dayhttp://www.camh.ca
  • 56. Key Points: Suicidality • Most people who kill themselves have  diagnosable MH, SUD or both • Majority have depressive illness • Best prevention = early recognition and  treatment of CD • CD doubles the risk of suicide compared with  SUD aloneCenter for Substance Abuse Treatment (2005), Substance Abuse Treatment for Persons with Co-OccurringDisorders, TIP Series 42, SAMHSA
  • 57. Practice Tips: Suicidal Clients • Screen for suicidal thoughts/plans • Assess risk – What is wrong? Why now? Current substance use? – Specific plans? Past attempts? Protective factors? • Develop a safety and risk management process – Remove means, follow through, access help • Provide 24 hour contact prior to psychiatric referral • Monitor, develop strategies for medication  adherence, long term recovery plan • Clinical supervision and documentationCenter for Substance Abuse Treatment (2005), Substance Abuse Treatment for Persons with Co-OccurringDisorders, TIP Series 42, SAMHSA
  • 58. Key Points: Personality Disorders • “Rigid, inflexible, and maladaptive patterns of  sufficient severity to cause internal distress or  significant impairment in functioning” • Enduring and persistent styles of behaviour and thought • Difficulty forming positive therapeutic alliance • Challenge in receiving/accepting corrective  feedbackCenter for Substance Abuse Treatment (2005), Substance Abuse Treatment for Persons with Co-OccurringDisorders, TIP Series 42, SAMHSA
  • 59. Practice Tips: Personality Disorders • Anticipate: progress may be slow or uneven • Assess risk of self‐harm • Maintain positive but neutral relationship,  seek supervision • Set clear boundaries and expectations re:  roles/behaviour • Work on skill development to manage  negative memories/emotionsCenter for Substance Abuse Treatment (2005), Substance Abuse Treatment for Persons with Co-OccurringDisorders, TIP Series 42, SAMHSA
  • 60. Key Points: Mood/Anxiety Disorders • Prevalence is higher in women vs men • Women more likely to have PTSD and/or depression • Older women at highest risk for concurrent SUD and  mood disorder • Withdrawal from depressants, opioids and  stimulants invariably includes potent anxiety  symptoms • Medical problems/medications can produce  symptoms of mood disorders/anxiety (e.g., stroke,  diabetes)Center for Substance Abuse Treatment (2005), Substance Abuse Treatment for Persons with Co-OccurringDisorders, TIP Series 42, SAMHSA
  • 61. Practice Tips: Mood/Anxiety  Disorders • Differentiate among: a) Commonplace expressions of anxiety/depression b) Anxiety/depression associated with SMI c) Medical conditions/medications side effects d) Substance‐induced changes • “Start low, go slow” • Monitor symptoms and respond immediately to  intensification • Gradually introduce skills for participation in group  therapy/self‐help • Integrate addiction and MH treatmentCenter for Substance Abuse Treatment (2005), Substance Abuse Treatment for Persons with Co-OccurringDisorders, TIP Series 42, SAMHSA
  • 62. Key Points: Schizophrenia/Other  Psychotic Disorders • High co‐prevalence of alcohol/other drug use • Requires longitudinal, multiple‐contact assessment  • Higher risk for self‐destructive/violent behaviours • Particularly vulnerable to homelessness,  victimization, poor nutrition, inadequate financial  resources • Program philosophy based on multidisciplinary team  approach with cross‐training and a long‐term focusCenter for Substance Abuse Treatment (2005), Substance Abuse Treatment for Persons with Co-OccurringDisorders, TIP Series 42, SAMHSA
  • 63. Practice Tips: Schizophrenia/Other  Psychotic Disorders • Work closely with interprofessional (may be cross‐ sectoral) team members • Be ready for crises with crisis intervention and  psychiatric resources to help stabilization • Shorter sessions and frequent breaks; employ  structure and support • Monitor medication and signs of SU relapse or return  of psychotic symptoms • Help obtain entitlements/social services • Involve family members/develop social networksCenter for Substance Abuse Treatment (2005), Substance Abuse Treatment for Persons with Co-OccurringDisorders, TIP Series 42, SAMHSA
  • 64. Key Points: Eating Disorders • Women in SU treatment have 15 x prevalence of  eating disorders vs men • SU more common in bulimia nervosa vs anorexia  nervosa • Significantly more likely to use stimulants and less  likely to use opioids • May alternate between SU and ED • Alcohol and cannabis can trigger binge eating • Craving, tolerance and withdrawal from drugs used  for purging (laxatives, diuretics) • Urges for food comparable to urges for drugsCenter for Substance Abuse Treatment (2005), Substance Abuse Treatment for Persons with Co-OccurringDisorders, TIP Series 42, SAMHSA
  • 65. Practice Tips: Eating Disorders • Interprofessional collaboration is paramount • Document full repertoire of weight loss behaviours in  assessment • Construct a behavioural analysis: – Foods and substances – High‐risk times/situations – Nature, pattern, interrelationship of SU and ED • Psychoeducation and CBT, treatment plan for both SU  and ED • Adjunctive strategies: – Nutritional consult, weight‐range goal, observed meal timesCenter for Substance Abuse Treatment (2005), Substance Abuse Treatment for Persons with Co-OccurringDisorders, TIP Series 42, SAMHSA
  • 66. Key Points: PTSD • PTSD is two to three times more common in women  vs men receiving substance use treatment (30 – 59%) • Women with SUD report lifetime history of  physical/sexual abuse ranging from 55‐99% • More likely to experience further trauma than PTSD  alone • High prevalence of cocaine/opioid use • Substance use can create vulnerability to trauma • Abstinence from substances does not resolve PTSD – need to address bothCenter for Substance Abuse Treatment (2005), Substance Abuse Treatment for Persons with Co-OccurringDisorders, TIP Series 42, SAMHSA
  • 67. What does ‘Trauma‐Informed’ mean? ‘Trauma‐Informed Service’: • Defined as particular treatment models (i.e. services  that might be offered, or modified) to be responsive  to the impacts of trauma ‘Trauma‐Informed Treatment’:  • Defined as incorporating the broader backdrop of:  clinical, agency, community and provincial/national  structures that enable clinicians/programs to adapt  their methods so as to influence a woman’s access  to treatment, and her careHien et al. (2009) Trauma Services for Women in Substance Abuse Treatment
  • 68. Practice Tips: PTSD • Avoid detailed exploration of traumatic memories in  early phase treatment (long‐term treatment may be  required) • Explore how symptoms can trigger substance use • Provide specific coping strategies, develop safety  plan • Respond more to behaviour than to words • Be aware of vicarious traumatization (group,  therapist) • Therapist self‐careCenter for Substance Abuse Treatment (2005), Substance Abuse Treatment for Persons with Co-OccurringDisorders, TIP Series 42, SAMHSA
  • 69. Marusha• Triggered to drink by “lump in my  throat”• Delayed seeking counselling b/c of  sister’s experience (severe flashbacks)• Appeal of brief outpatient counselling (don’t touch the trauma)• Able to develop effective coping in  reducing alcohol use to within low‐risk  guidelines
  • 70. Psychosocial Treatment Resources
  • 71. Continuum of Treatment Services HighlyMinimallyIntensive Levels of Treatment Intensity Intensive Custodial Care Prevention Facilitate Extended Residential Long-term Short-term Recovery Outpatient Social Residential Outpatient without Interventions Model Self-Change Treatment Oriented Interventions Day Treatment Residential Brief Short-term Hospital-Based Community Outpatient Interventions (e.g.., Therapist- self-help manuals, Directed physician’s advice) Interventions Mild to SubstantialModerate Severity of Problems To Severe CAMH
  • 72. Client‐Treatment Matching• Lack of strong evidence by which to match women to specific  treatments• Does not mean that women all require the same types of services• A variety of flexible and individualized services are required• Guidelines for selecting services are needed Drug Use Problem Social Support Severity Multiplicity & Stability Lo Lo Hi Brief Outpatient Lo-Hi Lo-Hi Mod-Hi Outpatient Day Treatment Mod-Hi Mod-Hi Mod Residential Mod-Hi Mod-Hi Lo Skinner & Martin, 1995
  • 73. • Quality of Research Ratings by Criteria (0.0‐4.0  scale) • External reviewers independently evaluate the  Quality of Research for an interventions reported  results using six criteria: – 1. Reliability of measures  – 2. Validity of measures  – 3. Intervention fidelity  – 4. Missing data and attrition  – 5. Potential confounding variables  – 6. Appropriateness of analysishttp://www.nrepp.samhsa.gov/Index.aspx
  • 74. Eight Interventions1. A Woman’s Path to Recovery2. Boston Consortium Model3. Dialectical Behaviour Therapy4. Forever Free5. Helping Women Recover / Beyond Trauma6. Reinforcement‐based Therapeutic Workplace7. Seeking Safety8. Trauma Affect Regulation: Guide for Education and  Therapy
  • 75. A Womans Path to Recovery (Based  on A Womans Addiction Workbook) (Najavits) • 12, 90‐minute sessions over eight weeks • Divided into two sections: Exploration and Healing • “Exploration" helps women look at their lives in relation to  gender and addiction issues • Identify life themes in five key areas relevant to women and  addiction: body and sexuality, stress, relationships, trauma  and violence, and thrill‐seeking • They can also evaluate their addiction and co‐occurring  mental disorders • “Healing" section guides women through four domains of  recovery: relationships, beliefs, actions, and feelings ‐‐ with a  series of exercises for each domainhttp://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=123
  • 76. A Womans Path to Recovery (Based  on A Womans Addiction Workbook) (Najavits) Reliability Validity Missing Confounding Data Overall Outcome of Measures of Measures Fidelity Data/Attrition Variables Analysis Rating1: Substance use 3.9 3.9 3.0 2.6 1.2 1.2 2.62: Global clinical improvement 3.3 3.3 2.5 3.3 1.2 1.2 2.43: Impulsive and addictive 3.0 2.5 2.5 3.3 1.2 1.2 2.3behavior4: Knowledge of workbook 1.0 1.8 2.5 3.3 1.2 1.2 1.8conceptshttp://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=123
  • 77. Boston Consortium Model: Trauma‐Informed  Substance Abuse Treatment for Women (Amaro et al.) • Developed by a consortium of urban substance abuse and  mental health treatment programs as an enhancement to  existing substance abuse treatment based on the Trauma  Recovery and Empowerment Model (TREM) • TREM uses a psychoeducational and skills‐building approach  to increase a womans understanding of the associations  among addiction, trauma, mental health disorders, and sexual  risk behaviors • Teaches coping skills to help women heal from past abuse and  avoid future abuse, along with behavioral strategies for  reducing trauma symptoms, substance use relapse, and  sexual riskhttp://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=86
  • 78. Boston Consortium Model: Trauma‐Informed  Substance Abuse Treatment for Women (Amaro et al.) Reliability Validity Missing Confounding Data Overall Outcome of Measures of Measures Fidelity Data/Attrition Variables Analysis Rating1: Substance use and 2.5 2.5 2.7 2.5 2.2 2.0 2.4related problem severity2: Mental health 3.7 3.7 2.7 2.5 2.0 2.0 2.8symptomatology3: Posttraumatic stress 3.7 3.7 2.7 2.5 2.0 2.0 2.8symptoms4: HIV sexual risk 1.7 1.7 2.8 2.5 2.0 2.0 2.1behaviors5: Perceived power in 2.9 2.9 2.8 2.5 2.0 2.0 2.5ones relationshiphttp://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=86
  • 79. Dialectical Behavior Therapy (Linehan) • Cognitive‐behavioral treatment approach with two key characteristics: a  behavioral, problem‐solving focus blended with acceptance‐based  strategies, and an emphasis on dialectical processes • "Dialectical" refers to the issues involved in treating patients with multiple  disorders and to the type of thought processes and behavioral styles used  in the treatment strategies • Five components: (1) capability enhancement (skills training); (2)  motivational enhancement (individual behavioral treatment plans); (3)  generalization (access to therapist outside clinical setting, homework, and  inclusion of family in treatment); (4) structuring of the environment  (programmatic emphasis on reinforcement of adaptive behaviors); (5)  capability and motivational enhancement of therapists (therapist team  consultation group) • Emphasizes balancing behavioral change, problem‐solving, and emotional  regulation with validation, mindfulness, and acceptance of patients • Therapists follow a detailed procedural manual.http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=36
  • 80. Dialectical Behavior Therapy (Linehan) Reliability Validity Missing Confounding Data Overall Outcome of Measures of Measures Fidelity Data/Attrition Variables Analysis Rating1: Suicide attempts 3.8 3.8 4.0 3.5 3.0 4.0 3.72: Nonsuicidal self-injury 3.8 3.8 3.3 2.9 2.6 3.7 3.3(parasuicidal history)3: Psychosocial 4.0 4.0 3.0 3.2 2.7 3.7 3.4adjustment4: Treatment retention 4.0 4.0 3.7 2.5 2.7 3.8 3.45: Drug use 3.6 3.6 3.5 2.8 2.8 3.5 3.36: Symptoms of eating 3.6 3.6 3.0 2.3 2.8 4.0 3.2disordershttp://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=36
  • 81. Forever Free (Prendergast, Hall et al.) • Aims to reduce drug use and improve behaviors of women during incarceration  and while on parole.  • While incarcerated, women participate in individual substance abuse counseling,  special workshops, educational seminars, 12‐step programs, parole planning, and  urine testing • Counseling and educational topics include self‐esteem, anger management,  assertiveness training, information about healthy versus dysfunctional  relationships, abuse, posttraumatic stress disorder, codependency, parenting, and  sex and health • The program lasts 4‐6 months • Women participate in 4 hours of program activities 5 days per week • After graduation and discharge to parole, women may voluntarily enter  community residential treatment • Residential treatment services include individual and group counseling. Some  women also participate in family counseling, vocational training/rehabilitation,  and recreational or social activities.http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=118
  • 82. Forever Free (Prendergast, Hall et al.) Reliability Validity Missing Confounding Data Overall Outcome of Measures of Measures Fidelity Data/Attrition Variables Analysis Rating1: Drug use 2.8 3.1 2.8 3.3 2.3 3.5 2.92: Parole outcomes 3.1 3.1 2.8 3.3 2.8 4.0 3.23: Employment after 3.0 2.5 2.5 3.0 2.5 3.5 2.8incarcerationhttp://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=118
  • 83. Helping Women Recover and Beyond  Trauma (Covington) • Women in criminal justice or correctional settings with concurrent substance  use/trauma • Delivered conjointly or separately as independent, stand‐alone treatments • Goals to reduce substance use, encourage enrollment in voluntary aftercare treatment  upon parole, and reduce the probability of reincarceration following parole.  • The trauma‐informed treatment sessions delivered by female counseling staff (who may  be assisted by peer mentors, typically women serving life sentences) to groups of 8‐12  female inmates, in a nonconfrontational and nonhierarchical manner • 17, 90 minute sessions one or two times per week • Counsellors use a strengths‐based approach with a focus on personal safety to help  clients develop effective coping skills, healthy relationships, and positive interpersonal  support networks • Uses cognitive behavioral skills training, mindfulness meditation, experiential therapies  (e.g., guided imagery, visualization, art therapy, movement), psychoeducation, and  relational techniqueshttp://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=181
  • 84. Helping Women Recover and Beyond  Trauma (Covington) Reliability Validity Missing Confounding Data Overall Outcome of Measures of Measures Fidelity Data/Attrition Variables Analysis Rating1: Substance use 3.2 2.5 1.4 2.2 2.2 2.5 2.32: Aftercare retention 2.3 2.8 1.4 2.2 2.7 3.5 2.5and completion3: Reincarceration 2.9 2.9 1.4 2.2 2.7 3.0 2.5http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=181
  • 85. Reinforcement‐Based Therapeutic  Workplace (Silverman, Wong et al.) • Women are hired, trained and paid to work in a supportive environment  Practical application of voucher‐based abstinence reinforcement therapy • Adjunct outpatient treatment/medication (e.g., methadone) • Reinforcement procedures are based on operant conditioning, or use of  consequences to modify the occurrence and form of behavior • Escalating monetary vouchers for drug‐free urine screens • Staff purchase goods/services for clients • Funded externally with a goal of becoming economically self‐sustaininghttp://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=52
  • 86. Reinforcement‐Based Therapeutic  Workplace (Silverman, Wong et al.) Reliability Validity Missing Confounding Data Overall Outcome of Measures of Measures Fidelity Data/Attrition Variables Analysis Rating1: Cocaine use 3.7 3.2 3.5 3.3 2.7 3.0 3.22: Opiate use 2.8 2.8 4.0 2.8 3.0 3.0 3.03: Cocaine and opiate 3.9 3.4 3.4 3.2 2.9 3.4 3.3use4: Cocaine craving 1.5 1.5 2.5 2.5 3.0 2.5 2.35: Workplace 4.0 3.7 4.0 3.4 3.0 2.9 3.5attendancehttp://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=52
  • 87. Seeking Safety (Najavits) • Present‐focused treatment for clients with a history of trauma and substance  abuse • Designed for flexible use: group or individual format, male and female clients,  and a variety of settings (e.g., outpatient, inpatient, residential) • Focuses on coping skills and psychoeducation • Five key principles:  – (1) safety as the overarching goal (helping clients attain safety in their relationships,  thinking, behavior, and emotions) – (2) integrated treatment (working on both posttraumatic stress disorder (PTSD) and  substance abuse at the same time) – (3) a focus on ideals to counteract the loss of ideals in both PTSD and substance  abuse – (4) four content areas: cognitive, behavioral, interpersonal, and case management – (5) attention to clinician processes (helping clinicians work on countertransference,  self‐care, and other issues)http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=139
  • 88. Seeking Safety (Najavits) Reliability Validity Missing Confounding Data Overall Outcome of Measures of Measures Fidelity Data/Attrition Variables Analysis Rating1: Substance use 2.3 2.3 2.3 2.0 1.6 2.0 2.12: Trauma-related 2.7 2.7 2.9 2.0 1.8 2.1 2.3symptoms3: Psychopathology 2.4 2.4 2.1 2.0 1.7 2.1 2.14: Treatment retention 2.0 2.0 3.4 2.2 1.9 1.9 2.2http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=139
  • 89. Trauma Affect Regulation: Guide for  Education and Therapy (TARGET) (Frisman, Ford et al.) • Strengths‐based approach to education and therapy for survivors of physical, sexual,  psychological, and emotional trauma • Teaches a set of seven skills summarized by the acronym FREEDOM: 1. Focus 2. Recognize triggers 3. Emotion self‐check 4. Evaluate thoughts 5. Define goals 6. Options 7. Make a contribution • Used to regulate extreme emotion states, manage intrusive trauma memories, promote  self‐efficacy, and achieve lasting recovery from trauma • Offered in 10‐12 individual or group counseling or psychoeducational sessions  conducted by trained implementers (e.g., clinicians, case managers, rehabilitation  specialists, teachers)http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=258
  • 90. Trauma Affect Regulation: Guide for  Education and Therapy (TARGET) (Frisman, Ford et al.) Reliability Validity Missing Confounding Data Overall Outcome of Measures of Measures Fidelity Data/Attrition Variables Analysis Rating1: Disciplinary 2.9 2.8 2.9 3.9 2.6 3.1 3.0incidents2: Disciplinary 2.9 2.8 2.9 3.9 2.6 3.1 3.0sanctions3: Recidivism 3.6 3.4 2.9 3.9 2.6 2.6 3.2http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=258
  • 91. Marusha• Success in brief treatment prompted  her to seek a referral for trauma‐ specific treatment• Success in one area can lead to success  in other areas• Respect for boundaries and control• “Things may get worse before they get  better”• Self‐efficacy: “I can handle this”
  • 92. 1. A feature that resonated for me2. A question I want to think through3. A seed I could plant now
  • 93. www.camh.ca
  • 94. marilyn.herie@camh.cawww.educateria.com@MarilynHerie