Transcript Healing from Trauma: Clinical Considerations

Developing Trauma-Informed Systems
of Care for Women in Substance Abuse
Treatment
Norma Finkelstein Ph.D.
Institute for Health and Recovery
[email protected]
Women’s Health: Addiction, Trauma and Hope
Princeton, New Jersey
October 5, 2007
Institute for Health and Recovery
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 person’s
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’
“That’s a victim thing; you ask yourself, ‘Am I
just crazy? Did I make all this up?’ Somehow it
might be easier to accept that you’re 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)
Institute for Health and Recovery
Traumatic Events
• Physical Assault
• Sexual Abuse including
sex work
• Emotional/
Psychological Abuse
• Domestic Violence
• War/Genocide
• Accidents
• Natural or Man-Made
Disaster
• Witnessing
abuse/violence
• Living in dangerous
environment
• Experienced as an
adult or child
• Occurred over time or
one incident or time
limited
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Interpersonal Violence
Interpersonal Violence —physical/sexual abuse
is not like natural disasters, car accidents, etc.
• Human-fostered violence against another human
being
• Causes extreme disconnection from other human
beings
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Why Trauma Matters
• A significant proportion of men and women entering
services for substance use disorders have histories of
trauma (Brems, 2004; Clark, 2001; Farley, 2004; Medrano, 1999; Moncrieff, 1996; Rice,
2001).
• Women in community samples report a lifetime
history of physical & sexual abuse ranging from 36
to 51%, while women with substance abuse problems
report a lifetime history ranging from 55 to 99%
(Najavits et al., 1997).
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Women in methadone treatment
• 75% report lifetime history of physical and/or sexual
abuse
• 33% report abuse in past year
• 50% report abuse as children
• 33% report witnessing abuse of mother
(El-Bassel et al., (2004)
• Women who were both physically and sexually
abused in childhood were six times more likely to
abuse alcohol then non abused women.
(Bensley, Eenwyk, and Simmons, 2000)
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• 50% of substance abusing women in treatment had
experienced rape or incest (Woodhouse, 1990)
• Rate of childhood sexual abuse among female
substance abusers is twice that of general population
(Simpson and Miller, 2002)
• African American women with histories of childhood
sexual abuse were addicted to more substances,
admitted to hospital or ER more often for substancerelated health issues, attended more substance abuse
treatment programs. (Young and Boyd, 2000)
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Co-occurrence of Substance Abuse
& Domestic Violence
• Research Institute on Addictions (1997)
80%of women with substance abuse disorders had
been the victim of domestic violence
• Brookhoff, et al. (1997)
42% of victims of domestic violence contacting the
police had used alcohol or other drugs on the day of
the assault
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Adverse Childhood Events
ACE 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
• ACE’s 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
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(Fellitti, 1998)
ACE Study
Controlling for other adverse childhood events
• Women with a history of childhood sexual abuse
were 60% more likely to have alcohol problems and
70% more likely to have used illegal drugs.
• Men with a history of childhood sexual abuse were
30% more likely to have alcohol problems and 60%
more likely to have used illegal drugs.
(Dube et al. (2005)
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Messina and Grella (2006)
Number of childhood traumatic events associated
with:
• Prostitution
• Eating Disorders
• Mental Health disorders
• STIs
• Alcohol problems
• Early onset of criminal behavior
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Trauma-Informed Treatment is Important for
Substance Abuse Because:
1. Substance use increases after trauma
2. Women with substance use disorders and trauma
histories appear to have worse treatment
outcomes (when treated in traditional treatment
programs)
3. A woman with both trauma and substance abuse
may have a variety of other problems such as
poverty, homelessness, increased risk for HIV
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Impact of Trauma
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Impact of Trauma: Physiological
• Changes in neurobiology and physical health that
can dysregulate emotions and distort thinking,
perceptions and behavior
• “The Body Keeps the Score”
(Bessel van der Kolk, MD 1999, p.214)
• “Emotional Memory May Be Forever”
(Le Doux, et al 1991, p.24)
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“A century of study of traumatic memories shows
that 1) they generally remain unaffected by other life
experiences; 2) they may return, triggered by
reminders at any time during a person’s life, with the
same vividness as if the subject were having the
experience all over again and 3) these memories are
primarily sensory and emotional, frequently leaving
victims in a state of speechless terror, in which they
may be unable to articulate precisely what they are
feeling and thinking.”
(Bessel van der Kolk, et al 1996, p.565)
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Impact of Trauma: Cognitive
• Amnesia
• Blocking
• Flashbacks
• Dissociation
• Confusion
• Difficulty concentrating
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Impact of Trauma
Feelings: Numb or Overwhelmed
• Fear, terror
• Anger, revenge, hate
• Frustration
• Guilt or self-blame (legitimate, illegitimate,
survivor)
• Shame, humiliation
• Grief or sorrow
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Impact of Trauma: Beliefs
• About self
• About other people
• About the world
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Impact of Trauma: Skill Deficits
• Self-awareness
• Self-protection
• Self-soothing/emotional modulation
• Relational mutuality/empathy/authenticity
• Accurate labeling of self and others
• A sense of agency
• Purpose and meaning
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Impact of Trauma:
Relational Disconnection
Centrality of relationships for women…
trauma affects view of self as well as
participation in relationships.
• Core experience of trauma is disconnection and
disempowerment
• Pathways to healing through connection and
empowerment
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Mental Health Problems
• PTSD
• Other anxiety disorders
• Depression, suicidality
• Eating disorders
• Self-harm
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PTSD
• Approximately 1/3 who experience significant
trauma will develop symptoms of PTSD
• 35-59% of women in substance abuse
treatment have PTSD
(Najavits, 2002)
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PTSD Symptoms
• Hyperarousal/persistent expectation of danger/
hypervigilance
◦ Irritability/outbursts
◦ Impaired concentration
◦ Exaggerated startle response
• Intrusion
◦ Reliving event—hallucinations, flashbacks
• Constriction: numbing/persistent avoidance
◦
◦
◦
◦
Avoids thoughts, feelings, people, places, activities
Detachment
Diminished interest
Sense of foreshortened future
(Herman, Trauma and Recovery, 1992)
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Pathways of Co-Occurrence
Trauma
Sequelae
Mental Health
Problems
SelfMedication
Victimization (Begin Anywhere) Addiction
Lack of
Self-Care
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Trauma-Informed Services
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The impact of violence/trauma on both men and
women is inadequately understood and addressed by
service providers.
Less than half of the women with interpersonal
trauma and co-morbidity will receive treatment that
addresses their trauma history and co-occurring
conditions.
(Timko & Moos, 2002)
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“I am an incest survivor & never dealt with it. Left
treatment, did drugs. The most important thing is to
integrate [services]. I’m a slicer & before no place
would take me & if [I] say I’ve been sexually abused
they boot you…I thought here we go again.
Substance abuse identified & you’re welcome…need
to work all 3 areas…others throw you out because
they are afraid.”
(WELL Project, 2005)
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Substance Abuse Treatment Programs
Often Fail to Adequately Deal with Trauma.
Why?
• Lack of research/knowledge dissemination; training
• Trauma not seen as central/critical to recovery
• “Uncovering” trauma would “destabilize”
symptoms—need to stabilize mental health/
substance abuse—Opening a “Pandora’s Box”
• A belief that trauma work requires more
sophisticated clinical skills
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Failure to understand
and address trauma can lead to:
1. Failure to engage in treatment services (Farley, 2004)
2. Increase in symptoms (eating disorders, selfharm)
3. Increase in management problems
4. Retraumatization (Harris and Fallot, 2001)
5. Increase in relapse
6. Withdrawal from service relationship
7. Poor treatment outcomes (Easton et al 2000; Ouimette et al 1999)
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Trauma-Informed Services
• Trauma-informed services are based on an
understanding of the impact of violence and
victimization.
• All treatment for substance abuse/co-occurring
disorders should be trauma-informed.
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Trauma-Informed vs.
Trauma-Competent Treatment
• Trauma-informed; basic training/education to all
staff—from secretaries to high level
administrators—understanding of trauma permeates
every aspect of treatment milieu and interventions.
• Trauma-competent treatment; educating fewer,
carefully selected staff/clinicians to conduct actual
trauma treatment
(Fallot & Harris, 2001; Najavits, 2006)
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Assumption 1:
Trauma is Central and Pervasive
• Central to the development of mental health and
addiction problems
• Impacts MANY aspects of a person’s life
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Assumption 2:
Universal Precautions
A client should not have to disclose trauma to
receive trauma-informed services—treat
everyone as a potential trauma survivor.
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Assumption 3:
Symptoms and Behaviors
Are often attempts to cope with the trauma
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Assumption 4:
Goal of Services
Is to return a sense of autonomy and control to
the victim
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Principles of Trauma-informed Services
1. Trauma-informed services recognize the impact of
violence and victimization on development and
coping strategies.
2. Trauma-informed services identify recovery from
trauma as a primary goal.
(Source: Elliott, D, Bjelajac, P, Fallot, R, Markoff, L, Reed, BG, J of Community Psychology, 2005, pp 461-477)
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Principles of Trauma-informed Services
3. Trauma-informed services employ an
empowerment model
•
•
•
Collaborative relationship between provider and
consumer
Focus on strengths
Build skills
4. Trauma-informed services strive to maximize a
woman’s choice and control over her recovery
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Principles of Trauma-Informed Services
5. Trauma-informed services are based in a relational
collaboration.
• Since the violation often occurred in relationship,
healing must occur by changing relational
context:
◦
◦
◦
◦
From abusive to nurturing
From unresponsive to empathic
From lies and denial to authenticity
From controlling to empowering
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Principles of Trauma-Informed Services
6. Trauma-informed services create an atmosphere
that is respectful of survivors’ need for safety,
respect and acceptance.
7. Trauma-informed services emphasize women’s
strengths, highlighting adaptations over symptoms
and resilience over pathology.
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Principles of Trauma-Informed Services
8. The goal of trauma-informed services is to
minimize the possibilities of retraumatization.
•
•
Reduce triggering situations
Identify triggers for individual consumers
9. Trauma-informed services strive to be culturally
competent and to understand each woman in the
context of her life experiences and cultural
background.
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Principles of Trauma-Informed Services
10. Trauma-informed agencies solicit consumer input
and involve consumers in designing and evaluating
services.
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SAMHSA’s Women with
Co-Occurring Disorders and Violence
Study
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SAMHSA’S Women, Co-occurring
Disorders and Violence Study (WCDVS)
(1998 – 2003)
Phase 1
•
•
•
•
2 years, 14 sites
Design of new Trauma Integrated Service System
Selection of most promising trauma interventions
Development of Cross-site protocols
Phase 2
• 3 years, 9 sites
• Implementation of Cross-site study comparing integrated
trauma-informed and trauma-specific services to services
as usual
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9 WCDVS Study Sites
Women Embracing Life
& Living (WELL) Project
Franklin County Women’s
Research Project
Allies Project
New Directions
for Families
Portal Project (NYC)
Prototypes
Community
Connections
Triad Women’s Project
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Boston
Consortium
of Services
for Families
in Recovery
Sample Sizes Across Program Sites by Condition
(N=2,729)
Program/Site
PROTOTYPES
Los Angeles, CA
Allies
Stockton, CA
Arapahoe House—New Directions for Families
Metropolitan Denver, CO
D.C. Trauma Collaboration
Washington, D.C.
Triad Women’s Project
Avon Park, FL
Boston Consortium of Services for Families in Recovery
Boston, MA
The W.E.L.L. Project
Cambridge, MA
Franklin County Women’s Research Project
Greenfield, MA
Portal Project
New York, NY
Total
Intervention Group
Comparison Group
187
215
169
266
57
108
150
97
179
123
181
161
218
110
105
120
169
114
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1415
1314
Triad Women’s
Project
Boston
Consortium
of Services
The W.E.L.L.
Project
Franklin Co.
Women’s Research
Project
Portal Project
(n =165)
(n =247)
(n =302)
(n =342)
(n =328)
(n =225)
(n =283)
(n=2729)
Hispanic Ethnicity (%)*
30.6
17.5
27.3
3.2
6.0
34.2
6.7
5.3
25.4
18.1
Race**
% White/Caucasian
41.3
56.3
52.1
13.4
81.5
37.4
78.4
85.3
7.1
50.3
Race**
% African-American
22.9
16.6
18.2
79.4
13.2
27.8
6.1
3.1
66.8
27.2
Race**
% Other Race
24.4
17.9
9.1
2.0
2.0
29.8
5.8
3.1
23.7
14.5
Race**
%Multi-racial***
11.4
7.6
4.8
4.0
1.0
2.6
8.2
4.9
2.1
5.6
Race**
% None-specified
0.0
1.6
15.8
1.2
2.3
2.3
1.5
3.6
0.4
2.4
Total
DC Trauma
Collaboration
Study
(n =435)
Allies
(n =402)
PROTOTYPES
SCC
New Directions
for Families
Baseline Demographic Characteristics by
Program Site:
Variable
* Hispanic ethnicity was measured independent
of race;
Not alland
percentages
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for **
Health
Recoverytotal to 100%, as excluded from the totals
were subjects for whom data were missing; *** Category includes subjects who identified two or more races
Participants in the Study
• 2,729 women were enrolled in the study
• All are 18 or older with histories of mental health and
substance abuse services use and histories of physical
or sexual abuse
• Average age (both groups) is about 26. Age ranges
from 18 to 76
• 54% were Caucasian, 18% Hispanic/Latina, 29%
African American
• 87% were mothers
• 50% had completed high school
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Primary Outcomes & Measures
Outcomes
Measures
Substance Abuse:
Addiction Severity Index
◦ Alcohol Composite (ASI-A)
◦ Drug Abuse Composite (ASI-D)
Mental Health:
Brief Symptom Inventory
◦ Global Severity Index (GSI)
Trauma:
Post Traumatic Diagnostic Scale
◦ Post Traumatic Symptom Scale
(PSS)
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Outcomes
• At 6 months—all women improved on all 4 major
outcomes (alcohol and drug use, mental health, and
trauma symptoms)
• Women in integrated condition did better than
women in usual care when provided with integrated
counseling
• At 12 months, women in the intervention group
maintained their improvement in drug use outcomes
and continued to improve in mental health and
trauma outcomes
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WCDVS Showed:
• Can start trauma treatment integrated with substance
abuse & mental health treatment from the
beginning—does not hurt but helps the recovery
process
• The importance of developing trauma specific
treatment models that address substance abuse and
co-occurring disorders
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Trauma-Specific Group Services
Used in WCDVS
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Trauma Specific Interventions
• Services designed specifically to address violence,
trauma, and related symptoms and reactions.
• Increase skills and strategies that allow survivors
to manage their trauma symptoms and reactions
with minimal disruption to their daily obligations
and quality of life, and eventually to reduce or
eliminate debilitating symptoms and prevent
further traumatization and violence.
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Trauma-Specific Curricula
Utilized in WCDVS
• Maxine Harris—
Trauma Recovery &
Empowerment (TREM)
• Lisa Najavits—
Seeking Safety
• Dusty Miller—
Addiction & Trauma Recovery
Integration Model (ATRIUM)
• Clark & Fearday— TRIAD
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Other Models Utilized in
Substance Abuse Treatment
• Stephanie Covington—Helping Women Recover &
Beyond Trauma
• Julian Ford—Trauma Adaptive Recovery Group
Education & Therapy for Persons in Recovery
from Addiction (TARGET-AR)
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Common Features
• Stage 1
• Cognitive-behavioral
• Teach coping skills
• Group curricula, but could be utilized
in individual sessions
• Can be co-facilitated by a professional & a peer
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Stages of Trauma Recovery
Treatment Aims
• Stage One: ESTABLISHING SAFETY
◦ Securing safety
◦ Stabilizing symptoms
◦ Fostering self-care
• Stage Two: REMEMBRANCE & MOURNING
◦ Reconstructing the trauma
◦ Transforming traumatic memory
• Stage Three: RECONNECTION
◦ Reconciliation with self
◦ Reconnection with others
◦ Resolving the trauma
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(Herman, Trauma and Recovery)
Stage I: Recovery
• Focus upon establishing both physical &
psychological safety
• Increasing understanding of links between
trauma & substance abuse
• Teaching coping skills
(Herman, Trauma and Recovery)
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Seeking Safety
Najavits, L.M. (2002). Seeking Safety: A treatment manual
for PTSD and substance abuse. New York: Guilford Press.
• Integrates safety and recovery
• Stresses accessing other community supports
• 25 topics, including Safety, When substances control you,
Grounding
• Session format:
◦ Check in
◦ Quotation
◦ Relating topic to women’s lives
◦ Closing
• 80 safe coping skills
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ATRIUM
Addiction & 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 women’s
project: Group facilitator’s 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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TREM
Trauma Recovery and Empowerment
Harris, M. & The Community Connections Trauma Work
Group (1998). Trauma Recovery and Empowerment: A
clinician’s 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: JosseyBass.
• Integrates expressive arts
• Accompanying journal
• 17 sessions, divided into four modules:
◦
◦
◦
◦
Self
Relationships
Sexuality
Spirituality
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TARGET-AR
Trauma Adaptive Recovery Group Education and
Therapy for Persons in Addiction Recovery
Ford, J.D., Mahoney, K., Russo, E., Kasimer, N., &
MacDonald, M. (2003). Trauma Adaptive Recovery Group
Education and Therapy (TARGET): Revised composite 9
session leader and participant guide. Farmington, CT:
University of Connecticut Health Center.
•
•
•
•
Cognitive-behavioral
Present-focused
Systematic skills training
Designed to be brief treatment
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Choosing a Curriculum
• Research, evaluation studies
• Program values and treatment philosophy
• Curriculum length and format
• Group facilitator’s expertise
• Adaptations for specific populations
• Cost, training, setting
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Integrating the Curriculum into
Substance Abuse Treatment
• Pilot-testing the curriculum
• Training for staff and supervisors
• Ongoing supervision and support for the new
practice
• Monitoring of fidelity
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SAMHSA’s WCDVS
Children’s Subset Study
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WCDVS Children’s Subset Study:
• 4 of the 9 WCDVS women’s study sites
• Development/implementation of standardized,
strengths-based intervention
• Outcome evaluation of children (ages 5-10)
• Interviews conducted with mothers/caregivers
• Generate empirical knowledge re: effectiveness of
trauma-informed, age-specific intervention models
• Identify models of care that will prevent or reduce
intergenerational perpetuation of violence
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WCDVS Children’s Study Sites
Women Embracing Life &
Living (WELL) Project
Allies Project
New Directions for
Families
Prototypes
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Core Intervention Components
• Clinical Assessment—Mother & Child
• Resource/Service Coordination and Advocacy
• Skills/Resiliency—Building Group
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Primary Goals of the Group Intervention
• Learn self-protection skills
• Develop skill in self-soothing
• Enhance interpersonal relationships
• Strengthen self-esteem and self identity
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Characteristics of Children
• Average age—7.28 years
• In legal custody of mother—74.3%
• Involved in child welfare system—39%
• Experiencing emotional or behavioral problems—
67.5 %
• Parent convicted of a crime—79.8%
• Parent treated for substance abuse—98%
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Outcomes
N=253 Baseline, 209 (6 months), 217 (12 months)
• 6 months post-baseline, mother’s overall treatment
outcome played a stronger role in children’s outcomes
than involvement in intervention – if mother did better,
children did better.
• However, children enrolled in intervention showed
general improvement regardless of mother’s outcome.
• 12 months post-baseline, participation in intervention
led to sustained positive improvement regardless of
mother’s outcome, with younger children showing a
greater degree of positive change than older children.
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Lessons Learned
• Children can be the motivator for women to seek
treatment
• Treatment of the woman offers an opportunity to
provide services to the children
• Traumatic childhood experiences influence the
ability to parent
• Victimization of children triggers memories in the
parent
• Motherhood is both a major source of identity and
self-worth, and a source of shame and guilt
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Lessons Learned
• Extreme guilt and shame must be addressed in order
to build healthy parenting relationships
• The support of a parent who has experienced similar
challenges is critical to overcome fear and guilt
• Must have well developed working relationships
with child welfare agencies
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Consumer Quote
“It was not until I became a part of the Women, CoOccurring 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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