trauma-informed substance abuse treatment

1. Trauma-Informed Substance Abuse Treatment Community Connections 2008

2. 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

3. 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

4. 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

5. Adverse Childhood Experiences(www.ACEstudy.org)

6. Scope of the Problem (5) Physically abused boys are more likely to become substance abusers (Malinosky-Rummel and Hansen, 1993)

7. 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

8. 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

9. 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.

10. 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

11. 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

12. 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

13. 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

14. Treatment Approaches Sequential Treatment Parallel Treatment Integrated Treatment

15. 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

16. 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

17. An Integrated Treatment Approach Integrative Explanations Content Modules Dual Recovery Skills Program Milieu Ancillary Services Contraindicated Approaches

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. Guidelines for Practice Universal screening Understanding the role of violence and abuse in people’s lives Appreciating the power of trauma dynamics

27. 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

28. Trauma-Informed Addictions Treatment A 20 Session Psycho-Educational Group Intervention Designed to Address Substance Abuse Issues within a Trauma-Informed Perspective

29. 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

30. Philosophy Room to incorporate other theoretical models Strengths-based model, “confrontation light” Emphasis on education

31. Group Format Icebreaker Questions Exercise Ending Ritual

32. 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

33. 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

34. Small Group Exercise Substance Abuse and Trauma Vignettes

35. 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.

36. 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.

37. 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 dad’s 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.

38. 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.

39. 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 wouldn’t 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.

40. 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 can’t really turn to family and friends for emotional or monetary support because she hasn’t talked to them in a while.

41. 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 didn’t 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 Marilyn’s boyfriend had sexually abused them. Marilyn thought that the accusation about the sexual abuse was especially ironic since when

42. Marilyn was sexually abused as a kid her mom didn’t 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 couldn’t 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

43. 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 doesn’t 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.

44. 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.

45. Darlene (2) Darlene was incested for years as a child. The family covered it up and when she became pregnant with her father’s 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

46. Darlene (3) dependable but she doesn’t believe it is going to last. She cuts herself and he has seen the scars all over her body. She doesn’t 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 doesn’t believe medication will be helpful. She is not willing to stop cutting. She says it is a part of her.

47. 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

48. 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

49. 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”