The Boston Consortium Model: Treatment of Trauma Among Women with Substance Use Disorders

1. The Boston Consortium Model: Treatment of Trauma Among Women with Substance Use Disorders Hortensia Amaro, Ph.D. Institute on Urban Health Research Bouvé College of Health Sciences Northeastern University

2. 1. Overview of the Problem Co-Occurring Disorders HIV Risk Behaviors Complex Clinical Presentation Worse Prognosis Current Treatments 2. Integrated Treatment Study Purpose & Methods Intervention Findings

3. Gender Differences in Trauma Exposure and Risk for PTSD • Lifetime trauma exposure: 60.7% men 51.2% women • Lifetime PTSD: 5.0% men 10.4% women • Risk of developing PTSD conditioned on trauma: 8.1% men 20.4% women Epidemiologic Catchment Area Survey and National Comorbidity Study

4. PTSD is Associated with Greater Risk of SUD in Women Risk National Comorbidity Survey

5. History of Abuse in Women with SUD Clinical Samples • Childhood: • 40% sexual assault 27 • 63% 4 to 80% 28 for both physical and sexual abuse • Adult: • 72% sexual assault • 67% physical assault 29 • 84% sexual abuse 30

6. Co-Occurring Disorders are Frequent Among Women with SUD • PTSD prevalence among women with SUD: • 27% in a general population sample 23 • 30-59% in clinical samples 11 • higher than the prevalence reported in men • Other comorbid disorders among drug abusing women: • Affective disorders (both depressive and anxiety-related) 31, 32 • Hostility 33, dissociation and somatization 34 • Our studies of women clients in SA treatment: • 93% lifetime history of abuse • 88% mental health symptoms in last 30 days • 83% have both

7. More Complex Clinical Presentation Compared to individuals diagnosed with DA disorders alone, people with SUD and PTSD are: • more likely to report psychiatric and medical comorbidity 3, 9, 13, 62and are more impaired than people with only one diagnosis 8 • have social and functional health concerns such as homelessness 12, unemployment 63, criminal activities and loss of custody of their children 12

8. Co-occurring Disorders are Associated with Worse Prognosis • Enter and drop out of treatment more often • Relapse more quickly • Treatment compliance lower • In and after SA tx: Lower motivation to quit, less positive coping skills (eg emotional vs implementing strategies to reduce stress) • Worse outcomes on life adjustment measures • PTSD intrusion symptoms increase risk of SUD relapse

9. Higher Risk for HIV • Drug abuse1, mental health disorders2, and history of trauma3 have each been shown to be associated with sexual risk behaviors. • The combination of drug abuse, mental health disorders, and history of abuse further increases HIV risk behaviors and HIV infection.4 • Women who have severe drug dependency are more likely to engage in unsafe sex with multiple partners and in sex for money or drugs, as well as to have unprotected sex with an injection drug user.5 1. Leigh & Stall (1993), Wingood & DiClemente (1998); 2. Alegria et al. (1994); 3. Bensley, Van Eenwik, & Simmons (2000), Koenig & Clark (2004); 4. Stall et al. (2003); 5. Health of Boston Report, Boston Public Health Commission, 2004; 5. Heise, Ellsberg, & Gottemoeler, (1999);

10. Hypothetical Cycle of PTSD and SUD PTSD Alcohol/Drug use SU Disorder • Men: 53% - 65% PTSD first then SUD • Women:: 65% - 84% PTSD first then SUD Short-term Anxiety reduction Escalating use

11. Current Treatments Do Not Sufficiently Address Trauma in Women • Prevention and treatment strategies that promote trauma recovery may be quite effective 72. Cognitive-behavioral based treatments that are specifically designed for people with a dual diagnosis of substance abuse disorders and PTSD have been developed and some have been tested. • Few studies to date exist on gender-specific trauma treatment in women with substance abuse disorders [7, 15]. • These have shown promise but a more recent RCT of a 12-session intervention showed no overall advantage of trauma treatment compared to the control group [17-21].

12. Are Brief Interventions Effective? • Test of a 12-session group intervention based on cognitive-behavioral and skills-building principles (Seeking Safety) in a RCT of women in Tx for SUD found: • No intervention effects overall (Hien et al, 2009) • Intervention was more effective than control in substance abuse improvement among those who were heavy users and had achieved significant PTSD reductions. Reverse relationship not found (Hien et al, 2010). • Intervention reduced sexual risk among those with high sexual risk (Hien et al, 2010)

13. Why Gender Specific Treatment? • Women and men experience different kinds of violence • Women respond to extreme stress differently than men (internalizing vs externalizing; greater reliance on social support in coping w stress) • Homogeneity in trauma experience among group members • Preference for same sex mental health services

14. Integrated Treatment vs Services as Usual SAMHSA-funded Women, Co-Occurring Disorders and Violence Study

15. Boston Consortium Model of Integrated SAD Treatment October 1998-September 2004 SAMHSA

16. Mechanisms of Action in Trauma-SA-HIV Risk Relationships Mental Health Symptoms: PTSD Depression Anxiety Perceived Stress Recovery Skills: Coping Social Support Relationship Power Alcohol and Drug Use HIV Risk Behaviors

17. Phase 2Primary Research Question How effective is the BCM in reducing subsequent signs and symptoms of trauma, mental illness, and substance abuse and HIV risk behaviors compared to SA services as usual?

18. Study Sites for the WCDVS Franklin County Women’s Research Project Boston Consortium ALLIES Project WELL Project Portal Project PROTOTYPES Community Connections New Directions for Families Triad Women’s Project

19. Study Participant Criteria

20. 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)

21. Process PHASE 1 • Developed partnerships across SA, MH, DV; and with policy makers • Assessed co-occurring disorders in our population • Agreed on intervention principles • Developed treatment model and manuals • Trained staff PHASE 2 • Implemented and evaluated model

22. Partnerships

24. Co-occurring Disorders Among Women in Boston SU Tx Programs (N= 354) • Brief screen developed • Administered to 354 consecutively admissions • 3 modalities of substance abuse treatment (methadone maintenance, outpatient and residential) • Items identify women with mental health symptoms in last month and lifetime experience of abuse and who should be referred for full assessment • Implemented in 5 publicly funded intervention programs

25. Mental Health Symptoms last month (n=354) %

26. Trauma History Ever (n=354) %

27. Association of Mental Health Symptoms with Trauma Exposure

28. Typical Presentation of Women in Tx • Chronic and severe physical and sexual abuse, in abusive relationship • Major depression, anxiety disorder, and/or PTSD • Addiction to crack, cocaine, heroin • Multiple treatment attempts • Partner is active drug user • Multiple health problems • Past/current criminal justice history • Few educational and job skills • Has 3-5 children, DSS involved • Living in poverty, may be homeless or in temporary housing • HIV Risk Behaviors

29. Intervention Principles • Consumer participation and input in decision making regarding the intervention • Cultural and linguistic tailoring of intervention approaches and delivery of interventions by staff who reflected the population of participants • A focus on gender specific approaches that paid attention to social and cultural influences in women’s lives. • Use of evidence based approaches when available or development of intervention components based on the best available evidence and consumer/provider input

30. BCM Integrated Treatment Model

31. Elements of Clinical Intervention Added to SA Tx • MH & Trauma Diagnostic & Integrated Tx Plan • System Boundary Spanner for: • MH Emergency Services • Individual/Family/Group Therapy • Psychopharmacological Treatment • ‘Package’ of manualized trauma recovery skills building groups

32. Staff Training • Case study workbook for staff training • Uses case examples to engage staff in discussions on issues that emerge in integrating treatment

33. Trauma Recovery and Empowerment

34. Leadership 3-session educational curriculum that teaches women how to become leaders and learn to speak up on their own behalf and on behalf of other women in recovery.

35. Economic Success 8-session educational curriculum designed to assist women in • examining how money management is related to the recovery process, • developing effective money management skills and • identifying and planning educational, vocational, and job training opportunities and objectives.

36. Family Reunification 10-week educational curriculum that focuses on the impact of substance abuse on parenting, family reunification and self-care. Engages participants in learning about child protective services and advocating effectively on their own behalf to reach a positive reunification outcome. Helps women build skills to cope with potentially triggers related to child custody issues.

37. Findings: Alcohol and Drug Use • The intervention group reported significantly higher drug abstinence rates than the comparison group at both 6- and 12-month follow-ups (6-month: 67% vs. 38%; 12-month: 75% vs. 40%; all p values < 0.0001). Amaro et al, 2009

38. Mental Health Symptoms The analysis for mental health symptomatology revealed a significant Condition X Time interaction, F (2, 556) = 4.55, p = .01 (d = .32), favoring the intervention group. (Amaro et al, 2009)

39. Trauma Symptoms The analysis for PTSD symptoms revealed a significant Condition X Time interaction, F (2, 553) = 4.49, p = .01 (d = .35), favoring the intervention group. (Amaro et al, 2009)

40. Moderating Effects of Race/Ethnicity • Analyses to determine if racial/ethnic group moderated the effects of intervention on each of the four outcomes: • No significant Condition X Time X Ethnicity interaction for any of the outcomes, thus indicating that the integrated model was efficacious for women across all ethnic groups.

41. Changes in Unprotected Sex (unadjusted) Logistic regression analyses: Strong significant association between intervention status and sexual risk behaviors at follow-up. Comparison group women had 2.8 times (6M) and 4.5 times (12M) more likelihood of engaging in unprotected sex than intervention group women. after adjustment for baseline characteristics and intermediate outcomes. (Amaro et al, 2007)

42. Relationship Power • For women in recent relationships, those with higher RPS scores were less likely to engage in unprotected sexual behaviors than women with lower scores at 6 M (p<.01) and 12M (p<.001). • Women in the intervention had more gain on RPS than those in the intervention.

43. National Registry of Evidence Based Models- the Boston Consortium Model http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=86 • Research that led to development of Boston Model of Integrated Treatment; Some Examples

44. Conclusions • Conclusions must be tempered due to limitations of the quasi-experimental study design. • Changes at 6-months and 12-months follow-up indicates that the integrated treatment model resulted in greater treatment improvements with drug use abstinence, mental health and trauma symptoms and HIV risk behaviors. • Qualitative data from staff and clients indicate high level of acceptability, feasibility and fit of intervention.

45. Conclusion • Integrated treatment results in better treatment outcomes including lower HIV risk behaviors • Staff training needed to integrate treatment of MH and trauma into SA tx and requires systems change • Further research and program development needed: • Key components to integrated treatment, • Level of intervention exposure needed, • Tandomized clinical trial w/longer f-up • Assess and integrate role of spirituality in healing and recovery

46. www.iuhr.neu.edu h.amaro@neu.edu