Presented by Dee-Dee Stout, MA, CADC II; member of MINT

1. Diamonds in the Rough:Multifaceted Women’s Treatment: Practicing Gender-Responsive, Trauma-Informed Treatment Presented by Dee-Dee Stout, MA, CADC II; member of MINT Sensiblerecovery@aol.com or ddstoutrps@aol.com (P): 510-919-9678 www.responsiblerecovery.org

2. Walk Away Skill #1 “We should be humbled in the presence of our clients for they are the heroes of their lives.” ----Scott Miller, PhD OK to reproduce in its entirety only

3. Before we get started… • “Safety” • IPV v DV: Intimate Partner Violence v Domestic Violence • Privileged Leaving • Binary talking/thinking • Empowerment • Cannot be given • Includes failures & achievements OK to reproduce in its entirety only

4. Safety • Defined as keeping you safe from the outside world, not from each other • Women supporting other women • Staff can model this behavior • Involve residents with curricula planning & rules OK to reproduce in its entirety only

5. Trauma-Informed • Trauma-informed (TI) does not equal trauma-treating • Being TI means to be committed to providing services in a welcoming & survivor-friendly manner • Accommodates vulnerabilities (think, ADA) • Allows for services to be delivered in a collaborative treatment setting • Appreciates that trauma/PTSD is a mental health condition/COD OK to reproduce in its entirety only

6. Trauma-Informed • Means the agency/clinician understands the role violence and victimization play in the lives of our clts • Means the agency/management understands trauma drives the treatment • Acknowledges drug use/other less than healthy behaviors are likely results of trauma not vice verse OK to reproduce in its entirety only

7. Gender-Responsive • Gender-responsive does not mean women only • Acknowledges and treats genders differently because: • 1970’s began female-focused research & treatment • Began to decline in 1980’s and re-emerged in 1990’s (though Federal funding streams still sporadic) OK to reproduce in its entirety only

8. What is gender-responsive, trauma-informed treatment? First, some history & statistics…

9. Why Women’s Treatment? • Stigma still great • Further study needed • Need to encourage gender-specific treatment (both men & women) OK to reproduce in its entirety only

10. Women’s Treatment • 59% of tx facilities who treat women have no special programs for women they serve – why? • 19% offer child care • 45% transportation • 40% housing asst • Facilities that do not offer gender-specific treatment: • 4% child care • 28% transportation • 24% housing asst OK to reproduce in its entirety only

11. Consequences to Women • Women more vulnerable physiologically, psychologically, socially • Women perceive their quality of life as less than men w/SUD • Health, sleep, nutrition, work, self-esteem, autonomy, love, stress, mood/affect, security, social nurturance, public support, environment, outlook and more OK to reproduce in its entirety only

12. Risk factors to Women • Possible reciprocal relationship between negative consequences and risk factors, leading to a vicious cycle: • Sex assault initially related to AOD misuse, prompts her to use more to ameliorate pain of assault (Kaysen et al, 2006 cited in “Helping Substance-Abusing Women of Vulnerable Populations” by An-Pyng Sun) • Conflict btwn woman & partner triggers a relapse, making the strain worse (Sun, 2007) OK to reproduce in its entirety only

13. Physiological/Health Conseqs • The “telescoping effect” • ETOH: more body fat/less water leads to higher BAC • Women’s lower ADH (alcohol dehydragenase) in GI tract (stabilizes during lifetime); more research needed • Health-related problems occur early in drinking; more liver,heart, brain trouble in spite of men’s drinking more; breast cancer, reproductive dysfunction, babies w/complications; HIV/AIDS; STD/STIs; much higher mortality rate than male counterparts OK to reproduce in its entirety only

14. Psychosocial Consequences • AOD use puts women at higher risk of sexual and non-sexual victimization • Women hold double standard for women’s AOD behaviors! • Women seen as “weak willed; being sexually promiscuous, and irresponsible in giving birth to/caring for children (often numerous) • Leads to rejection, isolation, depression, guilt, lower self-esteem(Finkelstein, 1994) OK to reproduce in its entirety only

15. Psychosocial Consequences • Intoxication of any kind can impair cognitive function and motor ability • Men often see women under-the-influence as targets for assault (neither tends to call it “rape”) • Women with SUD more likely to lose kids than non-SUD woman in child welfare system • Rates of parents/caretakers w/SUD: 40/50%-80% OK to reproduce in its entirety only

16. What is Trauma? • An event or series of events that threaten you - perhaps even with death – that causes physical or emotional harm and/or exploits your body and/or integrity • Trauma is pervasive and life-altering • Trauma has been reported by 55-99% of female substance abusers (Najavits et al, 1998) OK to reproduce in its entirety only

17. PTSD Symptoms - simplified • Re-experience • Recurrent and intrusive recollections of and/or nightmares about the event • Flashbacks, hallucinations, or other vivid feelings of the event happening again • Great psychological or physiological distress when certain things (objects, situations, etc.) remind them of the event. • Avoidance • Persistently avoiding things that remind them of the traumatic event • Including thoughts, feelings, or conversations associated with the incident to activities, places, or people that cause them to recall the event OK to reproduce in its entirety only

18. PTSD Symptoms (con’t) • General lack of responsiveness signaled by an inability to recall aspects of the trauma • Decreased interest in formerly important activities • Feeling of detachment from others, a limited range of emotion, and/or feelings of hopelessness about the future • Increased arousal • Includes difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, becoming very alert or watchful, and/or jumpiness or being easily startled Note: Folks w/PTSD are at increased risk for suicide OK to reproduce in its entirety only

19. More on Trauma • Trauma betrays our beliefs, values, and assumptions – trust – about the world around us: “wound of the soul” • Trauma can result in engaging in less healthy behaviors, aids us through our reactions to events. Behaviors: • Are an adaptation not a pathology • What kept us alive to get you to us! OK to reproduce in its entirety only

20. Possible Responses to Trauma • Intense fear; hypervigilance • Feelings of helplessness • Anxiety • Excessive worry • Intrusive thoughts & memories • Flashbacks • Depression OK to reproduce in its entirety only

21. More Possible Responses to Trauma • Anger or rage • Nightmares & Night Terrors • Detachment & Dissociation • Substance Use & Misuse/Abuse • Unusual sexual behavior • Difficulty with relationships • Others OK to reproduce in its entirety only

22. Post-trauma, women w/SUDs… • Improve less • Worse coping abilities • Greater distress • More positive views of substance use (understandably) • PTSD does not go away with abstinence: it gets worse! OK to reproduce in its entirety only

23. Connections between SUD & Trauma • Witnessing/experiencing childhood family violence • Childhood physical & emotional abuse • Women in chemical recovery • Typically have history of violent trauma • Substances used to numb or dissociate - medicinal • Violence often seen as “natural” part of life • Coping mechanism for frustration and anger OK to reproduce in its entirety only

24. Dissociation (complete numbing) • Not mentioned in DSM-IV as symptom of PTSD though sx of acute stress d/o • PTSD actually is a dissociative disorder not anxiety d/o? • Crucial to understand process – most severe consequence of PTSD/trauma OK to reproduce in its entirety only

25. Women’s Treatment: Getting Started • Increase clients’ feelings of well-being • Different RP: • Help them learn to anticipate, recognize, and effectively cope w/conflict situations & negative emotions (opposite of men) • Cope with stress! • Screen for childhood abuse • Screen for COD OK to reproduce in its entirety only

26. Women’s Treatment: Nuts & Bolts • Incorporate healthy eating, nutrition, and healthy weight control • Eating disorders including dissatisfaction w/body image • Smokers young or overweight need extra attention due to higher risk OK to reproduce in its entirety only

27. Women’s Treatment:Nuts & Bolts • To help reduce stigma, AOD family hx/dysfunctional family of origin discussions are helpful • Doesn’t ignore personal responsibility • Heredity factors unclear in women OK to reproduce in its entirety only

28. Women’s Treatment: Nuts & Bolts • Women’s only programs seem more beneficial than mixed • Easier discussing personal experiences re: sex, kids • Reduced sexual harassment • Reduced early drop out rates w/men met at treatment • Lesbians, women with young kids, and women w/childhood hx of sex abuse tend to participate more in female-only programs OK to reproduce in its entirety only

29. Features of Good Women’s Treatment • Case Management • One-Stop Shopping Model • Supportive Staff/Individual Counseling • Counselor's genuine concern • Respect for/ trust in client • Supportive, nonjudgmental attitude OK to reproduce in its entirety only

30. Trauma-Informed Services… • Asks: Are our policies and procedures, program, hiring practices, etc. all in line with preventing the re-traumatization of clients? OR • Are we letting our rules – defined as the need for “safety” - actually mimic any dynamics of a trauma/abusive relationship? OK to reproduce in its entirety only

31. Walk Away Skill #2 Watching our Language or Some Simple Do’s & Don’ts in GRTI Treatment

32. Abstinent, sober, or drug-free Powerful; empowered Women united for women Supportive relationships Not “clean” Not “Powerless” No “Gossiping” Not “enabling” or “co-dependency” Language is crucial: OK to reproduce in its entirety only

33. What shouldn’t we do? • Don’t explore past trauma(s) • In general, no psychodynamic work at first • No autobiographies until stable • Don’t ask about the trauma or the triggers • Gently guide conversation to present problems • Use complex reflections to highlight strengths OK to reproduce in its entirety only

34. Remember: • PTSD affects about 7.7 million American adults • Women are more likely to develop PTSD than men • Some evidence that susceptibility runs in families • PTSD is often accompanied by depression, substance abuse disorders, or one or more of the other anxiety disorders Thanks to NIMH @ www.nimh.nih.gov/health OK to reproduce in its entirety only

35. Administrative Commitment Universal screening Brief & non-threatening Soon after admission Training & education RICH Hiring Practices Review P&P Review committees need to be vigilent 1 staff min. who understands trauma/abuse & how it’s accidentally supported in agencies How to Create a TI Agency OK to reproduce in its entirety only

36. Understand Trauma Assume all clients have trauma hx “Split” of client due to trauma Ripple effect felt throughout life & in all areas of life Understand the Client Survivor Holistic view to understand their experiences Understand Services Goal is to return autonomy & control to clt Fish proverb Understand the Service Relationship We don’t have all the answers Trust & safety must be earned from the clt Invite the clt to participant Genuineness a must! Principles & Philosophy of TI Treatment OK to reproduce in its entirety only

37. 5 Core Elements in Trauma-Informed Addiction Treatment • Program must have a commitment to teaching explanations of events that integrate trauma & SUD’s • Milieu must promote consumer empowerment & relationship building as well as healing • Each woman must be encouraged to develop certain crossover skills that are equally important in recovery from trauma & SUD’s OK to reproduce in its entirety only

38. 5 Core Elements in Trauma-Informed Addiction Treatment • A series of ancillary services help a woman to continue her recovery once she leaves a structured program • The program avoids the use of recovery tactics that are contraindicated for women recovering from physical and sexual violence OK to reproduce in its entirety only

39. Elements in Building a Program • Women-only programs (more needed) • Making women-only groups available in all programs • Referring • Residential treatment best for women w/few resources & heightened environmental stress • Child care on-site w/other services (case mgmt) • Emphasizing non-judgmental, non-confrontational approaches for staff • 1x1 counseling OK to reproduce in its entirety only

40. Trauma-Informed Treatment… • Says women & their needs must be at center of all treatment components • Says that tx must not be parallel but simultaneous (ie, meds) • Says clients are the experts in their lives • Says providers must know the hx of past and current abuse of clients OK to reproduce in its entirety only

41. Trauma-Informed Treatment… • Says clients may choose their counselors – or switch • Says we must explain to clients why/how we are asking them to do something • Says the client’s needs come first – always! OK to reproduce in its entirety only

42. 1. Listen more; talk less 2. Gently help clients link SUDs & PTSD 3. Discuss only current - not past - problems 4. ‘Listen’ to client behaviors 5. Get training 6. Appreciate that substances do solve PTSD symptoms What can we do? OK to reproduce in its entirety only

43. Be willing to try new things; model healthy change for clients Believe the client & their CSOs are their most important resource See opportunities not problems Know we can’t know everything – & be OK with that Build alliances with other disciplines (MDs, AOD, other agencies, etc) Be flexible with staff re: how they approach their job Try walking in the clients’ shoes Have a great sense of humor! What more can we do? OK to reproduce in its entirety only

44. A few last thoughts… • Teach clients more about mental illnesses/COD’s • Add a COD group or coordinate with another agency to provide this service • Remember clients are customers: they can go elsewhere or not come to tx at all even if mandated • Engage in free trainings • Online through NIDA, ATTC, and more • Ontrack • Host trainings with other agencies OK to reproduce in its entirety only

45. Letting Go… If you let go a little, you’ll have a little peace If you let go a lot, you’ll have a lot of peace, & If you let go completely, you’ll have complete peace. • How much peace do you want in your professional life? OK to reproduce in its entirety only

46. Acknowledgements • The Body Remembers: The Psychophysiology of Trauma & Trauma Treatment.Babette Rothschild, 2000. WW Norton. • Trauma & Recovery. Judith Herman. 1992. Basic Books. • Many Roads, One Journey: Moving Beyond the 12-Steps. Charlotte Kasl, Ph.D. 1992. HarperCollins. • Seeking Safety: A Treatment Manual for PTSD and Substance Abuse. Lisa Najavits, Ph.D. 2002. Guilford Press. • Helping Substance-Abusing Women of Vulnerable Populations. An-Pyng Sun. 2009. Columbia University Press, NY. OK to reproduce in its entirety only

47. Acknowledgements • Motivational Interviewing, (2nd Ed), Preparing People for Change. William R. Miller & Stephen R. Rollnick, 2002. Guilford Press. • Waking the Tiger: Healing Trauma: The Innate Capacity to Transform Overwhelming Experiences by Peter Levine & Ann Frederick. 1997. North Atlantic Books. • The Change Book, (2nd Ed), ATTC. 2004. www.nattc.org/thechangebook. • Assessing and Treating Trauma & PTSD. Linda Schupp. 2004. Pesi, LLC. • New Directions for Mental Health Services Using Trauma Theory to Design Service Systems, No. 89, Spring 2001. Maxine Farris and Roger Fallot. 2001. Jossey-Bass. OK to reproduce in its entirety only

48. Thanks! Regional training materials developed by: • Dee-Dee Stout • ONTRACK Project Staff • Madalynn C. Rucker • Peggy Thomas OK to reproduce in its entirety only