WOMEN, TRAUMA, AND SUBSTANCE USE Trauma-informed Practices In Substance Use Services For Women

1. WOMEN, TRAUMA, AND SUBSTANCE USETrauma-informed Practices In Substance Use Services For Women Addictions & Mental Health Annual Conference May 27, 2013 Nancy Bradley, Jean Tweed Centre Janine Gates, Gates Consulting Inc.

2. Session Objectives: he Webinar • The critical role of trauma-informed practices in services for substance-involved women • The core principles and central concepts of trauma-informed practices • The guidelines for trauma-informed practices that have been developed through a federal (Drug Treatment Funding Program)

3. “Trauma is a public health risk of major proportions… Moreover, it often compounds medical and psychological conditions and injuries. This information too often goes unrecognized or under-recognized by medical and mental health practitioners. We have a major education, prevention and intervention issue.” Christine Courtois, Trauma Talks Conference. Toronto, 2012

4. Why is trauma an important issue? Experiences of trauma are common among substance-involved women • In three Canadian studies, over 80% reported histories of trauma • Numerous U.S. studies have found a high prevalence of trauma • Research has demonstrated connections between trauma and an array of health issues • Interconnections with substance use – both as a precipitator and as a risk factor “trauma is the rule, rather than the exception”

5. Why is trauma an important issue? Trauma affects the whole women - the impacts are broad and diverse: • Health risk behaviours, coping mechanisms • Psychological and cognitive adaptations • Myriad health problems Trauma responses are individual and variable • an interweaving of physical impacts and emotional adaptations • can be acute, chronic and/or delayed • are not determined by the event(s), but by a woman’s experience of the event(s)

6. Why trauma-informed practices? Without knowledge of trauma – its prevalence, its impacts, and its interconnections with substance use - service providers are at risk of: • Misinterpreting behaviour • Inadvertently using practices that trigger or retraumatize women • Providing ineffective services or interventions • Limiting engagement, higher drop-out, or unnecessary discharge

7. Why trauma-informed practices? Women who have lived experience told us about many gaps and barriers they encountered in Ontario substance use services. A few examples: • “The assessment agency didn’t ask about trauma.” • “I felt like there was a big elephant in the room and no one was naming it.” • “In a case conference they said they suspected I was abused as a child...no one asked me if I was abused and if it was OK to talk about it. I felt revictimized.”

8. Why trauma-informed practices? • “There were times when I was having flashbacks …I was told to just focus on my addiction.” • “Being in co-ed facilities retraumatized me. I suffered a lot of abuse and it was too difficult hearing the stories from men - a lot who were abusers.” • “There needs to be a program to include children and to re-affirm to children that they are okay. To be able to get tools with a trauma focus and to help the kids through it as well.”

9. Trauma-informed practices

10. Defining Trauma Trauma can be precipitated by a wide range of experiences and events, and occur at both individual level and collective levels. Traumatic events are more than merely stressful – they are also shocking, terrifying, and devastating to the victim, resulting in profoundly upsetting feelings of terror, shame, helplessness, and powerlessness.” (Courtois, 1999) Traumatic experiences are unique and individual. Experience may be influenced by an array of factors.

11. Defining Trauma “ The actual experience (of trauma)… and the assault that experience poses to sense of self, safety, belonging, and connection , are intertwined.” Kammerer & Mazelis, 2006 “Trauma is the sum of the event, the experience, and the effect.” SAMHSA , 2012

12. Trauma-informed practices Trauma informed care is: “a strength based framework that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment.” Coalescing on Women and Substance Use

13. Trauma-informed practices How are trauma-informed practices different from trauma-specific services? Programs and services that are trauma-specific: • Can include a range of service and interventions that focus directly on the impact of trauma, and on trauma recovery; • Are often delivered using evidence-based models or approaches (e.g. Seeking Safety); • Are delivered by practitioners who have extensive knowledge and skills in trauma treatment.

14. Trauma-informed practices Organizations - and their staff: REALIZEthe prevalence of trauma RECOGNIZE how trauma affects everyone involved with the organization (including its own workforce) RESPOND by putting that knowledge into practice

15. Trauma-informed practices from: What is wrong with this woman? to: What has happened to this woman? A change of perspective…

16. “It wasn’t until I got here that I realized that substances helped me to hide my trauma.” (focus group participant, Ontario, 2012)

17. Trauma-informed practices Should be universal • They should be used with every women, whether or not experiences of trauma have been disclosed Should be integral • They should be integrated into the organization’s culture, and braided with current practices, so that every interaction (verbal and non-verbal) is trauma-informed

18. Trauma-informed practices Should be used throughout an organization, to inform its: • Values and priorities, • Planning and strategies • Programs and services, • Policies and practices, • Human resources, training, and supervision • Infrastructure and site development

19. Trauma-informed practices • Should seek and use the input of women who have lived experience • Should recognize the full spectrum of women’s experience, and go ‘hand in hand’ with: • Gender-appropriate services for women • Anti-oppression approaches • Culturally competent organizations and staff • Other system tools that reflect best practices

20. Trauma-informed practices Six key principles: • Acknowledgement • Safety • Trustworthiness • Choice and control • Relational and collaborative approaches • Strengths-based empowerment modalities

21. Trauma-informed practices Examples Acknowledgement • Show an understanding of the relationship of trauma and substance use in written materials. • Implement universal screening. Safety • Minimize triggers and reduce retraumatization • Identify safety issues and work with women to make safely plans

22. Trauma-informed practices Examples Trustworthiness • Make sure that information is clear and that all of a woman’s questions are answered; explore her comfort level with the process. Choice and control • Review options and ask women’s opinions; support a woman’s role as an expert and an active agent in her own recovery

23. Trauma-informed practices Examples Relational and collaborative approaches • Work collaboratively with a woman, and think ‘outside the box’ of ‘treatment as usual’ when helpful Strengths based and empowerment • Focus on a woman’s resilience; reframe trauma-related behaviors and mechanisms; identify and celebrate changes and victories

24. Universal Screening for Trauma Can help to communicate validation and hope; Can invite a woman to acknowledge trauma, and it’s potential impacts; Can improve quality of services by: • Setting the stage for treatment planning and referrals • Flagging current safety concerns Screening for trauma requires skill, sensitivity, and flexibility: • Can trigger spontaneous disclosure, or emergence of trauma-related symptoms • Should not be intrusive, and should be paced

25. Who should implement trauma-informed practices? All organizations where women receive substance use services : • In both women-only and mixed gender environments • In all service types – ranging from early engagement, assessment, and withdrawal management to residential and community treatment • In services for women who have concurrent mental health issues

26. Pathways to Trauma-Informed Practices • Shift in organizational culture • Formal organizational commitment • Leadership to support change • Training for all staff • Assessment of programs, services, and organizational practices through a ‘trauma-informed lens’ • Clinical supervision and consultation • Monitoring, evaluation, and ongoing positive change

27. Vicarious Trauma • Impacts on staff who are indirectly exposed to trauma • Reducing risks of vicarious trauma • Organizational practices that recognize risks and provide support and resources • Staff practices that incorporate awareness and self-care

28. Trauma Matters Guidelines for Trauma-Informed Practices in Women’s Substance Use Services

29. Guidelines for the system • Federal (DTFP) grant to develop provincial guidelines for trauma-informed practices • The document – Trauma Matters : • Has been developed by a project team, managed by the Jean Tweed Centre • Was guided by an Advisory Committee comprised of service providers, funders and policy makers, and knowledge exchange specialists • Informed by the input of women who have lived experience

30. Guidelines for the system Trauma Matters will provide: • Information about the prevalence and impacts of trauma among substance-involved women • Guidelines and practical strategies for trauma-informed clinical and organizational practices • An overview of trauma-specific services • Information about resources for further learning

31. Guidelines for the system How the Guidelines were developed: • Advisory Committee and Terms of Reference • Request for proposals • Selection process • Project team hired to research and develop the guidelines, and write the document

32. Guidelines for the system • Evidence collected from: • Academic and research literature, • The grey literature – government reports, policy documents, • Subject area experts - specialist knowledge of women’s substance use and trauma, • Women who have lived experience of problematic substance use and trauma. • Draft guidelines developed - appropriate to the Ontario substance use service system. • Extensive review of multiple drafts by Advisory Committee and other subject area experts.

33. Guidelines for the system • Intended for use in Ontario substance use services • Must be braided with existing programs and with expertise of specialized services (e.g. for youth, Aboriginal and Native people, immigrant and refugee services, etc.) • May also be of help to: • Other services that work with substance involved women (mental health, primary health care, child welfare, VAW, justice system, etc.) • Policy makers, service and system planners, and funders Should be used as the beginning of a learning process about trauma and trauma-informed practices

34. Guidelines for the system Trauma Matters isavailable on-line, as of March 31, 2013 at: www.jeantweed.com www.ofcmhap.on.ca eenet.ca • And now posed on many other websites

35. When we use trauma-informed care, we respond to the need to heal from trauma and help to facilitate recovery. Coalescing on Women and Substance Use

36. What women have told us about their experiences in trauma-informed services…

37. “Staff recognized it first... I was having flashbacks…” “When I got triggered [and had a trauma reaction] it was helpful to be able to reflect on what was happening with me…. not getting into all the details and staying in the present moment during sessions was really helpful.” (focus group participant, Ontario, 2012)

38. “I learned skills in how to help yourself when you can’t really pin point what you are feeling and going through. I find that empowering and very helpful because they are skills I can take with me.” (focus group participant, Ontario, 2012)

39. “They always had blankets, that was really helpful, I feel like I need to cover up or something, I don’t want anyone looking at me, because of the trauma of it, I just need something there, even if it’s just my coat. I remember my counsellor’s office, there was a couch and a pillow and a blanket, and I always took the blanket because I didn’t want anyone to see my face while I was talking. It really, really helped.” (focus group participant, Ontario, 2012)

40. “Eventually I learned to nurture myself and to have a safe little spot in my home – when I’m feeling vulnerable… I am able to nurture myself.” (focus group participant, Ontario, 2012)

41. “The most important thing is validation. Validation. Validation. Validation. And the acknowledgment of the things we have been through and why we have done the things we have done. Just how it is all linked.” (focus group participant, Ontario, 2012)

42. Presenter Contact Information Project Manager: Nancy Bradley, Executive Director, The Jean Tweed Centre 416-255-7359 Email: nancybradley@jeantweed.com Project Team Lead: Janine Gates, Gates Consulting Inc. 613-547-8478 Email: janine.gates@sympatico.ca

43. Advisory Committee Members • Debbie Bang - Womankind Addiction Service • Nancy Bradley - Jean Tweed Centre • Gloria Chaim - Child, Youth and Family Program, CAMH • Robin Cuff - Toronto Drug Treatment Court Program, CAMH • Lucy Hume - Jean Tweed Centre • Kathryn Irwin-Seguin - Iris Addiction Recovery for Women • Paul McGary - Pinewood Centre, Lakeridge Health • Pam McIntosh - House of Friendship • Carol Wu - Amethyst Women’s Addiction Centre • Heather Bullock - Evidence Exchange Network, CAMH • Stephanie Gloyn - Evidence Exchange Network, CAMH • Julia Greenbaum - Knowledge and Innovation Support, CAMH • Kathy Kilburn - Kilburn Consulting, Health Systems • Danielle Layman-Pleet - Ministry of Health and Long Term Care • Jessica Penner - DTFP Project Coordinator, CAMH

44. Project Team Gates Consulting Inc. • Janine Gates • Wendy Reynolds (AWARE ) • Lucy Van Wyk (Therapist in Private Practice) • Jennifer Amos (Researcher and Editor)

45. Questions? Comments?