1. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Women with Substance Abuse & Trauma Related Psychiatric Problems Resource Manual Overview Paulette Giarratano

2. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Overview of Trauma Related Psychiatric Problems 1.Alterations in: Affect Regulation Consciousness (dissociation) Perception 2. Interpersonal issues 3. Substance Abuse 4. Anxiety 5. Depression 6. Anger 7. Intrusive experiences

3. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Overview of Trauma Related Psychiatric Problems Trust issues Unusual behavior & thinking Reenacting trauma Self-defeating behavior Somatic problems Alienation from others Unhealthy attachment patterns

4. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Indicators of Trauma related Psychiatric Problems Relationship problems Low self-esteem Addictive & compulsive behavior Self-destructive behaviors Poor self-care Risky Behavior

5. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Additional Challenges Poverty Parenting Adequate Housing Domestic Violence Isolation Lack of Medical Coverage Health Problems

6. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Additional Challenges Health problems Risky Behaviors (HIV, Hepatitis, accidents) Low self-esteem Mental health Substance Abuse

7. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Mental Health Qualify for multiple diagnoses Constellation of trauma reactions & Substance abuse Interaction among various social, physical, & emotional problems Impacts daily functioning Parenting ability is highly compromised

8. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Mental Health Common Diagnoses: Schizophrenia Depression Anxiety Bi-Polar Personality disorders

9. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group More Accurate Diagnoses for Trauma related Psychiatric Problems Post Traumatic Stress Disorder (PTSD) Disorders of Extreme Stress (DES) Dissociative Disorders not otherwise Specified (DDNOS) Common Chronic Symptoms: Anxiety Depression Self-injurious behavior Dissociation Interpersonal difficulties Cognitive Distortions

10. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Example: Schizophrenia Real cases of schizophrenia exist but symptoms are similar to those found in trauma survivors who could be diagnosed with PTSD or Dissociative Disorders. Careful assessment is needed Auditory hallucinations are characterized as “internal” in trauma related problems & “external” in schizophrenia

11. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Substance Abuse Interactive relationships between trauma symptoms & substance abuse Trigger disorders Perpetuate self-destructive cycle Alterations in consciousness

12. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Parenting & Substance Abuse Reckless behavior Lack supervision Child Maltreatment Inappropriate care takers Hostility & Violence Unresponsiveness

13. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Substance Abuse Treatment for Women & Children: Core Program Components Child Care Prenatal Care Women focused issues Mental health services Comprehensive programming Women specific programs

14. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Additional Services Parent Training Child Care Medical Care Transportation Education/Employment Services Advocacy Housing Assistance Case Management

15. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Studies: Outcomes Treatment completion Longer retention Decreased substance abuse Reduced mental health symptoms Improved birth outcomes Increased employment Improved health Decreased HIV risk

16. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Barriers to Treatment Feelings of shame, guilt, & inadequacy (stigma) Lack resources: Medical coverage, child care, & transportation Inexperienced/overloaded therapists Lack of integrated trauma & substance abuse programs Lack social support

17. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Treatment Engagement & Retention Strategies Outreach (Assertive Community Treatment; ACT) Motivational Interviewing Access to Health Care Access to Integrated treatment services for trauma, mental health, & substance abuse Ancillary Services Child Care

18. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Treatment: Mental Health & Substance Abuse Integrated treatment models Trauma Mental Health Substance Abuse Trained trauma, substance abuse, & mental health staff on assessment instruments & procedures & interventions

19. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Integrated Treatment Models Seeking Safety TREM: Trauma Recovery & Empowerment Triad TARGET: Trauma Adaptive Recovery Group, Education, & Therapy HWR: Helping Women Recover ATRIUM: Addiction & Trauma Recovery Integration Model

20. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Integrated Treatment Models Core Elements of Model Programs Safety Stabilization Skills Training: Affect regulation, Grounding, interpersonal & coping skills Cognitive & Behavioral Interventions

21. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Interventions for Trauma related psychiatric Disorders & Substance Abuse Interventions that can be target multiple Areas: Behavior Affect Cognitions Interpersonal Physiology

22. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Interventions cont’d Example: Dialectical Behavior Therapy (DBT) Researched & implemented mostly with Borderline Personality Disorder DBT Targets multiple areas using a range of techniques: Well integrated therapy for women with trauma & substance abuse issues

23. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group DBT: Dialectical Behavior Therapy Core Components Affect regulation skills Grounding Mindfulness Behavior Analysis Coping skills Exposure based techniques Cognitive Modification Validation

24. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Results from studies on Trauma Interventions Interventions with better outcomes address Trauma, psychiatric problems, & substance abuse Affect regulation skills Safety Self-care Behavior Modification Interpersonal issues Cognitive Reconstructuring

25. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Results from Studies on Substance Abuse Interventions for Women CBT: Cognitive Behavioral Therapy (adapted towards interactive nature of trauma & substance abuse) Trauma Informed programs (Integrated treatment) Services specifically for women Peer support services Advocacy

26. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group WCDVS: Women’s Co-Occurring Disorders & Violence Study Evaluated the effectiveness of integrated programs for women 9 program sites were evaluated after incorporating trauma informed treatment into mental health & substance abuse programs Compared to standard mental health & substance abuse treatment

27. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Treatment Models Used Seeking Safety TREM (Trauma Recovery & Empowerment Model) Triad Services: Peer run groups Advocacy Trauma Counseling Substance Abuse Treatment

28. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Results Moderate overall improvement in treatment outcomes Best outcomes were associated with the degree integrated counseling was incorporated into the program Worse outcomes were associated with programs with high service components

29. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Results 1 Program significantly produced good outcomes The variables within the program that contributed to clients’ improvement have not been revealed Future research may want to examine this finding more closely

30. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Limitations Amount of treatment varied across sites Components & services were not matched entirely across sites Inter-rater reliability of Methods? Staff training /treatment orientation across sites? Treatment/type of program prior to experimentation Client/Counselor relationships were not examined

31. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Implications Integrative programs for women need to focus on integrative counseling components due to the interactive nature of trauma reactions, mental health, & substance abuse Service components should be incorporated within the program sites because these women have a diversity of issues often as a result of social conditions & trauma histories Train Integrative Trauma staff/incorporate into Graduate educational programs/continuing education requirements

32. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Implications Women often do not engage or remain in treatment because of children Consequences may arise from seeking treatment Many programs use standardized models of treatment that can worsen trauma related problems & unmeet needs Treatment providers need to Collaborate with Criminal Justice & Child Protective Services while maintaining trust & advocacy for clients Incorporate programs especially for women & their children

33. © 2004-2005 CDHS/Research Foundation of SUNY/BSC College Relations Group Conclusion Assessment: Train clinicians to identify trauma related psychiatric problems is an important precursor to treatment Treatment Engagement & Retention: Outreach, engagement & retention interventions need to be incorporated, along with providing access to resources (Medical coverage) Treatment: Integrated Programs, use innovative interventions to target trauma related psychiatric problems & substance abuse Services: Adjunct women specialty services