1. Trauma & Substance Abuse Presented At: Presented At: Women Across the Life Span: A National Conference on Women, Addiction & Recovery By: By: Norma Finkelstein, Ph.D. Institute for Health & Recovery July 13, 2004

2. Trauma & Substance Abuse 1- NF - 7/13/2004 Institute for Health & Recovery “I am an incest survivor & never dealt with it. Left treatment, did drugs. The most important thing is to integrate [services]. I’m a slicer & before no place would take me & if [I] say I’ve been sexually abused they boot you…I thought here we go again. Substance abuse identified and you’re welcome..…need to work all 3 areas…others throw you out because they are afraid.”

3. Trauma & Substance Abuse 1- NF - 7/13/2004 Institute for Health & Recovery Definition of Trauma  Shock or severe distress from experiencing a disastrous event  Traumatic reactions occur when people feel powerless, when nothing they can do matters

4. Trauma & Substance Abuse 1- NF - 7/13/2004 Institute for Health & Recovery “Traumatic events are extraordinary, not because they occur rarely, but rather because they overwhelm the ordinary human adaptations to life. Unlike commonplace misfortunes, traumatic events generally involve threats to life or bodily integrity, or a close personal encounter with violence & death. They confront human beings with the extremities of helplessness & terror, & evoke the responses of catastrophe. According to the Comprehensive Textbook of Psychiatry, the common denominator of psychological trauma is feeling of ‘intense fear, helplessness, loss of control, and threat of annihilation’.” (Herman, Trauma Recovery)

5. Trauma & Substance Abuse 1- NF - 7/13/2004 Institute for Health & Recovery Defining Violence Against Women United Nations [1993] “…any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivations of liberty, whether occurring in public or private life.”

6. Trauma & Substance Abuse 1- NF - 7/13/2004 Institute for Health & Recovery Types of Violence  Physical assault  Sexual abuse – including rape & incest  Emotional or psychological abuse  Environmental violence  Experienced as an adult or a child  May have occurred over time or been one incident and / or time limited

7. Trauma & Substance Abuse 1- NF - 7/13/2004 Institute for Health & Recovery Violence Against Girls  83% of girls report being touched, pinched & grabbed in sexual ways in school [JAMA, 2001]  1 in 5 high school girls has suffered sexual / physical abuse from a boyfriend. [JAMA, 2001] [National Violence Against Women Survey, 1995]  More than 1/2 of women raped were under 18; over 1/3 were under 12 [National Violence Against Women Survey, 1995]

8. Trauma & Substance Abuse 1- NF - 7/13/2004 Abuse Effects Researchers say that girls who suffer physical & sexual abuse by dating partners are more likely to engage in risky behaviors. (Note: Odds of 2.0 mean a girl is twice as likely to engage in the behavior as one who was not abused.) BehaviorOdds Heavy smoking (within 30 days)2.5 Binge drinking (within 30 days)1.7 Cocaine use (ever)3.4 Diet pill use (within 30 days)3.7 Laxative use & / or vomiting (within 30 days)3.7 More than three sex partners (within 90 days)3.3 Pregnancy (ever)3.9 Considered suicide (within 1 year)5.7 Attempted suicide (within 1 year)8.6 Source: JAMA, 2001

9. Trauma & Substance Abuse 1- NF - 7/13/2004 Institute for Health & Recovery Substance Abuse & Abuse History [Najavits et al. (1997)] Women in community samples report a lifetime history of physical & sexual abuse ranging from 36 to 51%, while women with substance abuse problems report a lifetime history ranging from 55 to 99% [Najavits et al. (1997)]

10. Trauma & Substance Abuse 1- NF - 7/13/2004 Institute for Health & Recovery Substance Abuse & Sexual Assault  50% of substance abusing women in treatment had experienced rape or incest (Woodhouse, 1990)  Women with a history of childhood sexual abuse were 2 times as likely to become heavy consumers of alcohol & 20% more likely to become injection drug users (Zierler et al. 1991)  50% of women seen in a variety of psychiatric settings had been sexually abused as children (Muesser et al. 1998)

11. Trauma & Substance Abuse 1- NF - 7/13/2004 Institute for Health & Recovery  80% of women with substance abuse disorders had been the victim of domestic violence (Research Institute on Addictions, 1997)  42% of victims of domestic violence contacting the police had used alcohol or other drugs on the day of the assault (Brookhoff et al., 1997) Substance Abuse & Domestic Violence

12. Trauma & Substance Abuse 1- NF - 7/13/2004 Institute for Health & Recovery Special Issues of Victims of Violence Who Are Substance Abusers (Mackey, 1992) The presence of both substance abuse & domestic violence increases the severity of injuries & lethality rates (Mackey, 1992) Perpetrators may pose risk to partners by:  Introducing partner to drugs  Forcing or coercing partner use  Isolating partner from help  Coercing partner to engage in illegal acts  Using withholding drugs as a threat  Using legal history as a threat  Blaming abuse on partner use

13. Trauma & Substance Abuse 1- NF - 7/13/2004 Institute for Health & Recovery Adverse Childhood Events ACE Study  Kaiser Permanente (Felitti) & the CDC (Anda)  Large-scale epidemiological study of influence of stressful / traumatic childhood experiences  Interviewed over 17,000 people  Compares adverse childhood experiences against adult health status

14. Trauma & Substance Abuse 1- NF - 7/13/2004 ACE Study Recurrent & severe physical abuse11% Recurrent & severe emotional abuse11% Contact sexual abuse22% Growing up in a household with: Alcoholic or drug-user25% Member being imprisoned 3% Mentally ill, chronically depressed, or institutionalized member 19% The mother being treated violently12% Both biological parents NOT present22% (Felitti, 2003) Origins of Addiction

15. Trauma & Substance Abuse 1- NF - 7/13/2004 Institute for Health & Recovery ACE Study  Scoring system used – one point for each category of ACE before 18  ACE’s not only common, but effects were cumulative  Compared to persons with ACE score of 0, those with ACE score of 4 or more were 2 times more likely to be smokers, 12 times more likely to have attempted suicide, 2 times more likely to be alcoholic and 10 times more likely to have injected street drugs.

16. Trauma & Substance Abuse 1- NF - 7/13/2004 Adoption of Health-risk Behaviors Social, Emotional, & Cognitive Impairment Disease, Disability Adverse Childhood Experiences Early Death Death Birth The Influence of Adverse Childhood Experiences Throughout Life ACE’s Major Determinant of Health & Well Being (Felitti, 2003)

17. Trauma & Substance Abuse 1- NF - 7/13/2004 Institute for Health & Recovery Trauma is Central and Pervasive  Central to the development of addiction, & mental health problems in women MANY  Impacts MANY aspects of a woman’s life

18. Trauma & Substance Abuse 1- NF - 7/13/2004 Institute for Health & Recovery “The treatment facility I was lucky enough to be accepted into was one of the first dual diagnosis facilities in the country…[it] was not trauma- informed, even though they diagnosed the PTSD. Although I learned a lot about dual diagnosis, trauma was not part of their curriculum. There were about 15 women in the facility, and all of us were trauma survivors. We would discuss our trauma with one another. However, the staff remained ill- informed. I often wondered why my trauma was never talked about.”

19. Trauma & Substance Abuse 1- NF - 7/13/2004 (Begin Anywhere) Victimization Trauma Sequelae MentalHealthProblemsSelf-Medication Addiction Lack of Self-Care

20. Trauma & Substance Abuse 1- NF - 7/13/2004 Institute for Health & Recovery Impact of Trauma Feelings  Fear, terror  Anger, revenge, hate  Frustration  Guilt or self-blame  Shame, humiliation  Grief or sorrow Beliefs  About self  About other people  About the world

21. Trauma & Substance Abuse 1- NF - 7/13/2004 Institute for Health & Recovery  Symptoms & behaviors Attempts to cope with the trauma  Goal of treatment To return a sense of autonomy & control to the woman

22. Trauma & Substance Abuse 1- NF - 7/13/2004 Institute for Health & Recovery Safety safety “One of the most important things I have learned is how to keep myself safe. The word Safety never came up in treatment. I now realize how much jeopardy I put myself in when I was using substances, not caring what time of the night it was, not caring that the guy just came into the room waving a gun, just give me another hit. We continue to put ourselves in situations that can retraumatize us on a daily basis. Learning how important safety is to my recovery process has changed my outlook.”