Women with Substance
Abuse & Trauma Related
Psychiatric Problems
Resource Manual Overview
Paulette Giarratano
© 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
© 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
© 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
© 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
© 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
© 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
© 2004-2005 CDHS/Research Foundation of SUNY/BSC
College Relations Group
Mental Health
Common Diagnoses:
Schizophrenia
Depression
Anxiety
Bi-Polar
Personality disorders
© 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
© 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
© 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
© 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
© 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
© 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
© 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
© 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
© 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
© 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
© 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
© 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
© 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
© 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
© 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
© 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
© 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
© 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
© 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
© 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
© 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
© 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
© 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
© 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
© 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
© 2004-2005 CDHS/Research Foundation of SUNY/BSC
College Relations Group