Women and Concurrent Disorders

Women and Concurrent Disorders
(Addiction and Mental Health)
Women in Mind Conference
November 2, 2012

Marilyn Herie PhD, RSW
Director, TEACH Project, Centre for Addiction and Mental Health
Director, Collaborative Program in Addiction Studies, University of Toronto
Assistant Professor (Status Only) Factor‐Inwentash Faculty of Social Work, U of T

Disclosure of Potential for Conflict of
Interest for:

Dr. Marilyn Herie
• I do not have an affiliation (financial or otherwise) with a pharmaceutical,
medical device or communications organization; therefore cannot identify
any conflict of interest.

• I do not intend to make therapeutic recommendations for medications that
have not received regulatory approval (i.e., “off‐label” use of medication).

1. A feature that
resonated for me
2. A question I want to
think through
3. A seed I could plant
now

Learning Objectives
At the end of this session, you will be able to:
1. Identify specific risk factors and presenting
issues among women with concurrent
disorders
2. Critique emerging research and treatment
implications
3. Access woman‐centred treatment tools and
additional resources

Marusha
• 45 y/o, divorced, 2 daughters
• Employed part‐time as a cashier
• Trauma history – never sought
treatment (she and sister sexually
abused by father)
• Concerned about alcohol use (5‐7
drinks/day)
• Prescribed benzodiazepines for
anxiety PRN
• Past suicide attempt 5 years
previously – denies current ideation

March 2011 Academy Award Nominees’ SWAG
BAGS contained a pack of Swarovski-bedazzled
electronic cigarettes
(retail value = $100)
(promotional value = much more, to associate celebrity with product)

“Bruised, battered, belittled and bewildered,
buffeted by societal attitudes and stereotypes
are the women who end up in the offices of
[helping professionals].”
(Harrison, 1997)

Recovery and the Life Cycle of the Individual, Family
and Community

White, W. Journal of Substance Abuse Treatment, 33, 2007

A continuum of severity

No Severe
Problems Problems

http://www.samhsa.gov/samhsa_news/volumexii_5/article4.htm

Who has the authority to define
recovery?
Defining who is and who is not in recovery may also
dictate:
• Who is seen as socially redeemed and who remains
stigmatized
• Who is hired and who is fired
• Who remains free and who goes to jail
• Who remains in a marriage and who is divorced
• Who retains and who loses custody of their children
• Who receives and who is denied government
benefits


Recovery can be…
• Return to health following trauma or illness
• Assisted or unassisted (“natural recovery”)
• A process, not an event (“recovery career”,
“treatment career”)
• Sometimes characterized by quantum or
transformational change
Principles of recovery are nested within concepts
of community, national, global health


5 CD Subgroups
(1) Stress, Trauma & Substance Use Disorders
(2) Anxiety Disorders & Substance Use Disorders
(3) Mood Disorders & Substance Use Disorders
(4) Psychosis & Substance Use Disorders
(5) Impulsivity & Substance Use Disorders

Substance Abuse in Canada: Concurrent Disorders Report (CCSA, 2010)
http://www.ccsa.ca/2010%20CCSA%20Documents/ccsa-011811-2010.pdf 21

Examples of
Concurrent Disorders
Substance: Mental health:

1. Alcohol use & PTSD

2. Opioids & Depression

3. Cannabis use & Schizophrenia

22

Why is it important to understand CD?

1. Drug use can trigger mental health problems
2. Drug use may worsen symptoms of existing
mental illness
3. Substance use, intoxication and withdrawal from
substances can mimic symptoms of mental
health disorders
4. Substance use may mask mental illness that
already exists
23

Why is CD Important? (cont’d)
People with CD (treated or untreated) are at
higher risk for:
– Double or multiple layers of stigma
– Homelessness
– Suicide
– Family violence
– Victimization
– Child abuse/neglect
– HIV infection
– Incarceration/legal problems
– Re‐hospitalization 24

CD Etiological Models

25

ASSESSING THE
MODEL EXAMPLE RELATIONSHIP
(1) Secondary SUD •Self‐medication of •Does SU relieve MH
Substance use is a panic attack symptoms symptoms (e.g.
coping response for with alcohol anxiety)?
mental health symptoms •Crack cocaine used to
escape memories of •Is anxiety WORSE
trauma during abstinence?
2) Secondary MHD •Cocaine‐induced •Did SU precede MH?
Mental health symptoms depression •Does MH improve
are a result of chronic or •Cannabis‐induced during abstinence?
excessive substance use, psychosis •Does SU worsen MH?
or withdrawal
26
http://knowledgex.camh.net/amhspecialists/Screening_Assessment/screening/treating_cd_intro/Pages/treating_cd_relationship.aspx

ASSESSING THE
MODEL EXAMPLE RELATIONSHIP
(3) Common Factor •A traumatic event •How are the issues
Mental health and leads to PTSD and linked, and what are
substance use problems substance use possible precipitating
develop from a common •Genetic vulnerability factors/events?
underlying factor for psychosis and
substance dependence

4) Bi‐directional Models •Alcohol dependence •Did SU precede MH?
One problem may increases possibility of •Does MH improve
increase likelihood of job loss, increasing during abstinence?
developing problems in possibility for •Does SU worsen MH?
the other area depression
27
http://knowledgex.camh.net/amhspecialists/Screening_Assessment/screening/treating_cd_intro/Pages/treating_cd_relationship.aspx

The Influence of Sex and Gender
• Prevalence, course and burden of mental
illness
• Different pathways to substance abuse
• Different risk factors for substance abuse
• Different barriers to treatment
• Different support needs
• Differences in drug use, relapse predictors,
frequency and mode of use
SAMHSA, Addressing the needs of women and girls: Developing core competencies for
mental health and substance abuse service professionals, 2011

Women with Concurrent SMI and
SUD
• More likely to seek help in mental health and
outpatient settings
• Poorer occupational skills
• Serious physical health problems
• 11% of all adult women have SMI
• 6% SUD
• 2% both

NSDUH Report, Women with co-occurring SMI and SUD, 2004

SUD Only vs CD

NSDUH Report, Women with co-occurring SMI and SUD, 2004

What’s the Impact of CD?
• Poorer prognosis
• Poor retention in treatment
• Different needs in treatment:
– e.g. harm‐reduction
– longer duration
– flexibility
– greater focus on engagement
– need for medical management

31
Health Canada Best Practices: Concurrent Mental Health and Substance Use Disorders (2002)

Recovery Orientation
• Maintain optimism re: outcomes
• Recognize and respect avenues of staff/client
collaboration and sharing
• Respect resilience of women, girls and their
families
• Women with CD can be effective and caring
mothers, family members and contributing
members of the community with appropriate
services and support

Three Complementary Approaches
1. Public health approach
– Environmental factors, risk and resilience, role of culture,
socialization and gender
– Foundational to core competencies
2. Trauma‐informed care
– Women more likely than men to experience interpersonal trauma
3. Recovery‐oriented system of care
– Varying types and levels of services needed at different times (e.g.,
diabetes, heart disease)
– Reflection of gender differences: women have access to fewer
economic resources, greater vulnerability to violence, more family
responsibilities


Old & New CD Models of Care

Get Addictions Tx
Parallel Get MH tx at Addiction
= at mental health services + Services

Sequential And the other
= Treat one…
then

One team provides
*Integrated = mental health AND addiction treatment
within the same setting
34

Integrated Treatment

1. Goal is consistency
– Consistent explanations and treatment plan
(rather than a contradictory set of messages
from different providers)
2. Both diagnoses are considered ‘primary’
3. ‘No Wrong Door’ Approach

35

“Every door is the right door”

12 Considerations to Guide Care
1. Sex and gender 7. Relational/cultural context
2. Heterogenity among is key
women 8. Developmental stages
3. Vulnerability to violence have attendant risks and
and trauma opportunities
4. Risk of physical health & 9. Family‐centred approach
medical problems 10. Cross‐sectoral
5. Impact of social collaboration to
expectations/ messages accommodate multiple
6. Common experiences of needs/roles
staff/clients 11. Special issues re: criminal
justice involvement
12. Impact of stigma &
stereotypes on recovery

What do you see as essential core
competencies in working with women
with concurrent disorders?

Core Competency Domains
1. Sex and gender differences
2. Relational approaches in working with
women and girls
3. Family‐centred needs
4. Special considerations during pregnancy
5. Women’s health and health care
6. Interprofessional collaboration
7. Trauma‐informed care


Why is Screening Important?
• The prevalence of concurrent disorders is high

• You can best help clients when you have
comprehensive information about their problems
(screening is the 1st step)

• Health Canada recommends that ALL people
seeking help from mental health or substance use
services be screened for co‐occurring disorders
41

Screening:
Asking A Few Direct Questions
Questions about substance use:
• “Have you ever had any problems related to your use
of alcohol or drugs?”

• “Has a relative, friend, doctor or other health worker
been concerned about your drinking or other drug use,
or suggested cutting down?”

• “Have you ever said to another person, “No, I don’t
have an alcohol or drug problem ,when around the
same time, you questioned yourself and FELT, “Maybe I
DO have a problem?”
If answer ‘yes’ to any of the above, further assessment is warranted.
(Health Canada, 2002)
42

Alcohol Screening Tools
• TWEAK
• T‐ACE
Followed by a comprehensive assessment
if indicated
May also want to complete a safety plan with the
client

TWEAK TEST
T Tolerance: How many drinks does it take to make you feel
high?  (Record number of drinks)
W Worry: Have close friends or relatives worried or   complained about
your  drinking in the past year?
E Eye‐Opener: Do you sometimes have a drink in the morning
when you first get up?
A Amnesia (Blackouts): Has a friend or family  member ever  told
you about things  you said or did while you were drinking
that you could not remember?
K(C) Cut Down: Do you sometimes feel the need to cut down on your
drinking?

Russell et al. (1994)

TWEAK Scoring
The “tolerance” question scores 2 points if a
person reports  it takes 3 or more drinks to feel
the effects of alcohol.
The “worry” question scores 2 points for a positive
(“yes”) response.
Each of the last three questions scores 1 point for
a positive (“yes”) response.
A Total score of 2 or more points indicates the
woman is likely to have a drinking problem.

T-ACE
• A measurement tool of four questions that
are significant identifiers of risk drinking
(i.e., alcohol intake sufficient to potentially
damage the embryo/fetus).
• The T-ACE is completed at intake. The T-ACE
score has a range of 0-5. The value of each
answer to the four questions is totalled to
determine the final T-ACE score.
• A total score of 2 or greater indicates
potential risk for the purposes of Pregnancy
Outreach Program identification of prenatal
risk.

T‐ACE Questions
Sokol (1988)

1. How many drinks does it take to make you feel
high? (Tolerance)
(0) < 2 drinks (1) > 2 drinks
2. Have people annoyed you by criticizing your
drinking? (Annoyance)
(0) No (1) Yes
3. Have you felt you ought to cut down on your
drinking? (Cut Down)
(0) No (1) Yes
4. Have you ever had a drink first thing in the
morning to steady your nerves or to get rid of a
hangover? (Eye Opener)
(0) No (1) Yes Total Score = _____

Screening:
Asking A Few Direct Questions
Questions about mental health:
• “Have you ever been given a mental health diagnosis
by a qualified mental health professional?”
• “Have you ever been hospitalized for a mental
health–related illness?”
• “Have you ever harmed yourself or thought about
harming yourself, but not as a direct result of alcohol
or other drug use?”
If answer ‘yes’ to any of the above, further assessment is warranted.

48
Health Canada, 2002

Trauma Assessment:
‘Less is More’
• Destabilization may occur if clients are asked for too
much detail
• The assessor must serve as gatekeeper and limit
information to safe bounds
• At intake, ask only specific information needed for
the purposes of screening or assessment
• A ‘Checklist’ may provide more privacy

http://knowledgex.camh.net/amhspecialists/Screening_Assessment/screening/
screen_CD_youth/Pages/GSS.aspx

Factors to consider…
• Is the client/caller intoxicated?

• Has she been taking psychoactive medications or
other drugs?
• Is the client voicing suicidal ideation?
• Substance use is disinhibiting and can lead to
impulsivity = RISK FACTOR
• Are there medical safety risks?
51

Flexible Goal Choice
(1) Abstinence:
‐cold‐turkey
‐tapering down
‐medically‐assisted (e.g. benzodiazepines)
‐outpatient vs. inpatient
‐forever goal vs. temporary experiment

(2) Reduction goal:
e.g. Controlled drinking (not everyone is a candidate)
“See Low‐Risk Drinking Guidelines”:
Frequency: Alternate drinking days with abstinent days
Have one hour in between alcoholic drinks
(3) The ‘no‐change’ goal:
Agreement to at least monitor and discuss substance use

*Remember: goals are not static and neither is motivation…
52

Cross‐Cutting Issues
Alcohol use
Suicidality
Personality disorders
Mood/Anxiety disorders
Psychotic disorders
Eating disorders
PTSD

.0554

http://caaneo.ca/about/blog/?page_id=30

.0875

http://caaneo.ca/about/blog/?page_id=30

•Tolerance
•Cross‐tolerance
•Potentiation

11% of all breast
cancers

ACETADEHYDE damages genetic
material in cells, and causes cells to grow
too quickly
http://www.drugabuse.gov/publications/teaching-packets/brain-actions-cocaine-
opiates-marijuana/section-ii-introduction-to-reward-system/2-reward-pathw

Moderate drinking can…
• Reduce/inhibit build up of fat in arteries and
raise HDL (“good”) cholesterol
• Prevent clotting – guards against stroke and
heart attack
• Keep blood pressure in check

Smoking + Drinking POTENTIATES cancer-
causing properties of each substance

Potentially Potentially
reduced risk of increased risk
heart disease of cancer

Women:
10 drinks per week
2 drinks per day

Men:
15 drinks per week
3 drinks per day

http://www.camh.ca

Key Points: Suicidality
• Most people who kill themselves have
diagnosable MH, SUD or both
• Majority have depressive illness
• Best prevention = early recognition and
treatment of CD
• CD doubles the risk of suicide compared with
SUD alone

Center for Substance Abuse Treatment (2005), Substance Abuse Treatment for Persons with Co-Occurring
Disorders, TIP Series 42, SAMHSA

Practice Tips: Suicidal Clients
• Screen for suicidal thoughts/plans
• Assess risk
– What is wrong? Why now? Current substance use?
– Specific plans? Past attempts? Protective factors?
• Develop a safety and risk management process
– Remove means, follow through, access help
• Provide 24 hour contact prior to psychiatric referral
• Monitor, develop strategies for medication
adherence, long term recovery plan
• Clinical supervision and documentation


Key Points: Personality Disorders
• “Rigid, inflexible, and maladaptive patterns of
sufficient severity to cause internal distress or
significant impairment in functioning”
• Enduring and persistent styles of behaviour
and thought
• Difficulty forming positive therapeutic alliance
• Challenge in receiving/accepting corrective
feedback


Practice Tips: Personality Disorders
• Anticipate: progress may be slow or uneven
• Assess risk of self‐harm
• Maintain positive but neutral relationship,
seek supervision
• Set clear boundaries and expectations re:
roles/behaviour
• Work on skill development to manage
negative memories/emotions

Key Points: Mood/Anxiety Disorders
• Prevalence is higher in women vs men
• Women more likely to have PTSD and/or depression
• Older women at highest risk for concurrent SUD and
mood disorder
• Withdrawal from depressants, opioids and
stimulants invariably includes potent anxiety
symptoms
• Medical problems/medications can produce
symptoms of mood disorders/anxiety (e.g., stroke,
diabetes)


Practice Tips: Mood/Anxiety
Disorders
• Differentiate among:
a) Commonplace expressions of anxiety/depression
b) Anxiety/depression associated with SMI
c) Medical conditions/medications side effects
d) Substance‐induced changes
• “Start low, go slow”
• Monitor symptoms and respond immediately to
intensification
• Gradually introduce skills for participation in group
therapy/self‐help
• Integrate addiction and MH treatment


Key Points: Schizophrenia/Other
Psychotic Disorders
• High co‐prevalence of alcohol/other drug use
• Requires longitudinal, multiple‐contact assessment
• Higher risk for self‐destructive/violent behaviours
• Particularly vulnerable to homelessness,
victimization, poor nutrition, inadequate financial
resources
• Program philosophy based on multidisciplinary team
approach with cross‐training and a long‐term focus


Practice Tips: Schizophrenia/Other
Psychotic Disorders
• Work closely with interprofessional (may be cross‐
sectoral) team members
• Be ready for crises with crisis intervention and
psychiatric resources to help stabilization
• Shorter sessions and frequent breaks; employ
structure and support
• Monitor medication and signs of SU relapse or return
of psychotic symptoms
• Help obtain entitlements/social services
• Involve family members/develop social networks


Key Points: Eating Disorders
• Women in SU treatment have 15 x prevalence of
eating disorders vs men
• SU more common in bulimia nervosa vs anorexia
nervosa
• Significantly more likely to use stimulants and less
likely to use opioids
• May alternate between SU and ED
• Alcohol and cannabis can trigger binge eating
• Craving, tolerance and withdrawal from drugs used
for purging (laxatives, diuretics)
• Urges for food comparable to urges for drugs


Practice Tips: Eating Disorders
• Interprofessional collaboration is paramount
• Document full repertoire of weight loss behaviours in
assessment
• Construct a behavioural analysis:
– Foods and substances
– High‐risk times/situations
– Nature, pattern, interrelationship of SU and ED
• Psychoeducation and CBT, treatment plan for both SU
and ED
• Adjunctive strategies:
– Nutritional consult, weight‐range goal, observed meal times


Key Points: PTSD
• PTSD is two to three times more common in women
vs men receiving substance use treatment (30 –
59%)
• Women with SUD report lifetime history of
physical/sexual abuse ranging from 55‐99%
• More likely to experience further trauma than PTSD
alone
• High prevalence of cocaine/opioid use
• Substance use can create vulnerability to trauma
• Abstinence from substances does not resolve PTSD –
need to address both


What does ‘Trauma‐Informed’ mean?
‘Trauma‐Informed Service’:
• Defined as particular treatment models (i.e. services
that might be offered, or modified) to be responsive
to the impacts of trauma
‘Trauma‐Informed Treatment’:
• Defined as incorporating the broader backdrop of:
clinical, agency, community and provincial/national
structures that enable clinicians/programs to adapt
their methods so as to influence a woman’s access
to treatment, and her care
Hien et al. (2009) Trauma Services for Women in Substance Abuse Treatment

Practice Tips: PTSD
• Avoid detailed exploration of traumatic memories in
early phase treatment (long‐term treatment may be
required)
• Explore how symptoms can trigger substance use
• Provide specific coping strategies, develop safety
plan
• Respond more to behaviour than to words
• Be aware of vicarious traumatization (group,
therapist)
• Therapist self‐care


Marusha
• Triggered to drink by “lump in my
throat”
• Delayed seeking counselling b/c of
sister’s experience (severe flashbacks)
• Appeal of brief outpatient counselling
(don’t touch the trauma)
• Able to develop effective coping in
reducing alcohol use to within low‐risk
guidelines

Psychosocial Treatment Resources

Continuum of Treatment Services

Highly
Minimally
Intensive
Levels of Treatment Intensity Intensive

Custodial Care
Prevention

Facilitate Extended Residential Long-term
Short-term
Recovery Outpatient Social Residential
Outpatient
without Interventions Model
Self-Change
Treatment
Oriented
Interventions
Day Treatment Residential
Brief Short-term Hospital-Based
Community Outpatient
Interventions (e.g.., Therapist-
self-help manuals, Directed
physician’s advice) Interventions
Mild to Substantial
Moderate Severity of Problems To Severe

CAMH

Client‐Treatment Matching
• Lack of strong evidence by which to match women to specific
treatments
• Does not mean that women all require the same types of services
• A variety of flexible and individualized services are required
• Guidelines for selecting services are needed

Drug Use Problem Social Support
Severity Multiplicity & Stability
Lo Lo Hi
Brief Outpatient

Lo-Hi Lo-Hi Mod-Hi
Outpatient

Day Treatment Mod-Hi Mod-Hi Mod

Residential Mod-Hi Mod-Hi Lo

Skinner & Martin, 1995

• Quality of Research Ratings by Criteria (0.0‐4.0
scale)
• External reviewers independently evaluate the
Quality of Research for an intervention's reported
results using six criteria:
– 1. Reliability of measures
– 2. Validity of measures
– 3. Intervention fidelity
– 4. Missing data and attrition
– 5. Potential confounding variables
– 6. Appropriateness of analysis

http://www.nrepp.samhsa.gov/Index.aspx

Eight Interventions
1. A Woman’s Path to Recovery
2. Boston Consortium Model
3. Dialectical Behaviour Therapy
4. Forever Free
5. Helping Women Recover / Beyond Trauma
6. Reinforcement‐based Therapeutic Workplace
7. Seeking Safety
8. Trauma Affect Regulation: Guide for Education and
Therapy

A Woman's Path to Recovery (Based
on A Woman's Addiction Workbook)
(Najavits)
• 12, 90‐minute sessions over eight weeks
• Divided into two sections: Exploration and Healing
• “Exploration" helps women look at their lives in relation to
gender and addiction issues
• Identify life themes in five key areas relevant to women and
addiction: body and sexuality, stress, relationships, trauma
and violence, and thrill‐seeking
• They can also evaluate their addiction and co‐occurring
mental disorders
• “Healing" section guides women through four domains of
recovery: relationships, beliefs, actions, and feelings ‐‐ with a
series of exercises for each domain
http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=123

A Woman's Path to Recovery (Based
on A Woman's Addiction Workbook)
(Najavits)

Reliability Validity Missing Confounding Data Overall
Outcome of Measures of Measures Fidelity Data/Attrition Variables Analysis Rating

1: Substance use 3.9 3.9 3.0 2.6 1.2 1.2 2.6

2: Global clinical improvement 3.3 3.3 2.5 3.3 1.2 1.2 2.4

3: Impulsive and addictive 3.0 2.5 2.5 3.3 1.2 1.2 2.3
behavior
4: Knowledge of workbook 1.0 1.8 2.5 3.3 1.2 1.2 1.8
concepts


Boston Consortium Model: Trauma‐Informed
Substance Abuse Treatment for Women
(Amaro et al.)
• Developed by a consortium of urban substance abuse and
mental health treatment programs as an enhancement to
existing substance abuse treatment based on the Trauma
Recovery and Empowerment Model (TREM)
• TREM uses a psychoeducational and skills‐building approach
to increase a woman's understanding of the associations
among addiction, trauma, mental health disorders, and sexual
risk behaviors
• Teaches coping skills to help women heal from past abuse and
avoid future abuse, along with behavioral strategies for
reducing trauma symptoms, substance use relapse, and
sexual risk


Boston Consortium Model: Trauma‐Informed
Substance Abuse Treatment for Women
(Amaro et al.)


1: Substance use and 2.5 2.5 2.7 2.5 2.2 2.0 2.4
related problem severity
2: Mental health 3.7 3.7 2.7 2.5 2.0 2.0 2.8
symptomatology
3: Posttraumatic stress 3.7 3.7 2.7 2.5 2.0 2.0 2.8
symptoms
4: HIV sexual risk 1.7 1.7 2.8 2.5 2.0 2.0 2.1
behaviors
5: Perceived power in 2.9 2.9 2.8 2.5 2.0 2.0 2.5
one's relationship


Dialectical Behavior Therapy
(Linehan)
• Cognitive‐behavioral treatment approach with two key characteristics: a
behavioral, problem‐solving focus blended with acceptance‐based
strategies, and an emphasis on dialectical processes
• "Dialectical" refers to the issues involved in treating patients with multiple
disorders and to the type of thought processes and behavioral styles used
in the treatment strategies
• Five components: (1) capability enhancement (skills training); (2)
motivational enhancement (individual behavioral treatment plans); (3)
generalization (access to therapist outside clinical setting, homework, and
inclusion of family in treatment); (4) structuring of the environment
(programmatic emphasis on reinforcement of adaptive behaviors); (5)
capability and motivational enhancement of therapists (therapist team
consultation group)
• Emphasizes balancing behavioral change, problem‐solving, and emotional
regulation with validation, mindfulness, and acceptance of patients
• Therapists follow a detailed procedural manual.


Dialectical Behavior Therapy
(Linehan)

1: Suicide attempts 3.8 3.8 4.0 3.5 3.0 4.0 3.7

2: Nonsuicidal self-injury 3.8 3.8 3.3 2.9 2.6 3.7 3.3
(parasuicidal history)
3: Psychosocial 4.0 4.0 3.0 3.2 2.7 3.7 3.4
adjustment
4: Treatment retention 4.0 4.0 3.7 2.5 2.7 3.8 3.4

5: Drug use 3.6 3.6 3.5 2.8 2.8 3.5 3.3

6: Symptoms of eating 3.6 3.6 3.0 2.3 2.8 4.0 3.2
disorders


Forever Free
(Prendergast, Hall et al.)
• Aims to reduce drug use and improve behaviors of women during incarceration
and while on parole.
• While incarcerated, women participate in individual substance abuse counseling,
special workshops, educational seminars, 12‐step programs, parole planning, and
urine testing
• Counseling and educational topics include self‐esteem, anger management,
assertiveness training, information about healthy versus dysfunctional
relationships, abuse, posttraumatic stress disorder, codependency, parenting, and
sex and health
• The program lasts 4‐6 months
• Women participate in 4 hours of program activities 5 days per week
• After graduation and discharge to parole, women may voluntarily enter
community residential treatment
• Residential treatment services include individual and group counseling. Some
women also participate in family counseling, vocational training/rehabilitation,
and recreational or social activities.


Forever Free
(Prendergast, Hall et al.)


1: Drug use 2.8 3.1 2.8 3.3 2.3 3.5 2.9
2: Parole outcomes 3.1 3.1 2.8 3.3 2.8 4.0 3.2
3: Employment after 3.0 2.5 2.5 3.0 2.5 3.5 2.8
incarceration


Helping Women Recover and Beyond
Trauma
(Covington)
• Women in criminal justice or correctional settings with concurrent substance
use/trauma
• Delivered conjointly or separately as independent, stand‐alone treatments
• Goals to reduce substance use, encourage enrollment in voluntary aftercare treatment
upon parole, and reduce the probability of reincarceration following parole.
• The trauma‐informed treatment sessions delivered by female counseling staff (who may
be assisted by peer mentors, typically women serving life sentences) to groups of 8‐12
female inmates, in a nonconfrontational and nonhierarchical manner
• 17, 90 minute sessions one or two times per week
• Counsellors use a strengths‐based approach with a focus on personal safety to help
clients develop effective coping skills, healthy relationships, and positive interpersonal
support networks
• Uses cognitive behavioral skills training, mindfulness meditation, experiential therapies
(e.g., guided imagery, visualization, art therapy, movement), psychoeducation, and
relational techniques


Helping Women Recover and Beyond
Trauma
(Covington)


1: Substance use 3.2 2.5 1.4 2.2 2.2 2.5 2.3
2: Aftercare retention 2.3 2.8 1.4 2.2 2.7 3.5 2.5
and completion
3: Reincarceration 2.9 2.9 1.4 2.2 2.7 3.0 2.5


Reinforcement‐Based Therapeutic
Workplace
(Silverman, Wong et al.)
• Women are hired, trained and paid to work in a supportive environment
Practical application of voucher‐based abstinence reinforcement therapy
• Adjunct outpatient treatment/medication (e.g., methadone)
• Reinforcement procedures are based on operant conditioning, or use of
consequences to modify the occurrence and form of behavior
• Escalating monetary vouchers for drug‐free urine screens
• Staff purchase goods/services for clients
• Funded externally with a goal of becoming economically self‐sustaining


Reinforcement‐Based Therapeutic
Workplace
(Silverman, Wong et al.)

1: Cocaine use 3.7 3.2 3.5 3.3 2.7 3.0 3.2
2: Opiate use 2.8 2.8 4.0 2.8 3.0 3.0 3.0
3: Cocaine and opiate 3.9 3.4 3.4 3.2 2.9 3.4 3.3
use
4: Cocaine craving 1.5 1.5 2.5 2.5 3.0 2.5 2.3
5: Workplace 4.0 3.7 4.0 3.4 3.0 2.9 3.5
attendance


Seeking Safety
(Najavits)
• Present‐focused treatment for clients with a history of trauma and substance
abuse
• Designed for flexible use: group or individual format, male and female clients,
and a variety of settings (e.g., outpatient, inpatient, residential)
• Focuses on coping skills and psychoeducation
• Five key principles:
– (1) safety as the overarching goal (helping clients attain safety in their relationships,
thinking, behavior, and emotions)
– (2) integrated treatment (working on both posttraumatic stress disorder (PTSD) and
substance abuse at the same time)
– (3) a focus on ideals to counteract the loss of ideals in both PTSD and substance
abuse
– (4) four content areas: cognitive, behavioral, interpersonal, and case management
– (5) attention to clinician processes (helping clinicians work on countertransference,
self‐care, and other issues)


Seeking Safety
(Najavits)


1: Substance use 2.3 2.3 2.3 2.0 1.6 2.0 2.1
2: Trauma-related 2.7 2.7 2.9 2.0 1.8 2.1 2.3
symptoms
3: Psychopathology 2.4 2.4 2.1 2.0 1.7 2.1 2.1
4: Treatment retention 2.0 2.0 3.4 2.2 1.9 1.9 2.2


Trauma Affect Regulation: Guide for
Education and Therapy (TARGET)
(Frisman, Ford et al.)
• Strengths‐based approach to education and therapy for survivors of physical, sexual,
psychological, and emotional trauma
• Teaches a set of seven skills summarized by the acronym FREEDOM:
1. Focus
2. Recognize triggers
3. Emotion self‐check
4. Evaluate thoughts
5. Define goals
6. Options
7. Make a contribution
• Used to regulate extreme emotion states, manage intrusive trauma memories, promote
self‐efficacy, and achieve lasting recovery from trauma
• Offered in 10‐12 individual or group counseling or psychoeducational sessions
conducted by trained implementers (e.g., clinicians, case managers, rehabilitation
specialists, teachers)


Trauma Affect Regulation: Guide for
Education and Therapy (TARGET)
(Frisman, Ford et al.)


1: Disciplinary 2.9 2.8 2.9 3.9 2.6 3.1 3.0
incidents
2: Disciplinary 2.9 2.8 2.9 3.9 2.6 3.1 3.0
sanctions
3: Recidivism 3.6 3.4 2.9 3.9 2.6 2.6 3.2


Marusha
• Success in brief treatment prompted
her to seek a referral for trauma‐
specific treatment
• Success in one area can lead to success
in other areas
• Respect for boundaries and control
• “Things may get worse before they get
better”
• Self‐efficacy: “I can handle this”

marilyn.herie@camh.ca
www.educateria.com

@MarilynHerie

Women and Concurrent Disorders

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