Working with Women Concurrently on Substance Use, Experience of Trauma and Mental Health Issues
Reprinted from "Concurrent Disorders" issue of Visions Journal, 2004, 2 (1), p. 29
In September 2003, the Aurora Centre, BC’s provincial treatment centre for women with substance use problems sponsored a ground-breaking national conference on women’s treatment issues, to mark their 30th anniversary of service provision. In many areas, the conference addressed the emerging literature and practice on sex and gender role differences in the experience of addiction. The complex connections between women’s experience of trauma, their mental health and substance use received particular focus through a pre-conference workshop entitled ‘Numbing the Pain: Substance Abuse and Post-traumatic Stress Disorder.’
Research has shown that as many as two-thirds of women with substance misuse problems may have a concurrent mental health problem, such as depression, post-traumatic stress disorder (PTSD), panic disorder and/or an eating disorder.1 Research also shows that a large proportion of women with substance use problems are victims of domestic violence, incest, rape, sexual assault and child physical abuse.2 Compared with non-abused clients, women in treatment for problem substance use who have been victimized are more likely to suffer from depression and suicidal ideation, have lower self-esteem, negative psychological adjustment and more post-traumatic stress symptoms.
Lisa Najavits, PhD, an Associate Professor in the Department of Psychiatry at Harvard Medical School and an award-winning clinical researcher and practicing psychotherapist, facilitated the ‘Numbing the Pain’ workshop to lead off the September conference. She shared her evidence-based practice on concurrent work on trauma and substance use as outlined in her 2002 book Seeking Safety: A Treatment Manual for PTSD and Substance Abuse. The response to the workshop was lively, with 120 clinicians from across British Columbia and Canada in attendance.
The key principles of the Seeking Safety model are:
- Safety as the overarching goal and most urgent clinical need; helping clients attain safety in their relationships, thinking, behaviour and emotion.
- Integrated treatment: working on both PTSD and substance abuse at the same time rather than sequentially in order to be more successful with clients, as well as more cost-effective and more sensitive to client needs.
- A focus on ideals: to counteract the often profound demoralization and loss of ideals in both PTSD and substance abuse.
- Work in four content area of cognitive, behavioural, interpersonal and case management: while grounded in the present- and problem-oriented approach of cognitive-behavioural therapy, this programming is strongly focused on relational and planning skills.
- Attention to clinician processes: helping clinicians build therapeutic alliances and demonstrate compassion, as well as attend to client accountability and self-care.
Building on this workshop and their commitment to integrated and effective treatment for women, several organizations in BC are currently applying the Seeking Safety model in outpatient groups for women affected by trauma and substance misuse. The Pacifica Treatment Centre in Vancouver is currently offering a 12week group for women needing to work on trauma issues in the aftercare period, entitled ‘Continuing the Journey,’ funded by the BC Technology Social Venture Partnerships. The Victoria Women’s Sexual Assault Centre, with Vancouver Island Health Authority funding support, is offering a 15-week pilot Seeking Safety group in Victoria, with collaboration from Alcohol and Drug Services, BRIDGES, Victoria Native Friendship Centre, PEERS, Victoria Cool Aid Society, Victoria Women’s Transition House and the Youth Empowerment Society.
Women’s treatment organizations in the US are also making women’s treatment services ‘trauma informed’5 in a national project entitled the Women, Co-occurring Disorders and Violence Study. It is a five-year initiative jointly supported by the Center for Substance Abuse Treatment, the Center for Mental Health Services, and the Center for Substance Abuse Prevention. Knowledge gained from this study is expected to be useful in advancing national, state and local policy that affects how the various service systems respond to women with histories of substance use, mental health and physical and sexual abuse. (To learn more about this project see www.wcdvs.com)
The application of trauma-informed care is also emerging within the mental health system in BC. An example is the Vulnerable Patients Project undertaken by Riverview Hospital in 2001, where staff education was provided on how trauma is connected to the development and continuation of mental health problems. The program also provided education on re-traumatization prevention skills to be routinely applied by mental health workers in their work, to address the common co-existence of mental health, substance use and trauma histories in patients accessing care from the mental health system.
Many alcohol and drug service providers in BC who attended the ‘Numbing the Pain’ workshop are also finding ways to incorporate elements of the Seeking Safety approach within outpatient and residential addiction services, even where support for specific and ongoing group work is not currently available. For more information on the Seeking Safety model and on related resources see www.seekingsafety.org.
First Nations women suffer high rates of mental illness and addiction
Researchers at the University of New Mexico School of Medicine have completed what they believe is the first study of urban First Natons women in a primary care setting, looking at current and lifetime mental illness and substance abuse in relation to demographic and social factors. From a subject group of 234 First Nations women, the researchers found consistencies with other research showing that Aboriginal women suffer from higher rates of certain mental disorders, particularly depression and anxiety, compared with non First Nations women in similar settings.
Lifetime substance use disorder was reported in 62% of the women in the study. The researchers caution that the methods of measuring substance abuse do not put into context certain behaviours found in the study population - many women abstain from alcohol entirely, and binge drinking can distort the findings. Low education, high debt and self-reported poor health were associated with the current mental disorders.
In addition to substance abuse, First Nations women in this study had high rates of anxiety disorders and combined anxiety disorders and depression. The authors say that Aboriginal leaders and Indian Health Service leadership could work together to call for more mental health funding and to set up pathways form primary and urgent care settings to specialized mental health services that are culturally competent. The authors add that mental disorder prevention and treatment must consider concurrent substance use and mental disorders.
About the Author
Nancy is a research consultant on women and substances us at BCWomen's Hospital and BC Centre of Excellence for Women's Health
Duran, B et al (2004). Prevalence and correlates of mental disorders among Native American women in primary care, American Journal of Public Health, 94(I), 71-77
Zilberman, ML, Tavares, H, Blume, SB & el-Guebaly, N. (2003). Substance use disorders: Sex differences and psychiatric comorbidities. Canadian Journal of Psychiatry, 48(I), 5-13.
Ouimette, PC, Kimerling, R, Shaw, J & Moos RH. (2002). Physical and sexual abuse among women and men with substance use disorders.Alcoholism Treatment Quarterly, 18(3), 17-17.
Kang, SY Magura, S, Laudet, A & Whitney S. (1999). Adverse effect of child abuse victimization among substance-using women in treatment. Journal of Interpersonal Violence, 14(6), 650-57
Najavtis, LM, Weiss, RD & Shaw, SR. (1997). The link between substance abuse and posttramautic stress disorder in women: A research review, American Journal of Addictions, 6, 273-83
Harris, M & Fallot, RD. (2001). New directions for mental health services: Using trauma theory to design service systems. New York, NY: Jossey-Bass