Download - Women, Addiction and Trauma
Slide 1 Women, Addiction and Trauma
with
Stephanie Covington,
Ph.D., LCSW
Sponsored by
March 9, 2011
2:00-3:00 CST
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Slide 2
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© S. Covington, 2011
Women, Addiction and Trauma
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Slide 3
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© S. Covington, 2011
Women, Addiction and Trauma
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Slide 4
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© S. Covington, 2011
Women, Addiction and Trauma
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Slide 5 Women, Addiction and Trauma
with
Stephanie Covington,
Ph.D., LCSW
Sponsored by
March 9, 2011
2:00-3:00 CST
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Slide 6
Moderator:
Martha HardingDirector of Training and Consultation
Hazelden Publishing
Women, Addiction and Trauma
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Slide 7
• Define trauma, trauma-informed and gender-responsive
• Describe three critical components for clients and staff
• Delineate gender differences as they pertain to trauma
and addiction
• Discuss specific interventions for women
• Explore resources available
to help improve your services
for women
© S. Covington, 2011
Women, Addiction and Trauma
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Slide 8
Presenter:
Stephanie S. Covington, Ph.D., L.C.S.W.
Center for Gender and Justice
Institute for Relational Development
LaJolla, California
© S. Covington, 2011
Women, Addiction and Trauma
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Slide 9
© S. Covington, 2011
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Slide 10
© S. Covington, 2011
Levels of Violence
• Childhood
• Adolescence
• Adult
• Street (workplace and community)
• Consumer culture
• Media
• War
• Planet
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Slide 11
© S. Covington, 2011
Global Violence
Violence is a leading cause of
death among people aged 15-29
Source: World Health Organization
Centers for Disease Control and Prevention
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Slide 12
© S. Covington, 2011
International Homicide Rates(Rate per 100,000 in 2006)
0 1 2 3 4 5 6
United States
Israel
New Zealand
Finland
Canada
Poland
Australia
Norway
Ireland
Sweden
Italy
Spain
Netherlands
Austria
Denmark
Greece
France
Switzerland
Germany
SOURCE: World Health Organization, 2006; FBI 2006; Statistics Canada; Australian Bureau of Statistics
“The death and disability caused by
violence make it one of the leading
public health issues of our time.”World Health Organization
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Slide 13
© S. Covington, 2011
Two Kinds of Suffering
• Natural
• Created
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Slide 14
© S. Covington, 2011
Definition of Trauma
The diagnostic manual used by mental health providers
(DSM IV-TR) defines trauma as, “involving direct personal
experience of an event that involves actual or threatened
death or serious injury, or other threat to one’s physical
integrity; or a threat to the physical integrity of another
person; or learning about unexpected or violent death,
serious harm, or threat of death or injury experienced by a
family member or other close associate.”
(American Psychiatric Assoc. [APA] 2000, pg. 463).
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Slide 15
© S. Covington, 2011
Definition of Trauma (cont.)
“The person’s response to the event must involve intense fear, helplessness or horror (or in children, the response must involve
disorganized or agitated behavior).”
(American Psychiatric Assoc. [APA] 2000, pg. 463).
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Slide 16
© S. Covington, 2011
Definition of Trauma
Trauma occurs when an external threat overwhelms a person’s internal and external positive coping resources.
(Bloom & Fallot, 2009)
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Slide 17
© S. Covington, 2011
Violence Against Women
Violence against women is so pervasive that the United
Nations has addressed and defined violence against
women as “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.”
(United Nations General Assembly, 1993).
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Slide 18
© S. Covington, 2011
Moral Challenges
• 19th century - slavery
• 20th century - totalitarianism
• 21st century – brutality against women and girls
(NY Times 9/23/09)
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Slide 19
© S. Covington, 2011
Traumatic Events
Trauma can take many forms:
• Emotional, sexual or physical abuse
• Neglect and/or abandonment
• Extremely painful and frightening medical procedures
• Catastrophic injuries and illnesses
• Rape or assault
• Muggings
• Domestic violence
• Burglary
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Slide 20
© S. Covington, 2011
Traumatic Events (cont.)
• Witnessing murder
• Automobile accidents
• Immigration
• Natural disasters (hurricanes, earthquakes,
tornadoes, fires, floods, volcanoes)
• Abandonment (especially for small children)
• Terrorism such as September 11, 2001
• Witnessing violence such as a parent harming
another parent
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Slide 21
© S. Covington, 2011
Traumatic Events (cont.)
• Loss of a loved one and severe bereavements
(even of a pet)
• Combat/war
• Torture
• Kidnapping
• Intergenerational (cultural) trauma
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Slide 22
© S. Covington, 2011
Historical Trauma
• Across generations
• Massive group trauma
• Examples include: Native Americans, African
Americans, Holocaust survivors, Japanese
internment survivors
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Slide 23
© S. Covington, 2011© S. Covington, 2010
Intimate Partner Violence
Of all these forms of trauma, women
are at greater risk of intimate partner
violence (IPV) than men.
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Slide 24
© S. Covington, 2011
Events Considered to be Most
Traumatic and Prevalence of PTSD
7%
17%18%
21%
37%
%
10%
20%
30%
40%
IPV Illness/accident/
disaster
Unexpected death
of loved one
Witness trauma to
other
Childhood
maltreatment
Most traumatic event
Prevalence of PTSD
49%
42%44%
27%17%
N = 89
Source: Grella, Messina & Rodriguez presentation at American Psychological Association Conference, San Diego, CA on August 14, 2010
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Slide 25
© S. Covington, 2011
Trauma-informed Services
Trauma-informed services:
1. Take the trauma into account.
2. Avoid triggering trauma reactions and/or
traumatizing the individual.
3. Adjust the behavior of counselors, other staff and
the organization to support the individual’s coping
capacity.
4. Allow survivors to manage their trauma symptoms
successfully so that they are able to access, retain
and benefit from the services. (Harris & Fallot)
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Slide 26
© S. Covington, 2011
Core Principles
of Trauma Informed Care
• Safety (physical and emotional)
• Trustworthiness
• Choice
• Collaboration
• Empowerment
(Fallot & Harris, 2006)
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Slide 27
© S. Covington, 2011
Process of TraumaTRAUMATIC EVENT
Overwhelms the Physical & Psychological Systems
Intense Fear, Helplessness or Horror
SENSITIZED NERVOUS SYSTEM
CHANGES IN BRAIN
CURRENT STRESSReminders of Trauma, Life Events, Lifestyle
PAINFUL EMOTIONAL STATE
RETREAT SELF-DESTRUCTIVE ACTION DESTRUCTIVE ACTION
ISOLATION
DISSOCIATION
DEPRESSION
ANXIETY
SUBSTANCE ABUSE
EATING DISORDER
DELIBERATE SELF-HARM
SUICIDAL ACTIONS
AGGRESSION
VIOLENCE
RAGES
RESPONSE TO TRAUMAFight or Flight, Freeze, Altered State of Consciousness, Body Sensations, Numbing,
Hyper-vigilance, Hyper-arousal
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Slide 28
© S. Covington, 2011
ACE Study(Adverse Childhood Experiences)
Before age 18:
• Recurrent and severe emotional abuse
• Recurrent and severe physical abuse
• Contact sexual abuse
• Physical neglect
• Emotional neglect
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Slide 29
© S. Covington, 2011
Growing up in a household with:
• An alcoholic or drug-user
• A member being imprisoned
• A mentally ill, chronically depressed, or
institutionalized member
• The mother being treated violently
• Both biological parents not being present
(N=17,00
ACE Study(Adverse Childhood Experiences)
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Slide 30
© S. Covington, 2011
ACE Study(Adverse Childhood Experiences)
Results
ACEs still have a profound effect 50 years later, although now transformed from psychosocial experience into organic disease, social malfunction, and mental illness.
• Smoking
• Alcoholism
• Injection of illegal drugs
• Obesity
(Felitti, V.J.: Origins of Addictive Behavior: Evidence from the ACE Study. 2003
Oct:52(8): 547-59. German. PMID: 14619682 (PubMed-indexed for MEDLINE).
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Slide 31
© S. Covington, 2011
ACE Study(Cont.)
Women 50% more likely than
men to have 5 or more
(Higher scores more common in women)
(Feletti & Avida, 2010)
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Slide 32
© S. Covington, 2011
Childhood Traumatic Events
Largest Effect-Mental Health
• Psychotropic medication
• Mental health treatment
• Attempted suicide
• Traumatic stress
(Messina & Grella, 2005)
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Slide 33
© S. Covington, 2011
Childhood Traumatic Events
Largest Effect-Mental Health
980% increase in odds if exposure to 7
Childhood Traumatic Events (CTEs)
(Messina & Grella, 2005)
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Slide 34
© S. Covington, 2011
Critical and Interrelated Issues
• Substance Abuse
• Mental Health
• Trauma
• Physical Health
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Slide 35
© S. Covington, 2011
Trauma: Stages of Recovery
Syndrome Stage One Stage Two Stage Three
Hysteria
(Janet 1889)
Stabilization,
Symptom-
oriented
treatment
Exploration of
traumatic
memories
Personality
reintegration,
rehabilitation
Combat trauma
Scurfield (1985)
Trust, stress-
management
education
Re-experiencing trauma
Integration of
trauma
Source: Herman, 1992, 1997
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Slide 36
© S. Covington, 2011
Trauma: Stages of Recovery
Syndrome Stage One Stage Two Stage Three
Complicated
post-traumatic
stress disorders
Stabilization Integration of
memories
Development of
self, drive
integration
Source: Herman, 1992, 1997
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Slide 37
© S. Covington, 2011
Trauma: Stages of Recovery
Syndrome Stage One Stage Two Stage Three
Multiple personality disorder
(Putnam 1989)
Diagnosis, stabilization, communication cooperation
Metabolism of trauma
Resolution, integration, development of post-resolution coping skills
Traumatic
disorders
(Herman 1992)
Safety Remembrance
and mourning
Reconnection
Source: Herman, 1992, 1997
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Slide 38
© S. Covington, 2011
Trauma
Three Group Models
Group
Recovery
Stage One
Recovery
Stage Two
Recovery
Stage Three
Therapeutic
taskSafety
Remembrance
and mourningReconnection
Time
orientationPresent Past Present, future
Focus Self-care TraumaInterpersonal
relationships
Source: Herman, 1992, 1997
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Slide 39
© S. Covington, 2011
Trauma
Three Group Models
Group
Recovery
Stage One
Recovery
Stage Two
Recovery
Stage Three
Membership Homogeneous Homogeneous Heterogeneous
BoundariesFlexible,
inclusiveClosed
Stable, slow
turnover
Cohesion Moderate Very high High
Source: Herman, 1992, 1997
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Slide 40
© S. Covington, 2011
Trauma
Three Group Models
Group
Recovery
Stage One
Recovery
Stage Two
Recovery
Stage Three
Conflict
toleranceLow Low High
Time limitOpen-ended or
repeatingFixed Limit Open-ended
Structure Didactic Goal-directed Unstructured
ExampleTwelve-step
programsSurvivor group
Interpersonal
psychotherapy
group
Source: Herman, 1992, 1997
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Slide 41
© S. Covington, 2011
Areas of Separation
• Training
• Treatment
• Categorical Funding
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Slide 42
© S. Covington, 2011
Key Elements(Staff and Clients)
• Learn what trauma/abuse is
• Understand typical responses
• Develop coping skills
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Slide 43
© S. Covington, 2011
Trauma
Gender Differences
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Slide 44
© S. Covington, 2011
Definition: Gender-Responsiveness
Creating an environment through site selection,
staff selection, program development, content, and
material that reflects an understanding of the
realities of the lives of women and girls and that
addresses and responds to their strengths and
challenges.
(Covington and Bloom)
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Slide 45
© S. Covington, 2011
Trauma-informed Materials
• Women and Addiction: A Gender-Responsive Approach
• Helping Women Recover
• Voices: A Program for Girls
• Beyond Trauma: A Healing Journey
• Women in Recovery
• A Woman’s Way through The Twelve Steps
• Beyond Violence: A Prevention Program for Women
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Slide 46
© S. Covington, 2011
Trauma Materials
• ATRIUM (Dusty Miller)
• Beyond Trauma (Stephanie Covington)
• Seeking Safety (Lisa Najavits)
• TREM (Maxine Harris)
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Slide 47
© S. Covington, 2011
Five Senses
5 things you can see
4 things you can touch
3 things you can hear
2 things you can smell
1 thing you can taste
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Slide 48
© S. Covington, 2011
From the manual In Our Best Interest: A Process for Personal and Social Change.
Available through Domestic Abuse Intervention Project, 206 W. 4th St., Duluth, MN 55806
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Slide 49
© S. Covington, 2011
Self - Soothing
Alone With Others
Daytime
Night Time
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Slide 50
© S. Covington, 2011
Feeling Okay Chart
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Slide 51
© S. Covington, 2011
What does the prevalence
data tell us?
• Many people with trauma histories have overlapping problems with mental health, substance abuse, physical health and are victims or perpetrators of crime.
• Victims of trauma are found across all systems of care.
(Source: NASMHPD 2008)
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Slide 52
© S. Covington, 2011
Therefore…
We need to presume the clients we serve have a history of traumatic stress and exercise “universal precautions.”
(Source: NASMHPD 2008)
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Slide 53
© S. Covington, 2011
Emerging Paradigm
Values-Based Services
• Gender-responsive
• Trauma-informed
• Culturally competent
• Recovery-oriented
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Slide 54
© S. Covington, 2011
Sanctuary
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Slide 55
© S. Covington, 2011
What is Sanctuary?
• Sacred place
• Place of refuge/protection
• Shelter
• Oasis
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Slide 56
© S. Covington, 2011
What Makes a Difference?
• Creating a safe environment
• Listening to her story
• Empathy
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Slide 57
© S. Covington, 2011
Upward Spiral
Trauma
(constriction)
Healing
(expansion)
Transformation
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Slide 58 For More Information:
Dr. Stephanie S. Covington, PhD, LCSW
www.stephaniecovington.com
www.centerforgenderandjustice.org
7946 Ivanhoe Avenue, Suite 201B
La Jolla, CA 92037
Phone: 858-454-8528
Fax: 858-454-8598
Email: [email protected]
© S. Covington, 2011
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Slide 59
A Woman's Way through the
Twelve Steps
• Facilitator's guide for 13 group sessions
• 65-minute DVD
• 10 Softcover books,
• 10 Client workbooks
Price: $395.00
Resources from Stephanie Covington
© S. Covington, 2011
A Woman's Way through the Twelve Steps
“helps clients explore spirituality, powerlessness, and
the emergence of a feminine soul. This practical and
powerful program integrates the most current research
and best practices regarding women and recovery.”
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Slide 60
Beyond Trauma: A Healing
Journey for Women
• 11-Session Curriculum
• Facilitator’s Guide
• 3 DVDs
• 10 Client Workbooks
Price: $549.00
Resources from Stephanie Covington
Beyond Trauma helps clients understand the dynamics of
abuse in the family, power and abuse, and the connection
between alcohol and other drug use and trauma.
Beyond Trauma is extensively annotated and includes
research by the Center for Gender and Justice and the National
Institute of Corrections.© S. Covington, 2011
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Slide 61
© S. Covington, 2011
Women and Addiction A Gender
Responsive Approach
• Downloadable 104 page manual
• 75 Minute DVD
• CE test with 10 CE hours granted
Price: $175.00Print and online versions available
Now available as an online course at
www.hazelden.org/professionaled
Resources from Stephanie Covington
Women's treatment involves more than simply providing
women-only group settings.. In this program, Stephanie S. Covington presents
how to create effective recovery services for women and girls--services that reflect an
understanding of the realities of their lives and address their unique challenges and strengths.
Dr. Covington's comprehensive, integrated approach is based on years of theory, research,
and clinical experience.
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Slide 62 Visit the Behavioral
Health Evolution site:
BHEVOLUTION.orgInnovative resources for treating
substance use, mental health and
co-occurring disorders.
Sign up for Funding
Alerts and our
e-Newsletter
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Slide 63
Please use your Q&A feature on the
bottom right of your screen to send
questions to Stephanie!
For more information about Stephanie
Covington’s materials or to order call
1-800-328-9000
Participants in this web conference
will receive a 20% discount on any
of Stephanie Covington’s materials
Use this code to order: TRAUMA20
Time for discussion with
Stephanie Covington
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Slide 64
1) Go to www.hazelden.org/professionaled
2) Click on “Course Catalogue”
3) Search for the course: Women, Addiction and Trauma
4) Pay the administrative fee ($20.00) for the assessment
5) Take the assessment
6) Print your certificate!
Submit your certificate to your credentialing body to receive:
Two credits from NAADAC
One credit from APA
Continuing Education Credit
from NAADAC and APA
is available for this web conference
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