The Elements of Treatment Specific to Women with Co-

Occurring Addictive and Mental Health Disorders

Susanah Stone, LCSW, ICAADC, ICCDP-Dmsfyzabad@aol.com

Workshop Objectives

Creating a context: Gender does make a difference. Understand the initiation of substance use

among women. Importance of screening and assessment in a

paradigm of continuum of care Elements of Gender-Specific.

Treatment for women with

co-occurring disorders.

WOMEN HAVE SPECIAL NEEDS IN SUBSTANCE ABUSE TREATMENT

The Client with a Co-Occurring Disorder

What we do know: Substance Disorder and Mental Health

Disorder exist CONCURRENTLY. Each disorder is INDEPENDENT of the other. Disorders are CHRONIC. Each disorder AFFECTS the

other and CHANGES the

OUTCOME of treatment.

Co-Occurring Disorder

Approximately seven to 10 million adults in the United States have co-occurring disorders.(US Department of Health and Human Service 1999).

Women represent 48 percent of adults with co-occurring disorders. (OAS, 2004c).

4 million women age 18 or older have co-occurring mental illness and substance use disorder. (2002 National Survey on Drug Use and Health).

Co-Occurring Disorder

Among female substance abusers 29.6% has a mood disorder and 26.2% have an anxiety disorder. (National Epidemiology Survey on Alcohol and Related conditions).

Post Traumatic Stress Syndrome is 1.5 to five times higher among female substance abusers.

The co-occurrence of eating disorders and substance abuse disorders is about 40% or 4-10 in women. (International Journal of Eating Disorder).

Defining Substance Use Disorder

Substance Use Disorder (Addiction) A pathological relationship with any mood

altering substance that results in ongoing, recurring life damaging negative consequences. It can be diagnosed as either substance abuse or substance dependence.

Defining Mental Illness

Mental Health Disorder Significant and chronic disturbances with

“feelings, thinking, functioning and/or relationships that are not due to drug and alcohol use and are not the result of a medical problem.”

Addiction

TRUE OR FALSEAddiction is conceived as a behavioral

pattern that stems from a lack of moral fiber.

TRUE OR FALSEAddiction is a behavioral pattern that results

from mental illness coupled with physical dependence on a substance.

Defining Addiction

Addiction: A disease that has devastating effects on both the mind and body.

Addiction has to do with trauma, anxiety, depression and biochemical imbalance - the addict attempts to regulate and relieve his or her own level of pain. Co-occurring disorder deals with these so that the client can have a full recovery.

Creating a Context

We Need To Understand Our Client’s Experiences and

World View!

Does Gender Really Matter?

Telescope Effect

Women starts with lower levels of alcohol and drugs use but advances more rapidly & escalate into addiction more quickly.

Metabolic difference- experiences negative physiological consequences sooner with less use. Ends up binging to an even more deadly degree.

More medical, psychiatric and social consequences.

Gender Difference

How men and women brain are affected by Cocaine use and stress. Addicts’ cravings have different roots in men and women.

Biological and Psychological Components

BIOLOGICAL Women have higher percent of body fat. These

fat cells are the locale where the residue of foreign substances stockpiles.

Women body is ill-equipped to process excess amount of alcohol due to the small amount of alcohol dehydrogenase (the enzyme that breaks down alcohol).

Sheer body mass. Women body mass smaller than men.

Biological and Psychological Components

PSYCHOLOGICAL Women tend to use drugs to self-medicate

emotional and psychological issues. Chronic depression, low self-esteem, anxiety,

mental health disorder. RELATIONSHIP, childhood trauma, stress,

parental drug use, home environment, victimization precipitates substance abuse.

Drug use to suppress appetite or weight management.

Biological and Psychological Components

Psychological Components

Women experience anxiety, reduced self-esteem and depression more often than men.

Women tend to present to primary care and mental health facilities rather than drug and alcohol treatment.

Gender does make a difference

Gender difference comes into play when: It comes to understanding the needs and

treatment of co-occurring disorders for men and women.

What works for men in treatment doesn’t always work the same way for women.

Reasons for Drug Initiation

Introduction by significant other, spouse, family, friends (Relationships)

Relief stress and boredom (Parenting) Improve mood Self medicate depression or other mental

health symptoms Increase confidence (Self-Esteem) Loose weight (Body Dysmorphic) To suppress feelings related to trauma,

violence, victimization, homelessness

Specialized treatment is needed and it works!

But….

Assessment comes first

An integrated Model of Care

Client

ScreeningAssessment

Treatment Planning

Screening Practices

Screening : “The make it or break it” phase for the client.

Not a time to give client an appointment to come back.

Screening Practices

First phase of treatment.

Does the client being screen requires

further attention for his/her current

disorder.

or

Is there a presence of a co-occurring

substance use and mental health

disorder.

Screening Practices

1) Engage the client Rapport building is paramount. Client practical concerns are the priority. Find out what the client wants. Remember the person is not the problem and

separate the person from the problem. You want the client to be committed to the

helping process, commit yourself to the client.

Screening Practices

2) Develop a person-centered

relationship Try to create a safe and non-judgment

atmosphere.Figure out who the client is. Identify and acknowledge the client’s point of

view.

Screening Practices

3) Consider the possibility of TRAUMATraumatic history is prevalent and may

interfere with the client ability to trust the clinician.

Guardedness should not be interpreted as denial or resistance.

Clinician role is to promote safety in the interview and be supportive.

Screening Practices

4) Screening for SAFTEYCheck for possibility of violence or self-

injurious behaviors and thoughts. If there is a risk arrange for a more in-depth

assessment. Client should never be left alone. If family is involved seek consent from client

to get information from family.

Screening Practices

Screening Tools Screening tools should never take the place of

clinical judgment. A preliminary indication of whether the client

has a substance use and/or mental health problem.

Must incorporate questions about mental health, substance use and suicide.

Assessment Practices

Define and clarify the problems together, develop specific treatment recommendations to address these problems.

seeking to establish a formal diagnosis.Evaluate level of functioning. Assess readiness for change.Decisions about level of care.

Assessment Practices

Clinician’s BPS AssessmentBiological

Obtaining family history, demographic information

PsychologicalMental health, substance use, current and

past symptoms Social

Family, social supports, strengths, cultural barriers, finance, employment

Assessment Practices

Individualized assessment. Find out what the client want, her perception

of the problem, what she wants to change, how she thinks that change should occur.

Assessment tools geared to addressing Co-occurring issues.

Cultural identity, linguistic needs, sexual orientation.

Determine stage of change for each problem. Diagnosis - mental health and substance use.

Assessment Practices

Client-centered engagement is extremely important in performing a good assessment.

Assessment starts with a dialog with the client rather that a BPS.

Motivational Interviewing skills is handy. MI allows you to “roll with the resistance” of the client.

Treatment Planning Practices

Effective Planning Mirrors the consumer’s stage of change. Consumer focus is paramount. Problem, goal, objective, intervention flows

from each other. MI and active listening.

Treatment Planning Practices

Remember Treatment plan is not a static document. Any

changes must be reflected in the plan. Client-centered treatment plan is developed by

the clinician, the clinician team AND the client.

Treatment Planning Practices

Consumers often presents in the pre-contemplation stage.

As the clinician you should understand that your goal is to understand how your client understands his problem.

Gender-Specific Treatment

Most out-patient and in-patient drug treatment and mental health programs are ill-equipped to treat co-occurring clients.

One size fit all programs; very generic; mostly male-focused/oriented, co-ed groups.

Co-occurring is client with mental health diagnosis seeing a doctor.

Culture and Treatment

Consideration of common culture characteristic for race and ethnicity in the context of substance use disorders and treatment.

Distinguish the content of a client’s history from the environment in which their recovery occurs.

Understand the importance of culture by inquiring about it.

Women with co-occurring disorders needs are different

Elements of women CareAreas to address

TRAUMAPARENTIN

GRELATION

SHIPS

Elements of women care

Long-term approach to recoveryWomen with co-occurring disorders not likely

to achieve stability and functional improvement quickly. (Drake et al., 2001).

Recognize that recovery is a long-term process and small gains by the client should be applauded.

Elements of women care

Integrated treatment Simultaneous treatment of all disorders by a

dually trained clinician or crossed -trained team.

Clinicians trained and competent in psychopathology and substance abuse assessment and treatment strategies for both disorders.

Treatment is provided by the same clinicians or clinical team and at the same location.

Elements of women care

Comprehensive focus Women with co-occurring disorders requires

addressing multiple aspects of life as simultaneously as possible.

Needs comprehensive linkage to other services as they pursue functional goals. CSI worker becomes instrumental. ACT team outreach.

Elements of women care

Therapeutic techniques Motivational Interviewing interventions

MI -focus is on preventing anxiety rather than breaking through denial, reduction of negative consequence, goals and functioning not adhering to treatment.

Cognitive Behavioral interventionsUse to identify and replace self-defeating

beliefs and actions with thoughts and behavior oriented towards coping. Seeking Safety therapy to address PTSD and SA.

Elements of Women care

Stages of ChangeProchaska and DiClemente five stages of

change model designed to understand the different phases of motivation in treatment.

Double-Trouble - a twelve step fellowship approach to recovery designed to meet the needs of men and women with co-occurring disorders.

Some clients not able to adequately follow the principles of AA/NA – Schizophrenia, Bipolar.

Psychotropic Medication Management

Medication management is an essential program element.

Women who suffer from co-occurring disorders are at a higher risk for poor medication compliance.(SAMSHA 2002).

Therapist should ask client regularly about her symptoms and use of medication and look for signs of the mental disorder.

Learn to identify changes in symptoms to determine improvement or decompensation.

Monitor suicidal thoughts and behaviors.

Trauma

75% of substance abusing women have history of sexual or physical abuse as children. 55-99% of women in substance abuse treatment have had traumatic experiences.

Trauma gets addressed in individual therapy or group therapy (in an all female group) facilitated by a therapist trained in trauma and not in isolation of other issues.

Client takes control of how she shares her traumatic events thus allowing her to play an active role in her own healing process.

Trauma Informed Services

Seeking Safety Therapy Cognitive behavioral psychotherapy treatment

for individual struggling with post traumatic stress disorder (PTSD) and substance abuse.

The intervention is designed to help individuals with active substance abuse and PTSD to establish safety in their lives.

The Addictions and Trauma Recovery Integrated Model (ATRIM) Dusty Miller, Ph.D. and Laurie Guidry, Ph.D.

Parenting

Most women with co-occurring disorders view parenting as the central purpose and defining role of their lives.

Motherhood is both a major source of identify and self-worth and a source of shame and guilt.

Can be a motivation to enter treatment or a determent to seeking care.

Women with co-occurring issues are more at risk for problems in parenting or even for maltreating children.

Parenting

Parenting is not generally incorporated in most substance abuse treatment programs.

Most substance abuse treatment programs accepts women only; women then have to find care for their children.

Ones that do accepts children accepts a limited amount of children.

Out-patient clinics often only address the women’s substance use.

Parenting

Optimizing Treatment Develop a parenting curriculum built to focus

on strengths rather than deficits. Focus on a woman’s strengths.Acknowledges a woman’s role as a parent in

all service delivery activities. Improves interaction between the parent and

child/children.Provide family-centered, comprehensive and

multidisciplinary services to both mother and her children.

Optimizing care

Address concerns about social service reports/involvement both on a program and policy level.

Children receive their individualized care as well not just daycare.

Mothers with infants differ radically from those with preschool, school age or adolescent.

Mothers should not be discharged because their kids are misbehaving.

Parenting

TRUE OF FALSE:

Recovery must come first and women need their own space to recover and cannot

concentrate on their recovery with children present.

Parenting

“True recovery for a mother usually works only when it includes her children.”

Norma Finkelstein

Pregnant and Postpartum Women

Major Concerns:

Psychotropic medication Decision on whether or not to keep women on

psychotropic medication during their pregnancy.

How that affects her MH and the fetus health. How program deal with the women symptoms if

she is off medication. Breast feeding and medication.

Pregnancy and Postpartum

Drug use during pregnancy Increased guilt and shame. Dealing with the addicted baby. Addressing the pregnancy.

Optimizing care

Opportunity for prenatal care and postnatal care and education.

Particular attend to Postpartum depression. Monitoring or mental health and relapse

potential even more closely.

Relationship

The Relational Model - Women psychological development revolves around connectedness and relationship. Development of sense of self.

Women drug use is often initiated via a relationship.

Women speaks of drugs in terms of relationships.

Women entering treatment so as to keep their children or regain custody of their child is an opportunity to support mother-child connection.

Relationship

Support network are crucial for maintenance of change after treatment.

Re-integration among family and promoting positive ties among extended family and kinship networks are paramount.

Family includes spouse and significant other.

Family

Role of mother Role of grandparents Family conflicts (including intergenerational

conflicts) Neglect and physical abuse. Domestic violence ad sexual abuse.

Conclusion

Women may use drugs in private but their substance use affects their relationships with family, loved ones, the local community and society (Covington, 1998).

The approach to recovery is therefore designed in the context of women’s total experience in society.