women, trauma, and substance use trauma-informed practices in substance use services for women

WOMEN, TRAUMA, AND SUBSTANCE USE

Trauma-informed Practices In Substance Use Services For Women

Addictions & Mental Health Annual ConferenceMay 27, 2013

Nancy Bradley, Jean Tweed CentreJanine Gates, Gates Consulting Inc.

Session Objectives: he Webinar

1. The critical role of trauma-informed practices in services for substance-involved women

2. The core principles and central concepts of trauma-informed practices

3. The guidelines for trauma-informed practices that have been developed through a federal (Drug Treatment Funding Program)

“Trauma is a public health risk of major proportions… Moreover, it often compounds medical and psychological conditions and injuries.

This information too often goes unrecognized or under-recognized by medical and mental health practitioners.

We have a major education, prevention and intervention issue.”

Christine Courtois, Trauma Talks Conference. Toronto, 2012

Why is trauma an important issue?

Experiences of trauma are common among substance-involved women In three Canadian studies, over 80% reported histories of

trauma Numerous U.S. studies have found a high prevalence of

trauma Research has demonstrated connections between trauma

and an array of health issues Interconnections with substance use – both as a

precipitator and as a risk factor

“trauma is the rule, rather than the exception”

Why is trauma an important issue?

Trauma affects the whole women - the impacts are broad and diverse: Health risk behaviours, coping mechanisms Psychological and cognitive adaptations Myriad health problems

Trauma responses are individual and variable an interweaving of physical impacts and emotional

adaptations can be acute, chronic and/or delayed are not determined by the event(s), but by a woman’s

experience of the event(s)

Why trauma-informed practices?

Without knowledge of trauma – its prevalence, its impacts, and its interconnections with substance use - service providers are at risk of: Misinterpreting behaviour Inadvertently using practices that trigger or

retraumatize women Providing ineffective services or interventions Limiting engagement, higher drop-out, or

unnecessary discharge


Women who have lived experience told us about many gaps and barriers they encountered in Ontario substance use services.

A few examples: “The assessment agency didn’t ask about

trauma.” “I felt like there was a big elephant in the

room and no one was naming it.” “In a case conference they said they

suspected I was abused as a child...no one asked me if I was abused and if it was OK to talk about it. I felt revictimized.”


“There were times when I was having flashbacks …I was told to just focus on my addiction.”

“Being in co-ed facilities retraumatized me. I suffered a lot of abuse and it was too difficult hearing the stories from men - a lot who were abusers.”

“There needs to be a program to include children and to re-affirm to children that they are okay. To be able to get tools with a trauma focus and to help the kids through it as well.”

Trauma-informed practices

Defining Trauma

Trauma can be precipitated by a wide range of experiences and events, and occur at both individual level and collective levels.

Traumatic events are more than merely stressful – they are also shocking, terrifying, and devastating to the victim, resulting in profoundly upsetting feelings of terror, shame, helplessness, and powerlessness.” (Courtois, 1999)

Traumatic experiences are unique and individual. Experience may be influenced by an array of factors.

Defining Trauma

“ The actual experience (of trauma)… and the assault that experience poses to sense of self,

safety, belonging, and connection , are intertwined.”

Kammerer & Mazelis, 2006

“Trauma is the sum of the event, the experience, and the effect.”

SAMHSA , 2012


Trauma informed care is: “a strength based framework that is

grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment.”

Coalescing on Women and Substance Use


How are trauma-informed practices different from trauma-specific services?

Programs and services that are trauma-specific: Can include a range of service and interventions

that focus directly on the impact of trauma, and on trauma recovery;

Are often delivered using evidence-based models or approaches (e.g. Seeking Safety);

Are delivered by practitioners who have extensive knowledge and skills in trauma treatment.


Organizations - and their staff: REALIZE the prevalence of trauma RECOGNIZE how trauma affects everyone involved with the organization (including its own workforce)

RESPOND by putting that knowledge into practice


from: What is wrong with this woman?

to:

What has happened to this woman?

A change of perspective…

“It wasn’t until I got here that I realized that substances helped me to hide my trauma.”(focus group participant, Ontario, 2012)


Should be universal They should be used with every women, whether

or not experiences of trauma have been disclosed

Should be integral They should be integrated into the organization’s

culture, and braided with current practices, so that every interaction (verbal and non-verbal) is trauma-informed


Should be used throughout an organization, to inform its: Values and priorities, Planning and strategies Programs and services, Policies and practices, Human resources, training, and supervision Infrastructure and site development


Should seek and use the input of women who have lived experience

Should recognize the full spectrum of women’s experience, and go ‘hand in hand’ with:

Gender-appropriate services for women Anti-oppression approaches Culturally competent organizations and

staff Other system tools that reflect best

practices


Six key principles:AcknowledgementSafetyTrustworthinessChoice and controlRelational and collaborative approachesStrengths-based empowerment

modalities


ExamplesAcknowledgement Show an understanding of the relationship of trauma

and substance use in written materials. Implement universal screening.Safety Minimize triggers and reduce retraumatization Identify safety issues and work with women to make

safely plans


ExamplesTrustworthiness Make sure that information is clear and that

all of a woman’s questions are answered; explore her comfort level with the process.

Choice and control Review options and ask women’s opinions;

support a woman’s role as an expert and an active agent in her own recovery


ExamplesRelational and collaborative approaches Work collaboratively with a woman, and think

‘outside the box’ of ‘treatment as usual’ when helpful

Strengths based and empowerment Focus on a woman’s resilience; reframe

trauma-related behaviors and mechanisms; identify and celebrate changes and victories

Universal Screening for Trauma

Can help to communicate validation and hope;Can invite a woman to acknowledge trauma, and it’s

potential impacts;Can improve quality of services by:

Setting the stage for treatment planning and referrals Flagging current safety concerns

Screening for trauma requires skill, sensitivity, and flexibility: Can trigger spontaneous disclosure, or emergence of

trauma-related symptoms Should not be intrusive, and should be paced

Who should implement trauma-informed practices?

All organizations where women receive substance use services :

In both women-only and mixed gender environments

In all service types – ranging from early engagement, assessment, and withdrawal management to residential and community treatment

In services for women who have concurrent mental health issues

Pathways to Trauma-Informed Practices

Shift in organizational culture Formal organizational commitment Leadership to support change Training for all staff Assessment of programs, services, and

organizational practices through a ‘trauma-informed lens’

Clinical supervision and consultation Monitoring, evaluation, and ongoing positive change

Vicarious Trauma

Impacts on staff who are indirectly exposed to trauma

Reducing risks of vicarious trauma Organizational practices that recognize risks

and provide support and resources Staff practices that incorporate awareness

and self-care

Guidelines for Trauma-Informed Practices in Women’s Substance Use Services

Trauma Matters

Guidelines for the system

Federal (DTFP) grant to develop provincial guidelines for trauma-informed practices

The document – Trauma Matters : Has been developed by a project team, managed by

the Jean Tweed Centre Was guided by an Advisory Committee comprised of

service providers, funders and policy makers, and knowledge exchange specialists

Informed by the input of women who have lived experience


Trauma Matters will provide: Information about the prevalence and impacts

of trauma among substance-involved women Guidelines and practical strategies for trauma-

informed clinical and organizational practices An overview of trauma-specific services Information about resources for further

learning


How the Guidelines were developed: Advisory Committee and Terms of Reference Request for proposals Selection process Project team hired to research and develop the

guidelines, and write the document


Evidence collected from:◦ Academic and research literature, ◦ The grey literature – government reports, policy

documents,◦ Subject area experts - specialist knowledge of women’s

substance use and trauma, ◦ Women who have lived experience of problematic

substance use and trauma. Draft guidelines developed - appropriate to the Ontario

substance use service system. Extensive review of multiple drafts by Advisory Committee

and other subject area experts.


Intended for use in Ontario substance use services Must be braided with existing programs and with

expertise of specialized services (e.g. for youth, Aboriginal and Native people, immigrant and refugee services, etc.)

May also be of help to: ◦ Other services that work with substance involved women

(mental health, primary health care, child welfare, VAW, justice system, etc.)

◦ Policy makers, service and system planners, and funders

Should be used as the beginning of a learning process about trauma and trauma-informed practices


Trauma Matters is available on-line, as of March 31, 2013 at:

www.jeantweed.com www.ofcmhap.on.ca

eenet.ca • And now posed on many other websites

http://www.jeantweed.com/

http://www.ofcmhap.on.ca/

http://www.ofcmhap.on.ca/

http://www.jeantweed.com/

When we use trauma-informed care,

we respond to the need to heal from trauma

and help to facilitate recovery. Coalescing on Women and Substance Use

What women have told us about their experiences intrauma-informed services…

“Staff recognized it first...I was having flashbacks…”

“When I got triggered [and had a trauma reaction] it was helpful to be

able to reflect on what was happening with me….

not getting into all the details and staying in the present moment

during sessions was really helpful.”

(focus group participant, Ontario, 2012)

“I learned skills in how to help yourself when you can’t really pin

point what you are feeling and going through.

I find that empowering and very helpful because they are skills I can

take with me.”


“They always had blankets, that was really helpful, I feel like I need to cover up or something, I don’t

want anyone looking at me, because of the trauma of it, I just need something there, even if

it’s just my coat. I remember my counsellor’s office, there was a couch and a pillow and a

blanket, and I always took the blanket because I didn’t want anyone to see my face while I was

talking. It really, really helped.”(focus group participant, Ontario, 2012)

“Eventually I learned to nurture myself and

to have a safe little spot in my home – when I’m feeling vulnerable… I am able to nurture

myself.”


“The most important thing is validation.

Validation. Validation. Validation.

And the acknowledgment of the things we have been through and why we have done the things we have done. Just

how it is all linked.”(focus group participant, Ontario, 2012)

Presenter Contact Information

Project Manager:Nancy Bradley, Executive Director, The Jean Tweed Centre

416-255-7359Email: [email protected]

Project Team Lead:Janine Gates, Gates Consulting Inc.613-547-8478Email: [email protected]

mailto:[email protected]

mailto:[email protected]

Advisory Committee Members

Debbie Bang - Womankind Addiction Service Nancy Bradley - Jean Tweed Centre Gloria Chaim - Child, Youth and Family Program, CAMH Robin Cuff - Toronto Drug Treatment Court Program, CAMH Lucy Hume - Jean Tweed Centre Kathryn Irwin-Seguin - Iris Addiction Recovery for Women Paul McGary - Pinewood Centre, Lakeridge Health Pam McIntosh - House of Friendship Carol Wu - Amethyst Women’s Addiction Centre Heather Bullock - Evidence Exchange Network, CAMH Stephanie Gloyn - Evidence Exchange Network, CAMH Julia Greenbaum - Knowledge and Innovation Support, CAMH Kathy Kilburn - Kilburn Consulting, Health Systems Danielle Layman-Pleet - Ministry of Health and Long Term Care Jessica Penner - DTFP Project Coordinator, CAMH

Project Team

Gates Consulting Inc. Janine Gates Wendy Reynolds (AWARE ) Lucy Van Wyk (Therapist in Private Practice) Jennifer Amos (Researcher and Editor)

Questions?Comments?

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