Download Alcohol and Drug Use Among Girls and Women

The Boston Consortium Model:
Treatment of Trauma Among Women
with Substance Use Disorders
Hortensia Amaro, Ph.D.
Institute on Urban Health Research
Bouvé College of Health Sciences
Northeastern University
1. Overview of the Problem
Co-Occurring Disorders
HIV Risk Behaviors
Complex Clinical Presentation
Worse Prognosis
Current Treatments
2. Integrated Treatment Study
Purpose & Methods
Intervention
Findings
Gender Differences in Trauma
Exposure and Risk for PTSD
– Lifetime trauma exposure:
60.7% men
51.2% women
– Lifetime PTSD:
5.0% men 10.4% women
– Risk of developing PTSD conditioned on
trauma:
8.1% men 20.4% women
Epidemiologic Catchment Area Survey and National Comorbidity Study
PTSD is Associated with
Greater Risk of SUD in Women
Women
4.5
4
3.5
Risk 3
2.5
2
1.5
1
0.5
0
Men
Alcohol Disorder
Drug Disorder
National Comorbidity Survey
History of Abuse in Women with SUD
Clinical Samples
 Childhood:
– 40% sexual assault 27
– 63% 4 to 80% 28 for both physical and sexual
abuse

Adult:
– 72% sexual assault
– 67% physical assault
– 84% sexual abuse 30
29
Co-Occurring Disorders are
Frequent Among Women with SUD

PTSD prevalence among women with SUD:
– 27% in a general population sample 23
– 30-59% in clinical samples 11
– higher than the prevalence reported in men

Other comorbid disorders among drug abusing
women:
– Affective disorders (both depressive and anxiety-related)
31, 32
– Hostility 33, dissociation and somatization 34

Our studies of women clients in SA treatment:
– 93% lifetime history of abuse
– 88% mental health symptoms in last 30 days
– 83% have both
More Complex Clinical Presentation
Compared to individuals diagnosed with DA
disorders alone, people with SUD and
PTSD are:

more likely to report psychiatric and medical
comorbidity 3, 9, 13, 62 and are more impaired than
people with only one diagnosis 8

have social and functional health concerns such
as homelessness 12, unemployment 63, criminal
activities and loss of custody of their children 12
Co-occurring Disorders are
Associated with Worse
Prognosis

Enter and drop out of treatment more often

Relapse more quickly

Treatment compliance lower

In and after SA tx: Lower motivation to quit, less
positive coping skills (eg emotional vs
implementing strategies to reduce stress)

Worse outcomes on life adjustment measures

PTSD intrusion symptoms increase risk of SUD
relapse
Higher Risk for HIV

Drug abuse1, mental health disorders2, and history of
trauma3 have each been shown to be associated with
sexual risk behaviors.

The combination of drug abuse, mental health
disorders, and history of abuse further increases HIV
risk behaviors and HIV infection.4

Women who have severe drug dependency are more
likely to engage in unsafe sex with multiple partners
and in sex for money or drugs, as well as to have
unprotected sex with an injection drug user.5
1. Leigh & Stall (1993), Wingood & DiClemente (1998); 2. Alegria et al. (1994); 3. Bensley, Van
Eenwik, & Simmons (2000), Koenig & Clark (2004); 4. Stall et al. (2003); 5. Health of Boston
Report, Boston Public Health Commission, 2004; 5. Heise, Ellsberg, & Gottemoeler, (1999);
Hypothetical Cycle of PTSD and
SUD
PTSD
SU Disorder
Men: 53% - 65% PTSD
first then SUD
Women:: 65% - 84% PTSD
first then SUD
Escalating use
Alcohol/
Drug use
Short-term Anxiety
reduction
Current Treatments Do Not
Sufficiently Address Trauma in Women

Prevention and treatment strategies that promote
trauma recovery may be quite effective 72. Cognitivebehavioral based treatments that are specifically
designed for people with a dual diagnosis of substance
abuse disorders and PTSD have been developed and
some have been tested.

Few studies to date exist on gender-specific trauma
treatment in women with substance abuse disorders [7,
15].

These have shown promise but a more recent RCT of a
12-session intervention showed no overall advantage of
trauma treatment compared to the control group [1721].
Are Brief Interventions Effective?

Test of a 12-session group intervention based on
cognitive-behavioral and skills-building principles
(Seeking Safety) in a RCT of women in Tx for SUD
found:
– No intervention effects overall (Hien et al, 2009)
– Intervention was more effective than control in
substance abuse improvement among those who were
heavy users and had achieved significant PTSD
reductions. Reverse relationship not found (Hien et al,
2010).
– Intervention reduced sexual risk among those with high
sexual risk (Hien et al, 2010)
Why Gender Specific Treatment?
Women and men experience different
kinds of violence
 Women respond to extreme stress
differently than men (internalizing vs
externalizing; greater reliance on social
support in coping w stress)
 Homogeneity in trauma experience among
group members
 Preference for same sex mental health
services

Integrated Treatment
vs Services as Usual
SAMHSA-funded
Women, Co-Occurring Disorders
and Violence Study
Boston Consortium Model of
Integrated SAD Treatment
October 1998-September 2004
SAMHSA
Mechanisms of Action
in Trauma-SA-HIV Risk Relationships
Mental Health
Symptoms:
PTSD
Depression
Anxiety
Perceived Stress
Recovery Skills:
Coping
Social Support
Relationship Power
Alcohol and Drug Use
HIV Risk Behaviors
Phase 2
Primary Research Question
How effective is the BCM in reducing
subsequent signs and symptoms of
trauma, mental illness, and
substance abuse and HIV risk
behaviors compared to SA services
as usual?
Study Sites for
the WCDVS
Franklin County Women’s Research Project
Boston Consortium
ALLIES Project
WELL Project
Portal Project
PROTOTYPES
Community Connections
New Directions for Families
Triad Women’s Project
Study Participant
Criteria
Women age 18+
Lifetime experience of physical and/or
sexual abuse
DSM-IV Axis I SA Disorder- current
DSM-IV Axis I Mental disorder or Axis
II Personality Disorder- last 5 yrs
2 or more previous contacts with MH,
SA or related service system
Primary Outcomes Measures
Outcomes
Measures
Substance Abuse:
Addiction Severity Index
• Alcohol Composite (ASI-A)
• Drug Abuse Composite (ASI-D)
Mental Health:
Brief Symptom Inventory
• Global Severity Index (GSI)
Trauma:
Post Traumatic Diagnostic Scale
• Post Traumatic Symptom Scale
(PSS)
Process
PHASE 1
1.
2.
3.
4.
5.
Developed partnerships across SA, MH, DV; and
with policy makers
Assessed co-occurring disorders in our population
Agreed on intervention principles
Developed treatment model and manuals
Trained staff
PHASE 2
1.
Implemented and evaluated model
Partnerships
Co-occurring Disorders Among Women
in Boston SU Tx Programs (N= 354)





Brief screen developed
Administered to 354 consecutively admissions
3 modalities of substance abuse treatment
(methadone maintenance, outpatient and
residential)
Items identify women with mental health
symptoms in last month and lifetime experience of
abuse and who should be referred for full
assessment
Implemented in 5 publicly funded intervention
programs
Mental Health Symptoms
last month (n=354)
%
100
90
80
70
60
50
40
30
20
10
0
Depression
Anxiety
Suicide Attempts
Uncontrollable
Thoughts
Trauma History Ever (n=354)
100
90
80
70
% 60
50
40
30
20
10
0
Any Trauma
Intimate
Partner
Violence
Sexual Assault
Childhood
Abuse
Association of Mental Health
Symptoms with Trauma Exposure
Typical Presentation of Women in Tx





Chronic and severe
physical and sexual
abuse, in abusive
relationship
Major depression,
anxiety disorder,
and/or PTSD
Addiction to crack,
cocaine, heroin
Multiple treatment
attempts
Partner is active drug
user






Multiple health problems
Past/current criminal
justice history
Few educational and job
skills
Has 3-5 children, DSS
involved
Living in poverty, may be
homeless or in temporary
housing
HIV Risk Behaviors
Intervention Principles
1.
2.
3.
4.
Consumer participation and input in decision
making regarding the intervention
Cultural and linguistic tailoring of intervention
approaches and delivery of interventions by
staff who reflected the population of
participants
A focus on gender specific approaches that
paid attention to social and cultural influences
in women’s lives.
Use of evidence based approaches when
available or development of intervention
components based on the best available
evidence and consumer/provider input
BCM Integrated Treatment Model
Methadone
Outpatient
Residential
Substance Use
Treatment
Integrated
Intervention
& Treatment
Model
Psychotherapy
Pharmacology
Recovery Skill
Building
Mental
Health/Trauma
Treatment
Elements of Clinical
Intervention Added to SA Tx
MH & Trauma Diagnostic & Integrated Tx
Plan
 System Boundary Spanner for:

– MH Emergency Services
– Individual/Family/Group Therapy
– Psychopharmacological Treatment

‘Package’ of manualized trauma recovery
skills building groups
Staff Training
Case study workbook
for staff training
 Uses case examples
to engage staff in
discussions on issues
that emerge in
integrating treatment

Trauma Recovery and
Empowerment
Leadership
3-session educational
curriculum that teaches
women how to become
leaders and learn to
speak up on their own
behalf and on behalf of
other women in
recovery.
Economic Success
8-session educational
curriculum designed to
assist women in
(1) examining how money
management is related to
the recovery process,
(2) developing effective
money management
skills and
(3) identifying and planning
educational, vocational,
and job training
opportunities and
objectives.
Family Reunification
10-week educational curriculum
that focuses on the impact of
substance abuse on parenting,
family reunification and self-care.
Engages participants in learning
about child protective services
and advocating effectively on
their own behalf to reach a
positive reunification outcome.
Helps women build skills to cope
with potentially triggers related to
child custody issues.
Findings: Alcohol and Drug Use

The intervention group reported
significantly higher drug abstinence rates
than the comparison group at both 6- and
12-month follow-ups (6-month: 67% vs.
38%; 12-month: 75% vs. 40%; all p
values < 0.0001).
Amaro et al, 2009
Mental Health Symptoms
The analysis for mental health symptomatology revealed a
significant Condition X Time interaction, F (2, 556) = 4.55, p
= .01 (d = .32), favoring the intervention group. (Amaro et
al, 2009)
Trauma Symptoms
The analysis for PTSD symptoms revealed a
significant Condition X Time interaction, F (2,
553) = 4.49, p = .01 (d = .35), favoring the
intervention group. (Amaro et al, 2009)
Moderating Effects of
Race/Ethnicity

Analyses to determine if racial/ethnic group
moderated the effects of intervention on each of
the four outcomes:
– No significant Condition X Time X Ethnicity interaction
for any of the outcomes, thus indicating that the
integrated model was efficacious for women across all
ethnic groups.
Changes in Unprotected Sex (unadjusted)
Percentage of Unprotected Sex
50
45
40
35
30
Intervention
25
Comparison
20
15
10
5
0
Baseline
6-months
12-months
Logistic regression analyses: Strong significant association between
intervention status and sexual risk behaviors at follow-up.
Comparison group women had 2.8 times (6M) and 4.5 times (12M) more
likelihood of engaging in unprotected sex than intervention group women.
after adjustment for baseline characteristics and intermediate outcomes.
(Amaro et al, 2007)
Relationship Power
For women in recent relationships, those
with higher RPS scores were less likely to
engage in unprotected sexual behaviors
than women with lower scores at 6 M
(p<.01) and 12M (p<.001).
 Women in the intervention had more gain
on RPS than those in the intervention.

National Registry of Evidence Based Modelsthe Boston Consortium Model
http://www.nrepp.samhsa.gov/ViewIntervention.asp
x?id=86
 Research that led to development of Boston Model
of Integrated Treatment; Some Examples
Conclusions

Conclusions must be tempered due to
limitations of the quasi-experimental study
design.

Changes at 6-months and 12-months follow-up
indicates that the integrated treatment model
resulted in greater treatment improvements
with drug use abstinence, mental health and
trauma symptoms and HIV risk behaviors.

Qualitative data from staff and clients indicate
high level of acceptability, feasibility and fit of
intervention.
Conclusion
Integrated treatment results in better treatment
outcomes including lower HIV risk behaviors
 Staff training needed to integrate treatment of
MH and trauma into SA tx and requires systems
change
 Further research and program development
needed:

–
–
–
–
Key components to integrated treatment,
Level of intervention exposure needed,
Tandomized clinical trial w/longer f-up
Assess and integrate role of spirituality in healing and recovery
www.iuhr.neu.edu
[email protected]