Gender Matters: Creating Services for Women and Girls Stephanie S. Covington, Ph.D., L.C.S.W. Center for Gender and Justice Institute for Relational Development La Jolla, CA July 28, 2008 37thUniversity of Delaware Summer Institute Evolving Treatment Approaches 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. Text Box: (Covington and Bloom) Guiding Principles for Gender-Responsive Services •Gender •Environment •Relationships •Integrated Services •Economic & Social Status •Community Guiding Principles •Gender:Acknowledge that gender makes a difference. •Environment:Create an environment based on safety, respect, and dignity. Guiding Principles(cont.) •Relationships:Develop policies, practices, and programs that are relational and promote healthy connections to children, family, significant others, and the community. •Services:Address substance abuse, trauma, and mental health issues through comprehensive, integrated, and culturally relevant services. Guiding Principles(cont.) •Socioeconomic status:Provide women with opportunities to improve their socioeconomic conditions. •Community:Establish a system of comprehensive and collaborative community services. (Bloom, Owen, Covington 2003) Characteristics of Women Offenders (National Profile) •Disproportionately women of color •In their early to mid-thirties •Most likely to have been convicted of drug or drug-related offense •Fragmented family histories with other family members in the CJ system •Survivors of physical and/or sexual abuse Text Box: Who are the Girls? •Families struggling with poverty, domestic violence and substance abuse. •Low rates of serious and violent crime. •Higher risk for status offenses –promiscuity, truancy, running away. •Run away to survive abuse. •High incidence physical and sexual abuse. •High incidence of substance abuse. Text Box: Women’s Issues: An International Perspective Text Box: Women’s Issues: An International Perspective The PastThe FutureDEEPERPSYCHICCHANGECOGNITIVEINTERVENTIONS•Trust in others and in yourself•Courage to do new things•To like yourself as a womanManaging•Conflicts•Relationships•Relapseprevention•Workingtogether•SocialplanningLotta Länne, Sweden, 2006 Women’s Integrated Treatment ( WIT ) This model is holistic, integrated and based on: •The gender-responsive definition and guiding principles •A theoretical foundation •Interventions/strategies that are multi- dimensional (Covington, 2007) Theoretical Foundation The theories related to gender and substance abuse (and any other relevant treatment services) that create the framework of thought for program development. This is the knowledge base that creates the foundation upon which the program is developed. Treatment Strategies The approaches used in the program that create the therapeutic process. These are the ways in which theory is operationalized(how theory is applied). Helping Women Recover: A Comprehensive Integrated Approach Theory of Addiction •Holistic health model •Chronic neglect of self in favor of something or someone else Theory of Women’s Psychological Development •Relational–Cultural Theory (Stone Center) Theory of Trauma •Three Stage Model (Herman) •Upward Spiral –A Transformational Model (Covington) Text Box: Theory of Girls’ Psychological Development Relational–Cultural Theory (Stone Center, Gilligan, Brown) Theory of Attachment Ainsworth, Bowlby, Harlow, Stern Theory of Trauma Three Stage Model (Herman) Transformational Spiral (Covington) Beyond Trauma: A Healing Journey for Women Trauma Theory Sandra Bloom, M.D. Mary Harvey, Ph.D. Judith Herman, M.D. Peter Levine, Ph.D. et al. Integrates cognitive-behavioral, expressive arts, guided imagery, and relational therapy. Beyond Trauma Themes •Safety •Empowerment •Connection (Aloneness) •Normal reactions (Shame) •Mind-body connection •Substance abuse •Woman-centered •Uses a variety of treatment strategies: psychoeducational, cognitive, relational, expressive Client Assessment Scores Improve after Completion of HWR and BT 10.27.44.526.319.317.505101520253045 DaysHWRBTTOTAL=40-44BeckTSC-40Mean Score ChangeMean Score ChangeSource: KIVA Program records –BDI & TSC Assessment, August 31, 2004 –October 13, 2006Keaton, Curtis, and Burke (2006) SANDAG(p <.05 or less) Addiction: A Holistic Health Model •Physiological •Emotional •Social •Spiritual •Environmental •Political Upward SpiralUpward SpiralAddictionAddiction(constriction)(constriction) RecoveryRecovery(expansion)(expansion) TransformationTransformation Relational-Cultural Theory •Connection and development •Disconnection •Sociocultural disconnection •Privilege and domination Relational Theory Some women use drugs: •To maintain a relationship •To fill in the void of what’s missing in a relationship •To self-medicate the pain of abuse in relationships (Covington & Surrey, 1997) Addiction as a Relationship Text Box: Love . Love-Hate Text Box: Two Kinds of Suffering Trauma-informed Services Trauma-informed services: •Take the trauma into account. •Avoid triggering trauma reactions and/or traumatizing the individual. •Adjust the behavior of counselors, other staff and the organization to support the individual’s coping capacity. •Allow survivors to manage their trauma symptoms successfully so that they are able to access, retain and benefit from the services. (Harris & Fallot) 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.” “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).” Trauma & Abuse •Sexual abuse •Physical abuse •Emotional abuse •Domestic violence •Witnessing abuse/violence •Self-inflicted violence Trauma & Abuse(cont.) Stigmatization Women and girls in criminal justice system Women and girls of color Women and girls in poverty Lesbian, transgendered, bisexual Women and girls with mental illness Trauma Sexual Assault Graph Bureau of Justice Statistics Sexual Assault Graph Bureau of Justice Statistics Process of Trauma TRAUMATIC EVENT Overwhelms the Physical & Psychological Systems Intense Fear, Helplessness or Horror CURRENT STRESS Reminders 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 SENSITIZED NERVOUS SYSTEMCHANGES IN BRAINRESPONSE TO TRAUMAFight or Flight, Freeze, Altered State of Consciousness, Body Sensations, Numbing, Hyper-vigilance, Hyper-arousal Three Critical and Interrelated Issues •Substance Abuse •Mental Health •Trauma Addiction –Trauma –Mental Health Issues Areas of Separation •Training •Treatment •Categorical Funding ACE Study (Adverse Childhood Experiences) •Recurrent and severe emotional abuse •Recurrent and severe physical abuse •Contact sexual abuse 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 notbeing present (N=17,000) 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 theACE Study. 2003 Oct:52(8): 547-59. German. PMID: 14619682 (PubMed-indexed for MEDLINE). Childhood Traumatic Events Largest Effect-Mental Health ••980% increase in odds if exposure to 7 CTE980% increase in odds if exposure to 7 CTE’’ss(Messina & Grella, 2005)(Messina & Grella, 2005) Upward SpiralUpward SpiralTraumaTrauma(constriction)(constriction) HealingHealing(expansion)(expansion) TransformationTransformation Key Issues for Women in Recovery •Self •Relationships •Sexuality •Spirituality Source: Covington, S., (1994) A Woman’s Way Through the 12 Steps, Hazelden Voices:A Program of Self-discovery and Empowerment for Girls Four Modules •Self •Connecting with Others •Healthy Living •The Journey Ahead Points of Intervention •Cognitive •Behavioral •Affective Brain Left Side of BrainRight Side of Brain •Analytic•Intuitive •Logical •Emotional .... Sanctuary Card 27 What is Sanctuary? •Sacred place •Place of refuge/protection •Shelter What makes a difference for women and girls? female-only groups integrating substance abuse and trauma services safe, nurturing environment length of treatment completing treatment continuity of care (aftercare) continuity of relationship Women & Addiction: A Gender-Responsive Approach The Clinical Innovators Series (Hazelden) Manual, DVD, CEU’S Definition of Evidence-based Evidence-based practice (EBP) is defined as the integration of the best available research and clinical expertise within the context of patient characteristics, culture, values, and preferences. (APA Presidential Task Force, 2005) HOLISTIC, SPIRITUAL, INTUITIVE, CREATIVE, RAREHOLISTIC, SPIRITUAL, INTUITIVE, CREATIVE, RAREWISDOMWISDOMUNDERSTANDINGUNDERSTANDINGKNOWLEDGEKNOWLEDGEINFORMATIONINFORMATIONDATADATASEPARABLE, LINEAR, MECHANISTIC, MEASURABLE, ABUNDANTSEPARABLE, LINEAR, MECHANISTIC, MEASURABLE, ABUNDANT Women & Girls Healing Working on multiple levels: •Individual •Political •Spiritual For More Information •Stephanie S Covington, Ph.D, LCSW Phone: 858-454-8528 Email: Sc@stephaniecovington.com Websites: www.stephaniecovington.com www.centerforgenderandjustice.org