Curriculum written by Stephanie S. Covington, Ph.D., LCSW Training provided by Twyla Wilson, LCSW Text Box: Helping Women Recover: A Program for Treating Addiction 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 •Women’s 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) Who Are The Women? •Pathways to crime: -Survival of abuse and poverty -Addiction •Most are poor, undereducated, unskilled, single mothers, and disproportionately women ofcolor. •Between 1995 and 1996, female drug arrests increased by 95%, (male 55%). •Nationwide, the number of women incarcerated for drug offenses rose by 888% from 1986 to 1996. Gender Differences •Employment histories •Substance abuse problems •Criminal involvement •Psychological functioning •Sexual and physical abuse histories (Source: A Profile of Women in Prison-based Therapeutic Communities, N. Messina, W. Burton & M. Prendergast) 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. The PastThe FutureDEEPERPSYCHICCHANGECOGNITIVEINTERVENTIONS•Trust in others and in yourself•Courage to do new things•To like yourself as a womanManaging•Conflicts•Relationships•Relapseprevention•Workingtogether•SocialplanningLottaLänne, Sweden, 2006 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) Voices:A Program of Self-discovery and Empowerment for Girls Text Box: Beyond Trauma: A Healing Journey for Women Trauma Theory Sandra Bloom Mary Harvey Judith Herman Peter Levine 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 Addiction: A Holistic Health Model •Physiological •Emotional •Social •Spiritual •Environmental •Political Upward SpiralUpward SpiralUpward SpiralUpward SpiralAddictionAddiction(constriction)(constriction) RecoveryRecovery(expansion)(expansion) TransformationTransformation 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) Trauma-informed Services These are services that are provided for problems other than trauma but require knowledge about violence against women and the impact of trauma thereby increasing their effectiveness. 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) Ten Principles of Trauma-Informed Services Principle 1. Trauma-Informed Services Recognize the Impact of Violence and Victimization on Development and Coping Strategies Ten Principles of Trauma-Informed Services (cont.) Principle 2. Trauma-Informed Services Identify Recovery from Trauma as a Primary Goal Ten Principles of Trauma-Informed Services (cont.) Principle 3. Trauma-Informed Services Employ an Empowerment Model Ten Principles of Trauma-Informed Services (cont.) Principle 4. Trauma-Informed Services Strive to Maximize a Woman’s Choices and Control Over Her Recovery Ten Principles of Trauma-Informed Services (cont.) Principle 5. Trauma-Informed Services Are Based in a Relational Collaboration Ten Principles of Trauma-Informed Services (cont.) Principle 6. Trauma-Informed Services Create an Atmosphere That Is Respectful of Survivor’s Need for Safety, Respect, and Acceptance Ten Principles of Trauma-Informed Services (cont.) Principle 7. Trauma-Informed Services Emphasize Women’s Strengths, Highlighting Adaptation Over Symptoms and Resilience Over Pathology Ten Principles of Trauma-Informed Services (cont.) Principle 8. The Goal of Trauma-Informed Services Is to Minimize the Possibilities of Retraumatization Ten Principles of Trauma-Informed Services (cont.) Principle 9. Trauma-Informed Services Strive to Be Culturally Competent and to Understand Each Woman in the Context of Her Life Experiences and Cultural Background Ten Principles of Trauma-Informed Services (cont.) Principle 10. Trauma-Informed Agencies Solicit Consumer Input and Invoice Consumers in Designing and Evaluating Services Eliot, D.E.; Bjelajac, P.; Fallot, R.D.; Markoff, L.S.; Reed, B.G. Trauma-Informed or Trauma-Denied: Principles and Implementation of Trauma-Informed Services for Women. Journal of Community Psychology, July, 2005., 33(4): 461-477. 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).” Types of Abuse Sexual abuse Physical abuse Emotional abuse Domestic violence Witnessing abuse/violence Self-inflicted violence Types of Abuse (cont.) Stigmatization Women in criminal justice system Women of color Women in poverty Lesbian, transgendered, bisexual Women with mental illness Sexual Assault Graph Bureau of Justice Statistics Sexual Assault Graph Bureau of Justice Statistics Post-traumatic Stress Disorder •Nightmares; Flashbacks •Estrangement •Numbing of General Responsiveness •Insomnia •Exaggerated Startle Response •Hypervigilance (DSM-IVTR) 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 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 Women in CJ System CJ 21% .5+ (before age 16) HMO 13% .5+ (before age 18) Greater exposure to CTE’s increased likehood of 14 out of 20 health–related outcomes. (Messina & Grella, 2005) Childhood Traumatic Events CJ Women More: •Problems in adolescence •Homelessness •Substance abuse •Involvement with crime •Prostitution •Eating disorders •Hepatitis & STD’s •Gynecological problems •Asthma (Messina & Grella, 2005) Childhood Traumatic Events Largest Effect-Mental Health •Psychotropic medication •Mental health treatment •Attempted suicide •Traumatic stress (Messina & Grella, 2005) Childhood Traumatic Events Largest Effect-Mental Health •980% increase in odds if exposure to 7 CTE’s(Messina & Grella, 2005)(Messina & Grella, 2005) Text Box: Disorders Related to Trauma and Substance Abuse in Women’s Lives Trauma: Stages of Recovery Source: Herman, 1992, 1997 SyndromeStage 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 Trauma: Stages of Recovery Source: Herman, 1992, 1997Source: Herman, 1992, 1997 Syndrome Stage One Stage Two Stage Three Complicated post-traumatic stress disorders Stabilization, Integration of memories Development of self, drive integration Trauma: Stages of Recovery Source: Herman, 1992, 1997 SyndromeStage 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 Trauma Three Group Models Source: Herman, 1992, 1997 Group Recovery Stage One Recovery Stage Two Recovery Stage Three Therapeutic task Safety Remembrance and mourning Reconnection Time orientation Present Past Present, future Focus Self-care Trauma Interpersonal relationships Trauma Three Group Models Source: Herman, 1992, 1997 Group Recovery Stage OneRecovery Stage TwoRecovery Stage ThreeMembershipHomogeneous Homogeneous HeterogeneousBoundariesFlexible, inclusiveClosedStable, slow turnoverCohesionModerateVery highHigh Trauma Three Group Models Source: Herman, 1992, 1997 Upward SpiralUpward SpiralTraumaTrauma(constriction)(constriction) HealingHealing(expansion)(expansion) TransformationTransformation Comprehensive Treatment for Women Issues Within the treatment program, counselors should address the following issues: •The etiology of addiction, especially gender-specific issues related to addiction (including social, physiological, and psychological consequences of addiction and factors related to onset of addiction) Comprehensive Treatment for Women (cont.) •Low self-esteem •Race, ethnicity and cultural issues •Gender discrimination and harassment •Disability-related issues, where relevant •Relationships with family and significant others •Attachments to unhealthy interpersonal relationships Comprehensive Treatment for Women (cont.) •Interpersonal violence, including incest, rape, battering, and other abuse •Eating disorders •Sexuality, including sexual functioning and sexual orientation •Parenting •Grief related to the loss of alcohol or other drugs, children, family members, or partners Comprehensive Treatment for Women (cont.) •Work •Appearance and overall health and hygiene •Isolation related to a lack of support systems (which may or may not include family members and/or partners) and other resources •Life plan development •Child care and child custody Source: Practical approaches in the treatment of women who abuse alcoholand other drugs. CSAT 1994. Points of Intervention •Cognitive •Behavioral •Affective Women in Recovery: Understanding Addiction Alcohol and other Drug Education Women in Recovery: Understanding Addiction Program Design When and where to use the Twelve Steps Twelve Steps •A Women’s Way through the Twelve Steps •A Women’s Way through the Twelve Steps Workbook Key Issues for Women in Recovery •Self •Relationships •Sexuality •Spirituality Source: Covington, S., (1994) A Woman’’s Way Through the 12 Steps, Hazelden Helping Women Recover Self Module Powerful GroupLess Powerful Group men women adults young people boss workers teachersstudents whitespeople of color richpoor ChristiansJews, Moslems, Buddhists able-bodiedphysically challenged heterosexualgay, lesbian, bisexual formally educatednon-formally educated Power Chart Recovery Scale Self Module Recovery Scale Self Module Helping Women Recover Relationship Module Growth Fostering Relationships •Each person feels a greater sense of “zest”(vitality, energy) •Each person feels more able to act and does act•Each person has a more accurate picture of her/himself and the other person(s) •Each person feels a greater sense of worth•Each person feels more connected to the other person(s) and a greater motivation for connections with other people beyond those in the specificrelationshipSource: Stone Center, Wellesley College Wellesley, MA 02181Source: Stone Center, Wellesley College Wellesley, MA 02181 Outcomes of Disconnections •Diminished zest or vitality •Disempowerment •Confusion, lack of clarity •Diminished self-worth •Turning away from relationships Source: Stone Center, Miller Text Box: (Non-mutual or Abusive Relationships) Domestic Violence Domestic Violence Questions 1.Have you been hit or threatened in the last year? 2.Have your children been hit or threatened in the last year? 3.Have you ever been kicked? 4.Have you ever sustained bodily injury –bruises, cuts broken bones, etc.? 5.Do you know what a restraining order is? 6.Do you want more information? Domestic Violence (cont.) Responses 1.I am afraid for your safety. 2.I am afraid for the safety of your children. 3.It will only get worse. 4.I am here for you when you are ready. 5.You deserve better than this. Domestic Violence (cont.) Client returning home(Case Managers/Continuing Care) 1.Do you feel apprehensive about returning to your relationship? 2.Is the apprehension related to a fear of being physically hurt? We need to develop a safety plan (and find some additional resources). AA sponsor Community network Hot line Shelter Helping Women Recover Sexuality Module Sexuality SEXUALITYis a developmental process SEXUALITYis an identification, an activity, a drive, a biological process, an orientation, an outlook Itis who and how we are in the Universe SEXUAL GOOD HEALTHis the somatic, emotional, social and spiritual aspects of oneself integrated into one’s identity and style of life ©Covington, 1995 Text Box: Body Image Sexual-Chemical Lifeline Self -Soothing Alone With Others Daytime Night Time Sexual Bill of Rights Text Box: My Sexual Bill of RightsI have the right to…. Helping Women Recover Spirituality Module Tenets of Women’s Spirituality •Recognizing the interrelatedness of all life •Honoring the dignity of the female •Appreciating the human body as the container of the spirit Tenets of Women’s Spirituality (cont.) •Discovering the power of creating ritual •Perceiving work for ecological and social justice as a spiritual responsibility •Cultivating sensitivity to diverse multicultural experiences For More Information •Stephanie S Covington, Ph.D, LCSW Email: Sc@stephaniecovington.com Websites: www.stephaniecovington.com www.centerforgenderandjustice.org •Twyla Wilson, LCSW Email: Twyla.lcsw@gmail.com