Treatment Needs of Women with Co-Occurring Disorders

1. Treatment Needs of Women with Co-Occurring Disorders Joan E. Zweben, Ph.D. Executive Director: The 14th Street Clinic & East Bay Community Recovery Project Clinical Professor of Psychiatry; University of California, San Francisco

2. Overview • Epidemiology & Cultural Issues • In the general population • In criminal justice settings • Treatment Issues • Comorbid psychiatric disorders • Relationship issues • Domestic violence • Practical issues • Children’s issues

3. Epidemiology & Cultural Issues

4. Basic Findings • Women use less alcohol and illicit drugs, though the gender gap is narrowing • Women use more prescription psychoactive drugs • Tobacco smoking is rising and may become a female-dominated form of substance abuse • Risk factors vary in the course of the life cycle (Blume 1998)

5. Women & Alcohol Greater vulnerability to biomedical and other consequences: • higher morbidity and mortality • suicide • liver disorders • neuroendocrine effects

6. Minority Women and Alcohol Use Drinking patterns influenced by: • Religious activity • Genetic risk/protective factors • Level of acculturation to U.S. society • Historical, social and policy variables (Collins & McNair, 2002)

7. African American Women • Relatively high rates of abstention and low rates of heavy drinking among black women • Most over 40 did not consume alcohol • High participation in religious activities is a protective factor (Collins & McNair, 2002)

8. Asian American Women • Regardless of national origin, Asian American women have low rates of alcohol use and problem drinking • Facial flushing response (occurring in 47-85% of Asians) is a protective factor • ALDH2-2 leads to perspiration, headaches, palpitations, nausea, tachycardia, and facial flushing • Women report being more embarrassed than the men do • Acculturation promotes increased drinking (e.g., Japanese women) (Collins & McNair, 2002)

9. Native American Women • Availability of distilled spirits, its use outside specific cultural contexts, and modeling of heavy drinking by Europeans promoted binge drinking • Tribal policies about drinking on the reservation are influential • High density of alcohol outlets in poor urban communities • Marketing of high alcohol content to Native Americans (Crazy Horse) (Collins & McNair, 2002)

10. Latinas • Often did not drink, or drank small amounts in country of origin, but drinking patterns changed more dramatically than male counterparts • More research on Mexicans than Puerto Ricans or Cubans • After three generations, the drinking patterns of Mexican-American women are similar to other U.S. women (Collins & McNair, 2002)

11. Older Women Risk Factors: • Longer life expectancies • Many losses • Live alone longer • Less likely to be financially independent • More susceptible to the effects of alcohol, particularly as they age (Blow & Barry, 2002)

12. Physical Risk Factors • Age-related decrease in lean body mass increases the total distribution of alcohol and other mood altering drugs in the body • Liver enzymes become less efficient with age • CNS sensitivity increases • Heightened response to OTC or prescription drugs

13. Research Questions • Is elder, female-specific specialized treatment necessary, effective, or both? • Do older women in elder-specific programs show better outcomes than older women in mixed-age programs? • Are intervention and treatment approaches for alcohol and prescription drug misuse effective with older women? (Blow & Barry, 2002)

14. Women & the Criminal Justice System • Fastest growing segment nationally • 89% increase in # arrested for drug offenses nationally between 1982-1991 • Fewest appropriate social services available (Wellisch et al 1993)

15. Female Offenders--an overview • Dramatic increase of incarcerated women in California. • About 11,000 serving time--most non-violent • More than half in prison for lesser offenses relating to drugs, or crimes against property • Most used drugs immediately prior to commitment offense • Drug use predates to early teens • Increase in drug law violations accounted for more than 50% of increase in female inmates between 1986 - 1991 • Among substance involved female inmates, 78% have children

16. What is Normal?The National Comorbidity Study • structured psychiatric interview administered to national probability sample • non-institutionalized civilian population • nearly 50% reported at least one lifetime disorder • almost 30% reported one 12-month disorder (Kessler et al, 1994) Normal Does Not Mean Healthy

17. National Comorbidity Study (2) • women: higher affective and anxiety disorders • men: higher substance abuse and antisocial personality disorder • less than 40% with lifetime disorder had ever received professional treatment • less than 20% with a recent disorder had been in treatment during the last 12 months • less than 50% with lifetime history of 3 or more disorders get specialty mental health treatment

18. Women’s Issues • Heightened vulnerability to mood/anxiety disorders • Prevalence of childhood physical/sexual abuse and adult traumatic experiences • Treatment complications of PTSD • Practical obstacles: transportation, child care, homework help • Poor job skills

19. TREATMENTISSUES

20. Women & Drugs • Partner role in initiation • Partner role in relapse • Who leaves? Who stays? • Shame dynamics • Sex workers • Help-seeking behavior

21. Common Psychiatric Comorbiditiesin Women • Depression • Anxiety disorders, especially post traumatic stress disorder (PTSD) • Borderline personality disorder • Eating disorders

22. Depression

23. Depression Caveat: Does the study separate substance-induced mood symptoms from an independent condition? National Comorbidity Study • major depression & alcohol dependence the most common disorders • history of major depressive episode: 17% • episode within last 12 months: 10% • any affective disorder, lifetime prevalence: women 23.9% (MDE 21.3%), men 14.7% (MDE 12.7%) (Kessler et al 1994)

24. Mood & Anxiety Disorders: Treatment Recommendations Distinguish anxiety and mood disorders from: • Normal feelings in recovery • Symptoms of severe mental illness • Medical conditions • Medication side effects • Substance-induced changes (COD TIP, in press)

25. Mood & Anxiety Disorders:Treatment Recommendations (2) • Maintain calm demeanor, reassuring presence • Teach deep breathing, relaxation • Start low, go slow • Respond immediately to any intensification of symptoms • Understand special sensitivities to social situations • Gradually introduce and teach skills for participation in self-help groups (COD TIP, in press)

26. Suicidality • AOD use is a major risk factor, especially for young people • Alcohol: associated with 25%-50% • Alcohol & depression = increased risk • Intoxication is associated with increased violence, towards self and others • High risk when relapse occurs after substantial period of sobriety, especially if it leads to financial or psychosocial loss (COD TIP, in press)

27. Suicidality: Treatment Recommendations • Treat all threats with seriousness • Assess risk of self harm: Why now? Past attempts, present plans, serious mental illness, protective factors • Develop safety and risk management process • Avoid heavy reliance on “no suicide” contracts • 24 hour contact available until psychiatric help can be obtained Note: must have agency protocols in place (COD TIP, in press)

28. Post Traumatic Stress Disorder(PTSD)

29. PTSD: National Comorbidity Study Representative national sample, n = 5877, aged 14-54 • Women more than twice as likely as men to have lifetime PTSD (10.4% vs 5.0%) • Strongly comorbid with other lifetime psychiatric disorders • More than one third with index episode of PTSD fail to recover even after many years • Treatment appears effective in reducing duration of symptoms (Kessler et al 1995)

30. Domestic Violence and Substance Abuse • Use of alcohol or other drugs is a risk factor for domestic violence • High rates in men who commit domestic violence • 80% child abuse cases associated with domestic violence • Domestic violence and child abuse are linked • Interferes with treatment engagement and retention • Contributes to relapse (Fazzone et al 1997)

31. Domestic Violence • In 1994, over ½ million women were treated in emergency rooms for violence related injuries usually inflicted by intimate partner (Rand & Strom, 1997) • These women have many medical problems, often untreated • Substance abuse often a factor • Battered women often more motivated to work on safety than on substance abuse (Brown et al. 2000)

32. Screening Questions to Detect Partner Violence • Have you ever been hit, kicked, punched or otherwise hurt by someone within the past year? If so, by whom? • Do you feel safe in your current relationship? • Is there a partner from a previous relationship who is making you feel unsafe now? (Feldhaus 1997)

33. Possible Meanings of Drug Use in the Context of PTSD • Access feelings and memories • Shut off feelings and memories • Revenge against the abuser • Re-abuse of self • Slow suicide • Learned behavior (Najavits, 2001)

34. Relationships between Trauma and Substance Abuse • Traumatic experiences increase likelihood of substance abuse, especially if PTSD develops • Childhood trauma increases risk of PTSD, especially if it is multiple trauma • Substance abuse increases the risk of victimization • Need for linkages between systems: medical, shelters, social services, mental health, criminal justice, addiction treatment (Zweben et al 1994)

35. How PTSD Complicates Recovery More difficulty: • establishing trusting therapeutic alliance • obtaining abstinence commitment; resistance to the idea that AOD use is itself a problem • establishing abstinence; flooding with feelings and memories • maintaining abstinence; greater relapse vulnerability

36. Impact of Physical/Sexual Abuse on Treatment Outcome N=330; 26 outpatient programs; 61% women and 13% men experienced sexual abuse • abuse associated with more psychopathology for both; sexual abuse has greater impact on women, physical abuse has more impact on men • psychopathology is typically associated with less favorable tx outcomes, however: • abused clients just as likely to participate in counseling, complete tx and remain drug-free for 6 months post tx (Gil Rivas et al 1997)

37. How Substance Abuse Complicates Resolution of PTSD • early treatment goal: establish safety (address AOD use) • early recovery: how to contain or express feelings and memories without drinking/using • firm foundation of abstinence needed to work on resolving PTSD issues • full awareness desirable, vs emotions altered by AOD use • relapse risk: AOD use possible when anxiety-laden issues arise; must be immediately addressed

38. Building a Foundation BEWARE OF DOGMA May need to work with client who continues to drink or use for a long time • avoid setting patient up for failure • reduce safety hazards; contract about dangerous behavior • carefully assess skills for coping with feelings and memories; work to develop them

39. PTSD Treatments • Seeking Safety (Najavits et al 1996; Najavits 2002) • Eye Movement Desensitization and Reprocessing (Shapiro 1995) • Anger management/temper control (Reilly et al 1997) • Substance Dependence-Post Traumatic Stress Disorder Treatment (SDPT) (Triffleman 1999) • Stress inoculation training and prolonged exposure (flooding) (Foa et al 1991; 1998)

40. Seeking Safety:Early Treatment Stabilization • 25 sessions, group or individual format • Safety is the priority of this first stage tx • Treatment of PTSD and substance abuse are integrated, not separate • Restore ideals that have been lost • Denial, lying, false self – to honesty • Irresponsibility, impulsivity – to commitment

41. Seeking Safety: (2) • Four areas of focus: • Cognitive • Behavioral • Interpersonal • Case management • Grounding exercise to detach from emotional pain • Attention to therapist processes: balance praise and accountability; notice therapists’ reactions

42. Seeking Safety (3):Goals • Achieve abstinence from substances • Eliminate self-harm • Acquire trustworthy relationships • Gain control over overwhelming symptoms • Attain healthy self-care • Remove self from dangerous situations (e.g., domestic abuse, unsafe sex) (Najavits, 2002)

43. Safe Coping Skills • Ask for help • Honesty • Leave a bad scene • Set a boundary • When in doubt, do what is hardest • Notice the choice point • Pace yourself • Seek understanding, not blame • Create a new story for yourself ( from Handout in Najavits, 2002)

44. Detaching From Emotional Pain:Grounding • Focusing out on external world - keep eyes open, scan the room, name objects you see • Describe an everyday activity in detail • Run cool or warm water over your hands • Plan a safe treat for yourself • Carry a grounding object in your pocket to touch when you feel triggered • Use positive imagery (Najavits, 2002)

45. Anger Management & Temper Control • Identifying cues to anger: physical, emotional, fantasies/images, red flag words and situations • Developing an anger control plan • Cognitive-behavioral strategies for anger management • Breaking the cycle of violence; understand family of origin issues (Reilly et al 1997) Beware of gender bias; ask about parenting behaviors

46. Special Issues

47. Barriers to Accessing Offsite Psychiatric Services • Distance, travel limitations • Obstacle of enrolling in another agency • Stigma of mental illness • Cost • Fragmentation of clinical services • Becoming accustomed to new staff (COD TIP, in press)

48. Prescribing Psychiatrist Onsite • Brings diagnostic, behavioral and medication services to the clients • Psychiatrist learns about substance abuse • Case conferences, supervision allow counselors to learn more about dx and tx • Better retention and outcomes (COD TIP, in press)

49. Attitudes and Feelingsabout Medication • shame • feeling damaged • needing a crutch; not strong enough • “I’m not clean” • anxiety about taking a pill to feel better • “I must be crazy” • medication is poison • expecting instant results

50. Medication Adherence • important relationship to positive treatment outcome • reasons for non-compliance: denial of illness, attitudes and feelings, side effects, lack of support, other factors • role of the counselor: periodic inquiry, exploring charged issues, keeping physician informed • Work out teamwork, procedures with docs