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Co-Occurring Disorders – Session I

2010 College of Advanced Judicial Studies

May 25, 2010 Fort Myers, Florida

Roger H. Peters, Ph.D., University of South Florida, Tampa, Florida; Peters@fmhi.usf.edu

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Goals of this Session

Review:

• Relevant resources Relevant resources • Importance of co-occurring mental disordersImportance of co-occurring mental disorders• Differences between mental disorders Differences between mental disorders • Impact of co-occurring disorders on functioningImpact of co-occurring disorders on functioning• Co-occurring disorders in youth and adultsCo-occurring disorders in youth and adults

Resources

• CSAT TIP #42 and #44CSAT TIP #42 and #44

• CMHS National GAINS CenterCMHS National GAINS Center

• CMHS ToolkitCMHS Toolkit

• Council of State Governments Council of State Governments

• NDCI/NADCP MaterialsNDCI/NADCP Materials

• NIDA CJDATS-2 NetworkNIDA CJDATS-2 Network

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Defining “Co-Occurring Disorders”

The presence of at least two disorders:The presence of at least two disorders:

One being substance abuse or dependenceOne being substance abuse or dependence The other being a DSM-IV major mental The other being a DSM-IV major mental

disorder, usually Major Depression, Bipolar disorder, usually Major Depression, Bipolar Disorder, or SchizophreniaDisorder, or Schizophrenia

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Challenges in Addressing CODs

• At risk for relapseAt risk for relapse• Criminality/criminal Criminality/criminal

thinkingthinking• Housing needsHousing needs• Transportation needsTransportation needs• Family reunification Family reunification • Lengthier stays in jail Lengthier stays in jail

• Job skills deficitsJob skills deficits

• Educational deficitsEducational deficits

• Stigma related to Stigma related to criminal history and criminal history and SA and MH disordersSA and MH disorders

• Scarce prevention and Scarce prevention and treatment resourcestreatment resources

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Outcomes Related to CODs

• More rapid progression from initial use to More rapid progression from initial use to substance dependence substance dependence

• Poor adherence to medicationPoor adherence to medication• Decreased likelihood of treatment Decreased likelihood of treatment

completioncompletion• Greater rates of hospitalizationGreater rates of hospitalization• More frequent suicidal behaviorMore frequent suicidal behavior• Difficulties in social functioningDifficulties in social functioning• Shorter time in remission of symptoms Shorter time in remission of symptoms

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Typical Location of Services for Different Co-Occurring Populations

IIMental health

system

IPrimary healthcare settings

IVState hospitals,Jails/prisons,emergencyrooms, etc.

IIISubstance abuse

system

HighSeverity

HighSeverity

LowSeverity

Su

bsta

nce U

se D

isord

ers

Mental Health Disorders

(N. GAINS Center, 2004; Steadman et al., 2009)

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Prevalence of Mental Problems in Justice Settings by Gender

GenderGender State PrisonState Prison Fed. PrisonFed. Prison JailJail

MaleMale 55% 55% 44% 63% 44% 63%

FemaleFemale 73% 73% 61% 75% 61% 75%

* Based on a modified clinical interview for the DSM-IV, describing experiences * Based on a modified clinical interview for the DSM-IV, describing experiences during the “past 12 months”. (U.S. Department of Justice, 2006)during the “past 12 months”. (U.S. Department of Justice, 2006)

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Rates of Substance Use Among Offenders with Mental Problems

74% of state prisoners with mental problems also have substance abuse or dependence problems

(U.S. Department of Justice, 2006)

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Prevalence of Mental Disorders

Just the Facts:Just the Facts:• 26% of adults in US experience a diagnosable 26% of adults in US experience a diagnosable

mental disorder each year (60 million persons)mental disorder each year (60 million persons)• 6% have serious mental disorders 6% have serious mental disorders • Mental disorders are the leading cause of Mental disorders are the leading cause of

disability in US/Canada for ages 15-44disability in US/Canada for ages 15-44• About half suffer from multiple mental disordersAbout half suffer from multiple mental disorders• Co-occurring substance use disorders commonCo-occurring substance use disorders common

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Prevalence of Mental Disorders

Just the Facts:Just the Facts:• 10% of adults have a mood disorder (e.g., 10% of adults have a mood disorder (e.g.,

major depression)major depression)

• 3% of adults have Bipolar Disorder 3% of adults have Bipolar Disorder

• 2% of adults have Alzheimer’s Disease2% of adults have Alzheimer’s Disease

• 1% of adults have Schizophrenia1% of adults have Schizophrenia

• 33% have lifetime history of drug use33% have lifetime history of drug use

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Mental Disorders in Juveniles

Just the Facts:Just the Facts:• 67-70% of juveniles experience mental 67-70% of juveniles experience mental

disordersdisorders

• Key disordersKey disorders

• Substance use disorder – 46%Substance use disorder – 46%

• Conduct disorder – 46%Conduct disorder – 46%

• Anxiety disorder – 34%Anxiety disorder – 34%

• Mood disorder – 18%Mood disorder – 18%

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Severity of Disorders in Juveniles

• Over half of juveniles have multiple Over half of juveniles have multiple disordersdisorders

- 61% have co-occurring substance use - 61% have co-occurring substance use disordersdisorders

• 27% have disorders requiring immediate 27% have disorders requiring immediate treatmenttreatment

Types of Juvenile Disorders by Gender (n=1437)

Overall

%

Males

%

Females

%

Anxiety Disorder 34.4 26.4 56.0

Mood Disorder 18.3 14.3 29.2

Disruptive Disorder 46.5 44.9 51.3

Substance Abuse Disorder 46.2 43.2 55.1

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Traditional MH Services are not Effective for Offenders with CODs

• Unaddressed and ongoing SA interferesUnaddressed and ongoing SA interferes with with individuals’ ability to follow MH treatment individuals’ ability to follow MH treatment recommendationsrecommendations

• Active substance use Active substance use interferes with interferes with effectivenesseffectiveness of MH treatment (i.e., medications, of MH treatment (i.e., medications, etc.)etc.)

• MH treatment may not focus on MH treatment may not focus on changing changing substance usesubstance use and other maladaptive behaviorsand other maladaptive behaviors

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Traditional SA Services are not Effective for Offenders with CODs

• Absence of accurate MH diagnosisAbsence of accurate MH diagnosis prevents prevents effective treatmenteffective treatment

• Cognitive impairmentCognitive impairment detracts from detracts from understanding and processing informationunderstanding and processing information

• Confrontational approachesConfrontational approaches used in SA used in SA treatment are not well tolerated treatment are not well tolerated

• Frustration and dropoutFrustration and dropout may result from may result from requirements of abstinence requirements of abstinence

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Serious Mental DisordersAxis I Disorders:Axis I Disorders:• Major Depressive DisorderMajor Depressive Disorder• Bipolar DisorderBipolar Disorder• SchizophreniaSchizophrenia• Posttraumatic Stress DisorderPosttraumatic Stress Disorder

Often accompanied by Axis II (Personality) Often accompanied by Axis II (Personality) Disorders:Disorders:

• Borderline Personality DisorderBorderline Personality Disorder• Antisocial Personality DisorderAntisocial Personality Disorder

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Other Axis I Mental Disorders

• Anxiety Disorders (Panic, Obsessive-Anxiety Disorders (Panic, Obsessive-Compulsive, Social Phobia)Compulsive, Social Phobia)

• Eating Disorders (Anorexia, Bulimia)Eating Disorders (Anorexia, Bulimia)• Adjustment Disorders (with anxiety, or Adjustment Disorders (with anxiety, or

depressed mood)depressed mood)• Sleep DisordersSleep Disorders

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Other Axis II Mental Disorders

• Narcissistic Personality Disorder Narcissistic Personality Disorder • Dependent Personality DisorderDependent Personality Disorder• Adjustment DisorderAdjustment Disorder• Paranoid Personality DisorderParanoid Personality Disorder• Histrionic Personality DisorderHistrionic Personality Disorder

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Challenges Related to Mental Illness

• Vulnerability for rehospitalizationVulnerability for rehospitalization• Psychotic symptomsPsychotic symptoms• Severe depression and suicidal behaviorSevere depression and suicidal behavior• Higher rates of violence and incarcerationHigher rates of violence and incarceration• Difficulty with daily living skillsDifficulty with daily living skills• Difficulty complying with treatment regimensDifficulty complying with treatment regimens• Vulnerability to HIV infection, andVulnerability to HIV infection, and• High service utilizationHigh service utilization

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Outcomes Related to CODs

• More rapid progression from initial use to More rapid progression from initial use to substance dependence substance dependence

• Poor adherence to medicationPoor adherence to medication• Decreased likelihood of treatment Decreased likelihood of treatment

completioncompletion• Greater rates of hospitalizationGreater rates of hospitalization• More frequent suicidal behaviorMore frequent suicidal behavior• Difficulties in social functioningDifficulties in social functioning• Shorter time in remission of symptoms Shorter time in remission of symptoms

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Major Depression and Substance Use

• Onset of Major Depression usually Onset of Major Depression usually begins in late adolescence, about the begins in late adolescence, about the same time drug use patterns are same time drug use patterns are establishedestablished

• Involves withdrawal from pleasurable Involves withdrawal from pleasurable activities, tearfulness, depressed mood, activities, tearfulness, depressed mood, changes in appetite, sleep, morbid changes in appetite, sleep, morbid thoughts. thoughts.

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Major Depression and Substance Use

• No “drug of choice” has been identified, No “drug of choice” has been identified, i.e., no single drug is preferred over i.e., no single drug is preferred over others, or used exclusively others, or used exclusively

• Drug use exacerbates depression, but can Drug use exacerbates depression, but can be perceived as reducing symptomsbe perceived as reducing symptoms

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Schizophrenia and Substance Use

• Onset can include odd behaviors, Onset can include odd behaviors, withdrawal from peers, unusual thoughts withdrawal from peers, unusual thoughts and beliefs, depressed mood. and beliefs, depressed mood.

• Creates vulnerability for substance use to Creates vulnerability for substance use to impair concentration, impulse control, impair concentration, impulse control, abstract reasoningabstract reasoning

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Schizophrenia and Substance Use

• As with other mental disorders, no single As with other mental disorders, no single “drug of choice” has been identified“drug of choice” has been identified

• Persons with schizophrenia may use drugs Persons with schizophrenia may use drugs for same reasons as peers: To get along in for same reasons as peers: To get along in groups, feel relaxed, reduce boredomgroups, feel relaxed, reduce boredom

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Bipolar Disorder and Substance Use

• Onset appears at younger age, perhaps due Onset appears at younger age, perhaps due to concurrent substance use. to concurrent substance use.

• Rapid ‘cycling’.Rapid ‘cycling’.

• During mania, can be irritable or elated, During mania, can be irritable or elated, judgment is compromised, disturbed sleep, judgment is compromised, disturbed sleep, distorted thinking and speech distorted thinking and speech

• No single drug associated with bipolar No single drug associated with bipolar disorder. May use alcohol or stimulants disorder. May use alcohol or stimulants during mania and depression during mania and depression

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Relapse Factors

• The most common cause of mental illness The most common cause of mental illness relapse is substance abuserelapse is substance abuse

• The most common cause of substance The most common cause of substance abuse relapse is untreated mental illnessabuse relapse is untreated mental illness

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Co-Occurring Disorders – Session II

2010 College of Advanced Judicial Studies

May 25, 2010 Fort Myers, Florida

Roger H. Peters, Ph.D., University of South Florida, Tampa, Florida; Peters@fmhi.usf.edu

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Goals of this Session

Review:• Relevant resources Relevant resources • Key behaviors relevant to treatment of CODsKey behaviors relevant to treatment of CODs• Evidence-based practices for CODsEvidence-based practices for CODs• Modifying court-based programs for CODsModifying court-based programs for CODs

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Why Traditional Approaches are not Effective for Persons with CODs

• Absence of accurate MH diagnosisAbsence of accurate MH diagnosis prevents prevents effective treatmenteffective treatment

• Cognitive impairmentCognitive impairment detracts from detracts from understanding and processing informationunderstanding and processing information

• Confrontational approachesConfrontational approaches used in SA used in SA treatment are not well tolerated treatment are not well tolerated

• Frustration and dropoutFrustration and dropout may result from may result from requirements of abstinence requirements of abstinence

Challenging Behaviors Related to CODs

• Participant who remains silent in response to the Participant who remains silent in response to the judge’s questions due to paranoiajudge’s questions due to paranoia

• Participant who hears voices and talks to herself Participant who hears voices and talks to herself during treatment sessionsduring treatment sessions

• Man on community supervision who reports not Man on community supervision who reports not sleeping for days due to change in medicationssleeping for days due to change in medications

Behaviors Related to CODs

Limited attention spanLimited attention span Difficulty understanding and remembering Difficulty understanding and remembering

informationinformation

Not recognize consequences of behaviorNot recognize consequences of behavior

Poor judgmentPoor judgment

DisorganizationDisorganization

Not respond well to confrontationNot respond well to confrontation

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Clinical Features • Cognitive impairmentCognitive impairment

• Reduced motivationReduced motivation

• Impairment in social functioningImpairment in social functioning

(Bellack, 2003)(Bellack, 2003)

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Types of Cognitive Impairment

AttentionAttention Memory (particularly verbal)Memory (particularly verbal) Executive functionsExecutive functions

Consequences For Not Addressing CODs in Court Settings

• Difficulty in adjusting to treatment groups, Difficulty in adjusting to treatment groups, employment, and other program activitiesemployment, and other program activities

• Frequent hospitalization and other mental health Frequent hospitalization and other mental health emergenciesemergencies

• High rates of dropout from problem-solving High rates of dropout from problem-solving court programscourt programs

• Rapid cycling to other parts of the criminal Rapid cycling to other parts of the criminal justice system – re-arrest, re-incarcerationjustice system – re-arrest, re-incarceration

Placement Issues in Court Settings

• Excluding persons with co-occurring disorders is Excluding persons with co-occurring disorders is NOT a viable optionNOT a viable option

• Courts need to determine which individuals are Courts need to determine which individuals are eligible for serviceseligible for services

• Individuals should be matched to COD servicesIndividuals should be matched to COD services

Factors Affecting Participation in Court and Community Programs

• Severity of mental disorderSeverity of mental disorder• Functional abilitiesFunctional abilities• Motivation for recovery and “stage of change”Motivation for recovery and “stage of change”• Available resources in the court-based program Available resources in the court-based program

and affiliated community treatment programsand affiliated community treatment programs

What Works?: Evidence-Based Practices

• Integrated treatment for co-occurring disordersIntegrated treatment for co-occurring disorders

• MedicationsMedications

• Illness self-management skillsIllness self-management skills

• Motivational enhancement Motivational enhancement

• Contingency managementContingency management

• Family psychoeducationFamily psychoeducation

• Assertive Community Treatment (ACT)Assertive Community Treatment (ACT)

• Supported employmentSupported employment

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Features of COD Treatment

Highly structured therapeutic approachHighly structured therapeutic approach Destigmatize mental illness illness Destigmatize mental illness illness Focus on symptom management vs. cure Focus on symptom management vs. cure Education regarding individual diagnoses Education regarding individual diagnoses

and interactive effects of CODsand interactive effects of CODs ““Criminal thinking” groups Criminal thinking” groups Basic life management and problem-Basic life management and problem-

solving skillssolving skills

The Case for an Integrated Approach for CODs

• Traditional, non-integrated approaches result in poor Traditional, non-integrated approaches result in poor outcomesoutcomes

• An integrated, multidisciplinary approach is needed:An integrated, multidisciplinary approach is needed:• Similar to the integrated multidisciplinary team Similar to the integrated multidisciplinary team

process routinely used in court-based programsprocess routinely used in court-based programs• Incorporates approaches used in MH fieldIncorporates approaches used in MH field

• You already work with these individuals AND can be You already work with these individuals AND can be more effectivemore effective

Key Modifications for CODs

• Blended screening and assessmentBlended screening and assessment• Integrated and more intensive treatment Integrated and more intensive treatment • Linkage with community treatmentLinkage with community treatment• Medication monitoringMedication monitoring• Education on CODsEducation on CODs• Court hearings and judicial monitoringCourt hearings and judicial monitoring• Flexible application of sanctions and incentivesFlexible application of sanctions and incentives• Community supervisionCommunity supervision

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Why Screen and Assess for CODs?

High prevalenceHigh prevalence rates of mental rates of mental disorders in justice settingsdisorders in justice settings

Persons with undetected mental Persons with undetected mental disorders are likely to disorders are likely to cycle back cycle back throughthrough the criminal justice system the criminal justice system

Allows for Allows for treatment planningtreatment planning and and linking to appropriate treatment services linking to appropriate treatment services

Screening

• Routine screening for both sets of disordersRoutine screening for both sets of disorders• Identify acute symptoms:Identify acute symptoms:

• Suicidal thoughts and behaviorSuicidal thoughts and behavior• Depression, hallucinations, delusionsDepression, hallucinations, delusions• Potential for drug/alcohol withdrawalPotential for drug/alcohol withdrawal• History of MH treatment including use of History of MH treatment including use of

psychotropic medicationspsychotropic medications• Determine need/urgency for referralDetermine need/urgency for referral

Assessment

• Acquire information from previous court Acquire information from previous court evaluationsevaluations

• Focus on areas of functional impairment that Focus on areas of functional impairment that would prevent effective program participation:would prevent effective program participation:• Cognitive capacityCognitive capacity• Communication and reading skillsCommunication and reading skills• Capacity to handle stressCapacity to handle stress• Ability to participate in group interventionsAbility to participate in group interventions

• Assess participant motivationAssess participant motivation

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Assessment Considerations

• Substance abuse can Substance abuse can mimicmimic all major mental all major mental health disordershealth disorders

• Several strategies will help to gauge the potential Several strategies will help to gauge the potential effects of SA on MH disorderseffects of SA on MH disorders

• Use Use drug testingdrug testing to verify abstinence to verify abstinence• Take a longitudinal history of MH and SA Take a longitudinal history of MH and SA

symptom interactionsymptom interaction• Compile Compile diagnostic impressionsdiagnostic impressions over a over a

period of timeperiod of time• Repeat assessmentRepeat assessment over time over time

Treatment Modifications - I

• Higher staff-to-client ratioHigher staff-to-client ratio• Increased length of services:Increased length of services:

• Pace of treatment slowerPace of treatment slower• Flexible progression through treatment allowedFlexible progression through treatment allowed• Ongoing tracking and case monitoringOngoing tracking and case monitoring• Extended exit and re-entry policies Extended exit and re-entry policies • Treatment may last for more than one yearTreatment may last for more than one year

Treatment Modifications - II

• Integrated treatment to address MH and SA issuesIntegrated treatment to address MH and SA issues• More emphasis on education and support rather More emphasis on education and support rather

than compliance and sanctionsthan compliance and sanctions• Motivational interventions in both group and Motivational interventions in both group and

individual settingsindividual settings• Cognitive and memory enhancement strategiesCognitive and memory enhancement strategies• Case management and outreach servicesCase management and outreach services• Focus on housing, employment, medication needsFocus on housing, employment, medication needs

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Pharmacological Interventions

• Medications are routinely and effectively Medications are routinely and effectively prescribed for individuals with CODsprescribed for individuals with CODs

• Medications serve to successfully:Medications serve to successfully:

- Decrease drug- Decrease drug cravings cravings

- Reduce - Reduce reinforcing effectsreinforcing effects of drugs of drugs

- Assist in - Assist in acute withdrawalacute withdrawal

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Pharmacological Interventions

• Abuse of illicit drugs and alcohol can Abuse of illicit drugs and alcohol can impair impair the action of medicationsthe action of medications

• Toxic effectsToxic effects can occur if alcohol or illicit can occur if alcohol or illicit drugs are used while taking certain drugs are used while taking certain medications (e.g., lithium, tricyclic medications (e.g., lithium, tricyclic antidepressants, MOI inhibitors)antidepressants, MOI inhibitors)

• Medications with Medications with addictive potentialaddictive potential should should be avoided, or used with cautionbe avoided, or used with caution

Education

• Provide to all program participantsProvide to all program participants• Interactive nature of CODs and principles of careInteractive nature of CODs and principles of care• Review court and community-based treatment Review court and community-based treatment

resourcesresources• Use groups and assigned homework/readingsUse groups and assigned homework/readings

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Peer Support Interventions

• Traditional 12-step programs have Traditional 12-step programs have not always not always meshed wellmeshed well with the needs of individuals with the needs of individuals with co-occurring disorderswith co-occurring disorders

• 12-step models such as AA and NA have been 12-step models such as AA and NA have been adapted for co-occurring disordersadapted for co-occurring disorders

• ““Double Trouble”Double Trouble” and similar groups have and similar groups have been developed throughout the U.S.been developed throughout the U.S.

Linkage with Community Treatment

• Why engage community treatment agencies? Why engage community treatment agencies? • Medication monitoringMedication monitoring• Access financial, political and material Access financial, political and material

resourcesresources• Share informationShare information• Maximize outreach effortsMaximize outreach efforts

• Include community agencies in court meetingsInclude community agencies in court meetings• Develop Memoranda of AgreementDevelop Memoranda of Agreement

Court Hearings and Judicial Monitoring

• More frequent court hearings may be neededMore frequent court hearings may be needed• Hearings provide a good opportunity to recognize Hearings provide a good opportunity to recognize

and reward positive behavioral changeand reward positive behavioral change• Specialized dockets Specialized dockets

- Less formal, smaller, more private- Less formal, smaller, more private- More frequent- More frequent- Greater interaction between judge and participants- Greater interaction between judge and participants- Include mental health professionals- Include mental health professionals

Graduated Sanctions

• Wide range of rewards/incentivesWide range of rewards/incentives• Determine the impact of substance use on mental Determine the impact of substance use on mental

disorder and MH servicesdisorder and MH services• Flexibly apply sanctions to consider life Flexibly apply sanctions to consider life

circumstances (e.g., living arrangements, circumstances (e.g., living arrangements, medications) – more supportive, less punitive medications) – more supportive, less punitive response for behaviors related to mental disorderresponse for behaviors related to mental disorder

• Avoid sanctions that remove the participant from Avoid sanctions that remove the participant from active treatmentactive treatment

Community Supervision

• Smaller caseloads with more intensive servicesSmaller caseloads with more intensive services• Specialized MH/COD caseloads and trainingSpecialized MH/COD caseloads and training• Active involvement in court and community Active involvement in court and community

treatment teamstreatment teams• Problem-solving approachProblem-solving approach• Rapid crisis response capabilityRapid crisis response capability• Monitor medication compliance (MH agencies)Monitor medication compliance (MH agencies)• Home visits usefulHome visits useful• ““Fugitive” warrants receive priorityFugitive” warrants receive priority• Taper supervision over timeTaper supervision over time

Designing Programs for CODs

• Specialized COD docketsSpecialized COD dockets• Redirect or target resources to supplement the Redirect or target resources to supplement the

“core” set of modified services“core” set of modified services• Provide concurrent mental health servicesProvide concurrent mental health services• Provide additional “tracks” for participants with Provide additional “tracks” for participants with

CODsCODs

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Co-Occurring Disorders – Session III

2010 College of Advanced Judicial Studies

May 25, 2010 Fort Myers, Florida

Roger H. Peters, Ph.D., University of South Florida, Tampa, Florida; Peters@fmhi.usf.edu

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Goals of this Session

Review:• Relevant resources Relevant resources • Unique needs of women who have CODsUnique needs of women who have CODs• Importance of trauma and PTSDImportance of trauma and PTSD• Treatment approaches for trauma and PTSDTreatment approaches for trauma and PTSD

Women with CODs – Key Issues

Major depression, chronic substance Major depression, chronic substance abuse, other anxiety disordersabuse, other anxiety disorders

Trauma histories and PTSD Trauma histories and PTSD

-- May co-exist with depression and May co-exist with depression and anxietyanxiety-- PTSD may not be recognizedPTSD may not be recognized

Personality DisordersPersonality Disorders

Women with CODs – Key Issues

• High rates of victimizationHigh rates of victimization

• More medical problemsMore medical problems• Serious health risksSerious health risks• Unprotected sex with multiple and high-risk Unprotected sex with multiple and high-risk

partnerspartners

Dependency Issues

• Women with children in foster care and/or Women with children in foster care and/or involved in dependency court, are subject to involved in dependency court, are subject to Adoption and Safe Families Act, 1997Adoption and Safe Families Act, 1997

• Timeline for termination of parental rightsTimeline for termination of parental rights

• Goal – early and active engagement in treatmentGoal – early and active engagement in treatment

Trauma and Victimization

• Female offenders frequently have been Female offenders frequently have been victims of physical or sexual violencevictims of physical or sexual violence

• Trauma history – should be expectation for Trauma history – should be expectation for women in CJ settingswomen in CJ settings

• Impact of violence is widespread, can Impact of violence is widespread, can impair recovery from MH and SA disordersimpair recovery from MH and SA disorders

Physical and Sexual Violence Across the Lifespan

National Figures (All

U.S. Women)

Women Living In Poverty

Incarcerated Women

Severe Physical Violence by Childhood Caretakers Before Age 18

40%

63%

70%

Sexual Molestation in Childhood Before Age 16 (Any Perpetrator)

20-27%

42%

59%

Any Physical Violence or Sexual Molestation in Childhood

Not Available

72%

82%

Severe Physical Violence by Adult Intimate Partners

22% 61% 75%

Physical Violence or Sexual Assault by Intimates over Lifespan

Not Available

83%

94%

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Impact of Trauma

• Violation of trustViolation of trust

• Confusion over attachmentConfusion over attachment

• Never feeling safeNever feeling safe

• Confusion about intimacyConfusion about intimacy

• Forced to tell liesForced to tell lies

• Hold in feelings to surviveHold in feelings to survive

• Feeling of powerlessnessFeeling of powerlessness

• Overwhelming emotional painOverwhelming emotional pain

Practical Implications of Trauma

• Interaction with authority figuresInteraction with authority figures

• Disruption in sleep patternsDisruption in sleep patterns

• Self-injurious behaviorSelf-injurious behavior

• Rage and angerRage and anger

Long-Term Effects of Trauma - I

Cognitive and Perceptual EffectsCognitive and Perceptual Effects• Guilt, negativity, memory difficulties, Guilt, negativity, memory difficulties,

intrusive/obsessive thoughts, impaired intrusive/obsessive thoughts, impaired attention/concentrationattention/concentration

Emotional EffectsEmotional Effects• Depression, anxiety, other symptomsDepression, anxiety, other symptoms

Behavioral EffectsBehavioral Effects• Truancy and promiscuity among youthTruancy and promiscuity among youth• Self-injury, rageSelf-injury, rage

Long-Term Effects of Trauma - II

Sustained Effects on PersonalitySustained Effects on Personality - Symptoms of - Symptoms of Borderline Personality Disorder Borderline Personality Disorder

• Unstable interpersonal relationshipsUnstable interpersonal relationships• Fear of abandonmentFear of abandonment• Suicidal gesturesSuicidal gestures• Identity disturbanceIdentity disturbance• ParanoiaParanoia• EmptinessEmptiness• Intense angerIntense anger• DissociationDissociation

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Posttraumatic Stress Disorder (PTSD) - Diagnostic Criteria

• Exposure to a traumatic eventExposure to a traumatic event

• Traumatic event is persistently re-Traumatic event is persistently re-experienced in different waysexperienced in different ways

• Continuing avoidance of trauma-related Continuing avoidance of trauma-related stimuli, numbing of responsivenessstimuli, numbing of responsiveness

• Increased arousal (anxiety, vigilance)Increased arousal (anxiety, vigilance)

Symptoms of PTSD

•DepressionDepression•Grief and lossGrief and loss•IsolationIsolation•Interpersonal distancingInterpersonal distancing•MistrustMistrust•FutilityFutility•AnxietyAnxiety•Over stimulationOver stimulation•Sleep disturbancesSleep disturbances

•Rejection and betrayalRejection and betrayal•Anger, irritability, rageAnger, irritability, rage•Low self-esteemLow self-esteem•Alienation, avoidanceAlienation, avoidance•Fear of loss of controlFear of loss of control•Guilt and shameGuilt and shame•Intrusive thoughtsIntrusive thoughts•PsychosisPsychosis•Substance abuseSubstance abuse

PTSD and Women

• Rates of PTSD 2x higher among womenRates of PTSD 2x higher among women

• 94% of incarcerated women have experienced 94% of incarcerated women have experienced physical or sexual violencephysical or sexual violence

• One third will develop PTSD symptomsOne third will develop PTSD symptoms

• 33-59% of women in substance abuse 33-59% of women in substance abuse treatment have PTSDtreatment have PTSD

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• All women should be screened for trauma All women should be screened for trauma history across different justice settingshistory across different justice settings

• Initial screen does not have to be conducted by a Initial screen does not have to be conducted by a mental health clinician; doesn’t require mental health clinician; doesn’t require discussion of specific detailsdiscussion of specific details

• Many simple, non-proprietary screening Many simple, non-proprietary screening instruments availableinstruments available

• Positive screens should be referred for more Positive screens should be referred for more comprehensive assessment comprehensive assessment

Screening for Trauma/PTSD

Trauma and PTSD Screening Issues

• PTSD and trauma are often overlooked PTSD and trauma are often overlooked in screeningin screening

• Other diagnoses are used to explain Other diagnoses are used to explain symptomssymptoms

• Result – lack of specialized treatment, Result – lack of specialized treatment, symptoms masked, poor outcomessymptoms masked, poor outcomes

Foundations of Treatment

Provide integrated treatmentProvide integrated treatment Early focus on engagement and Early focus on engagement and

motivationmotivation Sense of optimism Sense of optimism Educate about trauma and CODsEducate about trauma and CODs Interventions at multiple levelsInterventions at multiple levels Encourage accountabilityEncourage accountability

Stages of Treatment

Stage One Stage One -- Focus on building trust, improving Focus on building trust, improving communication, stress management, education, communication, stress management, education, coping skills, stabilization and reduction of coping skills, stabilization and reduction of symptomssymptoms

Stage Two Stage Two - - Explore memories, exploring impact Explore memories, exploring impact of trauma and substance abuseof trauma and substance abuse

Stage Three Stage Three - - Integration of trauma experiences, Integration of trauma experiences, long-term coping strategies, and reconnection long-term coping strategies, and reconnection through work and relationshipsthrough work and relationships

Key Elements of Treatment - I

Explore relationship between SA/MH disorders and Explore relationship between SA/MH disorders and history of violencehistory of violence

Creation of safe and supportive environmentCreation of safe and supportive environment

Skill development to identify thoughts, feelings, Skill development to identify thoughts, feelings, behaviors, and to assist in recoverybehaviors, and to assist in recovery

Effective problem solvingEffective problem solving

Relaxation, grounding, stress reductionRelaxation, grounding, stress reduction

Key Elements of Treatment - II

Strengthening interpersonal skillsStrengthening interpersonal skills

Relapse preventionRelapse prevention

Alternatives to substance abuse and other Alternatives to substance abuse and other destructive behaviorsdestructive behaviors

Development of short-term and long-term “safety Development of short-term and long-term “safety plans” to protect self and childrenplans” to protect self and children

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Treatments for Trauma and Substance Abuse

• Seeking Safety (Najavits, 2002)Seeking Safety (Najavits, 2002)

• Trauma Recovery and Empowerment (TREM) Trauma Recovery and Empowerment (TREM) (Harris, 1998)(Harris, 1998)

• Treating concurrent PTSD and cocaine dependence Treating concurrent PTSD and cocaine dependence (Brady et al, 2001)(Brady et al, 2001)

• Substance Dependence Posttraumatic Stress Substance Dependence Posttraumatic Stress Disorder Therapy (Triffleman, Carrol, & Kellogg, Disorder Therapy (Triffleman, Carrol, & Kellogg, 1999)1999)

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Seeking Safety (Najavits, 2002)

• Manualized, modular formatManualized, modular format

• Integrates trauma and substance abuse Integrates trauma and substance abuse within 25 topic areaswithin 25 topic areas

• Guilford Press, 2002Guilford Press, 2002

• www.seekingsafety.orgwww.seekingsafety.org