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Women and DUI Part II

California Association of Drinker Driver Treatment Programs 2007 Fall Forum

Deborah WernerChildren and Family Futures, Inc.

4940 Irvine Boulevard, Suite 202 * Irvine, CA 92620714/505.3525 * dwerner@cffutures.org

www.cffutures.org/calwcf

This Presentation is Made Possible Through a Contract This Presentation is Made Possible Through a Contract with the State of California Department of Alcohol and Drug Programs

Part 1I: Gender Responsive Services

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Gender Differences at TreatmentReasons cited for not getting treatment by women classified as needing but not receiving treatment and who felt a need for treatment included: • 33% felt not ready to stop using• 27% felt could handle the problem on their own• 22% were concerned with stigma (compared to 10%

of men)17% ld t ff d t t t• 17% could not afford treatment

• 9 % did not have time (compared with 2% of men)• 8% did not know where to go, 7% indicated the

program type unavailable, 4% no openings and 4% transportation.

Source: Online analysis of the NSDUH 2003 Public Use file

Male-Based Approach• Knowledge of factors that contribute to DWI and

high-risk driving almost exclusively from studies of males. males.

• Factors: demographic characteristics; excessive alcohol use; personality traits; acute states of emotional distress; and driving-related attitudes.

• DUI Services based on a cognitive-behavioral model that integrates the influence of these factors on driving riskdriving risk.

(Donovan et al., 1983).

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Treatment for WomenGENDER DIFFERENCES

Bi l i l

SERVICE RESPONSES

80s/90s Gender Specific: S t f iliti• Biological

• Psycho-social

• Parenting/Family

• Motivators & Barriers

• Treatment Needs

• Recovery Support Needs

• Separate facilities

• Separate groups/services

• Childcare

2000s Gender Responsive:• Trauma Informed

• Strengths Basedy pp g

• Relational Theory

Adapted from Christine Grella, Ph.D., What’s so Special About Specialized Treatment for Women presented Adapted from Christine Grella, Ph.D., What’s so Special About Specialized Treatment for Women presented at National Conference on Women, Addictions and Recovery, July 2006. at National Conference on Women, Addictions and Recovery, July 2006.

CSAT Model of Comprehensive Services for Women & Children

CSAT Women, Youth and Families Task Force (2004). Unpublished draft.

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Comprehensive Model includes:Components• Clinical treatment services for women• Clinical support services for women• Community support services for women• Clinical treatment services for children• Clinical support services for children• Community support services for children

Cultural Competence, Gender Competence and Developmentally Appropriate

Characteristics of Gender Responsive Services

• Relational• Strength-based, motivational• Comprehensive• Comprehensive• Trauma informed• Address the different pathways to use,

consequences of use, motivations, treatment issues and relapse prevention needs unique to women

• Provided in an environment where women feel comfortable and safe

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Culturally Relevant Treatment

• Honors traditions and values• Acknowledges cultural pain and racism• Builds appropriate efficacy and support• Staff, management and Board reflective• Respects individuals• Differentiates drug culture from culture itself• Helps people learn cultural traditions

i• Relational

Clinical Treatment Services

FOR WOMEN• Outreach and Engagement• Screening• Pharmocotherapy

FOR CHILDREN• Intake• Screening• Medical Care and Servicesa ocot e apy

• Drug monitoring• Treatment planning • Mental health Services• Detoxification• Medical Care and Services• Assessment• Substance Abuse Counseling and

Education

e ca Ca e a Se v ces• Therapeutic Child Care• Development Services• Mental Health and Trauma

Services• Assessment• Residential Care in Residential

Settings• Case ManagementEducation

• Trauma Informed and Trauma-Specific Services

• Crisis Intervention• Case Management• Continuing Care

Case Management• Substance Abuse Education &

Prevention• Care Planning

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Clinical Support ServicesFOR WOMEN• Life skills• Advocacy

FOR CHILDREN• Primary health care services• Onsite or healthy child careAdvocacy

• Primary health care services• Family programs• Parenting and child

development education• Housing support• Education remediation and

support

Onsite or healthy child care• Recovery community

support services• Advocacy• Educational services• Recreational services• Prevention services• Mental health and

• Employment readiness services

• Linkages with legal system and child welfare systems

• Recovery community support services

• Life skills

remediation services

Community Support Services• Transportation• Child care

H i i• Housing services• Family strengthening• Recovery community support services• Employer support services• TANF linkages

V i l d d i d i i• Vocational and academic education services• Faith based organization support• Recovery management

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Strategies for Working with Women

Characteristics of Gender Responsive Services

• Relational• Strength-based, motivational• Comprehensive• Comprehensive• Trauma informed• Address the different pathways to use,

consequences of use, motivations, treatment issues and relapse prevention needs unique to women

• Provided in an environment where women feel comfortable and safe

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Selected Strategies• Welcoming/Relational• Strength-Based• Trauma• Relationships• Motivational

Welcoming• Welcoming environment

• Trusting relationship

• Building self efficacy

• Strength-based

• Perceived utility

• Ancillary services

• Empathetic counseling style

• Motivational interviewing

• Knowing consequences and alternatives

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Relational• Role Models• People who Care• People to Talk with• Safe Environment• Not a Tool for the Group Process• Female Staff and Peers

Strength-Based Focus

• What does she have - rather than what she d t hdoes not have

• What can she do - rather than what she cannot do

• What has she been successful at rather than how she has failedhow she has failed

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Major and/or repeated trauma becomes the core event in the life of the woman that defines:

Trauma

• Sense of self• Sense of efficacy• World view• Coping skills• Relationships with othersRelationships with others• Ability to regulate emotions• How one approaches services• How one approaches the culture of the courts

TraumaA meta-analysis of 126 studies on co-occurrence

between childhood abuse and substance abuse f d f 45% f d lt i found an average of 45% of adult women in treatment experienced childhood sexual abuse and 39% childhood physical abuse. For adolescent girls prevalence was 61% for sexual abuse and 46% for physical abuse. (Simpson and Miller, 2002)and Miller, 2002)

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3 Selves• The Real Self – contains the true self – the highest

potentialities for self realization and the actual self – those elements of personality such as strengths and weaknesses, p y g ,assets and liabilities

• The Despised Self– all of the unacceptable character defects which make one “unlovable” and despicable are stored. Contains shame, hurt, anger, inadequacy and fear.

• The False Self – delusion based on how people believe they should be, think, behave and feel. Can be grandiose or self-effacing, Based on others.

from Sandel, James “From Self to Self: Making Recovery Real” The Counselor, Nov/Dec 1990

Women benefit from nurturing strategies for actualizing the Real Self.

Addressing Trauma• Avoid retraumatizing women

• Non-confrontational soft approach

• Traumatized women over-respond to neutral cues and under-respond to danger

• Create safe environments

• Be aware of possible triggers and avoid triggering trauma response. p

• Develop referrals and linkages to support clients to identify triggers, self-soothe, ground and remain in services.

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Trauma Programs

• Clark, C., Fearday, F. (eds) (2003) Triad Women’s Project: Group facilitators manual. Tampa, FL: Louis de la Parte Florida Mental pHealth Institute, University of South Florida. (contact Colleen Clark at cclark@fmhi.usf.edu)

• Covington , S. S. (2003) Beyond Trauma: A Healing Journey for Women. Center City, MN: Hazelton Press. (Contact Stephanie Covington at sscird@aol.com)

• Ford, J.D., Mahoney, K., Russo, E., Kasimer, N., & MacDonald, M. (2003). Trauma Adaptive Recovery Group Education and Therapy (TARGET): Revised Composite 9-Session Leader and Participant Guide. Farmington, CT: University of Connecticut Health Center. (Contact Julian Ford at ford@psychiatry.uchc.org )

Trauma Programs continued

• Harris, M. (1998). Trauma, Recovery and Empowerment: A Clinician’s Guide for Working with Women in Groups. New York, NY: Free Press. (Contact Rebecca Wolfon Berley at rwolfson@ccdc1.org)

• Miller, D., & Guidry, L. ( 2001). Addictions and Trauma Recovery: Healing the Mind, Body, and Spirit. New York: W.W. Norton. (Contact Dusty Miller at dustymi@valinet.com)

• Najavits, L. (2001). Seeking Safety: Cognitive-Behavioral Therapy for PTSD and Substance Abuse. New York: Guilford. (Go to fo S a d Substa ce buse. ew o : Gu o d. (Go to www.seekingsafety.org)

• Saakvitne, K. W., Gamble, S.J., Pearlman, L.A., Lev, B.T. (2000). Risking Connection: A Training Curriculum for Working with Survivors of Childhood Abuse. Maryland: Sidran. (Go to www.sidran.org)

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Supportive Relationships

• Women, compared to men, are: i i / • More likely to report that their spouse/partners

encouraged initial and current drug use and less likely to pressure them to enter treatment

• Less likely to report help/support from family or friends

• More likely to report that family or friends used drugs in the past year (Grella & Joshi, 1999)

• Outcomes all improve when a partner/family participates in treatment BUT

• More than three-fourths of women participating in the RWC/PPW reported that their families were involved in alcohol- or drug-related activities

• Almost half (42.9%) of women in the RWC/PW programs reported having fewer than two friends

h did t dwho did not use drugs (Conners et al., 2004).

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Relationships

• Counselor:Client relationship

• Peer support (what is a healthy friendship?)

• Family (as defined by client)

• Self-esteem building interactions

• Reduced powerless … more assertiveness

• Communication skills

• Knowing children are safe

• Filling the “empty hole inside”

Relapse and Recovery

• Recovery - act of regaining or returning toward a normal or healthy state toward a normal or healthy state

• Relapse - slip or fall back into a former worse state (as of illness) after a change for the better.• Must first admit have problem

• Relapse does not occur until after actionRelapse does not occur until after action

• Moving from Acute to Chronic Perspective of Treatment

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Current Drinking Pattern of Individuals Meeting Criteria for Alcohol Dependence in the Past Year

percent of females

percent of males

No past month alcohol use 0.9% 1.9%Past month use but not binge use 3.5% 4.3%Binge use but not heavy use 17 5% 19 2%

for Alcohol Dependence in the Past Year

Office of Applied Studies (August 2, 2007). Gender Differences in Alcohol Use and Alcohol Dependence or Abuse: 2004 and 2005. Rockville, MD: Substance Abuse and Mental Health Services Administration. Available at http://www.oas.samhsa.gov

Binge use but not heavy use 17.5% 19.2%Heavy use 44.9% 44.6%

Considerations in Relapse • Women have more barriers to sustained

participation than men.

W j d d h hl f l h l/d • Women are judged more harshly for alcohol/drug problems than men.

• Women take on the alcohol/drug patterns of their partners, where men do not.

• Women with alcohol/drug problems have more emotional problems than men.p

• Women are more likely to experience negative feelings prior to relapse. Men are more likely to experience positive experiences and use as a reward.

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Motivational Interviewing & Engagement Strategies

Motivational Interviewing

• Express empathy through reflective listening.• Develop discrepancy between client’s goals or Develop discrepancy between client s goals or

values and their current behavior.• Avoid argument and direct confrontation• Adjust to client resistance rather than opposing it

directly.S t lf ffi d ti i• Support self-efficacy and optimism.

(source: SAMHSA TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment)

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FRAMES approach

• Feedback: regarding risk is given to individual.

• Responsibility: for change is placed with individual.

• Advice: about changing is clearly given in a non-judgmental manner.

• Menu: of self-directed change options and treatment alternatives.

• Empathetic Counseling: showing warmth, respect, and understanding. (uses reflective listening).

• Self-Efficacy: optimistic empowerment is engendered to encourage change.

(source: SAMHSA TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment)

Listening• Empathy. Put yourself in someone else's shoes.

Empathy is not the same as sympathy.• Non-judgmental behavior• Non-judgmental behavior• Repeat what you hear (paraphrase)• Nod, Make statements like "Uh huh"• Speak clearly, slowly and simply • Be direct, do not use jokes• Avoid arguments about what the participant is g p p

experiencing, seeing, feeling• Understand how the situation affects the participant.

What affects one person, may not affect another.• Help participant understand the available options

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Body Language• Be aware of your facial expressions• Be aware of tone, volume, cadence (i.e. "Is there

something bothering you?" is a statement that could be something bothering you? is a statement that could be said with caring and concern or with an "attitude.”)

• Be aware of your posture and stance• Do not fold arms or clench fists. This represents an

authoritative position which might threaten the client.• Do not conceal your hands. An individual who is paranoid

b li h h may believe that you have a weapon.• Personal Space• Avoid the challenge position which is eye-to-eye, toe-to-

toe.• Maintain 2-3 feet between you and participant for safety.

Enhancing Motivation

• Distress levels • Critical life events• Critical life events• Cognitive evaluation or appraisal• Recognizing negative consequences• Positive and negative external incentives

Cli i i ’ t k i t li it d h • Clinician’s task is to elicit and enhance motivation

(source: SAMHSA TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment)

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Motivators

• Contingency’s• Contingency s• Contracts• Carrots and Sticks• Build on Strengths• Building Self-EfficacyBuilding Self Efficacy• Do-able Goals and Objectives• Celebrating Successes

Comprehensive Development

• KnowledgeSkill• Skills

• Attitude• Efficacy and Sense of Worth• New Habits Emerge with Time

do for … do with … cheer on

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Program Analysis• Staffing• Education – female examples and experiences• Education – uses emotional examples, non-

shaming• Counseling – addressing powerlessness• Check-ins – resources and case management,

screening for mental health, violenceg• Safe Environment