Transcript Integrated trauma and substance misuse services

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KAREN BAILEY,
KINGS COLLEGE LONDON
NATIONAL ADDICTION CENTRE
INSTITUTE OF PSYCHIATRY PSYCHOLOGY
AND NEUROSCIENCE (IOPPN),
[email protected]
Integrated trauma and
substance misuse
services - what can
practice from the USA tell
us?
+ SAMSHA Women and Co-occurring Disorders and
Violence Study (2000-2005) - overview
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2,700 women - 9 sites across USA. Intervention = trauma
informed and integrated services for substance use, violence
and mental health.
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Phase 1 (2 years): cross site framework for service
intervention, local strategies, M&E
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Phase 2 (3 years): implementation and evaluation, 3, 6 and 12
month assessments
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Cross-site framework
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Gender specific
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Culturally competent
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Trauma-informed
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Trauma-specific
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Integrated; clinical and organisational level
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Informed by service users
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Comprehensive
COMPREHENSIVE = Eight core services
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outreach and engagement
screening and assessment
ongoing treatment activities
parenting skills training
resource coordination and advocacy
trauma specific services
crisis intervention
peer-run services
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Characteristics of study
participants
 Current
diagnosis of substance use problem or
PTS with history of other in past five years n=2,700
 Mean age: 36 yrs
 51 % BME
 70% had experienced homelessness at some point
in their lives
 50% reporting current serious illness or physical
disability
 90% receiving mental health treatment in past
 Average age when first mental health problem
began 14yrs
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Characteristics of study
participants
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50% Regular use of drugs and alcohol for at least 10 yrs
50% regular use of alcohol to intoxication in last five yrs
85% physical abuse in adulthood
60% sexual abuse in adulthood
47-55% dv in past 6 months (Physical and sexual abuse only)
73% emotional abuse or neglect as a child
62% sexual abuse in childhood
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WCDV Study Washington DC site
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Lead: Mental health agency
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Integrated trauma service teams
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TREM groupwork
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Other groups – spirituality in trauma recovery, domestic
violence groups, alcohol and drug treatment for trauma
survivors, relapse prevention, trauma issues and HIV
infection, parenting
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Women support and empowerment centre
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Access to psychiatric care, medication, 24 hour crisis line
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Trauma Recovery and
Empowerment Profile (TREP)
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12 DOMAINS, E.G:
• self awareness
• self protection
• self soothing
• emotional regulation
• accurate labeling of self and others
• sense of agency and initiative taking
• reliable parenting
• possessing a sense of purpose and meaning
• judgement and decision making
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LESSONS LEARNED
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importance of trauma informed context
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safe housing
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booster groups
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advanced relationship work
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WCDV Study - findings (Morissey
et al 2005)
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Six months - women in intervention sites showed slightly
greater reductions in drug use and PTS at 6 months - leveled
off at 12 months
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Women in some sites did far better than in others. Greater %
of women with more severe symptoms did better in sites that
had more integrated groupwork
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Total cost of integrated services was no more than treatment
as usual
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Fowler and Faulkner Meta-analysis
- 2011
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Women who had experienced recent domestic violence had
more successful alcohol and drug reduction when
participating in the trauma-focused interventions compared
to women who had not
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Women and Trauma study (Hien et
al 2009)
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14 Substance Misuse services, 350 participants
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RCT: Seeking Safety (SS) (condensed, 12 sessions over 6
weeks) vs Women's Health Education (WHE)
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Group on average – SS did not outperform on PTS or
substance use
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Subgroups: women with more severe substance use and PTS
at baseline did better in SS
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Those women who demonstrated improvement in PTS over
the course of the study were more likely to be in the low and
infrequent substance use trajectory at 12 months
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WCDV Study - Lessons learned 1
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SERVICE SYSTEM INTEGRATION
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establishing and maintaining 'buy-in' over time was critical to
the success of the project, but also a major challenge that
required strong commitment and constant communication.
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Relationship building early-on was key and impacted the
degree to which systems change occurred over time.
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Systems integration efforts must go beyond substance abuse,
mental health, and trauma systems to include a broader range of
stake- holders.
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Change can be facilitated by one or two people who inspire
others and are persuasive about the need to alter practices and
program operations within their agencies
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WCDV Study - Lessons learned 2
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CLINICAL INTEGRATION
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Co-facilitation is an effective strategy that can enhance integration at
both the service and systems levels
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Multi-disciplinary case conferencing was an effective approach for
promoting service and systems integration
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SERVICES
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Sites experienced difficulty retaining women in services, especially
the trauma groups, and were challenged to explore options for
boosting retention
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Group interventions can stimulate positive relationship formation
among women to promote recovery
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Women had a need for continuing services and supports, especially
after graduation from the trauma groups
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WCDV Study - Lessons learned 3
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SERVICE USER INVOLVEMENT
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Service users made an immeasurable impact on the project
to transform how services were designed, delivered, and
evaluated
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Challenging - more planning for service user involvement
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CROSS CUTTING ISSUES
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Initial resistance
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Cross-training
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Ongoing supervision, management and support of staff
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