Transcript No Slide Title

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
Overview
 Epidemiology
& Cultural Issues
• In the general population
• In criminal justice settings
 Treatment
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Issues
Comorbid psychiatric disorders
Relationship issues
Domestic violence
Practical issues
Children’s issues
Epidemiology &
Cultural Issues
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)
Women & Alcohol
Greater vulnerability to biomedical and other
consequences:
 higher morbidity and mortality
 suicide
 liver disorders
 neuroendocrine effects
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)
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)
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)
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)
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)
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)
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
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)
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)
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
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
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
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
TREATMENT
ISSUES
Women & Drugs
 Partner
role in initiation
 Partner role in relapse
 Who leaves? Who stays?
 Shame dynamics
 Sex workers
 Help-seeking behavior
Common Psychiatric Comorbidities
in Women
 Depression
 Anxiety
disorders, especially post traumatic stress
disorder (PTSD)
 Borderline personality disorder
 Eating disorders
Depression
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)
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Mood & Anxiety Disorders:
Treatment Recommendations
Distinguish anxiety and mood disorders from:
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Normal feelings in recovery
Symptoms of severe mental illness
Medical conditions
Medication side effects
Substance-induced changes
(COD TIP, in press)
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
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(COD TIP, in press)
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)
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)
Post Traumatic Stress Disorder
(PTSD)
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)
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)
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)
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)
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)
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)
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
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)
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
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
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)
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
Seeking Safety: (2)
 Four
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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
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)
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)
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)
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
Special Issues
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)
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)
Attitudes and Feelings
about 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
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
Pregnant Women
 Major
barriers, due to liability and other issues
 Criminalizing the pregnant woman will cause her to
avoid prenatal care
 Treatment must be comprehensive, with strong linkages
to obstetrical care
 Important to engage family/household members, but
program staff are often not trained to do so
 Methadone maintenance the treatment of choice for
opioid addicted pregnant women
HIV and HCV (1)
 Women
account for an increasing proportion of
AIDS cases
 High rates in African American and Hispanic
women
 Similar patterns of increase in hepatitis C
HIV and HCV (2)
 Imbalance
of power influences risk reduction
behaviors
 Difficulties negotiating condom use
 Managing caretaking responsibilities
 Fear of transmitting the viruses to family
members
 Anxiety and guilt if child show illness
Children’s Issues
 Bonding
with mother; early separation
 History of trauma; witnessing violence
 Fetal alcohol syndrome and effects
 Effects of prenatal drug exposure
 Learning difficulties; ADHD
FETAL ALCOHOL SYNDROME (FAS)
Fetal
growth retardation
• weight, length, head circumference
Facial
abnormalities
Mental retardation
Since no “safe level of drinking has yet been defined for pregnant
women, abstinence during pregnancy is the surest method for
preventing FAS.
Prenatal Alcohol Exposure:
Other Effects
 Alcohol-related
birth defects (ARBD) – Any of a number of
anomalies (e.g., heart or kidney defects) present at birth that are
associated with maternal drinking during pregnancy
 Alcohol-related
neurodevelopmental disorder (ARND) –
Evidence of CNS abnormality (small head, neurological signs);
evidence of a behavioral or cognitive disorder inconsistent with
expected developmental level, with hereditary factors, or with
environment; or both
(Alcohol and Health: 10th Special Report to Congress, 2000)
Social Service System Issues
 Children
as a motivator
 Children as a relapse hazard
 Unrealistic time frames
 Variable quality of social workers
 Visitation problems
 Coerced medication
Cross-Cultural Treatment Issues
 Attitudes
about sexual trauma (devaluation)
 Attitudes about disclosing interpersonal violence; fears of
abandonment
 Gender roles; patriarchy; degree of acculturation
 Institutional racism
 Lack of trust in police, social agencies, mental health
services
(Jo-Ellen Brainin-Rodriguez, MD Jan 1998)
Women-Sensitive Program Issues
 Female
staff at all levels of hierarchy
 Forthright feedback without harsh confrontation
 Women-only activities
 Priority (not barriers) for pregnant women
 Child care and links to medical services for kids
 Parenting classes
 Job training and life skills
Some Questions to Ask
 What
types/range of psychiatric disorders
 Credentials/qualifications of staff
 Psychiatry on site or by referral
 Attitudes/policies about medication
 Counselor training to promote compliance with
psychiatric treatment component
 Integrated, parallel, sequential treatment