Treatment Needs of Women with Co-Occurring

Disorders

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

OverviewOverview 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

Epidemiology & Cultural Issues

Epidemiology & Cultural Issues

Basic FindingsBasic 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 & AlcoholGreater vulnerability to biomedical and other

consequences: higher morbidity and mortality suicide liver disorders neuroendocrine effects

Minority Women and Alcohol UseMinority 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 WomenAfrican 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 WomenAsian 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 WomenNative 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)

LatinasLatinas 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 WomenOlder 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 FactorsPhysical 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 QuestionsResearch 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

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

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)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 IssuesWomen’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

TREATMENTISSUES

TREATMENTISSUES

Women & DrugsWomen & Drugs

Partner role in initiation Partner role in relapse Who leaves? Who stays? Shame dynamics Sex workers Help-seeking behavior

Common Psychiatric Comorbiditiesin Women

Common Psychiatric Comorbiditiesin Women

Depression Anxiety disorders, especially post traumatic stress

disorder (PTSD) Borderline personality disorder Eating disorders

DepressionDepression

DepressionDepressionCaveat: 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)

Mood & Anxiety Disorders: Treatment RecommendationsMood & 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)

Mood & Anxiety Disorders:Treatment Recommendations (2)

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)

SuicidalitySuicidality 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

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)

Post Traumatic Stress Disorder(PTSD)

PTSD: National Comorbidity StudyPTSD: National Comorbidity StudyRepresentative 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

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 ViolenceDomestic 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

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

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

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 RecoveryHow PTSD Complicates RecoveryMore 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

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

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 FoundationBuilding a FoundationBEWARE 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 TreatmentsPTSD 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 (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

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)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

Seeking Safety (3):Goals

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 SkillsSafe 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

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 ControlAnger 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 IssuesSpecial Issues

Barriers to Accessing Offsite Psychiatric Services

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 OnsitePrescribing 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 Feelingsabout Medication

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

Medication AdherenceMedication 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 WomenPregnant 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)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)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 IssuesChildren’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 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

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 IssuesCross-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 AskSome 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