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Stephanie S. Covington, Ph.D., LCSW Institute for Relational Development Center for Gender & Justice La Jolla, CA 43 rd Annual Addictions Conference May.

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Presentation on theme: "Stephanie S. Covington, Ph.D., LCSW Institute for Relational Development Center for Gender & Justice La Jolla, CA 43 rd Annual Addictions Conference May."— Presentation transcript:

1 Stephanie S. Covington, Ph.D., LCSW Institute for Relational Development Center for Gender & Justice La Jolla, CA 43 rd Annual Addictions Conference May 30, 2011 Toronto, Ontario The Addiction-Trauma Connection: Spirals of Recovery and Healing Spirals of Recovery and Healing

2 © S. Covington, 2011

3 Crisis=Danger & Opportunity © S. Covington, 2011

4 Levels of Violence Childhood Childhood Adolescence Adolescence Adult Adult Street (workplace and community) Street (workplace and community) Consumer Culture Consumer Culture Media Media War War Planet Planet © S. Covington, 2011

5 Global Violence Violence is a leading cause of death among people aged 15-29Violence is a leading cause of death among people aged Source: World Health Organization Centers for Disease Control and Prevention © S. Covington, 2011

6 International Homicide Rates (Rate per 100,000 in 2006) SOURCE: World Health Organization, 2006; FBI 2006; Statistics Canada; Australian Bureau of Statistics The death and disability caused by violence make it one of the leading public health issues of our time. World Health Organization © S. Covington, 2011

7 Two Kinds of Suffering Natural Natural Created Created © S. Covington, 2011

8 Definition of Trauma Definition of Trauma The diagnostic manual used by mental health providers (DSM IV-TR) defines trauma as, involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to ones physical integrity; or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate. (American Psychiatric Assoc. [APA] 2000, pg. 463). (American Psychiatric Assoc. [APA] 2000, pg. 463). © S. Covington, 2011

9 Definition of Trauma (cont.) The persons response to the event must involve intense fear, helplessness or horror (or in children, the response must involve disorganized or agitated behavior). (American Psychiatric Assoc. [APA] 2000, pg. 463). © S. Covington, 2011

10 Definition of Trauma Trauma occurs when an external threat overwhelms a persons internal and external positive coping resources. (Bloom & Fallot, 2009) (Bloom & Fallot, 2009) © S. Covington, 2011

11 Violence Against Women Violence against women is so pervasive that the United Nations has addressed and defined violence against women as any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivations of liberty, whether occurring in public or private life. (United Nations General Assembly, 1993). (United Nations General Assembly, 1993). © S. Covington, 2011

12 Moral Challenges 19 th century - slavery 19 th century - slavery 20 th century - totalitarianism 20 th century - totalitarianism 21 st century – brutality against women 21 st century – brutality against women and girls and girls (NY Times 9/23/09) © S. Covington, 2011

13 Traumatic Events Trauma can take many forms: Trauma can take many forms: Emotional, sexual or physical abuseEmotional, sexual or physical abuse NeglectNeglect Abandonment (especially for small children)Abandonment (especially for small children) Extremely painful and frightening medical proceduresExtremely painful and frightening medical procedures © S. Covington, 2011

14 Traumatic Events (cont.) Catastrophic injuries and illnessesCatastrophic injuries and illnesses Rape or assaultRape or assault MuggingsMuggings Domestic violenceDomestic violence BurglaryBurglary Automobile accidentsAutomobile accidents © S. Covington, 2011

15 Traumatic Events (cont.) ImmigrationImmigration Natural disasters (hurricanes, floods, earthquakes, tornadoes, fires, volcanoes)Natural disasters (hurricanes, floods, earthquakes, tornadoes, fires, volcanoes) Terrorism such as September 11, 2001Terrorism such as September 11, 2001 Witnessing violence such as a parent harming another parentWitnessing violence such as a parent harming another parent © S. Covington, 2011

16 Traumatic Events (cont.) Loss of a loved one and severe bereavements (even of a pet)Loss of a loved one and severe bereavements (even of a pet) Combat/warCombat/war TortureTorture KidnappingKidnapping Intergenerational (cultural) traumaIntergenerational (cultural) trauma © S. Covington, 2011

17 Historical Trauma Across generationsAcross generations Massive group traumaMassive group trauma Examples include: Aboriginal (First Nation), Native Americans, African Americans, Holocaust survivors, Japanese internment survivorsExamples include: Aboriginal (First Nation), Native Americans, African Americans, Holocaust survivors, Japanese internment survivors © S. Covington, 2011

18 Traumatic Events Of all these forms of trauma, women are at greater risk of interpersonal abuse than men. © S. Covington, 2011

19 Trauma-Informed Services Trauma-informed services: Trauma-informed services: Take the trauma into account.Take the trauma into account. Avoid triggering trauma reactions and/or traumatizing the individual.Avoid triggering trauma reactions and/or traumatizing the individual. (Harris & Fallot) (Harris & Fallot) © S. Covington, 2011

20 Trauma-Informed Services (cont) Adjust the behavior of counselors, other staff and the organization to support the individuals coping capacity.Adjust the behavior of counselors, other staff and the organization to support the individuals coping capacity. Allow survivors to manage their trauma symptoms successfully so that they are able to access, retain and benefit from the services.Allow survivors to manage their trauma symptoms successfully so that they are able to access, retain and benefit from the services. (Harris & Fallot) (Harris & Fallot) © S. Covington, 2011

21 Core Principles of Trauma-Informed Care Safety (physical and emotional)Safety (physical and emotional) TrustworthinessTrustworthiness ChoiceChoice CollaborationCollaboration EmpowermentEmpowerment (Fallot & Harris, 2006) (Fallot & Harris, 2006) © S. Covington, 2011

22 Process of Trauma TRAUMATIC EVENT Overwhelms the Physical & Psychological Systems Intense Fear, Helplessness or Horror SENSITIZED NERVOUS SYSTEM CHANGES IN BRAIN CURRENT STRESS Reminders of Trauma, Life Events, Lifestyle PAINFUL EMOTIONAL STATE RETREAT SELF-DESTRUCTIVE ACTION DESTRUCTIVE ACTION ISOLATION DISSOCIATION DEPRESSION ANXIETY SUBSTANCE ABUSE EATING DISORDER DELIBERATE SELF-HARM SUICIDAL ACTIONS AGGRESSION VIOLENCE RAGES RESPONSE TO TRAUMA Fight or Flight, Freeze, Altered State of Consciousness, Body Sensations, Numbing, Hyper-vigilance, Hyper-arousal

23 ACE Study (Adverse Childhood Experiences) Before age 18: Recurrent and severe emotional abuse Recurrent and severe physical abuse Contact sexual abuse Physical neglect Emotional neglect © S. Covington, 2011

24 Growing up in a household with: An alcoholic or drug-user A member being imprisoned A mentally ill, chronically depressed, or institutionalized member The mother being treated violently Both biological parents not being present (N=17,00) ACE Study (Adverse Childhood Experiences) © S. Covington, 2011

25 ACE Study (Adverse Childhood Experiences) Results ACEs still have a profound effect 50 years later, although now transformed from psychosocial experience into organic disease, social malfunction, and mental illness. SmokingSmoking AlcoholismAlcoholism Injection of illegal drugsInjection of illegal drugs ObesityObesity (Felitti, V.J.: Origins of Addictive Behavior: Evidence from the ACE Study Oct:52(8): German. PMID: (PubMed-indexed for MEDLINE). © S. Covington, 2011

26 Men 16% Sexual Abuse Men 30% Physical Abuse Women 27% Sexual Abuse (Felitti and Anda, 2010) ACE Study (continued) © S. Covington, 2011

27 Women 50% more likely than men to have a score of 5 or more. (Felitti & Anda, 2010) ACE Study (continued) © S. Covington, 2011

28 If a male child has six or more yes answers, his risk of becoming an IV drug user increases by 4,600% compared to a boy with a score of zero. (Felitti & Anda, 2010) ACE Study (continued) © S. Covington, 2011

29 Population Studied: 75% white 39% college (36% some) 18% high school grads Anda (Felitti & Anda, 2010) ACE Study (continued) © S. Covington, 2011

30 6 or more yes answers = 2 decades shorter life expectancy than person with 0 yes answers (Felitti & Anda, 2010) ACE Study (continued) © S. Covington, 2011

31 I see that you have… Tell me how that has affected you later in your life. (Felitti & Anda, 2010) ACE Study (continued) © S. Covington, 2011

32 Childhood Traumatic Events Largest Effect-Mental Health Psychotropic medication Psychotropic medication Mental health treatment Mental health treatment Attempted suicide Attempted suicide Traumatic stress Traumatic stress (Messina & Grella, 2005) (Messina & Grella, 2005) © S. Covington, 2011

33 Childhood Traumatic Events Largest Effect-Mental Health 980% increase in odds if exposed 980% increase in odds if exposed to 7 CTEs to 7 CTEs (Messina & Grella, 2005) (Messina & Grella, 2005) © S. Covington, 2011

34 Critical and Interrelated Issues Substance AbuseSubstance Abuse Mental HealthMental Health TraumaTrauma Physical HealthPhysical Health © S. Covington, 2011

35 Areas of Separation TrainingTraining TreatmentTreatment Categorical FundingCategorical Funding © S. Covington, 2011

36 Key Elements (Staff and Clients) Learn what trauma/abuse isLearn what trauma/abuse is Understand typical responsesUnderstand typical responses Develop coping skillsDevelop coping skills © S. Covington, 2011

37 Definition of Recovery The definition of recovery has shifted from a focus on what is deleted from ones life (alcohol and other drugs, arrests for criminal acts, hospitalizations) to what is added to ones life (the achievement of health and happiness). (Miller & Kurtz, 2005) (Miller & Kurtz, 2005) © S. Covington, 2011

38 Prevalence of Trauma and PTSD in Substance Use/Abuse 60% to 90% of a treatment-seeking sample of substance abusers also have a history of victimization60% to 90% of a treatment-seeking sample of substance abusers also have a history of victimization More than 80% of women seeking treatment for a substance use disorder reported experiencing physical/sexual abuse during their lifetimeMore than 80% of women seeking treatment for a substance use disorder reported experiencing physical/sexual abuse during their lifetime © S. Covington, 2011

39 Prevalence of Trauma and PTSD in Substance Use/Abuse Between 44% and 56% of women seeking treatment for a substance use disorder had a lifetime history of PTSDBetween 44% and 56% of women seeking treatment for a substance use disorder had a lifetime history of PTSD 10.3% of the men and 26.2% of the women with a lifetime diagnosis of alcohol dependence also had a history of PTSD10.3% of the men and 26.2% of the women with a lifetime diagnosis of alcohol dependence also had a history of PTSD © S. Covington, 2011

40 Histories of Trauma / Violence among Clients Treated for Methamphetamine Persons in treatment for methamphetamine report high rates of trauma Persons in treatment for methamphetamine report high rates of trauma 85% women85% women 69% men69% men © S. Covington, 2011

41 Histories of Trauma / Violence among Clients Treated for Methamphetamine Most common source of trauma/violence: For women, was a partner (80%)For women, was a partner (80%) For men, was a stranger (43%)For men, was a stranger (43%) History of sexual abuse 57% women57% women 16% men16% men © S. Covington, 2011

42 Disorders Related to Trauma and Substance Abuse in Womens Lives Depressive Disorders NOS 22.9%Depressive Disorders NOS 22.9% Major Depressive Disorders 17.5%Major Depressive Disorders 17.5% Post traumatic Stress Disorders 16.3%Post traumatic Stress Disorders 16.3% Neurotic Anxiety Disorders 13.8%Neurotic Anxiety Disorders 13.8% Bipolar Disorders 13.7%Bipolar Disorders 13.7% Mood or Dysthymic Disorders 5.3%Mood or Dysthymic Disorders 5.3% Psychotic Disorders 4.8%Psychotic Disorders 4.8% Personality and Misc. Disorders 5.8%Personality and Misc. Disorders 5.8% Source: Patterns of Comorbidity among Women with Childhood Interpersonal Trauma, Mental Health Disorders, and Substance Related Disorders. Journal of Behavioral Health Services & Research (in press) © S. Covington, 2011

43 Post-Traumatic Stress Disorder Re-experiencing the event through flashbacks and nightmares.Re-experiencing the event through flashbacks and nightmares. Avoidance of stimuli associated with the event (for example, if a woman was raped in a park, she may avoid parks, or if she was assaulted by a blonde man, she may avoid men with blonde hair).Avoidance of stimuli associated with the event (for example, if a woman was raped in a park, she may avoid parks, or if she was assaulted by a blonde man, she may avoid men with blonde hair). © S. Covington, 2011

44 Estrangement (the inability to be emotionally close to anyone)Estrangement (the inability to be emotionally close to anyone) Numbing of general responsiveness (feeling nothing most of the time)Numbing of general responsiveness (feeling nothing most of the time) Post-Traumatic Stress Disorder (cont.) © S. Covington, 2011

45 Post-Traumatic Stress Disorder (cont.) Hyper-vigilance (constantly scanning ones environment for danger, whether physical or emotional)Hyper-vigilance (constantly scanning ones environment for danger, whether physical or emotional) Exaggerated startle response (a tendency to jump at loud noises or unexpected touch) (DSM – IV)Exaggerated startle response (a tendency to jump at loud noises or unexpected touch) (DSM – IV) © S. Covington, 2011

46 Sexual abuseSexual abuse Physical abusePhysical abuse Emotional abuseEmotional abuse Domestic violenceDomestic violence Witnessing abuse/violenceWitnessing abuse/violence Self-inflicted violenceSelf-inflicted violence Military sexual assault (MST)Military sexual assault (MST) Trauma and Abuse © S. Covington, 2011

47 Trauma of Stigmatization PovertyPoverty Race/CultureRace/Culture Sexual OrientationSexual Orientation Mental IllnessMental Illness Physical DisabilityPhysical Disability IncarcerationIncarceration Trauma and Abuse (cont.) © S. Covington, 2011

48 Trauma GenderDifferences Gender Differences © S. Covington, 2011

49 Gender-Responsive Treatment Creating an environment through:Creating an environment through: site selectionsite selection staff selectionstaff selection program developmentprogram development content and materialcontent and material that reflects an understanding of the realities of the lives of women and girls, andthat reflects an understanding of the realities of the lives of women and girls, and addresses and responds to their strengths and challenges.addresses and responds to their strengths and challenges. Source: Covington, S.S., & Bloom, B.E. (2006). Gender-responsive treatment and services in correctional settings. In E. Leeder (Ed.), Inside and out: Women, prison, and therapy. Binghamton, NY: Haworth. © S. Covington, 2011

50 Gender-Responsive Materials (Trauma-informed) Women and Addiction: A Gender-Responsive Approach Helping Women Recover Helping Men Recover Voices: A Program for Girls Beyond Trauma: A Healing Journey for Women Women in Recovery A Womans Way through The Twelve Steps Beyond Violence: A Prevention Program for Women

51 Trauma Materials for Women ATRIUM (Dusty Miller)ATRIUM (Dusty Miller) Beyond Trauma (Stephanie Covington)Beyond Trauma (Stephanie Covington) Healing Trauma (Stephanie Covington)Healing Trauma (Stephanie Covington) Seeking Safety (Lisa Najavits)Seeking Safety (Lisa Najavits) TREM (Maxine Harris)TREM (Maxine Harris) Trauma Materials for Men Trauma Materials for Men M-TREM (Roger Fallot)M-TREM (Roger Fallot) © S. Covington, 2011

52 Helping Women Recover: A Program for Treating Addiction Theory of Addiction Holistic health model Holistic health model Chronic neglect of self in favor of something or Chronic neglect of self in favor of something or someone else someone else Theory of Womens Psychological Development Relational–Cultural Model (Stone Center) Relational–Cultural Model (Stone Center) Theory of Trauma Three Stage Model (Herman) Three Stage Model (Herman) Upward Spiral – A Transformational Model Upward Spiral – A Transformational Model (Covington) (Covington) © S. Covington, 2011

53 Helping Men Recover: A Program for Treating Addiction By Covington, Griffin & Dauer © S. Covington, 2011

54 Impact of male socialization on the recovery processImpact of male socialization on the recovery process Relational needs of menRelational needs of men Issues of abuse and traumaIssues of abuse and trauma Self, relationships, sexuality and spiritualitySelf, relationships, sexuality and spirituality Helping Men Recover © S. Covington, 2011

55 Power and Control Wheel From the manual In Our Best Interest: A Process for Personal and Social Change. Available through Domestic Abuse Intervention Project, 206 W. 4th St., Duluth, MN © S. Covington, 2011

56 Voices: A Program of Self-Discovery and Empowerment for Girls Theory of Girls Psychological Development Relational–Cultural Model (Stone Center, Gilligan, Brown) Theory of Attachment Ainsworth, Bowlby, Harlow, Stern Theory of Trauma Three Stage Model (Herman) Transformational Spiral (Covington) Theory of Resilience Biscoe, Wolin & Wolin Theory of Addiction Holistic Health Model

57 © S. Covington, 2011 Beyond Trauma: A Healing Journey for Women Beyond Trauma: A Healing Journey for Women Trauma Theory Sandra Bloom, M.D. Mary Harvey, Ph.D. Judith Herman, M.D. Peter Levine, Ph.D. Integrates cognitive-behavioral, expressive arts, guided imagery, and relational therapy.

58 © S. Covington, 2011 Client Assessment Scores Improve after Completion of HWR and BT Mean Score Change Source: KIVA Program records – BDI & TSC Assessment, August 31, 2004 – October 13, 2006 Keaton, Curtis, and Burke (2006) SANDAG (p <.05 or less)

59 © S. Covington, 2011 Prison Study (NIDA Funded) Randomized control groupRandomized control group Gender-responsive vs. Therapeutic CommunityGender-responsive vs. Therapeutic Community Significant differencesSignificant differences Greater reduction of drug use More likely to complete treatment Remained longer in aftercare Less recidivism (re-incarcerated) at 12 months (p.05)

60 © S. Covington, 2011 Drug Court Study (NIDA Funded) Four sites in San Diego CountyFour sites in San Diego County Randomized control groupRandomized control group Preliminary resultsPreliminary results Less substance use Fewer sanctions Longer in treatment Judge notices differences

61 © S. Covington, 2011 Trauma: Stages of Recovery Syndrome Stage One Stage Two Stage Three Hysteria (Janet 1889) Stabilization, Symptom- oriented treatment Exploration of traumatic memories Personality reintegration, rehabilitation Combat trauma Scurfield (1985) Trust, stress- management education Re-experiencing trauma Integration of trauma Source: Herman, 1992, 1997

62 © S. Covington, 2011 Trauma: Stages of Recovery Syndrome Stage One Stage Two Stage Three Complicated post-traumatic stress disorders Stabilization Integration of memories Development of self, drive integration Source: Herman, 1992, 1997

63 © S. Covington, 2011 Trauma: Stages of Recovery Syndrome Stage One Stage Two Stage Three Multiple personality disorder (Putnam 1989) Diagnosis, stabilization, communication cooperation Metabolism of trauma Resolution, integration, development of post-resolution coping skills Traumatic disorders (Herman 1992) Safety Remembrance and mourning Reconnection Source: Herman, 1992, 1997

64 © S. Covington, 2011 Trauma Three Group Models Group Recovery Stage One Recovery Stage Two Recovery Stage Three Therapeutic task Safety Remembrance and mourning Reconnection Time orientation PresentPast Present, future FocusSelf-careTrauma Interpersonal relationships Source: Herman, 1992, 1997

65 © S. Covington, 2011 Trauma Three Group Models Group Recovery Stage One Recovery Stage Two Recovery Stage Three MembershipHomogeneousHomogeneousHeterogeneous Boundaries Flexible, inclusive Closed Stable, slow turnover CohesionModerate Very high High Source: Herman, 1992, 1997

66 © S. Covington, 2011 Trauma Three Group Models Group Recovery Stage One Recovery Stage Two Recovery Stage Three Conflict tolerance LowLowHigh Time limit Open-ended or repeating Fixed Limit Open-ended StructureDidacticGoal-directedUnstructured Example Twelve-step programs Survivor group Interpersonal psychotherapy group Source: Herman, 1992, 1997

67 © S. Covington, 2011 Emerging Paradigm Values-Based Services Gender-responsive Gender-responsive Trauma-informed Trauma-informed Culturally competent Culturally competent Recovery-oriented Recovery-oriented

68 © S. Covington, 2011 Sanctuary

69 What is Sanctuary? Sacred placeSacred place Place of refuge/protectionPlace of refuge/protection ShelterShelter OasisOasis

70 © S. Covington, 2011 What Makes a Difference? Creating a safe environmentCreating a safe environment Listening to her/his storyListening to her/his story EmpathyEmpathy

71 © S. Covington, 2011 Upward Spiral Addiction& Trauma Trauma (constriction) (constriction)Recovery&Healing(expansion) Transformation


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