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Trauma-Informed Practices for Treating Co-Occurring Disorders Plenary Panel Norma Finkelstein, PhD Institute for Health and Recovery Roger Fallot, PhD.

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Presentation on theme: "Trauma-Informed Practices for Treating Co-Occurring Disorders Plenary Panel Norma Finkelstein, PhD Institute for Health and Recovery Roger Fallot, PhD."— Presentation transcript:

1 Trauma-Informed Practices for Treating Co-Occurring Disorders Plenary Panel Norma Finkelstein, PhD Institute for Health and Recovery Roger Fallot, PhD Community Connections Lisa Russell, PhD ETR Associates Vivian B. Brown, PhD PROTOTYPES Gloria Gonzales Family Ties

2 Institute for Health and Recovery Overview on Trauma-Informed Practices Norma Finkelstein, PhD Institute for Health and Recovery

3 I Drank to Their Diseases They pretended that there was nothing wrong, Their lies stole my trust. The said that they were “normal.” I felt insane. They said, “We love you,” I was alone. I used alcohol to kill the pain. It made me a liar. I drank to feel “normal,” I became insane. I cried, “Please love me!” I was still alone. – Katherine, age 40 (Source: Evans and Sullivan, Treating Addicted Survivors of Trauma, 1995, p. 1)

4 Institute for Health and Recovery Trauma Definition Extreme stress that overwhelms a person’s ability to cope The subjective experience of a threat to life, bodily integrity or sanity A normal response to an abnormal event that results in a disruption of equilibrium

5 Institute for Health and Recovery TRAUMATIC EVENTS ARE EXTRAORDINARY, not because they occur rarely, but rather because they overwhelm the ordinary human adaptations to life. Unlike commonplace misfortunes, traumatic events generally involve threats to life or bodily integrity, or a close personal encounter with violence or death. They confront human beings with the extremities of helplessness and terror, and evoke the responses of catastrophe. The common denominator of trauma is a feeling of intense fear, helplessness, loss of control, and threat of annihilation. (Judith Herman, MD, Trauma and Recovery, 1992)

6 Institute for Health and Recovery ‘Going Out of My Mind’ “That’s a victim thing; you ask yourself, ‘Am I just crazy? Did I make all this up?’ Somehow it might be easier to accept that you’re crazy and you made it all up than to admit that it happened and how awful it was.” Teri Hatcher, star of TV show Desperate Housewives and survivor of child sexual abuse by her uncle. (Source: Janet Yassen, VOV Program, Cambridge Hospital, 2006)

7 Institute for Health and Recovery Traumatic Events Physical Assault Sexual Abuse including sex work Emotional/ Psychological Abuse Domestic Violence War/Genocide Accidents Natural or Man-Made Disaster Witnessing abuse/violence Living in dangerous environment Experienced as an adult or child Occurred over time or one incident or time limited

8 Institute for Health and Recovery Interpersonal Violence Interpersonal Violence – physical/sexual abuse is not like natural disasters, car accidents, etc. Human-fostered violence against another human being Causes extreme disconnection from other human beings

9 Institute for Health and Recovery Why Trauma Matters A significant proportion of men and women entering services for substance use disorders have histories of trauma (Brems, 2004; Clark, 2001; Farley, 2004; Medrano, 1999; Moncrieff, 1996; Rice, 2001). Women in community samples report a lifetime history of physical & sexual abuse ranging from 36 to 51%, while women with substance abuse problems report a lifetime history ranging from 55 to 99% (Najavits et al., 1997).

10 Institute for Health and Recovery 75% report lifetime history of physical and/or sexual abuse 33% report abuse in past year 50% report abuse as children 33% report witnessing abuse of mother (El-Bassel et al., 2004) Women who were both physically and sexually abused in childhood were six times more likely to abuse alcohol then non abused women. (Bensley, Eenwyk, and Simmons, 2000) Women in Methadone Treatment

11 Institute for Health and Recovery Research Institute on Addictions (1997) 80% of women with substance use disorders had been the victim of domestic violence Brookhoff et al. (1997) 42% of victims of domestic violence contacting the police had used alcohol or other drugs on the day of the assault Co-occurrence of Substance Abuse & Domestic Violence

12 Institute for Health and Recovery Special Issues for Victims of Violence Who Have Co-Occuring Disorders The presence of both alcohol and drug use & domestic violence increases the severity of injuries & lethality rates (Mackey, 1992) Perpetrators may pose risk to partners by: Introducing partner to drugs Forcing or coercing partner use Isolating partner from help Coercing partner to engage in illegal acts Using withholding drugs as a threat Using legal history as a threat Blaming abuse on partner use

13 Institute for Health and Recovery History of Abuse & Mental Illness Muesser et al., 1998 90% of public mental health clients have histories of trauma most with multiple instances Kessler et al, 1995 34-53% report childhood physical or sexual abuse 43-81% report some type of victimization

14 Institute for Health and Recovery Domestic Violence & Mental Health Problems On average, over half of women seen in a range of mental health settings are either currently experiencing or have experienced abuse by an intimate partner.

15 Institute for Health and Recovery Prostitution &Trauma 99% report at least one traumatic event 93% report multiple traumas 53% report 6 or more traumatic events 75% report child sexual abuse 26% report child sexual abuse before age 6 81 % raped as adults 81% physically assaulted as adults (Roxburgh, Degenhardt, & Copeland [2006])

16 Institute for Health and Recovery Adverse Childhood Experiences ACE Study Kaiser Permanente (Felitti) & CDC (Anda) Large-scale epidemiological study of influence of stressful/traumatic childhood experiences Interviewed over 17, 000 people Compares adverse childhood experiences against adult health status

17 Institute for Health and Recovery ACE Study Scoring system used – one point for each category of Adverse Childhood Experiences (ACE) before 18 ACEs not only common, but effects were cumulative Compared to persons with ACE score of 0, those with ACE score of 4 or more were 2x more likely to be smokers, 12x more likely to have attempted suicide, 2x more likely to be alcoholic and 10x more likely to have injected street drugs

18 Institute for Health and Recovery Adverse Childhood Experiences Recurrent and severe physical abuse Recurrent and severe emotional abuse Sexual abuse Growing up in household with: ◦ Alcohol or drug user ◦ Member being imprisoned ◦ Mentally ill, chronically depressed, or institutionalized member ◦ Mother being treated violently ◦ Both biological parents absent ◦ Emotional or physical abuse (Fellitti, 1998)

19 Institute for Health and Recovery ACE Study Controlling for other adverse childhood experiences Women with a history of childhood sexual abuse were 60% more likely to have alcohol problems and 70% more likely to have used illegal drugs. Men with a history of childhood sexual abuse were 30% more likely to have alcohol problems and 60% more likely to have used illegal drugs. (Dube et al. (2005)

20 Institute for Health and Recovery Prostitution Eating Disorders Mental Health disorders STIs Alcohol problems Early onset of criminal behavior Messina and Grella (2006) Number of childhood traumatic events associated with:

21 Institute for Health and Recovery Impacts of Trauma Physiological – Changes in neurobiology and physical health Cognitive – Flashbacks, dissociation Feelings – Feeling numb or overhwhelmed Beliefs – About self, other people, the world Skill Deficits – Self-protection, self-soothing Mental Health – PTSD, Substance Abuse Relational Disconnection

22 Institute for Health and Recovery Victimization Lack of Self-Care Addiction Self- Medication Trauma Sequelae Mental Health Problems (Begin Anywhere) Pathways of Co-Occurrence

23 Institute for Health and Recovery What Makes Impact More Severe? Trauma Characteristics Interpersonal violence Perpetrator is known/trusted Recurrent Degree of exposure Response of social environment

24 Institute for Health and Recovery What Makes Impact More Severe? Person Characteristics Age Prior coping skills Prior trauma history Chronic stressors Current stressors

25 Institute for Health and Recovery The impact of violence/trauma on both men and women is inadequately understood and addressed by service providers. Less than half of the women with interpersonal trauma and co-morbidity will receive treatment that addresses their trauma history and co-occurring conditions. (Timko & Moos, 2002)

26 Institute for Health and Recovery “I am an incest survivor and never dealt with it. Left treatment, did drugs. The most important thing is to integrate [services]. I’m a slicer and before no place would take me and if [I] say I’ve been sexually abused they boot you…I thought, here we go again. Substance abuse identified and you’re welcome… need to work all 3 areas…others throw you out because they are afraid.” (WELL Project, 2005)

27 Institute for Health and Recovery Lack of research/knowledge dissemination; training Trauma not seen as central/critical to recovery “Uncovering” trauma would “destabilize” symptoms – need to stabilize mental health/ substance abuse – Opening a “Pandora’s Box” A belief that trauma work requires more sophisticated clinical skills Treatment Programs Often Fail to Adequately Deal with Trauma. Why?

28 Institute for Health and Recovery Failure to understand and address trauma can lead to: 1.Failure to engage in treatment services (Farley, 2004) 2.Increase in symptoms (eating disorders, self- harm) 3.Increase in management problems 4.Retraumatization (Harris and Fallot, 2001) 5.Increase in relapse 6.Withdrawal from service relationship 7.Poor treatment outcomes (Easton et al 2000; Ouimette et al 1999)

29 Institute for Health and Recovery Quote “It was not until I became a part of the Women, Co- Occurring Disorders & Violence Study that I became trauma informed. I remember realizing one day, what perfect sense this all makes. I was able to finally fit the pieces of the puzzle together. Being a survivor was the reason I drank & used drugs. Post Traumatic Stress Disorder had set in, & the drinking and using suppressed my true feelings. I am among one of the lucky few. So many of us have not solved the puzzle – survivors, & providers. One of the most important things I have learned is how to keep myself safe. The word Safety never came up in treatment. I now realize how much jeopardy I put myself in when I was using substances, not caring what time of the night it was, not caring that the guy just came into the room waving a gun, just give me another hit. We continue to put ourselves in situations that can retraumatize us on a daily basis. Learning how important safety is to my recovery process has changed my outlook.”

30 Trauma-Informed Services: Changes in Understanding and Changes in Practice Roger D. Fallot, Ph.D. Community Connections Conference on Co-Occurring Disorders Long Beach, California February 8, 2008

31 What are Trauma-Informed Services? Trauma-informed vs. trauma-specific Trauma-informed vs. trauma-specific Characteristics of trauma-informed services Characteristics of trauma-informed services  Incorporate knowledge about trauma— prevalence, impact, and recovery—in all aspects of service delivery  Hospitable and engaging for survivors  Minimize revictimization  Facilitate recovery and empowerment

32 Why Trauma-Informed Services? Trauma is pervasive Trauma is pervasive Trauma’s impact is broad and diverse Trauma’s impact is broad and diverse Trauma’s impact is deep and life-shaping Trauma’s impact is deep and life-shaping Trauma, especially interpersonal violence, is often self-perpetuating Trauma, especially interpersonal violence, is often self-perpetuating Trauma is insidious and differentially affects the more vulnerable Trauma is insidious and differentially affects the more vulnerable Trauma affects how people approach services Trauma affects how people approach services The service system has often been retraumatizing The service system has often been retraumatizing

33 A Repetitive Cycle of Risk HomelessnessIncarceration Substance Abuse Mental Health Problems Violence and Trauma

34 Comparing Traditional and Trauma-Informed Paradigms Understanding of Trauma Understanding of Trauma Understanding of the Consumer/Survivor Understanding of the Consumer/Survivor Understanding of Services Understanding of Services Understanding of the Service Relationship Understanding of the Service Relationship

35 A Culture Shift: The Core Principles of a Trauma-Informed System of Care Safety: Ensuring physical and emotional safety Safety: Ensuring physical and emotional safety Trustworthiness: Maximizing trustworthiness, making tasks clear, and maintaining appropriate boundaries Trustworthiness: Maximizing trustworthiness, making tasks clear, and maintaining appropriate boundaries Choice: Prioritizing consumer choice and control Choice: Prioritizing consumer choice and control Collaboration: Maximizing collaboration and sharing of power with consumers Collaboration: Maximizing collaboration and sharing of power with consumers Empowerment: Prioritizing consumer empowerment and skill-building Empowerment: Prioritizing consumer empowerment and skill-building

36 A Culture Shift: Scope of Change in a Distressed System Involves all aspects of program activities, setting, and atmosphere (more than implementing new services) Involves all aspects of program activities, setting, and atmosphere (more than implementing new services) Involves all groups: administrators, supervisors, line staff, consumers, families (more than direct service providers) Involves all groups: administrators, supervisors, line staff, consumers, families (more than direct service providers) Involves making change into a new routine, a new way of thinking and acting (more than new information) Involves making change into a new routine, a new way of thinking and acting (more than new information)

37 Protocol for Developing a Trauma-Informed Service System Services-level changes Services-level changes  Service procedures and settings  Formal service policies  Trauma screening, assessment, and service planning Systems-level/administrative changes Systems-level/administrative changes  Administrative support for program-wide trauma-informed services  Trauma training and education  Human resources practices

38 Trauma-Informed Services: Qualitative Pilot Outcomes Consumers report greater safety, trust, and engagement in services; more collaboration with providers; emphasis on empowerment, recovery, and healing Consumers report greater safety, trust, and engagement in services; more collaboration with providers; emphasis on empowerment, recovery, and healing Providers report greater collaboration with consumers; enhanced skills and sense of efficacy; more support from agency Providers report greater collaboration with consumers; enhanced skills and sense of efficacy; more support from agency Administrators report more collaboration within and outside agency; enhanced staff morale; fewer negative events and more effective services Administrators report more collaboration within and outside agency; enhanced staff morale; fewer negative events and more effective services

39 Conclusion What we know about trauma, its impact, and the process of recovery calls for trauma-informed service approaches What we know about trauma, its impact, and the process of recovery calls for trauma-informed service approaches A trauma-informed approach involves fundamental shifts in thinking and practice at all programmatic levels A trauma-informed approach involves fundamental shifts in thinking and practice at all programmatic levels Trauma-informed services offer the possibility of enhanced collaboration for all participants in the human service system Trauma-informed services offer the possibility of enhanced collaboration for all participants in the human service system

40 Trauma-Specific Group Services Lisa Russell, Ph.D. ETR Associates lisar@etr.org

41 Traumatic-Specific Interventions  Services designed specifically to address violence, trauma, and related symptoms and reactions.  Increase skills and strategies that allow survivors to manage their trauma symptoms and reactions and eventually to reduce or eliminate debilitating symptoms and prevent further traumatization and violence.

42 Trauma-Specific Curricula Used in Substance Abuse Treatment Settings  Maxine Harris—Trauma Recovery & Empowerment (TREM)  Lisa Najavits—Seeking Safety  Dusty Miller—Addiction & Trauma Recovery Integration Model (ATRIUM)  Clark & Fearday—TRIAD  Stephanie Covington—Helping Women Recover & Beyond Trauma  Julian Ford—Trauma Adaptive Recovery Group Education & Therapy for Persons in Recovery from Addiction (TARGET-AR)

43 Features in Common  Stages of trauma recovery  Cognitive behavioral  Coping skills  Group orientation, adaptable for individual sessions  Can be co-facilitated by a professional and a peer

44 Stages of Trauma Recovery: Treatment Aims  Stage One: ESTABLISHING SAFETY Securing safety Securing safety Stabilizing symptoms Stabilizing symptoms Fostering self-care Fostering self-care  Stage Two: REMEMBRANCE & MOURNING Reconstructing the trauma Reconstructing the trauma Transforming traumatic memory Transforming traumatic memory  Stage Three: RECONNECTION Reconciliation with self Reconciliation with self Reconnection with others Reconnection with others Resolving the trauma (Herman, Trauma and Recovery) Resolving the trauma (Herman, Trauma and Recovery)

45 Stage One: Establishing Safety  Focus upon establishing both physical & psychological safety  Increasing understanding of links between trauma & substance abuse  Teaching coping skills (Herman, Trauma and Recovery)

46 Seeking Safety Najavits, L.M. (2002). Seeking Safety: A treatment manual for PTSD and substance abuse. New York: Guilford Press. Integrates safety and recovery Integrates safety and recovery Stresses accessing other community supports Stresses accessing other community supports 25 topics, including Safety, When substances control you, Grounding 25 topics, including Safety, When substances control you, Grounding Session format: Session format: ◦ Check in ◦ Quotation ◦ Relating topic to women’s lives ◦ Closing 80 safe coping skills 80 safe coping skills

47 ATRIUM: Addiction and Trauma Recovery Integrated Model Miller, D. & Guidry, L. (2001). Addictions and Trauma Recovery: Healing the body, mind, and spirit. New York: WW. Norton & Co. Addresses mental, physical & spiritual health Addresses mental, physical & spiritual health Creating sacred connections to the world beyond the self Creating sacred connections to the world beyond the self 12 sessions, including self-harm, relationship changes, spiritual disconnections 12 sessions, including self-harm, relationship changes, spiritual disconnections

48 TRIAD Clark, C. & Fearday, F. (Eds.) (2003). Triad women’s project: Group facilitator’s manual. Tampa, FL: Louis de la Parte Florida Mental Health Institute, University of South Florida. Promotes survival, recovery & empowerment Promotes survival, recovery & empowerment 16 sessions, divided into 4 phases 16 sessions, divided into 4 phases ◦ Mindfulness ◦ Interpersonal effectiveness skills ◦ Emotional regulation ◦ Distress tolerance Has been modified for use in jails Has been modified for use in jails

49 TREM Trauma Recovery and Empowerment Harris, M. & The Community Connections Trauma Work Group (1998). Trauma Recovery and Empowerment: A clinician’s guide for working with women in groups. NY: Free Press. Current problematic behaviors and symptoms may have originated as legitimate and courageous attempts to cope with or defend against trauma Current problematic behaviors and symptoms may have originated as legitimate and courageous attempts to cope with or defend against trauma 33 topics, divided into four categories: 33 topics, divided into four categories: ◦ Empowerment (11 sessions) ◦ Trauma Recovery (10 sessions) ◦ Advanced Trauma Recovery Issues (9 sessions) ◦ Closing Rituals (3 sessions)

50 Helping Women Recover Covington, S.S. (1999). Helping Women Recover: A program for treating addiction. San Francisco: Jossey-Bass. Integrates expressive arts Integrates expressive arts Accompanying journal Accompanying journal 17 sessions, divided into four modules: 17 sessions, divided into four modules: ◦ Self ◦ Relationships ◦ Sexuality ◦ Spirituality

51 TARGET-AR Trauma Adaptive Recovery Group Education and Therapy for Persons in Addiction Recovery 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. Cognitive-behavioral Cognitive-behavioral Present-focused Present-focused Systematic skills training Systematic skills training Designed to be brief treatment Designed to be brief treatment

52 Considerations for Choosing a Curriculum  Evidence of effectiveness  Fit with client characteristics  Program values and treatment philosophy  Curriculum length and format  Group facilitator’s expertise  Adaptations for specific populations  Cost, training, setting

53 Integrating the Curriculum into Substance Abuse Treatment  Pilot-testing the curriculum  Adapting, if necessary, based on pilot results (Trying evidence-based adaptations first.)  Training for staff and supervisors  Ongoing supervision and support for the new practice  Monitoring of fidelity

54 Vivian B. Brown, Ph.D. Outcomes from the Women with Co-Occurring Disorders and Violence/Trauma Study CENTERS FOR INNOVATION IN HEALTH, MENTAL HEALTH AND SOCIAL SERVICES

55 SAMHSA’s Women with Co-Occurring Disorders and Violence Study

56 PROTOTYPES Allies New Directions for Families D.C. Trauma Collaboration Study Triad Women’s Project Portal Project Women Embracing Life & Living (W.E.L.L.) Franklin County Women’s Research Project Boston Consortium of Services for Families in Recovery The 9 National Program Sites

57 Program / SiteIntervention GroupComparison Group PROTOTYPES Los Angeles, CA 187215 Allies Stockton, CA 169266 Arapahoe House—New Directions for Families Metropolitan Denver, CO 57108 D.C. Trauma Collaboration Washington, D.C. 15097 Triad Women’s Project Avon Park, FL 179123 Boston Consortium of Services for Families in Recovery Boston, MA 181161 The W.E.L.L. Project Cambridge, MA 218110 Franklin County Women’s Research Project Greenfield, MA 105120 Portal Project New York, NY 169114 Total 14151314 Sample Sizes Across Program Sites by Condition (N=2,729)

58 Baseline Demographic Characteristics by Program Site: Hispanic Ethnicity Variable (n =402) (n =435)(n =165)(n =247)(n =302)(n =342)(n =328)(n =225)(n =283)(n=2729) Hispanic Ethnicity (%)*30.617.527.33.26.034.26.75.325.418.1 Race** % White/Caucasian 41.356.352.113.481.537.478.485.37.150.3 Race** % African-American 22.916.618.279.413.227.86.13.166.827.2 Race** % Other Race 24.417.99.12.0 29.85.83.123.714.5 Race** %Multi-racial*** 11.47.64.84.01.02.68.24.92.15.6 Race** % None-specified 0.01.615.81.22.3 1.53.60.42.4 PROTOTYPES SCCAllies New Directions for Families DC Trauma Collaboration Study Triad Women’s ProjectBoston Consortium of Services The W.E.L.L. Project Franklin Co. Women’s Research Project Portal ProjectTotal * Hispanic ethnicity was measured independent of race; ** Not all percentages total to 100%, as excluded from the totals were subjects for whom data were missing; *** Category includes subjects who identified two or more races

59 Participants in the Study 2,729 women were enrolled in the study All are18 or older with histories of mental health and substance abuse services use and histories of physical or sexual abuse Average age (both groups) is about 26. Age ranges from 18 to 76 54% were Caucasian, 18% Hispanic/Latina, 29% African American 87% were mothers 50% had completed high school

60 Trauma Experiences Profile Ever ExperiencedNumberPercent Sent to Jail or Juvenile detention1,91870% Been homeless1,96972% A serious physical or mental illness1,66661% Separated from Children against your will1,65361% Someone close to you other than your child died2,34986% Witness physical violence between family members 2,05475% Physically abused2,32385% Stalked1,95472% Sex because you felt forced1,98373%

61 When first experienced Trauma Age of First Onset 0-5 years 6-10 years 11-13 years 14-17 years 18+ years Witness physical violence between family members (n=2,054) 42%43%11%5% Emotionally abused or neglected (n=2,300) 32%33%13%10%13% Physically neglected (n=887) 31%36%13%8%12% Physically abused (n=2,323) 18%24%11%16%31%

62 Primary Outcomes & Measures OutcomesMeasures Substance Abuse:Addiction Severity Index –Alcohol Composite (ASI-A) –Drug Abuse Composite (ASI-D) Mental Health:Brief Symptom Inventory –Global Severity Index (GSI) Trauma:Post Traumatic Diagnostic Scale –Post Traumatic Symptom Scale (PSS)

63 The 6-Month Outcome Components Intent-to-treat design 2,006 women (1,023 in intervention condition, 983 in comparison condition) were interviewed 6 months after initial enrollment re: outcomes plus services received and other elements Four outcome measures: mental health symptoms, alcohol use, other drug use, and trauma-related symptoms Women in both intervention and comparison conditions had decreased symptoms in all four areas at 6 months

64 Differences between Intervention and Comparison Conditions On two of four measures (post-traumatic symptoms and drug use severity), women in the intervention programs showed significantly greater improvement than those in usual care On mental health status, differences almost reach significance Effect sizes are small, but present Morrissey, J.P. et al. (2005) Journal of Substance Abuse Treatment

65 6-Month Data on All Sites On drug use problem severity (ASI-D), 49% of the intervention women and 36% of the comparison women reported no drug use or drug-related problems at 6 months On alcohol use problem severity (ASI-A), 52% of intervention and 40% of comparison women reported no use or related problems at 6 months

66 The 12-Month Outcome Components 2,026 women were interviewed 12 months after initial enrollment re: outcomes plus services received and other elements Four outcome measures: mental health symptoms, alcohol use, other drug use, and trauma-related symptoms Women in both intervention and comparison conditions had decreased symptoms in all four areas at 12 months Morrissey, J.P. et al. (2005) Psychiatric Services

67 Differences between Intervention and Comparison Conditions The 12-month effect sizes for mental health and post traumatic symptoms show statistically significant improvements for women in the intervention condition relative to those in the comparison condition The two substance use severity outcomes show no additional improvement over the corresponding values at 6 months Morrissey, J.P. et al. (2005) Psychiatric Services

68 Program-Level Differences There is considerable variation across sites Sites were compared on eight program characteristics Integrated counseling was positively related to three of the four outcomes measured across sites

69 Program Differences (continued) Integrated counseling defined as receiving all three types of services in individual and/or group counseling reported in three-month interview Number of core services provided were not associated with improved outcomes, unless integrated counseling was present

70 Costs Controlling for baseline use, there are no significant differences in total costs between participants in the intervention condition and those in the usual care comparison This is true from a governmental or Medicaid reimbursement perspective

71 Some Key Learnings Providing complex sets of integrated services is feasible, including attention to trauma in systemic ways Collaborations between those with lived experience and researchers increases the quality of the research (and probably the services)

72 Learnings (continued) Women with these complicated sets of issues can reduce their problems Integrated counseling of mental health, substance abuse, and violence issues in a trauma-informed context appears to be more effective and no more costly than services as usual


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