KAREN BAILEY, KINGS COLLEGE LONDON NATIONAL ADDICTION CENTRE INSTITUTE OF PSYCHIATRY PSYCHOLOGY AND NEUROSCIENCE (IOPPN), KAREN.BAILEY@KCL.AC.UK 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 2,700 women - 9 sites across USA. Intervention = trauma informed and integrated services for substance use, violence and mental health. Phase 1 (2 years): cross site framework for service intervention, local strategies, M&E Phase 2 (3 years): implementation and evaluation, 3, 6 and 12 month assessments

Cross-site framework Gender specific Culturally competent Trauma-informed Trauma-specific Integrated; clinical and organisational level Informed by service users Comprehensive

COMPREHENSIVE = Eight core services outreach and engagement screening and assessment ongoing treatment activities parenting skills training resource coordination and advocacy trauma specific services crisis intervention peer-run services

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

Characteristics of study participants 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

WCDV Study - Washington DC site Lead: Mental health agency Integrated trauma service teams TREM groupwork Other groups – spirituality in trauma recovery, domestic violence groups, alcohol and drug treatment for trauma survivors, relapse prevention, trauma issues and HIV infection, parenting Women support and empowerment centre Access to psychiatric care, medication, 24 hour crisis line

Trauma Recovery and Empowerment Profile (TREP) 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

LESSONS LEARNED importance of trauma informed context safe housing booster groups advanced relationship work

WCDV Study - findings (Morissey et al 2005) Six months - women in intervention sites showed slightly greater reductions in drug use and PTS at 6 months - leveled off at 12 months 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 Total cost of integrated services was no more than treatment as usual

Fowler and Faulkner Meta-analysis - 2011 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

Women and Trauma study (Hien et al 2009) 14 Substance Misuse services, 350 participants RCT: Seeking Safety (SS) (condensed, 12 sessions over 6 weeks) vs Women's Health Education (WHE) Group on average – SS did not outperform on PTS or substance use Subgroups: women with more severe substance use and PTS at baseline did better in SS 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

WCDV Study - Lessons learned 1 SERVICE SYSTEM INTEGRATION 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. Relationship building early-on was key and impacted the degree to which systems change occurred over time. Systems integration efforts must go beyond substance abuse, mental health, and trauma systems to include a broader range of stake- holders. 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

WCDV Study - Lessons learned 2 CLINICAL INTEGRATION Co-facilitation is an effective strategy that can enhance integration at both the service and systems levels Multi-disciplinary case conferencing was an effective approach for promoting service and systems integration SERVICES Sites experienced difficulty retaining women in services, especially the trauma groups, and were challenged to explore options for boosting retention Group interventions can stimulate positive relationship formation among women to promote recovery Women had a need for continuing services and supports, especially after graduation from the trauma groups

WCDV Study - Lessons learned 3 SERVICE USER INVOLVEMENT Service users made an immeasurable impact on the project to transform how services were designed, delivered, and evaluated Challenging - more planning for service user involvement CROSS CUTTING ISSUES Initial resistance Cross-training Ongoing supervision, management and support of staff

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