1. KAREN BAILEY,
KINGS COLLEGE LONDON
NATIONAL ADDICTION CENTRE
INSTITUTE OF PSYCHIATRY PSYCHOLOGY AND NEUROSCIENCE (IOPPN),
Integrated trauma and substance misuse services - what can practice from the USA tell us?

2. 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

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

5. 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

6. 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

7. 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

8. 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

9. 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

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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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