Sub Abuse Ment Health For Dv Agencies Palm Deser C At 1 8 08 Werner

Mental Health, Substance Abuse & Domestic Violence Training of Trainers January 8, 2008

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DHS Grantee Meeting January 8, 2008 * Palm Desert, California

Facilitator/Trainer: Deborah Werner, MA

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Women communicate, make decisions, store knowledge and prioritize differently than men.Women are people and process oriented. Men tend to be more action and activity oriented.

Women are diverse.

creative … spiritual … capable … empathetic … resilient … able to multi-task … nurturing … smart … abstract thinkers … nice … fair … gardeners … generous … dedicated … strong … energetic

2Deborah Werner, 2007

High incidence of childhood and adult trauma from a “loved one.”

Learn to focus on how they appear doing something rather than how they feel doing

h ( l l f l)something (external locus of control).Expected to be able to have and do it all – career, beauty, care-taker, be a hero.

Psycho-social-spiritual awareness; creativity; self-care are often secondary to helping others.



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Sexualized images of women are used to market products.Women earn 76 cents for a male dollar, are less likely to be in labor force, more likely to be in povertypoverty.Women are more likely to be responsible for family members.Women face more stigma and shame for substance abuse, mental health problems especially when the results hurt family members.


Women are asked three wrong questions over and over again -◦ Why don’t you just leave?◦ Why don’t you just quit using?◦ Why don’t you just pull herself together?

5Deborah Werner, ONTRACK 2007

Mental Health Considerations

Deborah Werner, MA

The Werner Hartman Group

[email protected]

ONTRACK Program Resources, Inc.MH – 1


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Key Topics

Overview of Mental Health

Common Disorders

Factors to Consider

Treatment IssuesTreatment Issues

MH -2

Overview of Mental Illness

Myths

Prevalence

Needs

MH – 3

Common Myths and Realities

MYTH: People with mental illness (MI) are violent and dangerous. REALITY: Most people with MI are vulnerable rather than

violent.

MYTH: People with mental illness are lazy. They use their mental illness as an excuse.

REALITY: Most people with MI try to appear as normal as possible and try not to allow their symptoms to affect how they function. People with MI may not tackle new things because they do not believe they can. External stress may exacerbate mental health problems.

MH – 4Deborah Werner, updated 2005


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More Myths

MYTH: People with mental illness say so in order to get drugs. REALITY: Mental illness is heavily stigmatized. Drugs

prescribed appropriately will not have euphoric effects for a sober mentally ill person.

MYTH: People with mental illness are completely incapacitated and are unable to care for themselves or others.REALITY: Mental illnesses vary in degree of severity.

Some people are greatly debilitated. Some have periods of being able to care for themselves and their families and other periods when they need help. Most people with mental illnesses take care of themselves and their families, maintain jobs and function in society.

MH 5Deborah Werner, updated 2005

Myths continued

MYTH: People with mental illness are incapable of experiencing love.REALITY: Most mentally ill people are capable of loving

and all other emotions.

MYTH: People with mental illness are seductive “nymphomaniacs.”REALITY: Seductiveness and sexual acting out can be

symptoms of some mental health problems (though lack of sexual interest is equally common). Many mentally ill women are unable to assert themselves and thus find themselves in sexually compromising situations. Nymphomania is not a DSM IV diagnosis.


More Myths

MYTH: Mentally ill people are pyromaniacs who set fires.REALITY: Pyromania is classified as a mental illness,

however most mentally ill people do not set fires however, most mentally ill people do not set fires.

MYTH: Mentally ill people cannot be good parents.REALITY: Most parents with mental health problems can

be and are good parents to their children. Parents with mental illness need to be aware of how their symptoms may impact parenting. There may be times when they need strong social support and mental health care.



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Mental Health, Mental Illness

Mental Health – a mentally healthy woman has a positive self-image and is able to manage the challenges of everyday life such as work, family, traffic and relationships as well as periodic significant events (e.g., marriage, trauma, death)Mental Health Disorder or Mental Illness those Mental Health Disorder or Mental Illness – those diseases and conditions that have manifestations that mostly affect a person’s behavior, how a person feels, thinks and perceive the world around them. According to the DSM IV, a mental health disorders includes: • distress painful symptom or • disability impairment in one or more important areas of

functioningMH 8Deborah Werner, updated 2005

Prevalence of Serious Psychological Distress (SPD)

An estimated 24.6 million adults (11.3%) aged 18 or older in the United States had SPD in the past year.

Prevalence for women 18 or older (14.0%) is higher than men (8.4%).

45.3% received treatment for a mental health problem in the past year.

Reasons for no treatment among those reporting an unmet treatment need:

• 53.5% cost or insurance issues • 32.3% did not feel need for treatment at the time or believed

problem could be handled without treatment • 26.2% stigma associated with treatment • 21.8% not knowing where to go for services • 16.6% not having time

(NSDUH, 2005)MH 9

Deborah Werner, ONTRACK 2007

Major Depression Episode (MDE) Prevalence

In 2005, there were 30.8 million adults (14.2% of persons aged 18 or older) who had at least one Major Depressive Episode in their lifetime

15.8 million adults (7.3%) had at least one MDE in the past year Prevalence was higher among adult women (9 3%) year. Prevalence was higher among adult women (9.3%) than men (5.2%)

70.9% of women who had MDE in the past year received treatment for depression (i.e., saw or talked to a medical doctor or other professional or used prescription medication) compared with 55.6% of men.

Among adolescents 12-17, the rate of MDE in the past year was higher for females (13.3%) than males (4.5%)

MH 10Deborah Werner, ONTRACK 2007


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Bipolar Disorder

Prevalence: 1% of population Adults = AdolescentsMales = Females2-3 million American adults are diagnosed with bipolar disorderNIMH estimates that one in very one hundred people NIMH estimates that one in very one hundred people will develop the disorder

Controversies:

Severity and durationOnset before puberty is estimated to be rareDevelopmental variability

Misdiagnosis(Nancy Rappaport, Harvard Medical School)


Domestic Violence & Mental Health

Many women who experience domestic violence do not develop mental health conditions. They may have some symptoms of depression or other mental illnesses but symptoms resolve when social support and safety increase.

Other women experience significant mental distress. Women with domestic violence are at increased risk for depression and pPTSD. Substance abuse, eating disorders and mental health problems have been linked with adult and childhood abuse.

A review of 16 studies of depression and PTSD among women receiving domestic violence services found:

• A range of 33-64% of shelter clients met criteria for depression.

• A range of 33=88% of shelter clients met criteria for PTSD.

Carole Warshaw, MD Domestic Violence and Mental Health Policy Inititiave


4 Categories of Symptoms

PERCEPTIONS * Vision * Hearing * Taste * Touch *

* Smell * Time * Balance * Motor Coordination *

THOUGHTSTHOUGHTS* Confusion * Delusions (false beliefs) *

* Memory Loss * Inability to Pay Attention *

MOODS* Depression * Excitement * Irritability * Mood Swings *

BEHAVIOR* Withdrawal *Aggression * Agitation * Bizarre Behavior *



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Diagnosis

Diagnoses based on the Diagnostic and Statistical Manual of Mental Disorders, IV Text Revision (DSM IV TR) based primarily on onset, history and symptomology.

Diagnosis must be made by a qualified, licensed Diagnosis must be made by a qualified, licensed mental health professional.

Diagnosis is based on the Axis System in the DSM IV-TR. We usually refer to Axis 1 – Clinical Disorders.

Selected types of mental health disorders• Mood disorders

• Anxiety disorders

• Thought disordersMH 14


Mood Disorders

Depression

• Major Depressive Disorder

• Minor Depressive Disorder

ManiaMania

Bi-Polar Disorder

MH 15

Major Depressive Disorder

1. 5 or more symptoms during the same 2-week period:

• Depressed mood most of the day (sad, empty, tearful)

• Diminished pleasure in previously enjoyed activities

• Significant weight loss or weight gain (5% or g g g g (more/month)

• Insomnia or hypersomnia

• Psychomotor agitation or retardation

• Fatigue or loss of energy

• Feelings of worthlessness; excessive/inappropriate guilt

• Diminished concentration; indecisiveness

• Recurrent thoughts of death; suicidal ideation and/or plan … AND

MH 16


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Major Depressive Disorder

2. Symptoms cause clinically significant distress or impairment in social, occupational, or other areas of function

3. Symptoms are NOT due to direct physiological effects of a substance or general medical condition and criteria for Bipolar Disorder are not met

4. Symptoms are not better accounted for by bereavement (e.g. longer than 60 days)

MH 17

Bipolar Disorder

Characterized by the occurrence of one or more manic episodes or mixed episodes as well as one or more Major Depressive Episodes.

Bipolar Disorder is difficult to diagnose • Substance use mimics symptomsSubstance use mimics symptoms• Comorbidity with other disorders• Reaction to partner violence cycle can mimic

symptoms

Half of bipolar children have relatives with bipolar disorder

MH 18

Mania

A distinct period of abnormally and persistently elevated, expansive, or irritable mood more than 1 week.DIGFAST acronym (at least 3 of 7 symptoms)

• Distractible• Increased activity/psychomotor agitation• Grandiosity/Super-hero mentalityy p y• Flight of ideas or racing thoughts• Activity related to social behavior, sexual activity, work, or

combinations may be dangerous (thoughtless)• Sleep decreased/Insomnia• Talkative or pressured speech

Symptoms cause marked impairment in functioning.Symptoms not due to direct physiological effect of substances

(Nancy Rappaport, Harvard Medical School) MH 19


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Anxiety Disorders

Panic Disorders

Phobias

Post Traumatic Stress Disorder

MH 20

Posttraumatic Stress Disorder (PTSD)

1. A normal reaction after a traumatic experience (where one either experiences and/or witnesses a threat, or actual physical harm, to oneself or another), which results in a decreased ability to function (at work, school, interpersonal relationships, etc.).

2. The traumatic event involved intense fear, horror, and/or helplessness.

3. PTSD symptoms continue for more than 30 days after the event occurred (if less than 30 days, symptoms are diagnosed as Acute Stress Disorder).

MH 21

Symptoms of PTSD

• Anxiety• Numbing of responsiveness• Flashbacks• Upsetting reminders and triggers• Hyperarousal or hypervigilance (startled

response, emotional numbing)• Sleep disturbances• Fight or Flight response alarm reaction then

fear• Freezing: hyperarousal, dissociation

response may be seen as oppositionalMH 22


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Co-Occurring Substance Abuse

Between 40-75% of people with severe mental illness also have a substance use disorder.

• 32% of individuals with depression

• 64% bipolar affective disorder

• 36% of individuals with anxiety disorders

• 28% of individuals with eating disorders

• 28% of individuals with ADHAbased on Ziedonis & Brady, 1997


Integrated Treatment

Collaborative multi-disciplinary team

Access to mental health care

Ongoing assessment and planning

Integrated psychosocial counseling and skill Integrated psychosocial counseling and skill building

Social support

Individualized, strength-based services

Trauma informed programming

Maintaining SafetyMH 24


Comprehensive Treatment

Engagement

Screening

Assessment

SafetySafety

Prioritizing Target Symptoms

Pharmacological Interventions

Psychosocial Interventions

The Value of A Friend

Case Management & Crisis Intervention

On-Going Community/Recovery SupportMH 25Deborah Werner, ONTRACK 2007


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Mental Health Partner, Characteristics

Familiar with domestic violence, trauma and treatment needs

Familiar with substance abuse, recovery issues, appropriate medications

Gender responsive, culturally respectful

Willing to work with a multi-disciplinary team

Accepting a wide range of funding sources and able to identify affordable pharmacological interventions


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Substance Abuse Overview for Domestic Violence Shelters

D b h W MADeborah Werner, [email protected]

SA 1


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Agenda

Introduction to AOD Use & Substance Use Disorders

Substance Use and Domestic Violence

Introduction to Treatment Approaches

Closing

SA 2

Introduction to Substance Use and Substance Use DisordersSubstance Use Disorders

SA 3

Public Health Approach

Individualsbuilding protective factors reducing risk factors

intervention and treatment family recovery

Agentsalcohol policy (formal and informal) Interdiction

rules around AOD use on property

Environments building environments which discourage problem use

supportive social networks healthy community messages

SA 4 Deborah Werner, Children & Family Futures, 2006


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Why Girls/Women Initiate Use

Young women use substances to: improve mood

lf di t d di t bself-medicate mood disturbancesincrease confidencelose inhibitions enhance sexlose weight

Access to alcohol and other drugsPartners, boyfriends & peers encourage useHigher incidence of dependency associated with child abuse and neglect


Continuum of Substance Use

AbstinenceExperimental UseResponsible UseEpisodical or Situational AbuseChronic AbuseDependency

AbstinenceSA 6

Situational/Episodic AOD Abuse

Situational/Episodic Abuse is time-limited problem use.

Women are relational in alcohol/drug use, may only use under specific circumstances.specific circumstances.

Screening, assessment and counseling. Interventions may include: identification of personal AOD problem, potential warning signs and triggers, alternative activities, promotion of healthy living, development of alternative relationships.

Alcohol/drug abstinence encouraged. But if a woman uses, it provides opportunity for woman to evaluate impacts of AOD in her life.

Can be incorporated directly into DV curricula and groupsSA 7Deborah Werner, ONTRACK 2007


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Addiction and Dependency

Brain impactedCravingsToleranceAddictionWomen’s pathways to alcohol and drug use, consequences of use, motivations for treatment, treatment needs and relapse factors are different from men.


From NIDA teaching packet #5

From NIDA teaching packet


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Cravings

4 Phases:Introductory Phase – no cravingsMaintenance Phase – mild craving when preparing for useDisenchantment Phase – cravings become powerful, overpowering physical reaction even in situations that are far away from use, craving triggers similar experience to useDisaster Phase – all the person needs to do to activate the addicted brain is think about the substance. People need to be able to practice thought-stopping in order to interrupt this process.

Develop a physiological need for the substance.SA 11

Tolerance and Addiction

ToleranceIncreasingly larger amounts of drug are needed to produce the same effect

AddictionA state in which an organism engages in compulsive behavior

Behavior is reinforcingLoss of control in limiting intake

Addiction is a cycle driven to use, feel remorse, use againObsession and Compulsion

DependenceA state in which an organism only functions normally in the presence of the drug. Manifests itself when the drug is removed.

SA 12

Put Simply

Addiction Results in physiological cravings that lead to obsession and compulsion regardless of consequences.

Obsession Thinking, planning, anticipating

Compulsion I have got to do it

Use Relief from the need

Denial I can handle “it”. “It” is no big deal.

Guilt and Shame I did a bad thing. I am a bad person.

Return to Obsession Using drugs is all I ever think about. ...

SA 13 Deborah Werner, The Werner Hartman Group, 2003


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Substance Use & Domestic ViolenceViolence

So what can WE do?

SA 14

DV Victims & Substance Abuse

Victims of domestic violence are more likely to have drug/alcohol problems than the population in general.

89% of women entering treatment in one study reported a history of interpersonal violence (Li l t l 2006)history of interpersonal violence (Lincoln et al. 2006)

In one recent study, 59% of women with drinking problems experienced past year severe intimate partner violence (vs. 13% with no problem) (Weinsheimer et al, 2005)

Illicit drug use among women in violent relationships are 2-3 times those of women overall (Cunradi, 2000)

Women who abuse alcohol and other drugs are more likely to become victims of domestic violence (Miller et al., 1989)

SA 15 Deborah Werner, ONTRACK 2007

Women with Substance Use Disorders

May be perceived as disruptive or not serious when their substance use becomes evident in shelter. Face tremendous stigma and are often considered bad mothers, bad people, and resistant to treatment.Often need services the most and yet are among those who are least likely to seek or receive services.



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Non-Judgmental

The substance abuser does not have the ability to choose to stop using, s/he is not weak. S/he feels guilt shame and failure When s/he isS/he feels guilt, shame, and failure. When s/he is approached with cynicism, anger, resentment or hostility it furthers these negative feelings. A hard part of a caring professional’s job is to put aside her feelings and often values and judgments and dedicate her focus to helping someone. To do this she MUST also remember to take care of herself!!!

SA 17 Deborah Werner, The Werner Hartman Group, 2003

Chicken or the Egg Does not Matter

For some their substance dependency results in at-risk relationships For others substance dependency results as a way of p y ycoping with intimate partner violenceWhether substance use or intimate partner violence came first – the addicted woman in a violent relationship must address both issues in order to recover.Establishing safety and appropriate substance use interventions are first steps


Family Violence and Substance Abuse Have Many Commonalities

Pervasive social and health problemsImpact all cultural and economic groupsPotentially life threatening and tend to exacerbate with timeOften inter generationalOften inter-generationalAffect all members of the familyStigma and shame are barriers to helpDenial of problem is commonCo-occurring mental health problem (e.g., depression) commonOften lead to other problems (legal, housing, health, financial)

Gender responsive, trauma informed servicesIntegrated, comprehensive servicesOngoing recovery support



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Co-Related Factors

Women with Substance Use Disorders also often have one or more of the following challenges

Lack of self-esteem and self-efficacyLack of self-esteem and self-efficacyIntergenerational addictionPregnant or caretakers of childrenRelationships that encourage use and are unsupportive of treatmentHistory of trauma and childhood abuseCo-occurring disorders, PTSD Lack of intervention strategies or treatment optionsMay need– economic, parenting, life-skills & housing for recovery supportSA 20 Deborah Werner, The Werner Hartman Group, 2003

Elements of AOD Treatment

Detoxification and StabilizationMotivation and EngagementAssessment and Treatment PlanninggSkill Building Programming

Drug Resistance Skills Avoid Triggers and Walk through Cravings Problem Solving Skills Assertiveness Skills

Life Style and SupportInterpersonal Relationships Replace Drug Using Activities

Safe and Health Environments Family Recovery

Case ManagementAddress barriers to economic and social well being Parenting support

Housing Multiple Systems

SA 21 Adapted from NIDA resource by Deborah Werner, Children & Family Futures, 2006

Integrating AOD Services into Shelters

Remember Use Occurs on a ContinuumRemember Addiction is not a moral shortfall

Entering the Shelter is a Window of Opportunity, ScreenSERVICES TO PROVIDE ON-SITE OR IN COLLABORATION:

Engagement, Safety and Screening for All

Motivational Interventions, Structure and SupportHarm Reduction when neededAssessment and Intervention when needed

Appropriate, Integrated Treatment when neededOn-Going Support for All



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Remember …

People do not choose to develop the disease of addiction any more than they pick out batterersWork to keep women engaged Failing domesticWork to keep women engaged. Failing domestic violence shelter feeds a woman’s sense of hopelessness, powerlessness and failure. She needs hope and strength to make a change.

Rememberoffer respect, not rescueoptions, not orders safe treatment rather than revictimization

SA 23 Deborah Werner, ONTRACK, 2007

Overview of Treatment Approachespp

Selected Approaches• Comprehensiveness• Motivational/Strength-based• Trauma Informed• Integrated

G d R i• Gender Responsive

TX 2


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Comprehensive Treatment• Engagement• Screening• Assessment• Safety• Prioritizing Target Symptoms• Pharmacological Interventions• Psychosocial Interventions• The Value of A Friend• Case Management & Crisis Intervention• On-Going Community/Recovery Support

TX 3Deborah Werner, ONTRACK, 2007

CSAT Model of Comprehensive Services forWomen & Children

CSAT Women, Youth and Families Task Force (2004). TX 4

Comprehensive Model includes:

ComponentsClinical treatment services for womenClinical support services for womenCommunity support services for womenCommunity support services for womenClinical treatment services for childrenClinical support services for childrenCommunity support services for children

Cultural Competence, Gender Competence and Developmentally Appropriate

TX 5


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Gender-Responsive Services

• A substantial body of research identifies unique characteristics of substance abusing women.

• Characteristics of Gender Responsive Services are:RelationalAddress the different pathways to use, consequences of use, motivation for treatment, treatment issues and relapse prevention needs unique to womenStrength-based, motivationalComprehensiveTrauma informedProvided in an environment in which women feel safe and comfortable.

Children and Family Futures, 2007

TX 6

M i i l A hMotivational Approaches

TX 7

Stages of Change

• Pre-Contemplation

• Contemplation

• Preparation

• Action

• Maintenance

Source: Prochaska and DiClemente, 1984

TX 8


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Motivational Interviewing• Express empathy through reflective listening.

• Develop discrepancy between client’s goals or values and their current behavior.

• Avoid argument and direct confrontationg

• Adjust to client resistance rather than opposing it directly.

• Support self-efficacy and optimism.

(source: SAMHSA TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment)

TX 9

Motivational Enhancements using FRAMES

• Feedback: regarding risk is given to individual.

• Responsibility: for change is placed with individual.

• Advice: about changing is clearly given in a non-judgmental manner.

M• Menu: of self-directed change options and treatment alternatives.

• Empathetic Counseling: showing warmth, respect, and understanding. (uses reflective listening).

• Self-Efficacy: optimistic empowerment is engendered to encourage change.

(source: SAMHSA TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment)

TX 10

Trauma Informed Services• Trauma should be treated as present rather than the

exception. • Create safe environments• Support clients to identify triggers, self-soothe, ground and

remain in treatment• Offer specialized, therapeutic trauma servicesp , p• Provide mental health services as needed• Adjust the behavior of counselors, other staff, and the

organization to support the individual’s coping capacity.• Increase client skills and strategies to allow survivors to

manage their symptoms and reactions with minimal disruption to their daily obligations and quality of life, and eventually to reduce or eliminate debilitating symptoms and to prevent further traumatization and violence.

TX 11


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Trauma Programs• Clark, C., Fearday, F. (eds) (2003) Triad Women’s Project:

Group facilitators manual. Tampa, FL: Louis de la Parte Florida Mental Health Institute, University of South Florida. (contact Colleen Clark at [email protected])

• Covington , S. S. (2003) Beyond Trauma: A Healing Journey for Women. Center City, MN: Hazelton Press. (Contact Stephanie Covington at [email protected])

• 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. (Contact Julian Ford at [email protected] )

TX 12Children and Family Futures, 2006

Trauma Programs Continued• Harris, M. (1998). Trauma, Recovery and Empowerment: A

Clinician’s Guide for Working with Women in Groups. New York, NY: Free Press. (Contact Rebecca Wolfon Berley at [email protected])

• Miller, D., & Guidry, L. ( 2001). Addictions and Trauma Recovery: Healing the Mind,Body, and Spirit. New York: W.W. Norton. (Contact Dusty Miller at [email protected])

• Najavits, L. (2001). Seeking Safety: Cognitive-Behavioral Therapy for PTSD and Substance Abuse. New York: Guilford. (Go to www.seekingsafety.org)

• Saakvitne, K. W., Gamble, S.J., Pearlman, L.A., Lev, B.T. (2000). Risking Connection: A Training Curriculum for Working with Survivors of Childhood Abuse . Maryland: Sidran. (Go to www.sidran.org) Children and Family Futures, 2006

Integrated Treatment• Collaborative multi-disciplinary team• Access to mental health care• Ongoing assessment and planning• Integrated psychosocial counseling and skill

buildingbuilding• Social support• Individualized, strength-based services• Trauma informed programming• Maintaining Safety

TX 14Deborah Werner, ONTRACK, 2007


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If we don’t help the most disenfranchised, most helpless and hopeless of our community – who will?

“Alone we can do so little together we can doAlone we can do so little, together we can do so much.” Helen Keller

TOGETHER WE CAN

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Presentation developed by:Deborah WernerThe Werner Hartman Group415 Topanga Blvd., #205Topanga, CA [email protected]

For more information, training or technical assistance contact:

ONTRACK Program Resources, Inc.

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Documents

Sub Abuse Ment Health For Dv Agencies Palm Deser C At 1 8 08 Werner