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1 IRT.ENG.FINAL.2_IRT.ENG.FINAL.2 IRT.ENG.FINAL.2_IRT.ENG.FINAL.2 IRT.ENG.FINAL.2_IRT.ENG.FINAL.2 1/31/13 1/31/13 1/31/13 1:14 1:14 PM 1:14 PM Page PM Page 1Page 1 1 Integrated Integrated IntegratedSubstance Substance Substance Abuse, Abuse, Abuse, Mental Mental MentalHealth Health Healthand and and Trauma Trauma Trauma Treatment Treatment Treatment With With With Women Women Women Women s Women s Women s Leadership Leadership Leadership Training Training Training Institute Institute Institute Economic Economic Economic Success Success Success in Recovery in in Recovery Recovery Pathways Pathways Pathways to to Family to Family Family Reunification Reunification Reunification andand Recovery and Recovery Recovery Spirituality Spirituality Spirituality andand Recovery and Recovery Recovery (all(all these (all these these titles titles are titles are available are available available in English in English in English andand Spanish) and Spanish) Spanish) Additional Additional Additional educational educational educational materials: materials: materials: Integrated Integrated Integrated Substance Substance Substance Abuse, Abuse, Abuse, Mental Mental Mental Health Health Health andandand Trauma Trauma Trauma Treatment Treatment Treatment With With Women With Women Women (in (in English) (in English) English) Fact Fact Sheet Fact Sheet Sheet forfor Providers for Providers Providers on:on: Women on: Women Women Affected Affected Affected by by Trauma, by Trauma, Trauma, Addiction Addiction Addiction andand Mental and Mental Mental Illness Illness Illness (in (in English) (in English) English) Fact Fact Sheet Fact Sheet Sheet forfor Consumers for Consumers Consumers on:on: Abuse, on: Abuse, Abuse, Alcohol/Drugs, Alcohol/Drugs, Alcohol/Drugs, andandand Emotional Emotional Emotional Problems Problems Problems in Women s in Women s in Women s Lives Lives Lives (available (available (available in English in English in English andand Spanish) and Spanish) Spanish) Integrated Substance Abuse, Mental Health and Trauma Treatment With Women August 2005 Integrated Substance Abuse, Mental Health and Trauma Treatment With Women August 2005 Integrated Substance Abuse, Mental Health and Trauma Treatment With Women August 2005 Educational Educational Educational curricula curricula curricula forfor women for women women in recovery in in recovery recovery developed developed developed by by theby thethe Boston Boston Boston Consortium Consortium Consortium of of Services of Services Services forfor Families for Families Families in Recovery: in in Recovery: Recovery: August August August ForFor more For more more information, information, information, please please please contact: contact: contact: Hortensia Hortensia Hortensia Amaro, Amaro, Amaro, PhD, PhD, PhD, Associate Associate Associate ViceVice Provost Vice Provost Provost for for Community for Community Community Research Research Research Initiatives Initiatives Initiatives andand Dean's and Dean's Dean's Professor, Professor, Professor, School School School of Social of Social of Social Work Work and Work andand Dept Dept of Dept Preventive of Preventive of Preventive Medicine, Medicine, Medicine, University University University of Southern of Southern of Southern California California California Montgomery Montgomery Montgomery RossRoss Fisher Ross Fisher Fisher Building, Building, Building, MRFMRF 220, MRF 220,220, LosLos Angeles, Los Angeles, Angeles, CA CA CA T: , T: , T: , C: , C: , C: , F: F: F: A ACase ACase Case Study Study Study Workbook Workbook Workbook for for for Staff Staff Staff Training Training Training Amaro, Melendez, Melnick, and Nieves Amaro, Melendez, Melnick, and Nieves Amaro, Melendez, Melnick, and Nieves Rita Rita Nieves, Rita Nieves, Nieves, RN,RN, MPH, RN, MPH, MPH, MSW, MSW, MSW, Director, Director, Director, Bureau Bureau Bureau of Addictions of Addictions of Addictions Services Services Services Boston Boston Boston Public Public Public Health Health Health Commission Commission Commission Albany 774 Albany Albany Street, Street, Street, 2nd2nd floor 2nd floor floor Boston, Boston, Boston, MAMA MA T. (617) T. (617) T. (617) Hortensia Hortensia Hortensia Amaro, Amaro, Amaro, Ph.D., Ph.D., Ph.D., Michael Michael Michael Paul Paul Paul Melendez, Melendez, Melendez, LICSW, LICSW, LICSW, Sharon Sharon Sharon Melnick, Melnick, Melnick, Ph.D. Ph.D. Ph.D. and and and Rita Rita Rita L. L. Nieves, L. Nieves, Nieves, RN, RN, MPH, RN, MPH, MPH, MSW MSW MSW BOSTON PUBLIC HEALTH COMMISSION Institute Institute Institute on Urban on Urban on Health Urban Health Health Research Research Research Funded Funded Funded by The by by The Center The Center Center for for Substance for Substance Substance Abuse Abuse Abuse Treatment, Treatment, Treatment, SAMHSA SAMHSA SAMHSA

2 Integrated Substance Abuse, Mental Health and Trauma Treatment With Women: A Case Study Workbook for Staff Training August 2005 Hortensia Amaro, Ph.D. Associate Vice Provost for Community Research Initiatives and Dean's Professor of Social Work and Preventive Medicine University of Southern California, Los Angeles, CA Michael Paul Melendez LICSW Urban Leadership Program Simmons College School of Social Work Sharon Melnick, Ph.D. Staff, Victims of Violence Program Harvard Medical School Rita Nieves, RN, MPH, MSW Bureau Director Bureau of Addictions Prevention, Treatment and Recovery Support Services Boston Public Health Commission BOSTON PUBLIC HEALTH COMMISSION Institute on Urban Health Research Funded by The Center for Substance Abuse Treatment, SAMHSA

3 2012. All rights reserved. No part of this book may be reproduced, in any form or by any means, without permission in writing from the editors; Hortensia Amaro. Ph.D and Rita Nieves, RN, MPH, MSW. The Institute on Urban Health Research (IUHR), under the direction of Dr. Hortensia Amaro, conducts research on health issues that disproportionately impact urban communities, particularly the urban poor, African-American and Hispanic communities. The Institute s research focuses on racial and ethnic health disparities and the cultural and community contextual factors that affect health status and health-care access. The IUHR provides Fellowships to create opportunities for student involvement in research and maintains a Faculty Scholars Program to equip scholars and researchers to assume leadership roles in urban health research. Contact Information: Hortensia Amaro, PhD Associate Vice Provost for Community Research Initiatives and Dean's Professor of Social Work and Preventive Medicine University of Southern California Montgomery Ross Fisher Building, MRF 220 Los Angeles, CA T. (213) office, C. (617) cell, F. (213) fax The Boston Public Health Commission (BPHC) formed the Boston Consortium of Services for Families in Recovery (BCFR), under the direction of Rita L. Nieves and Dr. Hortensia Amaro. The BCFR is a partnership of service programs and stakeholders that developed an integrated, culturally and linguistically appropriate model of services for women with co-occurring substance abuse and mental health disorders and trauma histories. The population of women served by the BCFR was primarily poor urban Latina and African American women. The specific BCFR approach was to develop, link, and integrate trauma and mental health treatment services into the existing substance abuse programs operated by the Consortium. The service and system integration approaches were developed in two phases. Phase 1, which lasted two years focused on an assessment and planning process during which partnerships were solidified and intervention approaches were developed. Phase 2 involved the implementation of the interventions and evaluation of the program s effects. This curriculum was one of several implemented as part of this effort. Contact Information: Rita Nieves, RN, MPH, MSW Director, Bureau of Addictions Services Boston Public Health Commission 774 Albany Street, 2nd floor Boston, MA T. (617) office

4 ACKNOWLEDGEMENT This workbook is a product of the Boston Consortium of Services for Families in Recovery (BCFR) project. The BCFR project was funded by a grant from the Substance Abuse and Mental Health Services Administration to the Boston Public Health Commission (Grant No. TI 11397) under the leadership of Dr. Hortensia Amaro as the Principal Investigator for the project. The Editors would like to recognize the efforts and the leadership provided by the team of the Women and Families Division, the staff of the Substance Abuse Prevention and Treatment Division (SAPT), Women s Circle and Griffin House staff who participated in the case conferences that provided the content for the development of this casebook. Special thanks to editors Dr. Sharon Melnick and Michael Melendez, LICSW for making sure we developed a product that would be relevant to treatment providers and to the graphic artist Maritza Medina for the cover design. We would like to also thank other members of the Women and Families Division for their contribution to this work and for participating in focus groups, case conferences and for providing ongoing feedback throughout the development process. i

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6 Table of Contents A Case Study Workbook for Staff Training Introduction History References for History Section IRT Case Presentation #1: Sharon Mothering the Mother : The role of substance abuse and trauma on the childhood development of a young adult mother. Learning Objectives Sharon Discussion Questions Critical Factors to Consider Putting It All Together Final Thoughts References For This Case Study IRT Case Presentation #2: Catherine After the First Death : The role of grief and loss in relapse Learning Objectives Catherine Discussion Questions Critical Factors to Consider Putting It All Together Final Thoughts References For This Case Study IRT Case Presentation # 3: Annie Taking Back Control of the Residential Setting : Managing disruptive clients, treatment coordination, and integration of services Learning Objectives Annie Discussion Questions Critical Factors to Consider Putting It All Together References For This Case Study iii

7 IRT Case Presentation #4: Susana Letting Go : Unfinished work, after-care planning, and working through separation. Learning Objectives Susana Discussion Questions Critical Factors to Consider Putting It All Together References For This Case Study IRT Case Presentation #5: Seneida Who asked for your Help Anyway? Working with young mandated clients newly exposed to treatment Learning Objectives Seneida Discussion Questions Critical Factors to Consider Putting It All Together References For This Case Study IRT Case Presentation #6: Margarita Looking for Love in All the Wrong Places : Understanding the role of social relationships in clients with early-onset substance abuse and severe trauma history. Learning Objectives Margarita Discussion Questions Critical Factors to Consider Putting It All Together References For This Case Study IRT Case Presentation #7: Julia Getting the Message : The role of passivity, hopelessness, and avoidance with a difficult-to-engage client. Learning Objectives Julia Discussion Questions Critical Factors to Consider Putting It All Together References For This Case Study iv

8 A Case Study Workbook for Staff Training Introduction This manual is a product of research-based treatment enhancement activities developed and conducted by the Boston Consortium of Services for Families in Recovery (BCFR), a program of the Boston Public Health Commission that was funded by the Women, Co-occurring Disorders and Violence Study (WCDVS); WCDVS was sponsored by the Substance Abuse and Mental Health Services Administration. The aim of the WCDVS was to develop, implement, and test strategies for integrating services targeted toward women with co-occurring substance abuse and mental health disorders who also have a history of trauma. Nine sites throughout the country participated in the WCDVS. The BCFR was the Boston-based site of the WCDVS. In the section below, we provide a brief history of the WCDVS and BCFR and summary description of their findings to date. For more detailed information on the WCDVS or the BCFR, readers should refer to the published articles listed at the end of the History section. 1

9 HISTORY Women, Co-occurring Disorders, and Violence Study (WCDVS) Existing studies indicate that 55 to 99 percent of women with co-occurring mental health and substance use disorders also have histories of trauma. 1-3 These women, with a range of multiple and complex needs, often are not well served by the existing array of discrete and fragmented services found in most American communities. 4-7 The Substance Abuse and Mental Health Services Administration sponsored the Women, Co-Occurring Disorders and Violence Study (WCDVS), a multi-site program developed to demonstrate more effective service interventions for these women. A total of 2,729 women enrolled in the WCDVS at nine sites in a nonrandom, quasi-experimental comparison group study for women with histories of mental health and substance use disorders who have experienced interpersonal violence. 8 In the intervention condition, women received a trauma-specific, manual-based intervention in addition to existing treatment-as-usual services. In the comparison condition, women received treatment-as-usual services only. The primary goals of the WCDVS were to generate empirical knowledge on developing integrated service approaches and to evaluate the effectiveness of these approaches for women who have traditionally been highend users of services. 9,10 Findings from the WCDVS indicate that the integrated care model produced better outcomes for substance abuse, mental health, and trauma symptoms compared with the services-as-usual model of care 9. In addition, the integrated model had beneficial effects in helping women stay in residential treatment longer and reduce HIV sexual risk behaviors compared with the standard care model. 9 Boston Consortium of Services for Families in Recovery (BCSFR) Through collaboration among the service agencies collectively known as the BCSFR, the Boston Public Health Commission (BPHC) implemented an integrated model of trauma-informed services that is culturally and linguistically appropriate to its service population of primarily poor, urban Latina and African American women. The enhanced intervention was implemented in five Consortium-affiliated alcohol and drug addiction treatment programs providing outpatient, 2

10 residential, and methadone services for women. Programs adopted trauma-informed service system enhancements and offered study participants a package of trauma-specific and trauma-informed clinical services. The assessment and consensus building processes, enhanced model components, implementation process, challenges and lessons learned are described by Amaro and colleagues in a journal article. 11 Prior to implementation of the intervention, the BPHC and affiliated programs within the Consortium had a long history of providing alcohol and drug addiction treatment including methadone and drug-free programs based in both outpatient and residential settings. Clinicians reported that a significant proportion of women clients had mental disorders and/or a history of trauma. Yet, as in many alcohol and drug addiction treatment programs, 4 there was no systematic or formal assessment process of co-occurring disorders, staff lacked training in trauma treatment, and coordination of services across systems of care was informal. Many clinicians and consumers felt the result was a disjointed system of care with little connection among treatments for alcohol and drug addiction, trauma, and mental health disorders. Service and system integration approaches were developed in two phases. Phase 1, from September 1999-September 2001, focused on an assessment and planning process during which partnerships were solidified and intervention approaches were developed. Phase 2, from October 2001-September 2004, involved implementation of the interventions and evaluation of the enhanced model. Although the overarching goal of systems integration remained the same, the Consortium evolved in its structure, focus, and specific strategies during the formative Phase 1 period. Despite the proliferation of studies on violence against women during the past twenty years, 12,13 limited research is available on the experience of violence among Latina and African American women. 14,15 Furthermore, although there is general agreement about the profound negative impact of interpersonal violence on women s substance use and mental health, little is known about effective interventions for these women. Even less is known about the efficacy of trauma interventions for the subgroups of Latina and African American women. 28 3

11 There is a growing awareness that ethnicity and culture are important factors in understanding the ways women respond to violence, as well as the barriers they may face in seeking help. 15,29 Latinos and African Americans now comprise 25.4 percent of the U.S. population, and they are more likely to rely on publicly funded substance abuse treatment programs due to their disproportionately high rates of poverty. 30 The consequences of alcohol and drug addiction such as HIV infection and incarceration have had a disproportionate impact on these populations Acculturation is associated with increased risk of substance use among Latinas. 34 This combination of characteristics places these women at risk for interpersonal violence, mental illness, and substance abuse. Limited access to culturally and linguistically appropriate substance abuse treatment and other services to help women stay safe may mean that women of color, especially those with dual diagnoses of mental health and substance use disorders, are also more likely to fall through the cracks of our current system of care. Even integrated treatment models may not be perceived as valuable by women from racial and ethnic minority groups or the models may be ineffective if they do not appeal to cultural values or address specific barriers faced by these target women. For example, culturally determined gender roles, strong ties to the family, and fear of telling outsiders about abuse and stigma related to mental illness may promote denial of abuse among Latina and African American women. 15,35,36 Furthermore, women of color are frequently at placed at risk by a low level of economic resources with resultant family stress Interpersonal violence occurs in a cultural context, and factors such as degree of acculturation, expectations about gender roles, and power in relationships and normative values about gender roles may contribute to increased risk among some cultural/ethnic groups. 14,35,39,43-48 Thus, successful interventions must address cultural as well gender factors related to social norms regarding trauma and mental illness. During the Phase 1 planning process, a needs assessment was conducted to identify service needs and gaps for target women in the Boston area. Data were collected using a variety of methods including focus groups and in-depth interviews with managers, clinicians, front line staff, and women receiving services from varied service sectors including alcohol and drug addiction treatment, mental health treatment, health and social services, and domestic violence programs. 4

12 Additional information was obtained from community hearings held by the Boston Public Health Commission and notes from deliberations by Consortium members. The major themes that emerged from the needs assessment are summarized below. Service providers, administrators, and consumers characterized the existing system of care as difficult to access and marked by inadequate and fragmented services. Some alcohol and drug abuse treatment programs did not allow women to be on psychotropic medications, as highlighted by the following comment from a provider: Finding a dual diagnosis program first of all, for women, is impossible. I ve had a client go off her meds to go into a residential program She would go off her meds, go extremely acute and flip out there and then they wouldn t let her back in. The fragmented or disparate nature of services meant that communication among providers within and across different treatment sectors was very difficult at best, often non-existent. There were substantial differences among substance abuse treatment programs in terms of their philosophies of care, staffing, and specific services offered. Substance abuse treatment providers had little incentive or structure to facilitate communication with counterparts in mental health services. One consumer observed, Because you start getting broken up and this one knows a little bit about yourself, this one know a lot about you, this one doesn t know, this one is giving you medication.it gets a little crazy, you know. Another consumer said, The hardest thing for me is finding what I need in one place.you know, a lot falls in the cracks. In addition to lack of coordination and communication, existing services lacked the capacity to screen for and treat a history of violence or abuse. Women complained that providers would often overlook their history. One consumer said, I ve seen women that you d notice right away that they ve been beat up, that they re using drugs. They re going to the hospital and nobody there is paying attention, while another commented, They never truly addressed me, they patched me up and sent me on my way. Women who wanted services often faced stigmatization and feared losing custody of their children. These fears also made it difficult for them to seek wanted care. One consumer said, What made me stay quiet was that people panic when you talk about drug use or domestic violence. 5

13 The problems they encountered facing a system of poorly coordinated, fragmented care for stigmatized illnesses were compounded by the general lack of culturally competent services. The lack of appropriate services for women in general was further compounded for women of color. One woman said, You know, if there was some place that I could feel at home, you know, with my own people, I would have stayed, but there is no program like that. Only Americanos, and they re rough. I had already been through them programs and I didn t like them. Women also experienced difficulties trusting their providers: If I feel that a person is being judgmental, if that person really isn t compassionate, I am not going to feel enough trust in them to open up. In sum, the needs-assessment interviews with individual providers, program directors, and consumers own voices validated the rationale behind more closely linking mental health, trauma, and substance abuse services and to directly addressing the impact of childhood and persistent trauma on women s lives. Information from the needs assessment and deliberations within the Consortium was used to develop the final intervention model. Shared philosophy. Based on these findings, the Consortium dedicated significant time in the beginning to discuss and agree on philosophy, principles, and a statement to guide its work. The final agreed-upon mission and philosophy statement is The mission of the Boston Consortium of Services for Families in Recovery is to implement an integrated system of care for women and families recovering from drug addiction, mental illness, and physical and/or sexual abuse. Based on existing evidence that has demonstrated the strong link between trauma, mental illness and addiction disorders, we believe that treatment for alcohol and drug addiction needs to include mental health services as well as services to help families be safe and heal from violence. Services should be respectful of consumer rights and be informed by their participation. Staff cross-training. Various mechanisms for cross training of staff were implemented: a) threeday training on substance abuse, mental health and trauma services integration for a broad array of substance abuse, mental health, domestic violence, public health and medical service providers; 6

14 b) a series of two-hour-long training sessions on integrated trauma-informed systems of care for administrators and managers from collaborating agencies; c) intensive training on manual-based trauma treatment groups; d) a Service Integration Roundtable luncheon that met quarterly for training and discussions on trauma, mental health and service integration; and e) establishment of an Interdisciplinary Resource Team (IRT). The IRT meetings were attended by staff from collaborating sites and included a brief lecture by an expert trauma consultant, case presentations by substance abuse treatment counselors, and discussion about approaches to integrated trauma services relevant to case presentations. It is the work of the IRT that is presented in this manual. References for History Section 1. Jennings, A. (1997). On being invisible in the mental health system. In: M. Harris & C. Landis (Eds.), Sexual Abuse in the Lives of Women Diagnosed with Serious Mental Illness. Netherlands: Harwood Academic Publishers. 2. Miller, D. (1994). Women Who Hurt Themselves. New York: Basicbooks. 3. Najavits, L., Weiss, R., & Liese, B. (1996). Group cognitive behavioral therapy for women with PTSD and substance abuse disorder. Journal of Substance Abuse Treatment, 13(1), Grella, C. (1996). Background and overview of mental health and substance abuse treatment systems: Meeting the needs of women who are pregnant or parenting. Journal of Psychoactive Drugs, 28(4), Grella, C. (2003). Contrasting the views of substance misuse and mental health treatment providers on treating the dually diagnosed. Substance Use & Misuse, 38(10), Harris, M. (1994). Modifications in service delivery and clinical treatment for women diagnosed with severe mental illness who are also the survivors of sexual abuse trauma. Journal of Mental Health Administration, Special Issue: Women's Mental Health Services; 21(4), Young, N., & Grella, C. (1998). Mental health and substance abuse treatment services for dually diagnosed clients: Results of a statewide survey of county administrators. Journal of Behavioral Health Services & Research, 25(1), McHugo, G., Kammerer, N., Jackson, E., Markoff, L., Gatz, M., Larson, M., et al. ( 2005). Women, co-occuring disorders, and violence study: Evaluation design and study population. Journal of Substance Abuse Treatment,.vol. 28: 1 7

15 9. Becker, M., Noether, C., Larson, M., Gatz, M., Brown, V., Heckman, J., et al. (insert year). Characteristics of women engaged in treatment for trauma and co-occurring disorders: Findings from a national multi-site study. Journal of Community Psychology, (insert vol/page info). 10. Domino, M., Morrissey, J., Nadlicki-Patterson, T., & Chung, S. (2004 or 2005?). Service costs for women with co-occuring disorders and trauma. Journal of Substance Abuse Treatment, (insert vol/page info). 11. Amaro, H., et al (insert other author information). (2005). Boston Consortium of Services for Families in Recovery: A trauma-informed intervention model for women's alcohol and drug addiction treatment. Alcoholism Treatment Quarterly 22 (3/4), Gelles, R. J., & Conte, J. R. (1990). Domestic violence and sexual abuse of children: A review of research in the eighties. Journal of Marriage and the Family, 52, Browne, A., & Bassuk, S. S. (1997). Intimate violence in the lives of homeless and poor housed women: Prevalence and patterns in an ethnically diverse sample. American Journal of Orthopsychiatry, 6, Amaro, H., Nieves, R., Wolde Johannes, S., & Labault Cabeza, N. (1999). Residential substance abuse treatment with Latinas: Critical issues and challenges. Hispanic Journal of Behavioral Sciences, 21(3), Senturia, K., Sullivan, M., Ciske, S., & Shiu-Thornton, S. (2000). Cultural issues affecting domestic violence service utilization in ethnic and hard to reach populations. Washington, DC: National Institute of Justice/NCJRS. 16. Browne, A. (1991). The victim s experience: Pathways to disclosure. Psychotherapy: Theory, Research, Practice, Training, 28(1), Browne, A. (1993). Family violence and homelessness: the relevance of trauma histories in the lives of homeless women. American Journal of Orthopsychiatry, 63(3), Boyd, C. J. (1993). The antecedents of women s crack cocaine abuse: Family substance abuse, sexual abuse, depression and illicit drug use. Journal of Substance Abuse Treatment, 10, Brown, V., Huba, G. J., & Mechior, L.A. (1995). Level of burden: Women with more than one co-occurring disorder. Journal of Psychoactive Drugs, 27(4),

16 20. Caetano, R., Cunradi, C. B., Clark, C. L., & Schafer, J. (2000). Intimate partner violence and drinking patterns among White, Black, and Hispanic couples in the U.S. Journal of Substance Abuse, 11(2), Fullilove, M. T., Fullilove, R. E., Smith, M., Winkler, K., Michael, C., Panzar, P. G., & Wallace, R. (1993). Violence, trauma and posttraumatic stress disorder among women drug users. Journal of Traumatic Stress, 6, Goodman, L. A., Rosenberg, S. D., Mueser, K. T., & Drake, R. E. (1997). Physical and sexual assault history in women with serious mental illness: Prevalence, impact, treatment, and future directions. Schizophrenia Bulletin, 23, Kilpatrick, D. G., Acierno, R., Saunders, B., Resnick, H. S., & Best, C. L. (1997). A 2-year longitudinal analysis of the relationships between violent assault and substance use in women. Journal of Consulting and Clinical Psychology, 65(5), Liebshulz, J., Mulvey, K., & Samet, J. (1997). Victimization among substance abusing women. Archives of General Medicine, 157, McCauley, J., Kern, D., Koloder, K., Dill, L., Schroeder, A. F., DeChant, H. K., Ryden, J., Derogatis, L. R., & Bass, E. B. (1997). Clinical characteristics of women with a history of childhood abuse. Journal of the American Medical Association, 277, Najavits, L. M., Weiss, R. D., & Shaw, S. R. (1997). The link between substance abuse and post traumatic stress disorder in women. American Journal of Addictions, 6(4), Poulsny, M. A., & Follete, V. M. (1995). Long-term correlates of child sexual abuse: Theory and review of the empirical literature. Applied Preventive Psychology, 4, Chalk, R., & King, P. A. (Eds.) (1998). Violence in Families: Assessing Prevention and Treatment Programs. Committee on the Assessment of Family Violence Interventions, National Research Council and Institute of Medicine, Washington, DC: The National Academies. 29. Dutton, M. A., Orloff, L. E., & Aguilar Hass, G. (2000). Characteristics of help-seeking behaviors, resources and service needs of battered immigrant Latinas. Georgetown Journal on Poverty Law & Policy, 2 (2), Bureau of the Census (2002). Race and Hispanic or Latino Origin by Age and Sex for the United States: 2000 (PHC-T-8). Retrieved May 5, 2002, from U.S. Census Bureau website: 9

17 31. The Sentencing Project. (2003). Hispanic Prisoners in the United States. Retrieved May 5, 2002 from The Sentencing Project website: 32. Beck, A., Karlberg, J., & Harrison, P. (2002). Prison and jail inmates at midyear Washington DC: Bureau of Justice Statistics. 33. United States Centers for Disease Control and Prevention (2001). HIV/AIDS Surveillance Report, 13(2). Retrieved May 5, 2002 from CDC website: 34. Amaro, H., Whitaker, R., Coffman, G., & Heeren, T. (1990). Acculturation and marijuana and cocaine use: Findings from the Hispanic HANES. American Journal of Public Health, 80, Perilla, J. A., Bakeman, R., & Norris, F. H. (1994). Culture and domestic violence: The ecology of abused Latinas. Violence and Victims, 9(4), West, C. M., Kaufman Kantor, G., & Jasinski, J. L. (1998). Sociodemographic predictors and cultural barriers to help-seeking behavior by Latina and Anglo American battered women. Violence and Victims, 13(4), West, C. M. (1998). Lifting the political gag order : Breaking the silence around partner violence in ethnic minority families. In J. L. Jasinski & L. M. Williams (Eds.). Partner Violence: A Comprehensive Review of 20 Years of Research (pp ). Thousand Oaks, CA: Sage Publications. 38. Jasinski. J. L. (1996). Structural inequalities, family and cultural factors, and spousal violence among Anglo and Hispanic Americans. Unpublished Doctoral Dissertation, University of New Hampshire, Durham. 39. Kaufman Kantor, G., Jasinski, J. L., & Aldarondo, E. (1994). Sociocultural status and incidence of marital violence in Hispanic families. Violence and Victims, 9(3), Eberstein, I., & Frisbie, W. M. (1976). Differences in marital instability among Mexican Americans, Blacks, and Anglos: 1960 and Social Problems, 23, Sorenson, S. B., & Telles, C. A. (1991). Self-reports of spousal violence in a Mexican-American and non-hispanic white population. Violence and Victims, 6, Okamura, A., Heras, P., & Wong-Kerberg, L. (1995). Asian, Pacific Island, and Filipino Americans and sexual child abuse. In L.A.Fontes (Ed.). Sexual abuse in nine North American cultures: Treatment and prevention (pp ). Thousand Oaks, CA: Sage Publications. 10

18 43. Amaro, H., Navarro, A. M., Conron, K. J., & Raj, A. (2001). Cultural influences on women s sexual health. In: R. J. DiClemente & G. M. Wingood (Eds) Women s Sexual & Reproductive Health: Social, Psychological and Public Health Perspectives (pp ). New York: Plenum Press. 44. Amaro, H., & Raj, A. (2000). On the margin: The realities of power and women s HIV risk reduction strategies. Journal of Sex Roles, 42(7/8), Amaro, H., & Hardy-Fanta, C. (1995). Gender relations in addiction and recovery. Journal of Psychoactive Drugs, 27(4), Fullilove, M., Fullilove, R. E., Haynes, K., & Gross, S. (1990). Black women and AIDS Prevention: A view towards understanding the gender rules. Journal of Sex Research, 27(1), Marin, B. V., Gomez, C. A., Tschann, J. M., & Gregorich, S. E. (1997). Condom use in unmarried Latino men: A test of cultural constructs. Health Psychology, 16(5), Wingood, G. M., & DiClemente, R. J. (2000). Application of the theory of gender and power to examine HIV-related exposures, risk factors, and effective interventions for women. Health Education & Behavior, 27(5),

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20 IRT Case Presentation #1: Sharon Mothering the Mother : The role of substance abuse and trauma on the childhood development of a young adult mother. Learning Objectives Women presenting to substance abuse treatment centers are increasingly younger than they have been in the past. Drug use among young women has increased in recent years and the traditionally observed gender gap in drug use between boys and girls has been decreasing. This trend has resulted in more young women presenting for treatment. Often young women with alcohol or drug addiction problems face other problems such as unwanted or unplanned pregnancy or the parenting of young children. Age of onset of substance use and abuse (when an individual begins to experiment and use substances) is a critical diagnostic indicator because it predicts later problems with substance abuse. Individuals who initiate alcohol or drug use at a younger age are more likely to develop substance abuse problems than those who begin use later in childhood or in adulthood. Early substance use can interfere with the mastery of key developmental tasks and academic achievement. These young adults in recovery often appear child-like in their presentation. The excessive dependency that these women express can be difficult for providers and clinicians to manage. Dependency is even more complicated when there is a question of cognitive impairment. These young mothers often lack the skills to adequately parent infants and toddlers. With Sharon s case we will consider the following: Differential diagnosis for a client with a complicated clinical presentation Understanding the impact of early onset of substance use on developmental mastery of an adult who is currently actively using substances. Choosing a therapeutic approach based on overall character style: skill- building versus insight-oriented approaches. 13

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