Hortensia Amaro, Ph.D. Institute on Urban Health Research Northeastern University

Transcription

1 The Boston Consortium Model: Treatment of Trauma Among Women with Substance Use Disorders Hortensia Amaro, Ph.D. Institute on Urban Health Research Northeastern University

2 1. Background of the Problem Co-Occurring Disorders HIV Risk Behaviors Complex Clinical Presentation Worse Prognosis Gender Specific Treatments 2. Integrated Treatment Study Purpose & Methods Intervention Findings

3 The Boston Consortium Model October September 2004 SAMHSA Implemented in: Women and Family Division Bureau of Addiction Treatment t Boston Public Health Commission National Registry of Evidence Based Models GRAM_ID=271 - start-content

4 BCS Research Question How effective are comprehensive, integrated, trauma-informed services in reducing symptoms of trauma, mental illness and substance abuse, and HIV sexual risk behaviors compared to services as usual?

5 Boston Consortium Integrated Treatment Model Methadone Outpatient Residential Substance Abuse Treatment Integrated Treatment Model Psychotherapy Pharmacology Recovery Skills Building Mental Health/Trauma Treatment Amaro H McGraw S Larson M J Lopez L Nieves R & Marshall B (2005) Boston Amaro, H., McGraw, S., Larson, M.J., Lopez, L., Nieves, R., & Marshall, B. (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),

6 Intervention Principles and Elements Principles Consumer participation Cultural and linguistic tailoring Gender specific Use of evidence-based approaches Core Elements In-depth staff training on trauma informed care, links between trauma, mental illness and substance abuse disorders; and trauma specific intervention. Integration of trauma and mental health in assessment, crisis intervention, counseling, psychotherapy. Trauma-specific treatment with HIV component

7 Elements of Clinical Intervention MH & Trauma Diagnostic & Integrated Tx Plan System Boundary Spanner for: MH Emergency Services Individual/Family/Group d l /G Therapy Psychopharmacological Treatment Package of manualized trauma recovery skills building groups Culturally and linguistically tailored Amaro, H., McGraw, S., Larson, M.J., Lopez, L., Nieves, R., & Marshall, B. (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),

8 1. Case study workbook for staff training 2. Uses case examples to engage staff in discussions of issues that emerge in integrated treatment Staff Training Amaro, H, Melendez, MP, Melnick, S, and Nieves, RL. (2005). Integrated Substance Abuse, Mental Health and Trauma Treatment with Women: Acase study workbook for staff training. Boston Consortium of Services for Families in Recovery, Public Health Commission, Boston, MA.

9 Trauma Recovery and Empowerment Saber es Poder 1.TREM cultural adaptation & translation 2.25-week psycho educational trauma weekly group treatment. 3.Focuses on personal safety, empowerment and coping skills, links among substance abuse, mental health problems, and trauma. 4.Enhanced with HIV intervention focusing on sexual negotiation and sexual safety. Harris, M, Wallis, F and Amaro, H. (2006). Saber es Poder: Modelo de Trauma y Recuperacion para Mujeres Latinas. (A Spanish translation and cultural adaptation of Maxine Harris Trauma Recovery and Empowerment manual). Boston Consortium of Services for Families in Recovery, Public Health Commission, Boston, MA.

10 Leadership Skills 3-session (half-day each) educational curriculum teaches women how to: 1. regain voice and agency 2. become leaders and 3. learn to speak up on behalf of themselves and other women in recovery. Amaro, H, Nieves, RL, and Saunders, L.(2004). Women s Leadership Training Institute: An educational group curriculum for women in recovery. Boston Consortium of Services for Families in Recovery, Public Health Commission, Boston, MA.

11 8-session educational curriculum designed to assist women in Economic Skills 1. money management in the recovery process, 2. effective money management skills and 3. identifying and planning educational, vocational, and job training opportunities and objectives. Amaro, H, and Nieves, RL. (2004). Economic Success in Recovery: An educational group curriculum for women in recovery. Boston Consortium of Services for Families in Recovery, Public Health Commission, Boston, MA.

12 Family Reunification 10-week educational curriculum 1. impact of substance abuse on parenting, family reunification and self-care 2. learn about child protective services and self-advocacy 3. build skills to cope with triggers related to child custody issues Amaro H and Nieves RL (2004) Pathways to Family Reunification: An Amaro, H and Nieves, RL. (2004). Pathways to Family Reunification: An educational group curriculum for women in recovery. Boston Consortium of Services for Families in Recovery, Public Health Commission, Boston, MA.

13 Primary Outcomes Measures Outcomes Substance Abuse: Measures Addiction Severity Index Alcohol Composite (ASI-A) Drug Composite (ASI-D) Mental Health: Trauma: HIV: Brief Symptom Inventory Global Severity Index (GSI) Post Traumatic Diagnostic Scale Post Traumatic Symptom Scale (PSS) Unprotected sex in last 30 days

14 Findings: Alcohol and Drug Use Alcohol Addiction Severity: non-significant Condition X Time interaction Drug Addiction Severity non-significant Condition X Time interaction Post-hoc analyses: Intervention group reported significantly higher h drug abstinence rates than the comparison group at both 6- and 12-month follow-ups (6-month: 67% vs. 38%; 12-month: 75% vs. 40%; all p values < ) Amaro, H., Dai, J., Arevalo, S., Acevedo, A., Matsumoto, A., & Nieves, R. (2007). Effects of integrated trauma treatment on outcomes in a racially/ethnically diverse sample of women in urban communitybased substance abuse treatment. Journal of Urban Health, 84(4), Amaro, H., Gampbel, J., Larson, M.J., Lopez, L., Richardson, R., Savage, A., & Wagner, D. (2005). Racial/Ethnic Differences in Social Vulnerability among Women with Co-occurring Mental Health and Substance Abuse Disorders: Implications for Treatment Services. Journal of Community Psychology, 33(4),

15 Findings: Mental Health and Trauma Mental health symptoms: significant Condition X Time interaction, F (2, 556) = 4.55, p =.01 (d =.32), favoring the intervention group. PTSD symptoms: significant Condition X Time interaction, F (2, 553) = , p=.01 (d =.35), favoring the intervention group. Amaro, H., Dai, J., Arevalo, S., Acevedo, A., Matsumoto, A., & Nieves, R. (2007). Effects of integrated trauma treatment on outcomes in a racially/ethnically diverse sample of women in urban communitybased substance abuse treatment. Journal of Urban Health, 84(4),

16 Findings: HIV Risk Behaviors Strong significant association between intervention ti status t and sexual risk behaviors) was replicated (OR: 0.22, 95% CI: ) Comparison group women had 4.5 times more likelihood lih of engaging in unprotected t sex than intervention group women. Amaro, H., Larson, M. J., Zhang, A., Acevedo, D., Dai, J., & Matsumoto, A. (2007). Effects of trauma intervention ti on HIV sexual risk behaviors among women with co-occurring disorders in substance abuse treatment. Journal of Community Psychology, 35(7),

17 Relationship Power Perception of relationship control and decision- making measured by the Relationship Power Scale (RPS) (Pulerwitz et al., 2002). Analysis were restricted to those in relationships in the past 6 months At baseline, no differences in RPS At both follow-ups, intervention group had significantly higher RPS than comparison group (p<.01) RPS was significantly associated with lower HIV risk behaviors at 6M f-up (p<.01) Amaro, H., Larson, M. J., Zhang, A., Acevedo, D., Dai, J., & Matsumoto, A. (2007). Effects of trauma intervention on HIV sexual risk behaviors among women with co-occurring occurring disorders in substance abuse treatment. Journal of Community Psychology, 35(7),

18 Conclusion Limitations of quasi-experimental study design. Evidence that integrated treatment results in better treatment outcomes including lower HIV risk behaviors Qualitative data from staff and clients indicate high level of acceptability, feasibility and fit of intervention. Staff training needed to integrate treatment of MH and trauma into SA tx and requires systems change W t f th h ffi di t Warrants further research on efficacy, mediators and key program elements

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