Seeing Is Believing. By Karen Feldscher. Photography by Tanit Sakakini

Transcription

1 Seeing Is Believing To help women battling substance abuse, urban-health expert Hortensia Amaro develops on-the-ground programs that address the daunting web of problems that can lead to addiction By Karen Feldscher Photography by Tanit Sakakini

2 In the mid-1980s, Hortensia Amaro interviewed a patient in the Boston City Hospital maternity ward. The woman, who was HIV positive, was petrified worried her baby would be born sick, too. Amaro, newly launched into her academic career, was there simply to gather data for a study of women s drug use during pregnancy. The research, she says, was designed to be purely descriptive, with no education, no intervention. Yet she found it hard to listen to the woman s fears and not be able to help. And this was no isolated incident. I met a lot of women who were in abusive relationships, who were addicted to drugs, she recalls. It was early in the AIDS epidemic. Antiretroviral drugs weren t available to protect unborn babies, or halt the progress of the disease in infected people. Then Amaro s younger brother contracted AIDS, and died. Amaro had been publishing research articles on drug use among Hispanics and pregnant adolescents, on women s experience of violence during pregnancy.

3 I asked myself, What am I doing, writing articles that go on a shelf? Amaro says. I ve always been committed to social action and improving life for people who don t have it so great. Suddenly, the work felt too removed from real - ity at a time when people were in real trouble. I asked myself, What am I doing, writing articles that go on a shelf? she says. I ve always been committed to social action and improving life for people who don t have it so great. So Amaro decided to switch gears, to conduct research by seeing how vulnerable populations actually respond to different programs. Once she saw what clicked, she could outline models for helping people that could be replicated by clinicians anywhere. Today, she directs Northeastern s Institute on Urban Health Research. Many of her projects are conducted in partnership with the Boston Public Health Commission. She works in real-life settings, she writes on her website, developing programs from scratch for real-life communities. Keeping her eye trained on what really helps women, Amaro has discovered that those who struggle with multiple issues say, addiction in combination with mental illness and posttraumatic stress disorder respond best to integrated treatment. Simply put, integrated treatment is care that addresses all of an individual s issues at the same time, through a coordinated effort by the individual s care providers. Amaro knows this approach works because she s spent six years studying its impact on close to three thousand Boston-area women. According to Bouvé College of Health Sciences dean Stephen Zoloth, Amaro is one of those rare people who can really translate an idea into practice. She is known worldwide for her ability to take an intervention, evaluate its success, and make it a lasting part of the publichealth world. This is unique and it s the Holy Grail of public health. The work she does in Boston is not limited to Boston, Zoloth adds. She s working on issues that are critical to the health of people throughout the world. And she s doing it at the right university. Northeastern, says Amaro, has the values and history of working with local communities, of valuing applied research, and valuing what students can learn from engaging with the world. A new leaf. Iliana Rivera (standing) directs outpatient services at the Mom s Project and MORE, comprehensive programs for addicted women that grew out of Amaro s research. A COMPREHENSIVE FOCUS When Amaro had her research epiphany in the 1980s, she was working at Boston University s School of Public Health. In 2001, she moved across town to Northeastern, becoming associate dean and Distinguished Professor of Health Sciences and Counseling Psychology. Amaro came to Northeastern because of its emphasis on applied research and urban outreach and for another reason, too. This is a university that s helped many immigrants get an education, says Amaro, who was ten when she arrived in Los Angeles as a Cuban refugee. That really resonated with me. Amaro has been incredibly energized in her research. Her curriculum vitae lists more than a hundred journal articles, many widely cited; fifty funded research projects, many supported with millions of federal dollars; and eight training manuals, which have been adopted around 26 Northeastern University Alumni Magazine Spring 2010

4 FOR ADDICTED WOMEN, A TRANSFORMATION Ada Rosario says she never realized why she used alcohol and drugs. I was abused when I was eight, says Rosario, a thirty-fi veyear-old single mother of three. My mother used to beat us up. My father was an alcoholic. There was a lot of pain. But I didn t know those traumas were what caused me to try to numb the pain with alcohol and drugs. Participating in the MORE (Moving On to Recovery and Empowerment) program really helped me, says Rosario. Every day, my teachers teach me new things. I really love the program. MORE begun by Hortensia Amaro and administered by the Boston Public Health Commission helped its fi rst clients in Through MORE, women attend counseling eight to ten hours a week to address their addiction as well as issues related to trauma, HIV prevention, parenting, stress reduction, anger management, selfesteem, spirituality, and leadership. We try to cover all aspects of a woman s life, says Iliana Rivera, director of outpatient services for MORE and its sister program, the Mom s Project. We see a wonderful transformation among women who come through these programs. Rosario can attest to that. Because of her drug habit, her two older daughters are offi cially in her mother s custody. She spent last summer in jail. She discovered at the beginning of her incarceration that she was pregnant again. Now, she s been clean since last May. She s living with her baby at Entre Familia, a residential substance-abuse treatment program for pregnant and postpartum Latina women, also begun by Amaro. And she s spending many hours each week at MORE. I get a lot of help here, she says. The more I understand about my choices, the better it is for me. Karen Feldscher the world, detailing step-by-step programs to help people deal with substance abuse, mentalhealth problems, trauma, and AIDS. Her integrated approach to addiction is getting a lot of attention from substance-abuse experts. Results show that women who get integrated treatment fare better than those who receive treatment that focuses solely on the addiction. They stay in treatment longer. They have lower rates of post-treatment drug use, mental-health problems, and trauma symptoms. They exhibit fewer HIV risk behaviors. Integrated treatment is deemed so effective that the U.S. government recently placed it on an approved list of treatment models (see sidebar, page 28). The model makes a lot of intuitive sense. And yet addiction programs have traditionally focused only on the addiction. If a woman also had mental-health problems, she had to seek out a separate care provider to deal with them. Still another care provider to deal with problems caused by abuse. And so on. There were these silos of service systems and professional cultures that did not communicate with one another and, in fact, had conflicts, says Amaro. Our work became about, okay, how do we create a treatment model for women who are poor, with low literacy, with mental-health problems, with children with behavioral problems? she says. How do we really address all their needs, not just help them stay off drugs? We needed to deal with the things that led them to getting on drugs in the first place. BREAKING THE CYCLE The work grew organically. Starting about ten years ago, Amaro assembled a team of people from city and state agencies that serve people dealing with addiction, abuse, and other issues. Participants in the team, known as the Boston Consortium, worked in substance-abuse, mental-health, domestic-violence, and childwelfare offices; the courts; and the police department. They met weekly to discuss what had happened in clinical sessions with women, evaluating what worked and what didn t. It was like building blocks. One project led to another, says Rita Nieves, director of the Boston Public Health Commission s Bureau of Addictions Prevention, Treatment, and Recovery Support Services. Nieves has partnered with Amaro for the past sixteen years to create comprehensive services for people with multiple issues. Nieves says, We would do a project, recognize gaps in treatment, go after more grant money, implement another project, then learn from that and get another grant for another project. Integrated treatment programs offer women with substance-abuse problems one-stop shopping, says Nieves. The women we work with Spring 2010 Northeastern University Alumni Magazine 27

5 A HIGH-LEVEL THUMBS-UP Hortensia Amaro has spent years developing effective ways to help women kick substance abuse, ease their trauma symptoms, and improve their mental health. Now, a prestigious commendation by the U.S. government will ensure many more women are helped by her strategies. The treatment model for women developed by Amaro s Institute on Urban Health Research, in collaboration with the Boston Public Health Commission, was recently approved for inclusion in the National Registry of Evidence-Based Programs and Practices, managed by the Substance Abuse and Mental Health Services Administration (SAMHSA). Formally known as the Boston Consortium Model: Trauma-Informed Substance-Abuse Treatment for Women, Amaro s novel approach treats women not just for drug addiction but for problems related to abuse and mental illness as well. The SAMHSA registry highlights interventions that have been tested and found effective. The decision to include Amaro s methods on this list which followed a rigorous two-year review by a panel of national experts means social-services agencies searching for effective substance-abuse treatments are much more likely to adopt her model, 1 of only about 150 so approved. Amaro is pleased her work will have even greater reach. I get calls from people in other states saying, We want to use your model, she reports. Karen Feldscher have complicated lives. For them to have a place to go where people can address their issues in an integrated way makes a huge difference in how they feel, and in how empowered they are to fix some of their problems. The issues the women face are often profound, Amaro says: Childhood abuse, sexual abuse, neglect. From male partners, from community violence, from all kinds of sources. Many times, she continues, the abuse is pretty horrific, and long term, and from multiple sources. This is the reason the women are using drugs they are self-medicating. Because who could live with that level of abuse? The reality of self-medication helps explain why any approach that simply treats the addiction is likely to fail. When women stop using drugs, their trauma symptoms come up, Amaro says. Then they want to use again. There s high risk for relapse. An integrated intervention model succeeds by teaching women to recognize the vicious cycle they re trapped in quit drugs/experience trauma symptoms/take drugs again then make better choices. Which is decidedly not easy, Amaro admits. Research shows that family support is one of the most important predictors of success when it comes to breaking a drug habit, says Amaro. But what do you do when it s your family that s caused you pain? Where does that leave you? Our treatment model tries to help women heal from that, reconcile what they can and can t have with their family, and create new networks of support, she says. All-in-one. Rita Nieves (left), a Bos ton Public Health Commission director, con fers with Rivera and another staffer. Integrated services offer the best hope for women who self-medicate, Nieves says. 28 Northeastern University Alumni Magazine Spring 2010

6 REAL PROGRAMS, REAL RESULTS Amaro s tenacious pursuit of workable models for social-service providers has created muchneeded programs in Boston. The Mom s Project, for instance, initially an HIV-prevention and -intervention program for pregnant women, has grown into a more-encompassing substance-abuse program. Entre Familia (Spanish for between family ) is a residential comprehensive-care program for women and children. Both programs, created and run by the Boston Public Health Commission, are based on treatment models Amaro developed and tested on groups of Boston women in the 1990s and early 2000s. The benefits to the city of Boston have been many, says Nieves. This work has provided [grant] money to start or improve programs. We ve been able to provide care we otherwise would not have been able to provide. And we ve been able to publish papers documenting the effectiveness of the interventions. Another tangible result of Amaro s work is a set of treatment manuals, offering step-by-step guides for clinicians around the world. The manuals cover a variety of topics: Amaro s integrated approach, child custody and family reunification, economic success, spirituality, women s leadership training, and the use of mindfulness techniques to prevent relapse. Hortensia s work has helped develop protocols for treatment, says provost Stephen Director. What works becomes incorporated into practice. These are national models other cities will certainly want to take a very serious look at. Amaro is already working on additional clinical models to improve social services for those who need it most. She s creating a community reentry program for incarcerated women. She s looking at how to bring comprehensive services to men in addiction recovery. She s developing an integrated approach to medical and mental-health services for children. A match made in heaven is what Nieves calls her work with Amaro a unique example of how a city health department partnering with an academic institution like Northeastern can be a wonderful thing. Each year, about a dozen graduate students and several undergraduates work with Amaro. They assist with focus groups, interviews, data coding and analysis, grant writing, presentations, and the preparation of scientific publications. One student, behavioral-neuroscience undergrad Sergio Escobar, recently helped teach patients in addiction treatment about the neurobiology of drug addiction. This has been a wonderful opportunity to get involved with the community, especially those in need, says Escobar. Director praises Amaro s ability to bring people together to improve services. She does a great job of forging unique collaborations between city agencies and the university, he says. Nieves calls her collaborations with Amaro a match made in heaven, and a unique example of how a city health department partnering with an academic institution like Northeastern can be a wonderful thing. Amaro, who s received numerous awards and wide recognition for her work, says she s thankful to be able to conduct research that helps real people solve real problems. Generally, says Amaro, academics are trained to do research in the objective, supposedly neutral environment of the university. Then we write research articles. Then it s somebody else s job we never know whose to take that knowledge off the library shelf and figure out how to apply it to improve something in the world. What I do conduct research and adapt knowledge to specific populations in real-life service environments, like clinics, hospitals, and community-health centers is rare, she says. She s doubly grateful Northeastern supports her brand of research: When President Aoun came to Northeastern, he took time to come to my programs and talk to the women who are served there, and to the staff, Amaro says. The provost, the vice provost for research, and Dean Zoloth have also made a point of visiting her programs, she says. They get why it s important the connection between scholarship and community, the learning opportunities for students. All along, the university leadership has made clear that this work is valued. That s a big deal. Karen Feldscher is a senior writer. Spring 2010 Northeastern University Alumni Magazine 29