The Addiction-Trauma Connection: Spirals of Recovery & Healing

The Addiction-Trauma Connection: Spirals of Recovery & Healing Stephanie S. Covington, PhD, LCSW Institute for Relational Development Center for Gender and Justice 7946 Ivanhoe Ave., Suite 201B La Jolla, CA 92037 (858) 454-8528 (858) 454-8598 FAX Email: sc@stephaniecovington.com www.stephaniecovington.com www.centerforgenderandjustice.org Institute on Violence, Abuse & Trauma (IVAT) 18th Annual International Conference & Summit 18th Annual International Conference & Summit September 10, 2013 San Diego, CA

The Addiction-Trauma Connection: Spirals of Recovery & Healing Stephanie S. Covington, Ph.D., L.C.S.W. Center for Gender and Justice Institute for Relational Development La Jolla, CA Institute on Violence, Abuse & Trauma (IVAT) 18th Annual International Conference & Summit September 10, 2013 San Diego, CA History Addiction Colonial period Moral issue Mental health field Disease Paraprofessionals Addiction-Trauma Connection, Sept 10, 2013 San Diego 1

Addiction History (cont.) Recovery movement Criminalization Neuroscience Medication assisted Opiate addiction Addiction 16% of Americans over 12 years of age 40 million people More than heart disease (27m), diabetes (26m), or cancer (19m) (CASA, 2012) Addiction (cont.) Another 32% (80 million) use tobacco, alcohol and other drugs in risky ways that threaten health and safety. (CASA, 2012) Addiction-Trauma Connection, Sept 10, 2013 San Diego 2

Cost The cost of addiction and risky substance use to the government alone is $484 billion per year. Definition of Trauma The diagnostic manual used by mental health providers defines trauma as: exposure to actual or threatened death, serious injury or sexual violation. (American Psychiatric Assoc. [APA] DSM-5) Definition of Trauma (cont.) The exposure must result from one or more of the following scenarios in which the individual: directly experiences the traumatic event; witnesses the traumatic event in person; (American Psychiatric Assoc. [APA] DSM-5) Addiction-Trauma Connection, Sept 10, 2013 San Diego 3

Definition of Trauma (cont.) The exposure must result from one or more of the following scenarios in which the individual: learns that the traumatic event occurred to a close family member or close friend; experiences first-hand repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, television or movies unless work-related). (American Psychiatric Assoc. [APA] DSM-5) Definition of Trauma (cont.) The disturbance, regardless of its trigger, causes significant distress or impairment in the individual s: social interactions, capacity to work, or other important areas of functioning. (It is not the physiological result of another medical condition, medication, drugs or alcohol.) (American Psychiatric Assoc. [APA] DSM-5) Definition of Trauma The diagnostic manual used by mental health providers defines trauma as: exposure to actual or threatened death, serious injury or sexual violation. (American Psychiatric Assoc. [APA] DSM-5) Addiction-Trauma Connection, Sept 10, 2013 San Diego 4

Definition of Trauma (cont.) The exposure must result from one or more of the following scenarios in which the individual: directly experiences the traumatic event; witnesses the traumatic event in person; (American Psychiatric Assoc. [APA] DSM-5) Definition of Trauma (cont.) The exposure must result from one or more of the following scenarios in which the individual: learns that the traumatic event occurred to a close family member or close friend; experiences first-hand repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, television or movies unless work-related). (American Psychiatric Assoc. [APA] DSM-5) Definition of Trauma (cont.) The disturbance, regardless of its trigger, causes significant distress or impairment in the individual s social interactions, capacity to work, or other important areas of functioning. (It is not the physiological result of another medical condition, medication, drugs or alcohol.) (American Psychiatric Assoc. [APA] DSM-5) Addiction-Trauma Connection, Sept 10, 2013 San Diego 5

Definition of Trauma Trauma occurs when an external threat overwhelms a person ss internal and external positive coping resources. Source: Van der Kolk, B. (1989). Violence Against Women Violence against women is so pervasive that the United Nations has addressed and defined violence against women as any act of gender- based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivations of liberty, whether occurring in public or private life. (United Nations General Assembly, 1993). Traumatic Events Trauma can take many forms: Emotional, sexual or physical abuse Neglect Abandonment (especially for small children) Extremely painful and frightening medical procedures Addiction-Trauma Connection, Sept 10, 2013 San Diego 6

Traumatic Events (cont.) Catastrophic injuries and illnesses Rape or assault Muggings Domestic violence Burglary Automobile accidents Traumatic Events (cont.) Immigration Natural disasters (hurricanes, floods, earthquakes, tornadoes, fires, volcanoes) Terrorism such as September 11, 2001 Witnessing violence such as a parent harming another parent Traumatic Events (cont.) Unexpected/violent loss of a loved one (even of a pet) Combat/war Torture Victim of trafficking Kidnapping Intergenerational (cultural) trauma Addiction-Trauma Connection, Sept 10, 2013 San Diego 7

Historical Trauma Across generations Massive group trauma Examples include: Native Americans, African Americans, Holocaust survivors, Japanese internment survivors, Aboriginal (First Nation) Definition of Historical Trauma the cumulative emotional and psychological wounding spanning generations, which emanates from a massive group trauma. Source: Brave Heart, M.Y.H. (2005). From intergenerational trauma to intergenerational healing. Keynote address at the Fifth Annual White Bison Wellbriety Conference, Denver, CO, April 22, 2005. Traumatic Events Of all these forms of trauma, women are at greater risk of intimate partner violence than men. Addiction-Trauma Connection, Sept 10, 2013 San Diego 8

Trauma-informed Services Take the trauma into account. Avoid triggering trauma reactions. Adjust organization so that trauma survivors can access and benefit from services. (Harris & Fallot) Core Principles of Trauma-Informed Care Safety (physical and emotional) Trustworthiness thi Choice Collaboration Empowerment (Fallot & Harris, 2006) Becoming Trauma Informed Creates a Culture Shift Addiction-Trauma Connection, Sept 10, 2013 San Diego 9

A Culture Shift: Core Values of a Trauma-Informed System of Care Safety: Ensuring physical and emotional safety Trustworthiness: Maximizing trustworthiness, making tasks clear, and maintaining appropriate boundaries Choice: Prioritizing consumer choice and control A Culture Shift: Core Values of a Trauma-Informed System of Care (cont.) Collaboration: Maximizing collaboration and sharing of power with consumers Empowerment: Prioritizing consumer empowerment and skill-building Source: Roger Fallot, Ph.D. A Culture Shift: Scope of Change in a Distressed System Involves all aspects of program activities, setting, relationships, and atmosphere (more than implementing i new services) Involves all groups: administrators, supervisors, direct service staff, support staff, and consumers (more than service providers) Source: Roger Fallot, Ph.D. S. Covington, Ph.D., 2013 Addiction-Trauma Connection, Sept 10, 2013 San Diego 10

A Culture Shift: Scope of Change in a Distressed System (cont.) Involves making trauma-informed change into a new routine, a new way of thinking and acting (more than new information) Source: Roger Fallot, Ph.D. A Culture Shift: Changes in Understanding and Practice Thinking differently as a prelude to acting differently Thinking differently initiates and sustains changes in practice and setting Acting differently reinforces and clarifies changes in understanding Source: Roger Fallot, Ph.D. S. Covington, Ph.D., 2013 Process of Trauma TRAUMATIC EVENT Overwhelms the Physical & Psychological Systems RESPONSE TO TRAUMA Fight or Flight, Freeze, Altered State of Consciousness, Body Sensations, Numbing, Hyper-vigilance, Hyper-arousal SENSITIZED NERVOUS SYSTEM CHANGES IN BRAIN CURRENT STRESS Reminders of Trauma, Life Events, Lifestyle PAINFUL EMOTIONAL STATE RETREAT HARM TO SELF HARM TO OTHERS ISOLATION DISSOCIATION DEPRESSION ANXIETY SUBSTANCE ABUSE EATING DISORDER DELIBERATE SELF-HARM SUICIDAL ACTIONS AGGRESSION VIOLENCE RAGES Source: Covington, S., Beyond Trauma: A Healing Journey for Women and Healing Trauma: Strategies for Abused Women CD-Rom. Addiction-Trauma Connection, Sept 10, 2013 San Diego 11

The Adverse Childhood Experiences (ACE) Study Collaboration between Centers for Disease Control and Prevention (CDC) Kaiser Permanente HMO in California Largest study ever 17,000 adult members participated ACE Study (Adverse Childhood Experiences) Before age 18: Recurrent and severe emotional abuse Recurrent and severe physical abuse Contact sexual abuse Physical neglect Emotional neglect ACE Study (Adverse Childhood Experiences) Growing up in a household with: An alcoholic or drug-user A member being imprisoned A mentally ill, chronically depressed, or institutionalized member The mother being treated violently Both biological parents not being present (N=17,000) Addiction-Trauma Connection, Sept 10, 2013 San Diego 12

ACE Study (Adverse Childhood Experiences) Results: ACEs still have a profound effect 50 years later, although now transformed from psychosocial experience into organic disease, social malfunction, and mental illness. Smoking Alcoholism Injection of illegal drugs Obesity (Felitti, V.J.: Origins of Addictive Behavior: Evidence from the ACE Study. 2003 Oct:52(8): 547-59. German. PMID: 14619682 (PubMed-indexed for MEDLINE). Higher ACE Score Chronic Health Conditions Heart disease Autoimmune diseases Lung cancer Pulmonary disease Liver disease Skeletal fractures Sexually transmitted infections HIV/AIDS Addiction ACE Study (cont.) Men 16% Sexual Abuse Men 30% Physical Abuse Women 27% Sexual Abuse (Felitti and Anda, 2010) Addiction-Trauma Connection, Sept 10, 2013 San Diego 13

ACE Study (cont.) Population studied: 75% white 39% college (36% some) 18% high school grads (Felitti & Anda, 2010) ACE Study (cont.) Women are 50% more likely than men to have a score of 5 or more. (Felitti & Anda, 2010) ACE Study (cont.) If a male child has 6 or more yes answers, his risk of becoming an IV drug user increases by 4,600% compared to a boy with a score of zero. (Felitti & Anda, 2010) Addiction-Trauma Connection, Sept 10, 2013 San Diego 14

Adverse Childhood Experiences Five-State Study 2010 Collaboration between CDC and state health departments of AR, LA, NM, TN and WA. 26,229 adults were surveyed S. Covington, Ph.D., 2013 ACE Scores and Impact Adverse childhood experiences are underlying factors for: Chronic depression Suicide attempts Serious and persistent mental health challenges Addictions Victimization of rape and domestic violence Source: Ann Jennings, Ph.D. Adverse Childhood Experiences (www.acestoohigh.com) (www.cdc.gov/ace) R. Fallot, Ph.D. Addiction-Trauma Connection, Sept 10, 2013 San Diego 15

ACE Study (cont.) I see that you have Tell me how that has affected you later in your life. (Felitti & Anda, 2010) Women in Prison Largest Effect-Mental Health Psychotropic medication Mental health treatment Attempted suicide Traumatic stress (Messina & Grella, 2005) Women in Prison (cont.) Largest Effect-Mental Health 980% increase in odds if exposed to 7 CTE s (Messina & Grella, 2005) Addiction-Trauma Connection, Sept 10, 2013 San Diego 16

ACE Study Walla Walla, WA www. ACEStooHigh.com Wow. Are you okay? What s going on? 1 10 with anger Washington High School (cont.) 2009 2010 (Before new approach) 798 suspensions 50 expulsions 600 written referrals 2010 2011 (After new approach) 135 suspensions 30 expulsions 320 written referrals Critical and Interrelated Issues Addiction Mental Health Trauma Physical Health Crime Addiction-Trauma Connection, Sept 10, 2013 San Diego 17

Changes in Understanding: The Centrality of Trauma Incarceration Homelessness Violence and Trauma Addiction Mental Health Problems Key Elements (Staff and Clients) Learn what trauma/abuse is Understand typical responses Develop coping skills Secondary Traumatic Stress (STS) Compassion fatigue: No empathy doesn t happen Charles Figley sudden Burnout: Bloom conflict of values Vicarious traumatization: Laurie Pearlman slow Addiction-Trauma Connection, Sept 10, 2013 San Diego 18

Definition of Recovery The definition of recovery has shifted from a focus on what is deleted from one s life (alcohol and other drugs, arrests for criminal acts, hospitalizations) to what is added to one s life (the achievement of health and happiness). (Miller & Kurtz, 2005) Prevalence of Trauma and PTSD in Substance Use/Abuse 60% to 90% of a treatment-seeking sample of substance abusers also have a history of victimization iti i More than 80% of women seeking treatment for a substance use disorder reported experiencing physical/sexual abuse during their lifetime Prevalence of Trauma and PTSD in Substance Use/Abuse (cont.) Between 44% and 56% of women seeking treatment for a substance use disorder had a lifetime history of PTSD 10.3% of the men and 26.2% of the women with a lifetime diagnosis of alcohol dependence also had a history of PTSD Addiction-Trauma Connection, Sept 10, 2013 San Diego 19

Histories of Trauma/Violence among Clients Treated for Methamphetamine Persons in treatment for methamphetamine report high rates of trauma: 85% women 69% men Histories of Trauma/Violence among Clients Treated for Methamphetamine Most common source of trauma/violence: For women, was a partner (80%) For men, was a stranger (43%) Histories of Trauma/Violence among Clients Treated for Methamphetamine History of sexual abuse: 57% women 16% men Addiction-Trauma Connection, Sept 10, 2013 San Diego 20

Prevalence of Trauma and PTSD in Severe Mental Illness 98% reported exposure to at least one traumatic event, lifetime 43% of sample received a current diagnosis i of PTSD; only 2% had PTSD diagnosis in their charts Severely mentally ill patients who were exposed to traumatic events tended to have been multiply traumatized, with exposure to an average of 3.5 different types of trauma. Disorders Related to Trauma and Substance Abuse in Women s Lives Depressive Disorders NOS 22.9% Major Depressive Disorders 17.5% Post traumatic Stress Disorders 16.3% Neurotic Anxiety Disorders 13.8% Bipolar Disorders 13.7% Mood or Dysthymic Disorders 5.3% Psychotic Disorders 4.8% Personality and Misc. Disorders 5.8% Source: Patterns of Comorbidity among Women with Childhood Interpersonal Trauma, Mental Health Disorders, and Substance Related Disorders. Journal of Behavioral Health Services & Research (in press) Posttraumatic Stress Disorder (PTSD) Intrusive symptoms flashbacks, nightmares, intense or prolonged distress Avoidant symptoms avoiding people, places and situations which are triggers or reminders; disconnection (Source: DSM-5) Addiction-Trauma Connection, Sept 10, 2013 San Diego 21

Posttraumatic Stress Disorder (cont.) (PTSD) Negative emotions and thoughts blaming, excessive negativity, fear, anger, shame, diminished interests, feelings of isolation Arousal symptoms angry outbursts, reckless and dangerous behavior, hypervigilance, difficulty sleeping (Source: DSM-5) Trauma: Stages of Recovery Syndrome Stage One Stage Two Stage Three Hysteria (Janet 1889) Stabilization, Symptom- oriented treatment Exploration of traumatic memories Personality reintegration, rehabilitation Combat trauma Scurfield (1985) Trust, stress- management education Re-experiencing experiencing trauma Integration of trauma Source: Herman, 1992, 1997 Trauma: Stages of Recovery Syndrome Stage One Stage Two Stage Three Complicated post-traumatic traumatic stress disorders Stabilization Integration of memories Development of self, drive integration Source: Herman, 1992, 1997 Addiction-Trauma Connection, Sept 10, 2013 San Diego 22

Trauma: Stages of Recovery Syndrome Stage One Multiple personality Diagnosis, stabilization, ti disorder communication (Putnam 1989) cooperation Traumatic disorders (Herman 1992) Safety Stage Two Metabolism of trauma Remembrance and mourning Stage Three Resolution, integration, ti development of post-resolution coping skills Reconnection Source: Herman, 1992, 1997 Trauma Three Group Models Group Therapeutic task Recovery Stage One Safety Recovery Stage Two Remembrance and mourning Recovery Stage Three Reconnection Time orientation Focus Present Self-care Past Trauma Present, future Interpersonal relationships Source: Herman, 1992, 1997 Trauma Three Group Models Group Recovery Stage One Recovery Stage Two Recovery Stage Three Membership Homogeneous Homogeneous Heterogeneous Boundaries Flexible, inclusive Closed Stable, slow turnover Cohesion Moderate Very high High Source: Herman, 1992, 1997 Addiction-Trauma Connection, Sept 10, 2013 San Diego 23

Trauma Three Group Models Group Recovery Stage One Recovery Stage Two Recovery Stage Three Conflict tolerance Low Low High Time limit Open-ended ended or repeating Fixed Limit Open-endedended Structure Didactic Goal-directed Unstructured Example Twelve-step programs Survivor group Interpersonal psychotherapy group Source: Herman, 1992, 1997 Trauma Gender Differences How Men Respond to Trauma Men respond differently to similar events: No big deal Just get over it Suck it up Don t be a wimp Never let them see you sweat Pull yourself up by your bootstraps! Suffer in Silence But the real reason is.. Addiction-Trauma Connection, Sept 10, 2013 San Diego 24

Real Men Can Handle Anything! What I have concluded from decades of working with every kind of violent criminal is that the way to prove one s manhood to gain respect is to commit a violent act. - James Gilligan Gender-responsive responsive Materials (trauma-informed) Women and Addiction: A Gender-Responsive Approach Helping Women Recover Helping Men Recover Beyond Trauma: A Healing Journey for Women Healing Trauma: Strategies for Abused Women Addiction-Trauma Connection, Sept 10, 2013 San Diego 25

Gender-responsive responsive Materials (trauma-informed) Women in Recovery A Woman s Way through The Twelve Steps Voices: A Program of Self-Discovery and Empowerment for Girls Becoming Trauma Informed: A Training Curriculum for Correctional Professionals Gender-responsive responsive Materials (trauma-informed) Beyond Violence: A Prevention Program for Criminal Justice- Involved Women (available November 2013) Beyond Anger and Violence: A Program for Women (available June 2014) Self-Help Books Leaving the Enchanted Forest: The Path from Relationship Addiction to Intimacy (relationships) Awakening Your Sexuality: A Guide for Recovering Women (sexuality) A Woman s Way through The Twelve Steps (addiction and recovery, also available as an app) Addiction-Trauma Connection, Sept 10, 2013 San Diego 26

Trauma-specific Materials for Women Beyond Trauma (Stephanie Covington) Healing Trauma (Stephanie Covington) TREM (Maxine Harris) Trauma-specific Materials for Men Helping Men Recover (Stephanie Covington) M-TREM (Roger Fallot) Trauma and Relapse Prevention Sexual Issues Relationship Issues Trauma Issues Evolving Treatment Approaches Addiction-Trauma Connection, Sept 10, 2013 San Diego 27

Gender-Responsive Treatment Creating an environment through: site selection staff selection program development content and material that reflects an understanding of the realities of the lives of women and girls, and addresses and responds to their strengths and challenges. Source: Covington, S.S., & Bloom, B.E. (2006). Gender-responsive treatment and services in correctional settings. In E. Leeder (Ed.), Inside and out: Women, prison, and therapy. Binghamton, NY: Haworth. Women s Integrated Treatment ( WIT ) This model is holistic, integrated and based on: The gender-responsive definition and guiding principles A theoretical foundation Interventions/strategies that are multidimensional (Covington, 2007) Theoretical Foundation The theories related to gender and substance abuse (and any other relevant treatment services) that create the framework of thought for program development. This is the knowledge base that creates the foundation upon which the program is developed. Addiction-Trauma Connection, Sept 10, 2013 San Diego 28

Treatment Strategies The approaches used in the program that create the therapeutic process. These are the ways in which theory is operationalized (how theory is applied). Helping Women Recover: A Program for Treating Addiction Theory of Addiction Holistic health model Chronic neglect of self in favor of something or someone else Theory of Women s Psychological Development Relational Cultural Theory (Stone Center) Theory of Trauma Three Stage Model (Herman) Upward Spiral A Transformational Model (Covington) Voices: A Program of Self-discovery and Empowerment for Girls Theory of Girls Psychological Development Relational-Cultural Theory (Stone Center, Gilligan, Brown) Theory of Attachment Ainsworth, Bowlby, Harlow, Stern Theory of Trauma Three Stage Model (Herman) Transformational Spiral (Covington) Theory of Resilience Biscoe, Wolin & Wolin Theory of Addiction Holistic Health Model Addiction-Trauma Connection, Sept 10, 2013 San Diego 29

Helping Men Recover: A Program for Treating Addiction (Covington, Griffin & Dauer) Theory of Addiction Holistic health model Chronic neglect of self in favor of something or someone else Theory of Men s Psychological Development Relational Cultural Theory (Stone Center) Kivel, Pollack, etc. Theory of Trauma Three Stage Model (Herman) Upward Spiral A Transformational Model (Covington) Helping Men Recover First gender-responsive responsive and trauma- informed treatment intervention for men History Copyright 2013, Stephanie S. Covington, Ph.D. What s Been Missing? Impact of male socialization on recovery Relational needs of men Abuse and trauma (experienced and perpetuated) Copyright 2013, Stephanie S. Covington, Ph.D. Addiction-Trauma Connection, Sept 10, 2013 San Diego 30

Gender-Responsive Treatment Creating an environment through: site selection staff selection program development content and material that reflects an understanding of the realities of women/men and girls/boys, and addresses and responds to their strengths and challenges. Source: Covington, S.S., & Bloom, B.E. (2006). Gender-responsive treatment and services in correctional settings. In E. Leeder (Ed.), Inside and out: Women, prison, and therapy. Binghamton, NY: Haworth. Copyright 2013, Stephanie S. Covington, Ph.D. Beyond Trauma: A Healing Journey for Women Trauma Theory Sandra Bloom, M.D. Judith Herman, M.D. Peter Levine, Ph.D. Integrates cognitive-behavioral, expressive arts, guided imagery, and relational therapy. Beyond Trauma: A Healing Journey for Women 11 sessions Healing Trauma: Strategies for Abused Women 5 sessions Facilitator s Guide, Workbook and DVD Printable Facilitator s Guide, and Workbook (Workbook in English & Spanish) Addiction-Trauma Connection, Sept 10, 2013 San Diego 31

Beyond Trauma and Healing Trauma Themes Safety Empowerment Connection (Aloneness) Normal reactions (Shame) Mind-body connection Substance abuse Woman-centered Uses a variety of treatment strategies: psychoeducational, cognitive, relational, expressive Helping Women Recover Helping Men Recover (two versions) Community Criminal Justice Gender-responsiveresponsive Female socialization Male socialization Addiction-Trauma Connection, Sept 10, 2013 San Diego 32

Module A Self Helping Women Recover Module A: Self Session 1 Session 2 Session 3 Session 4 Defining Self Sense of Self Self-Esteem Sexism, Racism, and Stigma (13 activities) Helping Men Recover Module A: Self Session 1 Session 2 Session 3 Session 4 Session 5 Defining Self Men in Recovery Sense of Self Men: Inside & Out Men and Feelings (11 activities) Addiction-Trauma Connection, Sept 10, 2013 San Diego 33

Group Agreements Attendance Confidentiality Safety Participation Honesty Respect Questions Task Punctuality Five Senses Helping Men Recover Feelings Shame and guilt Feelings as a boy Masculinity Addiction-Trauma Connection, Sept 10, 2013 San Diego 34

Male Messages Male Messages Don t act like a girl Don t show affection Don t be emotional Don t be weak Who Am I? Feelings Beliefs Personal qualities Addiction-Trauma Connection, Sept 10, 2013 San Diego 35

Sense of Self People Events Experiences Addiction-Trauma Connection, Sept 10, 2013 San Diego 36

Small Group Exercise What are some of the features on the outside of your house that you are proud of and would like to maintain? What are some of the features on the outside of your house that t are unnecessary and you would be willing to discard? What are some of the things inside your house that you are proud of and want to maintain? What are some things inside your house that work against you and you would like to discard or change? Anger Funnel HURT, SADNESS, FEAR, INSECURITY ANGER (RAGE AND VIOLENCE) Addiction-Trauma Connection, Sept 10, 2013 San Diego 37

Module B Relationships Helping Women Recover Module B: Relationships Session 5 Family of Origin Session 6 Mothers Session 7 Mother Mth Myths Session 8 Interpersonal Violence Session 9 Creating Healthy Relationships and Support Systems (18 activities) Helping Men Recover Module B: Relationships Session 6 Family of Origin Session 7 Barriers to Relationships Session 8 Fathers Session 9 Mothers Session 10 Creating Healthy Relationships and Support Systems Session 11 Effective Communication & Intimacy (14 activities) Addiction-Trauma Connection, Sept 10, 2013 San Diego 38

Family Sculpture Domestic Violence Domestic Violence Questions 1. Have you been hit or threatened in the last year? 2. Have your children been hit or threatened in the last year? 3. Have you ever been kicked? 4. Have you ever sustained bodily injury bruises, cuts broken bones, etc.? 5. Do you know what a restraining order is? 6. Do you want more information? Domestic Violence (cont.) Responses 1. I am afraid for your safety. 2. I am afraid for the safety of your children. 3. It will only get worse. 4. I am here for you when you are ready. 5. You deserve better than this. Addiction-Trauma Connection, Sept 10, 2013 San Diego 39

Domestic Violence (cont.) Client returning home (Case Managers/Continuing Care) 1. Do you feel apprehensive about returning to your relationship? 2. Is the apprehension related to a fear of being physically hurt? We need to develop a safety plan (and find some additional resources). AA sponsor Community network Hot line Shelter Power and Control Wheel From the manual In Our Best Interest: A Process for Personal and Social Change. Available through Domestic Abuse Intervention Project, 206 W. 4th St., Duluth, MN 55806 Characteristics of person Characteristics of relationships My role, My feelings Rewards of relationship Price of relationship Involvement with chemicals or other addictive behaviors Response to addictive behaviors Relationship History Chart Mother Father 3) 4) 5) Addiction-Trauma Connection, Sept 10, 2013 San Diego 40

Module C Sexuality Helping Women Recover Module C: Sexuality Session 10 Sexuality and Addiction Session 11 Body Image Session 12 Sexual Identity Session 13 Sexual Abuse Session 14 Fear of Sex while Clean and Sober (14 activities) Addiction-Trauma Connection, Sept 10, 2013 San Diego 41

Helping Men Recover Module C: Sexuality Session 12 Session 13 Session 14 Session 15 Sexuality and Addiction Sexual Identity Barriers to Sexual Health Healthy Sexuality (11 activities) Sexuality SEXUALITY is a developmental process SEXUALITY is an identification, an activity, a drive, a biological process, an orientation, an outlook It is who and how we are in the Universe SEXUAL GOOD HEALTH is the somatic, emotional, social and spiritual aspects of oneself integrated into one s identity and style of life Covington, 1995 Body Image Addiction-Trauma Connection, Sept 10, 2013 San Diego 42

Body Image Helping Men Recover Interactive Lecture: Problematic Sexual Behavior Addiction-Trauma Connection, Sept 10, 2013 San Diego 43

Questions Examples of nonconsensual sex Know anyone who s been a victim Any experience or know anyone experience of childhood sexual abuse Sexual Abuse in Families Psychological Abuse Covert Abuse Overt Abuse Sexual Jokes Verbal harassment Violating boundaries Telling child inappropriate sexual information Inappropriate touching Voyeurism Ridicule of bodies Sexual Hugs Pornography Exhibitionism French kissing Fondling Oral Sex Penetration Helping Men Recover Interactive Lecture: Abuse & Trauma Addiction-Trauma Connection, Sept 10, 2013 San Diego 44

Questions How might abuse occur as the result of trying to control another? Types of physical abuse? (least to most serious) Sexual abuse Verbal abuse Impact on the person? Sexual Chemical Lifeline Sexual Bill of Rights Addiction-Trauma Connection, Sept 10, 2013 San Diego 45

Module D Spirituality Helping Women Recover Module D: Spirituality Session 15 Session 16 Session 17 What is Spirituality? Prayer and Meditation Creating a Vision (10 activities) Helping Men Recover Module D: Spirituality Session 16 Session 17 Session 18 What is Spirituality? Real Men Creating a Vision (11 activities) Addiction-Trauma Connection, Sept 10, 2013 San Diego 46

Tenets of Women s Spirituality Recognizing the interrelatedness of all life Honoring the dignity of the female Appreciating the human body as the container of the spirit Tenets of Women s Spirituality (cont.) Discovering the power of creating ritual Perceiving work for ecological and social justice as a spiritual responsibility Cultivating sensitivity to diverse multicultural experiences What makes a difference? Creating a safe environment Listening to her/his story Empathy Addiction-Trauma Connection, Sept 10, 2013 San Diego 47

Sanctuary Upward Spiral Transformation Addiction & Trauma (constriction) Recovery & Healing (expansion) Contact Information Stephanie S. Covington, PhD, LCSW 7946 Ivanhoe Ave., Suite 201B La Jolla, CA 92037 (858) 454-8528 (858) 454-8598 FAX www.stephaniecovington.com www.centerforgenderandjustice.org sc@stephaniecovington.com Addiction-Trauma Connection, Sept 10, 2013 San Diego 48

About your presenter. Dr. Stephanie S. Covington is a nationally recognized clinician, author, organizational consultant, and lecturer. She is a pioneer in the field of women s issues, addiction, and recovery. She has developed an innovative, gender-responsive, and trauma-informed approach to the treatment needs of women and girls that results in effective services in public, private, and institutional settings. Her presentations, staffdevelopment seminars, and technical assistance focus on systems change and the development of caring, compassionate, and empowering therapeutic environments. They provide professionals an opportunity to learn new skills for dealing with personal, institutional, and societal changes and are always in demand, both nationally and internationally. Dr. Covington s clients include the Betty Ford Treatment Center, the United Nations Office on Drugs and Crime, the Center for Substance Abuse Treatment in Washington, D.C., the Michigan Department of Corrections, and numerous other treatment and correctional settings. Dr. Covington was a workshop chair for the women s treatment improvement protocol (TIP) and the trauma TIP (published by CSAT) and is the co-author of a three-year research project, Gender-Responsive Strategies: Research, Practice, and Guiding Principles for Women Offenders, for the National Institute of Corrections. This publication received the University of Cincinnati Award for its outstanding contribution to the field of corrections in the U.S. and Canada. She was selected to be the featured therapist on the Oprah Winfrey Network docu-reality show Breaking Down the Bars: Rockville. Educated at Columbia University and the Union Institute, Dr. Covington has served on the faculties of the University of Southern California, San Diego State University, and the California School of Professional Psychology, and she is a former chair of the Women's Committee of the International Council on Alcoholism and Addiction. She is a board-certified Diplomate of the National Association of Social Workers and the American Board of Sexology and is a member of the American Association of Marriage and Family Therapy and the American Psychological Association. She also served on the Advisory Council for Women s Services for the federal agency SAMHSA. Dr. Covington is based in La Jolla, California, where she is co-director of the Institute for Relational Development and the Center for Gender and Justice, which seeks to expand gender-responsive policies and practices for females who are under criminal justice supervision. Among the many articles and books written by Dr. Covington are: Women and Addiction: A Gender-Responsive Approach Awakening Your Sexuality: A Guide for Recovering Women Leaving the Enchanted Forest: The Path from Relationship Addiction to Intimacy She also has program materials to help meet the needs of women and girls. The following curricula include training manuals for professionals and complementary materials for participants: Helping Women Recover: A Program for Treating Addiction (with special edition for the criminal justice system) Beyond Trauma: A Healing Journey for Women Healing Trauma: Strategies for Abused Women Voices: A Program of Self-Discovery and Empowerment for Girls A Woman s Way through The Twelve Steps Beyond Anger and Violence: A Program for Women (with special edition for the criminal justice system) Becoming Trauma Informed: A Training Program for Correctional Professionals (USA and Canadian) For a list of Dr. Covington s recent articles, and descriptions of her current seminars for professionals, visit: www.stephaniecovington.com and www.centerforgenderandjustice.org. About Your Presenter March 2013

STEPHANIE S. COVINGTON, PhD, LCSW Institute for Relational Development / Center for Gender and Justice, 7946 Ivanhoe Avenue, Suite 201 B, La Jolla, California 92037 Phone: (858) 454-8528 Fax: (858) 454-8598 Email: info@stephaniecovington.com www.stephaniecovington.com www.centerforgenderandjustice.org BOOK ORDER FORM PROGRAM DEVELOPMENT GUIDE PRICE QTY. TOTAL PRICE CLINICAL INNOVATOR SERIES WOMEN AND ADDICTION: A Gender-Responsive Approach Manual/DVD/CE Test $175.00 $ Manual & CE Test $ 74.95 $ MANUALIZED, TRAUMA-INFORMED TREATMENT CURRICULA TWELVE STEP MATERIALS A WOMAN S WAY THROUGH THE TWELVE STEPS Complete Set (10 books, 10 workbooks, 1 FG, 1 DVD) $449.00 $ DVD $225.00 $ 1 Facilitator s Guide, 10 workbooks $195.00 $ Facilitator s Guide $ 89.95 $ Set (1 Book, 1 Workbook in English) $ 23.95 $ A Woman s Way through the Twelve Steps (Book in English) $ 14.95 $ La Mujer Y Su Práctica de los Doce Pasos (Book in Spanish) $ 14.95 $ Workbook (English) $ 13.95 $ Libro de Ejercicios (Spanish) $ 12.95 $ BEYOND TRAUMA: A Healing Journey for Women An 11-session trauma-specific curriculum Complete Set (FG, 10 workbooks, 3 DVDs) $595.00 $ Two-volume Facilitator s DVD Set $275.00 $ Client DVD $99.00 $ Facilitator s Guide & 10 workbooks $159.00 $ Facilitator s Guide $ 89.95 $ Workbooks (pack of 10) $ 84.00 $ Workbook $ 10.95 $ HEALING TRAUMA: Strategies for Abused Women CD-Rom $ 99.95 $ VOICES: A Program of Self-Discovery and Empowerment for Girls Facilitator s Guide (includes 1 journal) $ 80.00 $ Journal $ 9.15 $ Book Order Form, January 2013 Page 1 of 3 Stephanie S. Covington

STEPHANIE S. COVINGTON, PhD, LCSW Institute for Relational Development / Center for Gender and Justice, 7946 Ivanhoe Avenue, Suite 201 B, La Jolla, California 92037 Phone: (858) 454-8528 Fax: (858) 454-8598 Email: info@stephaniecovington.com www.stephaniecovington.com www.centerforgenderandjustice.org BOOK ORDER FORM (continued) MANUALIZED, TRAUMA-INFORMED TREATMENT CURRICULA (continued) HELPING WOMEN RECOVER: A Program for Treating Addiction A 17-session program for treating women with addictive disorders Facilitator s Guide (includes 1 journal) $205.00 $ Participant s Journal $ 30.00 $ Special Edition for use in the criminal justice system Facilitator s Guide (includes 1 journal) $205.00 $ Participant s Journal $ 30.00 $ HELPING MEN RECOVER: A Program for Treating Addiction A 18-session program for treating men with addictive disorders Facilitator s Guide (includes 1 journal) $195.00 $ Participant s Workbook $ 26.00 $ Special Edition for use in the criminal justice system Facilitator s Guide (includes 1 journal) $195.00 $ Participant s Workbook $ 26.00 $ ALCOHOL AND DRUG EDUCATION WOMEN IN RECOVERY: Understanding Addiction English version $ 6.85 $ Spanish version $ 6.85 $ BOOKS AWAKENING YOUR SEXUALITY: $ 15.95 $ A Guide for Recovering Women LEAVING THE ENCHANTED FOREST: $ 14.95 $ The Path from Relationship Addiction to Intimacy - Continue Next Page - Book Order Form, January 2013 Page 2 of 3 Stephanie S. Covington

STEPHANIE S. COVINGTON, PhD, LCSW Institute for Relational Development / Center for Gender and Justice, 7946 Ivanhoe Avenue, Suite 201 B, La Jolla, California 92037 Phone: (858) 454-8528 Fax: (858) 454-8598 Email: info@stephaniecovington.com www.stephaniecovington.com www.centerforgenderandjustice.org BOOK ORDER FORM (continued) SUBTOTAL (from previous pages): U.S. Shipping & Handling Add 10% before tax: Outside U.S. Shipping & Handling Add 25% before tax 1 : California Sales Tax Add 8% before shipping for California residents only 2 : TOTAL 3 : $ $ $ $ $ 1 International order payments by check/money order must be in U.S. currency and drawn from a U.S. affiliated bank 2 Only residents of California need to add California sales tax 3 Review the bottom of this page for processing options to place your order BILLING ADDRESS Name of Organization: Contact Name: Address: City: State: Zip: Country: Phone: Email: Tax Exempt Number: Your Internal Order #: SHIPPING ADDRESS (please note, we are unable to ship to P.O. Box addresses) Same as Billing Address (check box): Name of Organization: Contact Name: Address: City: State: Zip: Country: Phone: Email: ADDITIONAL INSTRUCTIONS: PLEASE ALLOW 10-14 DAYS FOR DELIVERY PLEASE CHOOSE ONE OF THE FOLLOWING METHODS TO SUBMIT YOUR ORDER: Mail completed form with check/money order payable to "Dr. Stephanie Covington" to the La Jolla, California address Fax or Email completed form with purchase order (obtained from your accounting department) to 858-454-8598 or info@stephaniecovington.com. We will process your order immediately and bill you under Net 30 terms. Credit cards may only be accepted via our online shopping cart and checking out via Paypal. We are unable to take credit cards over the phone. Visit www.stephaniecovington.com and select Books and Curricula. Book Order Form, June 2013 Page 3 of 3 Stephanie S. Covington