Integrated Substance Abuse, Mental Health and Trauma Treatment With Women

140 Pages·2013·7.12 MB·English

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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

P U B L I C
HEALTH
COMMISSION
Institute on Urban Health Research
www.iuhr.neu.edu
Funded by The Center for Substance Abuse Treatment, SAMHSA
© 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 90089-0411
T. [phone] office, C. [phone] cell, F. [phone] fax
[email protected]

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 02118
T. [phone] office
Email: [email protected]
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
ii
Table of Contents
A Case Study Workbook for Staff Training–Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
References for History Section. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
IRT Case Presentation #1: Sharon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
“Mothering the Mother”:The role of substance abuse and
trauma on the childhood development of a young adult mother.
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Sharon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Discussion Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Critical Factors to Consider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Putting It All Together . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Final Thoughts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
References For This Case Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
IRT Case Presentation #2: Catherine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
“After the First Death”:The role of grief and loss in relapse
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Catherine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Discussion Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Critical Factors to Consider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Putting It All Together . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Final Thoughts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
References For This Case Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
IRT Case Presentation # 3:Annie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
“Taking Back Control of the Residential Setting”:Managing
disruptive clients,treatment coordination,and integration of services
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Annie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Discussion Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Critical Factors to Consider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Putting It All Together . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
References For This Case Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
iii
IRT Case Presentation #4: Susana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
“Letting Go”:Unfinished work,after-care
planning,and working through separation.
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Susana. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Discussion Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Critical Factors to Consider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Putting It All Together . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
References For This Case Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
IRT Case Presentation #5: Seneida. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
“Who asked for your Help Anyway? “Working with
young mandated clients newly exposed to treatment
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Seneida . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Discussion Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Critical Factors to Consider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Putting It All Together . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
References For This Case Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
IRT Case Presentation #6: Margarita. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
“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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Margarita. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Discussion Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Critical Factors to Consider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Putting It All Together . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
References For This Case Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
IRT Case Presentation #7: Julia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
“Getting the Message”:The role of passivity,hopelessness,
and avoidance with a difficult-to-engage client.
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Julia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Discussion Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Critical Factors to Consider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Putting It All Together . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
References For This Case Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
iv
A Case Study Workbook for Staff Training
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.
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A Case Study Workbook for Staff Training
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 “high-
end” 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,
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A Case Study Workbook for Staff Training
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,16-27 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