Gender Matters: Creating Trauma-Informed Services

Transcription

1 Gender Matters: Creating Trauma-Informed Services Stephanie S. Covington, PhD, LCSW Institute for Relational Development Center for Gender and Justice 7946 Ivanhoe Ave., Suite 201B La Jolla, CA USA (858) (858) FAX RIKK - Institute for Gender, Equality and Difference University of Iceland September 1, 2015 Plenary Reykjavík, Iceland

2 Gender Matters: Creating Trauma-Informed Services Stephanie S. Covington, Ph.D., L.C.S.W. Center for Gender and Justice Institute for Relational Development La Jolla, CA, USA RIKK - Institute for Gender, Equality and Difference University of Iceland September 1, 2015 Plenary Reykjavík, Iceland Gender Differences Sex Differences Gender Matters History Fact vs. Fiction Sept 1, 2015 Morning Plenary Gender Matters 1

3 Gender Matters (cont.) Finger dexterity Raging hormones Fear of success Penis envy Gender Matters (cont.) Radical changes Convergence Gender Matters (cont.) Life experiences Resources Power Sept 1, 2015 Morning Plenary Gender Matters 2

4 Gender Matters (cont.) Health Economics/income Family responsibilities Why Gender Matters Gendered prevalence of disorders Gender-specific risk factors Gender-specific helpseeking & service disparities Gender-specific medication issues Gender-specific services & environments Gender-responsive treatment (Surgeon General s Report on Women s Mental Health 2005) Sept 1, 2015 Morning Plenary Gender Matters 3

5 Economics Women in US earn 77% of what men earn One-third of working women are the family breadwinner (Villeneuv, Study Gives Details on Gender Pay Disparities, USA Today, 2012) Gender Matters (cont.) Attribution Self-esteem Fear Gender Female Male Transgendered Sept 1, 2015 Morning Plenary Gender Matters 4

6 Gender Relevance? Self-Made Man: One Woman s Journey Into Manhood and Back Written by Norah Vincent History of Services Addiction treatment services designed for men by men Mental health services designed by men for women Criminal justice services designed by men for men Evolving Treatment Approaches (Grella, 2000) Sept 1, 2015 Morning Plenary Gender Matters 5

7 Two Kinds of Suffering Natural Created Although the world is full of suffering, it is also full of the overcoming of it. ~Helen Keller 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) Sept 1, 2015 Morning Plenary Gender Matters 6

8 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) Sept 1, 2015 Morning Plenary Gender Matters 7

9 Definition of Trauma Trauma occurs when an external threat overwhelms a person s internal and external positive coping resources. (Van der Kolk, B., 1989) Traumatic Events Single event Enduring, ongoing (complex) Traumatic Events Trauma can take many forms: Emotional, sexual or physical abuse Neglect Abandonment (especially for small children) Extremely painful and frightening medical procedures Sept 1, 2015 Morning Plenary Gender Matters 8

10 Traumatic Events (cont.) Catastrophic injuries and illnesses Rape or assault Muggings Domestic violence Burglary Automobile accidents Immigration Traumatic Events (cont.) Natural disasters (hurricanes, floods, earthquakes, tornadoes, fires, volcanoes) Stigmatization Terrorism such as 11 th September 2001 Witnessing violence such as a parent harming another parent Traumatic Events (cont.) The unexpected/violent loss of a loved one (even of a pet) Combat/war Torture Kidnapping Victim of trafficking Intergenerational (cultural) trauma Sept 1, 2015 Morning Plenary Gender Matters 9

11 Historical Trauma Across generations Massive group trauma Examples include: Native Americans, African Americans, Holocaust survivors, Māori, First Nations, and others Definition of Historical Trauma the cumulative emotional and psychological wounding spanning generations, which emanates from a massive group trauma. (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) Sept 1, 2015 Morning Plenary Gender Matters 10

12 Interpersonal Violence (Intimate Partner Violence IPV) Of all these forms of trauma, women are at greater risk of interpersonal abuse than men. Trauma Gender Differences Sept 1, 2015 Morning Plenary Gender Matters 11

13 Gender and Abuse As children, boys and girls suffer similar rates of abuse Girls - sexually abused Boys - emotional neglect or physical abuse. In adolescence, boys are at greater risk if they are gay, young men of color, or gang members. Young men - people who dislike or hate them. Young women relationships; from the person to whom she is saying, I love you. Adulthood Man - combat or being a victim of crime Woman relationship; the person I love you. Canadian Study (Juvenile Justice) Sample Size Ever been raped, or been in danger of being raped. 118 Females 46.90% 235 Males 6.2% (S. Brown, Ph.D.) Differences in Risk 1 in 4 women and 1 in 8 men experience psychological abuse from a partner 38% of female homicides are committed by male partner; 6% of male homicides by female partner 1 in 5 women will be raped in their lifetime compared to 1 in 71 men (Brieding, Chen & Black, 2014; World Heath Organization, United Nations Development Programe, and United Nations Office on Drugs and Crime, 2014; Black, Basile, Breiding, Smith, Walters, Merrick, Chen & Stevens, 2011) Sept 1, 2015 Morning Plenary Gender Matters 12

14 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 Values of Trauma-Informed Care Safety (physical and emotional) Trustworthiness Choice Collaboration Empowerment (Fallot & Harris, 2006) Core Values of Trauma-Informed Environment Safety: Trustworthiness: Choice: Ensuring physical and emotional safety Maximizing trustworthiness, modeling openness, maintaining appropriate boundaries, and making tasks clear Emphasizing individual choice and control (adapted from Fallot & Harris, 2006) Sept 1, 2015 Morning Plenary Gender Matters 13

15 Core Values of Trauma-Informed Environment (cont.) Collaboration: Empowerment: Providing equality in participation, sharing power, and creating a sense of belonging Striving for empowerment and skill building (adapted from Fallot & Harris, 2006) Becoming Trauma Informed Creates a Culture Shift. A Culture Shift: Scope of Change in a Distressed System Involves all aspects of program activities, setting, relationships, and atmosphere (more than implementing new services) Involves all groups: administrators, supervisors, direct service staff, support staff, and clients (more than service providers) Involves making trauma-informed change into a new routine, a new way of thinking and acting (more than new information) (Roger Fallot, Ph.D.) Sept 1, 2015 Morning Plenary Gender Matters 14

16 Process of Trauma Traumatic Event Overwhelms the physical and psychological coping skills Response to Trauma Fight, Flight or Freeze Altered state of consciousness, Body sensations, Numbing, Hyper-vigilance, Hyper-arousal, Collapse Sensitized Nervous System Changes in the Brain Brain Body Connection Physical and Psychological Distress Current stressors, Reminders of trauma (triggers) Sensations, Images, Behavior, Emotions, Memory Retreat Isolation Dissociation Depression Anxiety Emotional and/or Physical Responses Harmful Behavior to Self Substance use disorders Eating disorders Deliberate self-harm Suicidal actions Harmful Behavior to Others Aggression Violence Rages Threats Physical Health Issues Lung Disease Heart disease Autoimmune disorders Obesity ACE Study (Adverse Childhood Experiences) Before age 18: Recurrent and severe emotional abuse Recurrent and severe physical abuse Contact sexual abuse Emotional neglect Physical neglect ACE Study (Adverse Childhood Experiences) Growing up in a household with: Both biological parents not being present Your mother being treated violently An alcoholic or drug-user A mentally ill, chronically depressed, or family member attempting suicide A family member being imprisoned (N = 17,000) Sept 1, 2015 Morning Plenary Gender Matters 15

17 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 Oct:52(8): German. PMID: (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 ACE Study (continued) Women 50% more likely than men to have a score of 5 or more. (Felitti & Anda, 2010) Sept 1, 2015 Morning Plenary Gender Matters 16

18 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) 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 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 (Ann Jennings, Ph.D.) Sept 1, 2015 Morning Plenary Gender Matters 17

19 Adverse Childhood Experiences ( ( Death Whole Life Perspective Conception R. Fallot, Ph.D. 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) Sept 1, 2015 Morning Plenary Gender Matters 18

20 Women in Prison Largest Effect-Mental Health (cont.) 980% increase in odds if exposed to 7 CTE s (Messina & Grella, 2005) Critical and Interrelated Issues Substance Abuse Mental Health Trauma Physical Health Crime Changes in Understanding: The Centrality of Trauma Incarceration Homelessness Violence and Trauma Substance Abuse Mental Health Problems Sept 1, 2015 Morning Plenary Gender Matters 19

21 What does the prevalence data tell us? Many people with trauma histories have overlapping problems with mental health, substance abuse, physical health and are victims or perpetrators of crime. Victims of trauma are found across all systems of care. (NASMHPD 2008) Therefore We need to presume the women we serve have a history of traumatic stress and exercise universal precautions. Universal Design (NASMHPD 2008) Key Elements (Staff and Clients) Learn what trauma/abuse is Understand typical responses Develop coping skills Sept 1, 2015 Morning Plenary Gender Matters 20

22 Secondary Traumatic Stress (STS) Compassion fatigue: No empathy doesn t happen Charles Figley sudden Burnout: Bloom conflict of values Vicarious traumatization: Laurie Pearlman slow What does all this mean for the people we serve? 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 (men and boys), and addresses and responds to their strengths and challenges. (S. Covington Women and Addiction: A Trauma-Informed Approach. Journal of Psychoactive Drugs, SARC Supplement 5, November 2008, ) Sept 1, 2015 Morning Plenary Gender Matters 21

23 Gender-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 Gender-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 Materials (trauma-informed) Beyond Violence: A Prevention Program for Criminal Justice- Involved Women Beyond Anger and Violence: A Program for Women Sept 1, 2015 Morning Plenary Gender Matters 22

24 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 app) Trauma-Specific Interventions Services designed specifically: To address violence, trauma, and related symptoms and reactions; and To facilitate recovery and healing. Trauma-specific Materials for Women Beyond Trauma (Stephanie Covington) Healing Trauma (Stephanie Covington) TREM (Maxine Harris) Trauma-specific Materials for Men Helping Men Recover (Covington, Griffin & Dauer) M-TREM (Roger Fallot) Men & Trauma (Covington & Rodriquez, 2016) Sept 1, 2015 Morning Plenary Gender Matters 23

25 Evidence-Base for Curricula Researched in Residential treatment Women s prison Drug court Listed on NREPP 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) Guiding Principles for Gender-Responsive Services Gender Environment Relationships Integrated Services Economic & Social Status Community Sept 1, 2015 Morning Plenary Gender Matters 24

26 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. 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 Model (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 Model (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 Sept 1, 2015 Morning Plenary Gender Matters 25

27 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. 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). Treatment Strategies Cognitive-behavioral Guided imagery Relational therapy Mindfulness Eye Movement Desensitization and Reprocessing (EMDR) Emotional Freedom Technique (EFT) Expressive arts Mind-body (yoga) Sept 1, 2015 Morning Plenary Gender Matters 26

28 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) Trauma and Gender Lens What is a Gender-Responsive Approach? Less about differences between males and females and more about using research on girls and women (boys and men) to guide what we do. Sept 1, 2015 Morning Plenary Gender Matters 27

29 Women-Only Treatment Long-Term Outcomes (10 year follow-up) Women-only (WO) treatment compared to mixed-gender (MG) WO increased odds of successful outcome by 49% (Evans, et. al., JSAT, 2013) What Makes a Difference? Creating a safe environment Listening to her story Empathy Sanctuary Sept 1, 2015 Morning Plenary Gender Matters 28

30 What is Sanctuary? Sacred place Place of refuge/protection Shelter Oasis Upward Spiral Transformation Addiction & Trauma (constriction) Recovery & Healing (expansion) Sept 1, 2015 Morning Plenary Gender Matters 29