Presented by: Ginny Redmon, LCSW, Domestic Violence Coordinator/Therapist and Tonya Jernigan, LCSW, Clinical Director. Chrysalis House, Inc.

Transcription

1 Presented by: Ginny Redmon, LCSW, Domestic Violence Coordinator/Therapist and Tonya Jernigan, LCSW, Clinical Director Chrysalis House, Inc.

2 Learning Objectives Understanding of the co-occurring nature of IPV and Substance Use Disorders Ability to identify triggers, coping skills to alleviate triggers, and identify risky situations of continued drug use Theoretical approaches to relapse prevention planning and introductions of examples of plans

3 What is Intimate Partner Violence (IPV)? Intimate Partner Violence is the willful intimidation, physical assault, battery, sexual assault, and/or other abusive behavior as part of a systematic pattern of power and control perpetrated by one intimate partner against another. IPV can include physical, emotional, verbal, sexual, and financial abuse. Frequency and severity can differ dramatically; however, the one constant component of IPV is the partner s consistent efforts to maintain power and control.

4 Technology/Social Media: Good vs. Evil Technology has had a major impact on victims/survivors of Intimate Partner Violence (IPV). It can be very useful to a victim such as: Access help/resources available Stay connected with family/friends Used to help prove guilt and hold perpetrators accountable

5 Technology/Social Media: Good vs. Evil The term Cyberstalking has been used to describe a variety of behaviors that involve repeated threats and/or harassment, by the use of electronic mail or other computer-based communication, that would make a reasonable person afraid or concerned for his/her safety. Apps used for Stalking: SpoofCard- gives the caller the ability to change the # shown, change sound of voice, record calls SpoofSMS- send text messages anonymously Mobile Spy- track victim s cell phone activity such as: calls, Facebook activity, see photos, view , and monitor location GPS- monitor and track the precise, real-time physical locations of victims. Some packages even give abusers power to control their victim s vehicles-locking doors, flashing lights, or even completely disabling a vehicle s engine

6 Effects of Stalking on Victims Stalking victims report higher levels of anxiety, depression, fear, and symptoms of PTSD Victims of stalking experience a wider range of economic problems: employed victims are more easily stalked (may experience repercussions from management regarding stalker s behavior), cost to repair property damage, and difficulty getting to work because of damage to vehicles, unable to take child to daycare, etc Due to these effects/emotional triggers, victims may selfmedicate by using substances to alleviate their pain

7 What is the definition of a Substance Use Disorder? Substance use disorders occur when the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. According to the DSM-5, a diagnosis of substance use disorder is based on evidence of impaired control, social impairment, risky use, and pharmacological criteria.

8 Pharmacological Criteria Distinguishing between substance abuse and substance dependence..someone can abuse a substance, but neither be dependent nor addicted. Dependence and addiction can be independent from one another. Someone can be dependent on prescription medication, but not addicted. Addiction conveys both social and health problems, whereas dependence only encompasses the latter, according to SAHMSA. Substance Use Disorder- must meet at least two criteria. Subtypes- mild (2-3), moderate (4-5), severe (6 or more).

9 Risk Factors for Addiction Exposure to or experience with physical, sexual, and/or emotional abuse or trauma as a child Substance use or addiction in family, genetic predisposition Low Socioeconomic Status Substance use among peers Starting alcohol/drug use at an early age Mental Health condition (anxiety, depression, PTSD) Drug of choice, method/route of use

10 The link between IPV and Substance Use Does IPV lead to Substance Abuse? Victims may turn to substance abuse as a coping skill and/or self-medicate to alleviate pain due to injuries IPV victims are more likely to be prescribed highly addictive drugs (i.e. pain killers and sedatives) Abuse/trauma of any form can cause someone to suffer from low self-esteem, depression, anxiety, and symptoms of PTSD Perpetrators may introduce and/or encourage drug use as a way of maintaining power and control over their partner

11 The link between IPV and Substance Use How does Substance Abuse affect a victim of IPV? Victim will be less likely to reach out for help if under the influence of a substance due to: fear of children being removed, fear of legal charges, fear of not being believed Dependency on a substance by victim, therefore victim may stay in relationship because perpetrator supplies the substances Safety Plan may not be followed through with if victim is under the influence Previous negative experiences with the police due to victim s history of substance abuse

12

13 Sidebar: PTSD and SUD In considering PTSD and alcohol use disorder, association of the two disorders was stronger for women than men. Individuals with PTSD and SUD tend to have poorer outcomes. Improvements in PTSD have been found to have a greater impact on alcohol use disorder than vice versa. PTSD and SUD should be treated concurrently both involve triggers and can be treated with combinations of cognitive behavioral approaches that involve education of PTSD and SUD and identification of triggers for both. The development of safe coping skills is integral to the treatment of both disorders.

14 Safe Coping Skills Good support system that includes but not limited to friends, family, and support from recovery support groups/sponsor Attend meetings- attending support group meetings for accountability, discuss similar experiences, gain strength, and hope from others Distract yourself- do something such as: physical exercise or a hobby/activity Remind yourself of negative consequences- make a list of all of the negative consequences that came with your addiction (emotional, physical, legal) Self-talk- develop positive self-talk and remind yourself that you are not alone and encourage yourself to stay sober

15 Safe Coping Skills cont Using Dialectical Behavior Therapy skills to cope: Learning to think Dialectically- Dialectical means that 2 ideas can both be true at the same time Using Core Mindfulness skills- observe, describe, participate, non-judgmentally, one-mindfully, effectively Changing emotions by acting opposite to the current emotion Radical Acceptance- Even though certain factors can t be changed, acceptance allows you to more effectively tolerate the things that you can t change.

16 What is Grounding? Grounding is a term used to describe any techniques which are used to bring a person back in contact with the present moment. Many people with PTSD and substance abuse struggle with feeling either too much or too little; finding a balance is key! Let s practice some different types of grounding!

17 Identifying Triggers According to Terence Gorski, relapse is more than just using drugs or alcohol. It is the progressive process of becoming so dysfunctional in recovery that self-medication with drugs and/or alcohol seems like a reasonable choice. Triggers for increased symptoms of PTSD also occur (location of trauma, persons associated with the trauma (s), olfactory triggers, etc.). Relapse is a process and there are warning signs that you might be headed for relapse As we see an increase in triggers for one disorder, we might see an increase in triggers for the other disorder.

18 What about those people, places & things? People: old friends who use; family/friends/acquaintances who serve as a reminder for triggers; strained relationships; abusive partners and their family members; former drug suppliers Places: neighborhoods where substances were purchased; old places of employment; legal proceedings; place of residence Things: pregnancy/childbirth; other medical issues; drug paraphernalia; hearing others stories of trauma and/or use

19 Why is Relapse Prevention Important? Relapse to substance use can significantly decrease an individual s ability to remain safe and utilize a safety plan. High risk for overdose due to going back to amount of substance previously used. Self-efficacy in recovery is an important construct in longterm recovery.

20 Theoretical approaches to relapse prevention planning Cognitive-Affective-Behavioral Approach Based on the work of Marlatt & Gordon and has been transformed over the years Gorski s model is based on the work of Martlatt & Gordon Incorporates the medical model of the disease of addiction but includes contextual factors for relapse (environmental and affective stimuli) Is comprehensive in that it allows individuals to perform a full global self-assessment (life, substance use and relapse history) Can be useful when working with women as there is a focus on relationships and interactions with individuals who might be triggering When considering cognitive-behavioral approaches for treatment of anxiety-related disorders (including PTSD), this can be a complementary addition to treatment.

21 Marlatt & Gordon, Original Cognitive-Behavioral Model of Relapse, 1985

22 Revised Cognitive-Behavioral Model of Relapse (Witkiewitz & Marlatt, 2004)

23 Mindfulness-Based Relapse Prevention MBRP includes identification of personal triggers, along with practical skills to use and also incorporates mindfulness practices that foster a heightened awareness of both internal (emotions, thoughts, sensations) and external (environmental cues), promoting a greater sense of choice, compassion, and freedom. MBRP differs from the AA/NA 12-step model- MBRP discourages the use of labels of addict or alcoholic and to admit powerlessness over their disease. 12-step model views substance abuse and dependence as chronic, progressive diseases of the brain.

24 Mindfulness means paying attention in a particular way: on purpose, in the present moment and nonjudgmentally. - Jon Kabat-Zinn

25 Mindfulness-Based Relapse Prevention cont. According to Bowen, Chawla, and Marlatt, MBRP can be broken down into 8 sessions. Session 1: Automatic Pilot and Relapse Session 2: Awareness of Triggers and Cravings Session 3: Mindfulness in Daily Life Session 4: Mindfulness in High-Risk Situations Session 5: Acceptance and Skillful Action Session 6: Seeing Thoughts as Thoughts Session 7: Self-Care and Lifestyle Balance Session 8: Social Support and Continuing Practice

26 Breakdown of MBRP Sessions Session 1: Automatic Pilot and Relapse: Automatic pilot or the tendency to behave mechanically or unconsciously without full awareness of what we are doing. Cravings and urges tend to be acted on (relapse) automatically without awareness. Session 2: Awareness of Triggers and Craving: Recognizing triggers, urges, and cravings and what the reactions to them feel like in the body. Learning to experience these in a way that increases our choices in how we respond.

27 Session 3: Mindfulness in Daily Life: Introduction of SOBER (Stop, Observe, Breath, Expand, Respond)breathing space. Mindfulness meditation can increase our awareness and subsequently help us make better choices in our daily lives. Session 4: Mindfulness in High Risk Situations: Focuses on identifying individual relapse risks, being in situations with previously associated with substances, and using mindfulness to learn to experience pressure or urges to use without automatically reaching for the substance.

28 Session 5: Acceptance and Skillful Action: Practicing accepting unwanted thoughts, feelings, and sensations. Using skillful action by participating in mindful movement as we practice paying attention to the sensations in the body while moving, stretching, and engaging in different postures. Session 6: Seeing Thoughts as Thoughts: Starting to practice acknowledging the presence of thinking as yet another phenomenon occurring in the present moment. Start to recognize that thoughts are not the enemy, nor do we have to give them power over our emotions and behaviors.

29 Session 7: Self-care and Lifestyle Balance: Taking care of oneself and engaging in nourishing activities are an essential part of recovery. Learning the importance of lifestyle balance in order to reduce vulnerability to relapse. Session 8: Social Support and Continuing Practice: Having a support network is crucial in continuing along the path of practice and recovery. In this final session, we review skills and practices learned in the course and discuss the importance of building a support system.

30 Mindfulness-Based Relapse Prevention cont Designed as an aftercare program or outpatient program MBRP is ideally suited for individuals who have already undergone initial treatment and wish to continue maintaining their sobriety and progress Individuals in early recovery may not be as successful in practicing mindfulness due to intense emotions/feelings and physiological issues (PAWS)

31 MBRP Effectiveness Research has shown MBRP has a more enduring effect, which can be explained by the clients ability to recognize and tolerate discomfort associated with craving or negative affect. MBRP increases an individual s internal and environmental events that precipitate relapse and alter responses to cravings and negative affects via exposure based processes facilitated through mindfulness practices. According to a study published in 2014, participants in a MBRP program for substance use and heavy drinking experienced a significantly lower risk of relapse compared to those in a traditional 12- step relapse prevention program.

32 Relapse Prevention Planning for Relationships Establish safety first: Before we can plan for the idea of an IPV victim s relapse (returning to his/her abusive partner) we must make sure the victim is and feels safe, which includes her children and/or pets. Obtain safe housing, change phone number, obtain a protective order (if desired), notify neighbors of situation and develop a code word, also develop a code word with trusted family and friends, safety plan with children, notify children s school, change jobs if necessary, install motion sensitive lighting or alarms, notify landlord of situation (landlords are NOT allowed to discriminate against victims of IPV), use different stores, and change routes taken to frequent places.

33 Relapse Prevention Planning for Relationships Individual and Group therapy: Participate in individual and/or group therapy to identify triggers that could lead you to relapse such as: low selfesteem/self-worth, financial stress, co-dependency issues, PTSD symptoms, and other toxic relationships. Identify coping skills: create a relapse prevention plan to help list out negative or dangerous thoughts and behaviors to be aware of.

34 Safety Planning Tips Types of Protective Orders: Emergency Protective Order (EPO) Domestic Violence Order (DVO) Temporary Interpersonal Protective Order (TIPO) Interpersonal Protective Order (IPO) No Contact- Absolutely NO contact from perpetrator No Violent Contact- May have contact, however there may be no more threats/harassment of any kind Website for more information- VINE- Victim Information Notification Everyday- App for phone is VINEmobile; websitewww.vinelink.com

35 Safety Planning Tips cont Cell Phone- 911 cell phones are available to pick up at the courthouse at no cost. Any inactivated phone can be used as a 911 cell phone and it will still allow a person to call 911 if needed. SMART Website that allows you to create a profile where you can add details about you and your family that automatically populates for responders when 911 is dialed. Survivor s Handbookhttps:// on-page/ /a%20survivors%20handbook% pdf

36 Relapse Prevention Plan Handout: Relapse Prevention/ Aftercare Plan (Chrysalis House) Clients complete this prior to being approved to transition into Independent Living or completion of the residential portion. Clients should be able to identify triggers, high risk situations, support group information and numbers, etc. at this point of their recovery

37 References Bowen, S., Carroll, H., Chawla, N., et al. (2014). Relative efficacy of mindfulness-based relapse prevention, standard relapse prevention, and treatment as usual for substance use disorders. JAMA Psychiatry, 71(5), Bowen, Sarah, Chawla, Neha, Marlatt, G. Alan. (2011). Mindfulness-Based Relapse Prevention for Addictive Behaviors: a clinician s guide. New York: The Guilford Press. El-Guebaly, N. (2012). The meanings of recovery from addiction: Evolution and promises. Journal of Addiciton Medicine, 6(1), 1-9. Gorski, Terence. (2001). Understanding relapse. GORSKI- CENAPS Web Publications. Retrieved 6/11/17. Hendershot, C.S., Witkiewitz, K., George, W.H., & Marlatt, G.A. (2011). Relapse prevention for addictive behaviors. Substance Abuse Treatment, Prevention and Policy, 6(17), 1-17.

38 References National Center on Domestic Violence and Sexual Violence. Retrieved 6/11/17. National Coalition Against Domestic Violence. Retrieved 6/11/17. Navajits, L. (2002). Seeking Safety: A treatment manual for PTSD and substance abuse. New York: The Guilford Press. Persson, A., Back, S.E., Killeen, T.K., Brady, K.T., Schwandt, M.L., Heilig, M., & Magnusson, A. (2017). Concurrent treatment of PTSD and substance use disorders using prolonged exposure (COPE): A pilot study in alcohol-dependent women. Journal of Addiction Medicine, 11(2), Wolitzky-Taylor, K., Operskalski, J.T., Ries, R., Craske, M.G., Roy-Byrne, P. (2011). Understanding and treating comorbid anxiety disorders in substance users: Review and future directions. Journal of Addiction Medicine, 5(4),