WOMEN MATTER SAMHSA’S TRAINING TOOLBOX D E G S Tnadcpconference.org/wp-content/uploads/2018/06/D-16.pdf · Co-Occurring Disorders Impacting Women Pregnancy and Parenting Moving

WOMEN MATTER! SAMHSA’S TRAINING TOOLBOX: DELIVERING EFFECTIVE GENDER-

SPECIFIC TREATMENT

Niki Miller, MS, CPS

Deb Werner, MA, PMP

Advocates for Human Potential, Inc.

NADCP 24th Annual Training ConferenceMay 31, 2018 * Houston, Texas

This presentation supported by SAMHSA’s Women and Families Training and Technical Assistance Contract 283-12-3803.

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DISCLAIMER• This presentation is supported by the Substance

Abuse and Mental Health Services Administration (SAMHSA) and the U.S. Department of Health and Human Services (DHHS).

• The contents of this presentation do not necessarilyreflect the views or policies of SAMHSA or DHHS.

• The session and resources it offers should not be considered a substitute for individualized client care and treatment decisions.

INTRODUCTIONS: DEB WERNER

Deborah (Deb) Werner, M.A.WCF Project DirectorSenior Program ManagerAdvocates Human Potential

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INTRODUCTIONS - LEARNING ABOUT:What you do…

PPO

Counselor Case Manager

Program Manager

Peer Support

Other Court Staff

Prosecutor

Judge

TreatmentProvider

Other

Evaluator

Niki Miller, M.S., CPSSenior Research AssociateAdvocates for Human Potential

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INTRODUCTIONS: NIKI MILLER

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INTRODUCTIONS - LEARNING ABOUT:Where you do it…

Other Diversion

Drug Court

Tribal Court

Juvenile Drug Court

Federal Drug Court

Women’s Program

Mental Health CourtVets

Court

Domestic Violence

Other

Family Court

• Impact of sex/gender on substance use and recovery

• Maximizing points of justice system contact

• Gender responsive treatment/recovery practices

Featuring –SAMHSA’s Training Tool Box: Addressing the Gender-Specific Service Needs of Women

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HELPING WOMEN SUCCEED IN DRUGCOURTS (DCS)

ABOUT THE TOOL BOX Slide 8

WHAT IS THE TRAINING TOOL BOX?

• Addressing the Gender-Specific Substance

Use Disorder (SUD) Service Needs of Women

offers sample training content thatpresenters can draw upon and tailor tooffer trainings and presentations to avariety of audiences.

• Content is available for download at:https://www.samhsa.gov/women-children-families/trainings/training-tool-box

Slide 9

TRAINER’S TOOL BOX MODULES

Women, Substance Use,and SubstanceUse Disorders

Gender-Responsive

Services for Women: Principles & Core

Components

Treatment/Recovery

Considerations for Women

Co-Occurring Disorders Impacting

Women

Pregnancy and

Parenting

Moving Forward From

Here

and Women Veterans Supplement

REFLECTIVE QUESTIONS

• Where do I get myknowledge on thistopic?

• What do I know?

• How can I best drawupon thisknowledge?

WOMEN AND CRIMINAL JUSTICE

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WOMEN IN THE JUSTICE SYSTEM: WHERE?

Probation

Jails

Maximum impact: intercepts 2 & 3(Bureau of Justice Statistics, 2018; BJS, 2015; Kajstera, 2017)

Prisons

WOMEN’S OFFENSES (FBI UNIFORM CRIME REPORT, 2015)

Women comprised 27% of all arrestees charged

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INCARCERATED WOMEN (KAJSTERA, 2017)

Fastest growth of any segment of the justice population, especially in small jails. Increased 14-fold (5-fold for men).

(Vera Institute of Justice, 2016)

DC criteria: addiction + high risk of… Recidivism/re-arrest Failure in less intensive

rehabilitative dispositions(NADCP Standards, 2012)

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GROWTH OF FEMALE JAIL POPULATION

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WHY WOMEN ARE JAILED

•Low-income –fewer make bail• Jailed for unpaid fines and fees• Failure to appear/respond to citations

• Probation 'failures’ –pathway to custody• Due to technical violations

More detained pre-trial

(like men) but also

more likely to be:

(Vera Institute of Justice, 2016)

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DRUG COURTS: A UNIQUE OPPORTUNITY

• More women facing charges have SUDs (Vera Institute of

Justice, 2016)

• Most likely resolution: community supervision (Bureauof Justice Statistics, 2010)

• DC model aligned with key gender responsiveprinciples (Shaffer, Hartman & Litswan, 2009

A. Relapse, addiction severity

B. Mental health issues

C. Critical community service needs (housing,childcare, transportation)

D. Partners/family who use, are violentor involved in criminal activity

E. Something else…

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What is your biggest challenge with women in DC

programs?

AUDIENCE POLL

GENDER RESPONSIVE APPROACHES FORWOMEN

Slide 21

GRT: GENDER RESPONSIVETREATMENT

1. Addresses women’s unique experiences

2. Trauma informed

3. Relational approaches

4. A healing environment

5. Comprehensive: meets fullrange of needs

Core components of effective addiction treatment for women

SEX AND GENDER DIFFERENCES

• Sex differences refer to the biologicalcomponents of SUDs.

• Gender is related to culturally-definedcharacteristics of masculinity and femininitythat are part of a person’s identity.

• Both sex and gender differences influenceSUD onset, progression and recovery formen and women.

Addictive Illness Felony Court

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WOMEN’S PATHWAYS

Relationships

Mental Illness

Trauma

Relationships

Mental Illness

Addictive Illness

DIFFERENCES IN WOMEN’SRESPONSE TO DRUGS

• More physical consequences

• Higher overdose risk

• Greater intoxication at lower doses

• Physical dependency at lower level ofconsumption

• Drug cravings and withdrawal symptomsmore intense

(NIDA, 2017) 25

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MENTAL HEALTH: JUSTICE-INVOLVED WOMEN WITH SUDS

Most common co-occurring disorders: (BJS, 2013; Zweben, 2011)

• Post-traumatic stress disorder (PTSD)• Major depressive disorder

Likely to have more than one SMI: (BJA, 2013; SAMHSA, 2009)

• Bi-polar disorder• Anxiety disorders• Personality disorders

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Top exposure: childhood sexual abuse

Top exposure: witnessing a killing or serious violence

More likely to develop PTSD if exposed to violence

Exposure to violence more likely; less likely to develop PTSD

Repeat exposures: sexual/violent victimization begins in childhood

Violence from strangers; sexual abuse from outside family

Internalize: self-harm, eating disorders, drug use, avoidance

Externalize: violence, alcohol use, crime, hyper-arousal

Likely to get services through mental health

Likely to get services through addiction treatment

Recovery: safety, emotion regulation, empowerment

Recovery emphasis on feelings, relationships, empathy

(Miller and Najavits, 2011)

Trauma Exposure

BARRIERS TO ACCESSING HELPCommon barriers for women:

• Cost (socioeconomic hardship)

• Feelings of shame, guilt, harsh judgements

• Family

• Self (not readyor feels she doesn’tneed help)

• Partners

• Systemic

• Practical

BARRIERS TO DRUG COURTPARTICIPATION

• High need – low risk

• Transportation

• Mental health issues

• Caring for minor children

• Friends/partners who use

• Controlling/violent partners

• Housing insecurity

(Messina, Calhoun & Warda, 2012; Shaffer, Hartman & Listwan, 2009) 29

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DRUG COURTS : WHAT WORKSWITH WOMEN

Aspects of the DC Model:• Effective SUD treatment• Team approach to care coordination• Supportive supervision; consistent accountability• Relational: connection with peers and staff

Gender Responsive Enhancements • Integrated interventions• Community service linkages• Resolving barriers women face• Tailored to low-risk, high need offenders

(Carmichael, Gover, Koons-Witt & Inabnit, 2007; Dowden & Andrews, 1999)

“Drug Courts have an affirmative legal and ethical obligation to provide equal access to their services and

equivalent treatment for all citizens.” -Vol. I, p 12

“[Without] comprehensive training workshops and receive ongoing supervision… outcomes are unlikely

to improve for women…” -Vol. I, pp 14-15

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DRUG COURT STANDARDS (NADCP, 2012; 2015)

WOMEN’S UNIQUE EXPERIENCES

• Person-centered and relevant to eachwoman’s experiences

• Gender-responsive and culturallyresponsive; respectful

• Addresses the treatment needs ofwomen

• Acknowledges those needs aredifferent and more complex

TRAUMA INFORMED

SAMHSA’s four Rs of a trauma-informed approach:

• Realizes the widespread impact of trauma andunderstands potential paths for recovery

• Recognizes the signs and symptoms of trauma

• Responds by fully integrating knowledge abouttrauma into policies, procedures, and practices

• Resists re-traumatization

SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach

TRAUMA INFORMEDSAMHSA’s six principles of trauma-informed care:

Safety

Trustworthiness and transparency

Peer support and mutual self-help

Collaboration and mutuality

1. Empowerment, voice, and choice

2. Cultural, historical, and gender issues

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SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach

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ArousalExtreme responsiveness and excitability or numbing detachment

Hyper-aroused Numb

AttentionInattentive, blocking triggers or acute focus and awareness of them

Dissociative Hyper-focused

PerceptionVision and hearing are sharpened or thinking is clouded and dull

Heightened Dulled

EmotionFeelings are devastating and painful or detached from experience

Overwhelming Absent

(Miller, 2011)

TRAUMA & CRIMINOGENIC RISKS

“Better outcomes have been achieved…in Drug Courts and other substance abuse treatment programs that developed specialized groups for women

with trauma histories.” -NADCP Best Practice Standards, Vol. I, p 14

• Assessed using a validated instrument for trauma history,trauma-related symptoms and PTSD.

• Clients with PTSD receive an evidence-based intervention thatteaches them to manage distress without substances.

• Females receive trauma-related services in gender-specificgroups. -NADCP Best Practice Standards, Vol. I, p 14

-NADCP Best Practice Standards, Vol. II, pp 6-736

TRAUMA-INFORMED DC STANDARDS

SAMHSA COMPREHENSIVE TREATMENT MODEL

• Clinical treatmentservices

• Clinical supportservices

• Communitysupport services

• Where indicated, participants receive assistance findingsafe, stable, and drug-free housing. -Vol. II, p 6

• Must identify a range of complementary needs amongparticipants, make referrals for indicated services, andensure they are delivered in effective sequence -Vol. II, p 10

• Mental illness and addiction are treated concurrently usingan evidence-based curriculum that focuses on the mutuallyaggravating effects of the two conditions. -Vol. II, p 6

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COMPREHENSIVE (NADCP BEST PRACTICE STANDARDS)

“The risk-assessment tool has been demonstrated empirically to predict criminal recidivism or failure on community supervision and is equivalently predictive for women…” -NADCP Best Practice Standards, Vol. I, pp 5-6

Forensic vs Clinical Assessment

• Clinical assessment answers a yes/no question,determines severity, level of care & guides treatmentplanning.

• Forensic assessment determines risk of re-offending,identifies criminogenic needs & helps planprogramming to address them.

RELATIONAL = FOCUS ONCONNECTIONS

Women tend to prioritize relationships as a means of growth and development.

Relationships play a significant role in both development and recovery from SUDs.

Relationships/connections central in women’s:

Identities

Self-esteem

Decision-making

Support systems

RELATIONAL: THERAPEUTIC ALLIANCE & PEERS• Women: Trust and warmth is of primary importance.

• Men: Relationships that help them solve problems are ofprimary importance.

“A strong therapeutic relationship with acounselor is one of the largest factors in anindividual’s ability to recover from the overwhelming effects of trauma.” -TIP 57, p. 176

RELATIONAL – FAMILY/PARTNERSRelational approaches to service:

• Sensitive to relationship/family history womenbring into treatment—positive and negative.

• Family-focused using a broad definition - encouraging awoman to define her family/support system.

• Are welcoming to children.

• Help a woman understand roles and dynamics; examining herpartner’s influence on her substance use.

WORKING WITH OTHER SERVICE SYSTEMS

When working with other service systems, try:

• Assisting women with navigating child welfare,intimate partner violence services, mental healthand victim assistance.

• Educating other providers about the special needsof justice-involved women: trauma, mental healthand SUDs.

COLLABORATING WITH OTHER AGENCIES

When working with other agencies, try:

• To understand the different priorities, goals,and challenges of the various agenciesinvolved with addressing the diverse needsof women.

• Partnering with service providers fromdifferent disciplines to facilitate woman-andfamily-centered decision-making.

HOW CAN YOUUSE THE

TOOL BOX?

Slide 45

Take Away for Drug Court Programs

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Q & A

QuestionsCommentsExperiences…

Introduction to Women with SUDs online course http://healtheknowledge.org

Bureau of Justice Assistance (2013) Policy Brief, Women’s Pathways to Jail: Examining Mental Health, Trauma, and Substance Use, By Lynch, S., DeHart, D., Belknap, J. & Green, B. Retrieved from: https://www.bja.gov/publications/WomensPathwaysToJail.pdfs

Bureau of Justice Statistics (2010). Correctional Populations in the United States, Lauren E. Glaze, December 2010, NCJ 231681 Bulletin: Retrieved from: https://www.bjs.gov/index.cfm?ty=pbdetail&iid=2316

BJS (1999). Greenfield, L. & Snell, T. Women Offenders, BJS No. 175688. Retrieved from: https://www.bjs.gov/index.cfm?ty=pbdetail&iid=568

BJS (2006). Mental Health Problems of Prison and Jail Inmates. Retrieved from: https ://www.bjs.gov/index.cfm?ty=pbdetail&iid=789

BJS (2016). Census of Problem Solving Courts, 2012. Retrieved from: https://www.bjs.gov/content/pub/pdf/cpsc12.pdf

BJS (2015). Probation and Parole in the United States, 2013, BJS Statisticians - Herberman, E.R., & Bonczar, T.P. Retrieved from: http://www.bjs.gov/content/pub/pdf/ppus13.pdf

BJS, Drug Use, Dependence and Abuse Among State Prisoners and Jail Inmates, 2007-2009. Bronson, J., Stroop, J., Zimmer, S. & Berzofsky, M. 2017) Retrieved from: https://www.bjs.gov/content/pub/pdf/p16.pdf

BJS (2018). Jail Inmates Summary Report, 2016, Zhang, Z. Retrieved from: https://www.bjs.gov/content/pub/pdf/ji16_sum.pdf

BJS of Justice Statistics, December 19, 2014 Correctional Populations in the United States, 2013. Retrieved from: https://www.bjs.gov/index.cfm?ty=pbdetail&iid=5177

BJS, 2017. HIV in Prison, 2015- L. Marischak & J. Bronson, August 24, 2017. Retrieved from: https://www.bjs.gov/frf.cfm

BJS (2006). Maruschak, L. Medical Problems of Jail Inmates. Retrieved from: https://www.bjs.gov/content/pub/pdf/mpji.pdf

BJS (2015). Maruschak, L., Berazofsky, M. & Unangst, J. Medical Problems of State and Federal Prisoners and Jail Inmates. Retrieved from: https://www.bjs.gov/index.cfm?ty=pbdetail&iid=5219

Carmichael, S., Gover, A., Koons-Witt, B. & Inabnit, B. (2007). The Successful Completion of Probation and Parole Among Female Offenders. Women & Criminal Justice 17(1):75-97 September. Retrieved from: https://www.ncjrs.gov/App/Publications/abstract.aspx?ID=241299

Dowden, C. & Andrews, D. (1999) What Works for Females Offenders: A Meta-analytic Review. Crime and Delinquency, Vol. 45 No. 4, pp 438-452. More women involved in the criminal justice system have parents who abused drugs and alcohol. Retrieved from: http://journals.sagepub.com/doi/abs/10.1177/0093854815621100

FBI Uniform Crime Report (2016). Crime in the United States, 2015 . Table 33, Ten-Year Arrest Trends by Sex, 2006–2015. Retrieved from: https://ucr.fbi.gov/crime-in-the-u.s/2015/crime-in-the-u.s.-2015/tables/table-33

Galbraith, S. (1998). Working with Women in the Criminal Justice System, GAINS Center. Albany, New York: Policy Research Associates

Holmstrom, A., Adams, E., Morash, M., Smith, S. & Cobbina, J. (2017). Supportive Messages Female Offenders Receive From Probation and Parole Officers About Substance Avoidance: Message Perceptions and Effects. Criminal Justice and Behavior, (44 )11. Retrieved from: http://journals.sagepub.com/doi/abs/10.1177/0093854817723395?journalCode=cjbb

Kajstura, A. (2017). Women’s Mass Incarceration: The Whole Pie, 2017, ACLU Smart Justice/Prison Policy Initiative. Retrieved from: https://www.prisonpolicy.org/factsheets/women_pie_chart_report_2017.pdf 46

REFERENCES

Messina, N., Calhoun, S. & Warda, U. (2012). Gender-responsive Drug Court Treatment: A Randomized Controlled Trial. Criminal Justice and Behavior, Vol. 39 No. 12, pp 1539-1558. Retrieved from: http://gap.hks.harvard.edu/gender-responsive-drug-court-treatment-randomized-controlled-trial

Miller, N. & Najavits, L. (2012). Creating trauma-informed services in correctional settings: A balance of goals and environment. European Journal of Psychotraumatology. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3402099/

Miller, N., & MacDonald, D. (2008). Indicators of marginalization and response among justice-involved women with co-occurring disorders. Paper presented to the American Academy of Criminal Justice Sciences. Boston, MA.

Najavits, L. (2002). Seeking Safety: A Treatment Manual for PTSD and Substance Abuse. New York: Guilford Press

National Institute on Drug Abuse (2017). Substance Use in Women. Retrieved from: http://www.drugabuse.gov/publications/drugfacts/substance-use-in-women

National Association of Drug Court Professionals (2013). Adult Drug Court Best Practice Standards, Volume I. Retrieved from: https://www.nadcp.org/sites/default/files/nadcp/AdultDrugCourtBestPracticeStandards.pdf

National Association of Drug Court Professionals (2015). Adult Drug Court Best Practice Standards, Volume II. Retrieved from: https://ndcrc.org/resource/nadcp-adult-drug-court-best-practice-standards-volume-ii/

Shaffer, D., Hartman, J. & Listwan, S. (2009). Drug Abusing Women in the Community: The Impact of Drug Court Involvement of Recidivism. Journal of Drug Issues 22-0426/09/04 pp 803-828.

Sickmund, M., Sladky, M., Kang, T. & Puzzanchera, C. (2015). Easy Access to the Census of Juveniles in Residential Placement. Washington D.C.: Office of Juvenile Justice and Delinquency Prevention: Retrieved from: https://www.ojjdp.gov/ojstatbb/ezacjrp/asp/display.asp

Substance Abuse and Mental Health Services Administration (2017). Addressing the Gender-Specific Substance Use Disorder (SUD) Service Needs of Women. US Department of Health and Human Services. Retrieved from: https://www.samhsa.gov/women-children-families/trainings/training-tool-box

SAMHSA Center for Behavioral Health Statistics and Quality (2016). Half of Women on Probation or Parole Experience Mental Illness, Data Spotlight. National Survey on Drug Use and Health, March 6, 2012: https://www.samhsa.gov/data/sites/default/files/Spot063WomenParole2012/Spot063WomenParole2012.pdf

Van Voorhis, P., Salisbury, E., Wright, E., and Bauman, A. 2008. Achieving Accurate Pictures of Risk and Identifying Gender-Responsive Needs: Two New Assessments for Women Offenders. National Institute of Corrections: Retrieved from: https://nicic.gov/achieving-accurate-pictures-risk-and-identifying-gender-responsive-needs-two-new-assessments-women

Vera Institute of Justice, 2016. Overlooked: Women and Jails in an Era of Reform. Elizabeth Swavola, Kristine Riley, and Ram Subramanian. Retrieved from: https://www.vera.org/publications/overlooked-women-and-jails-report

Zweben, J. Women’s Treatment in Criminal Justice Settings, in Leukenfeld, C, Gullotta, T. & Gregrich, J (Eds.) (2011). Handbook of Evidence-basedSubstance Abuse Treatment in Criminal Justice Settings. New York: Springer. 47

REFERENCES (CONTINUED)

Deborah (Deb) Werner, M.A., PMPSenior Program ManagerAdvocates for Human Potential, Inc.Los Angeles, [email protected]

Niki Miller, MS, CPSSenior Research AssociateAdvocates for Human Potential, Inc.Boston, [email protected]

CONTACT INFORMATION