Does Mandated Treatment Improve Outcomes for Women with Co-occurring Disorders and Histories of Violence?
Although there is extensive literature on mandated treatment for people with substance use and mental health disorders, few studies address its effectiveness in women who also have histories of violence. Researchers examined data on 2726 such women from nine study sites participating in the national Women, Co-occurring Disorders, and Violence Study to determine if women mandated to substance abuse treatment had better substance use, mental health, and trauma outcomes compared with demographically similar women who entered treatment voluntarily. Analyses also compared the effect of integrated, trauma-informed treatment to services as usual in both groups. At baseline, more than one-third of participants had been mandated to treatment. Outcomes were measured at six and 12 months.
- Participants mandated to treatment (68% residential) showed significantly greater improvement on all four outcome measures (mental health, drug use, alcohol use, and trauma symptoms).
- Participants receiving integrated treatment also showed significantly greater improvement across all four outcome areas.
- There were no significant interactive effects between coercive status (mandatory or voluntary) and treatment condition (integrated or usual services) on any of the four outcome measures.
Comments by Norma Finkelstein, PhD, LICSW
This study confirms the value of mandatory treatment for women with co-occurring disorders regardless of whether they receive integrated treatment or services as usual. Although women mandated to treatment benefited even more from integrated treatment including mental health and trauma services, even those receiving services as usual showed improvement on all four domains. It would be interesting to see if these results held true for the subgroups of women in outpatient treatment or in later stages of recovery. It is also important to reiterate the authors' concern that these treatment results should not be generalized to retraumatizing practices such as seclusion and restraint.
Trauma-Focused Group Therapy Reduces HIV Sexual Risk Behaviors in Women with PTSD and Substance Use Disorders
Studies indicate the frequent co-occurrence of trauma histories and substance use disorders in women, which may increase HIV sexual risk behaviors. Researchers studied the impact of 2 group therapy interventions to reduce unprotected sexual occasions (USO) among women with co-occurring posttraumatic stress disorder (PTSD) and substance use disorders: Seeking Safety (SS), a cognitive behavioral intervention addressing substance use and PTSD symptoms, and Women's Health Education (WHE), a psycho-educational intervention focused on health, nutrition, and sexual behavior including sessions on HIV risk and transmission. A total of 346 women from 6 community-based drug treatment programs participating in the NIDA Clinical Trials Network were randomized to receive 1 of the 2 interventions. Forty-six percent of the total sample reported at least one USO in the 30 days prior to intake. Most had experienced physical or sexual violence in their lifetime (94% and 90%, respectively), and all met DSM-IV criteria for either full (80%) or subthreshold (20%) PTSD.
- Women in the SS group with the highest sexual risk at baseline (at least 12 USO per month) had significantly fewer USO at 12-month follow-up compared with women with the highest baseline sexual risk in the WHE group (4.97 versus 8.60 USO per month, respectively).
- There was no difference in USO between groups at 12 months among women with the lowest baseline sexual risk (≤2 USO per month).
Comments by Norma Finkelstein, PhD
Findings from this randomized controlled trial show that SS, which emphasizes coping skills and reducing unsafe behavior and treats PTSD and substance misuse concurrently, may be more effective than traditional sexual risk reduction interventions in high-risk women with co-occurring PTSD and addictive disorders. Addressing trauma and improving women's coping and behavior skills may also prove effective in HIV education services. It would be interesting to know whether SS combined with HIV-specific education would have further reduced USO among high-risk women in this study.
Integrated Trauma and Substance Abuse Treatment and Occurrence of Adverse Events
Although research has demonstrated a significant relationship between physical/sexual abuse and substance use disorders, there is a dearth of studies exploring whether symptoms of post-traumatic stress disorder, depression, or anxiety increase in programs that integrate trauma therapy with substance abuse treatment. In this multisite clinical trial, researchers recruited 353 women to examine whether adverse events were more common in patients enrolled in a combined treatment program compared with women enrolled in non–trauma-focused treatment.
- No difference was seen in the number of women reporting study-related adverse events between the 2 groups.
- Of the 353 participants, only 17% experienced any study-related adverse events.
- Only 8 of all participants reported increased substance use while undergoing treatment.
- No relationship was demonstrated between number of study-related adverse events and length of treatment.
Comments by Norma Finkelstein, PhD, LICSW
Substance-abuse treatment providers frequently express concern that simultaneously addressing trauma will open a Pandora's box, contributing to increased mental health symptoms, substance use, and other negative consequences. This study provides evidence that this is not the case. It is important to note that the trauma intervention in this study was cognitive-behavioral rather than exposure-based, which may have resulted in the observed outcomes. Further research on the efficacy of various kinds of trauma treatment for women with substance use disorders is needed.
Impact of Early Trauma on Residential Treatment Outcomes for Women
A growing body of research is demonstrating that exposure to early childhood physical and sexual abuse is associated with adult outcomes including revictimization, substance use disorders, and numerous mental and physical health problems. A recent study examined the impact of early childhood abuse, including effects on 12-month treatment outcomes, in a population of 146 homeless women with children undergoing residential substance abuse treatment.
The study was a secondary analysis of data from the SAMHSA Homelessness Prevention Project and used the statistical technique of propensity scores to control for differences between women who had experienced early abuse and those who had not. Results of the study were as follows:
- 69% reported some form of childhood abuse, and most reported exposure to multiple forms of abuse (physical, sexual, emotional);
- 89% reported being abused at some point in their lives;
- women with early childhood abuse reported greater severity of dysfunctional psychological symptoms and functioning as well as poorer treatment outcomes in the areas of substance use, mental health, and recent trauma;
- no differences were found in either time (number of days) in treatment or treatment completion between abused and nonabused women. The differential response to treatment appeared due instead to a history of early childhood trauma.
Comments by Norma Finkelstein, PhD, LICSW:
The study findings reinforce the importance of improving both the identification and assessment of childhood abuse and trauma as well as developing treatment interventions for women that address trauma and co-occurring disorders. Counselors would benefit from increased training in the provision of trauma-informed, integrated treatment models of care.
Trauma Interventions for Women With Co-Occurring Disorders
Research has demonstrated a significant relationship between interpersonal trauma (physical or sexual abuse) and mental health and substance use disorders. This study, based on data from a national, multi-site trial, examined the impact of an intervention that integrated care for these disorders among 2729 women with varying levels of symptom severity.
Integrated care, consisting of 12 to 33 brief group sessions that were not standardized across sites, was compared with usual care. Severity of post-traumatic stress disorder (PTSD) and substance use symptoms was determined with standardized instruments.
- In most instances, both the intervention and control groups showed improvements in their PTSD symptoms, alcohol and drug problems, and mental health problems over a year.
- Improvements were generally greater in the intervention group, particularly among women with the most severe PTSD and substance use symptoms.
- However, the intervention had little effect on women with the least severe symptoms.
Comments by Norma Finkelstein, Ph.D., LICSW
This study provides a valuable look at the issue of targeting trauma interventions and is particularly important because studies of trauma interventions for women with co-occurring disorders are rare. The impact of the intervention was similar to that reported in other PTSD intervention studies. But, given the preliminary and exploratory nature of the original study, the authors' conclusion to reserve integrated trauma-related interventions to women with the most severe symptoms seems premature.
Also, it is important to note that this study did not compare specific trauma interventions (sites were free to choose one from several models). The field would benefit immensely from additional well-designed experimental studies on this critical issue.
Smoking Among Patients With Alcohol or Drug Use Disorders
Smoking is much more common in people with alcohol or drug use disorders. But, the specific relationship between smoking and other substance use, as well as the effects of gender on this relationship, is not clear. Therefore, researchers analyzed data from a nationally representative sample of 42,565 U.S. adults who had participated in a survey on alcohol and related conditions.
Comments by Norma Finkelstein, Ph.D, LICSW
- Prevalence of daily smoking was 21% among the total sample, 40% among people with a current alcohol use disorder, and 55% among people with a current drug use disorder.
- Ex-smokers made up about 20% of the total sample, 13% of people with a current alcohol use disorder, and 8% of people with a current drug use disorder.
- The likelihood of daily smoking, versus never smoking, was highest among women with a current drug use disorder (odds ratio [OR], 6.5), followed by men with a current drug use disorder (OR, 4.6), women with a current alcohol use disorder (OR, 3.5), and men with a current alcohol use disorder (OR, 2.9).
- The likelihood of occasional smoking, versus never smoking, was also highest among women (e.g., OR, 5.2 for those with a current alcohol use disorder).
While the use of tobacco is more common in men than women in the general population, gender differences in smoking among people diagnosed with substance use disorders has not been widely studied. These findings suggest that the association between substance use disorders and smoking is moderated by gender, and they reinforce the critical importance of addressing tobacco use within substance use disorder treatment. Specific smoking prevention and treatment strategies targeted to women might prove to be more effective than universal approaches.
Do Behavioral Strategies Help Pregnant Women With Drug Dependence Stay in Treatment?
Pregnant women with drug dependence have historically poor attendance in treatment and high treatment drop-out rates. This study examined whether behavioral incentives, specifically escalating monetary vouchers, integrated into an ongoing substance abuse treatment program could enhance treatment participation and retention in these women.
Researchers randomized 91 pregnant women in treatment for opiate and/or cocaine dependence (7-day residential program followed by a 7-day intensive outpatient program) to receive vouchers that increased in value for each full day of counseling completed or no vouchers (control group). Most subjects were African American (84%) with an average age of 30.
- Retention and length of stay in residential treatment (first 7 days) was not affected by vouchers.
- During residential treatment, a little over one-third of both groups left against medical advice. Most who left did so within the first 2 days of care.
- Of the remaining women, those in the voucher group stayed in treatment longer (average of 11 days versus 9 days for the control group) and were more likely to attend treatment consistently (i.e., for 12 to 14 full days) (46% versus 16%)
- During the 30-day follow-up period, women who consistently (versus inconsistently) attended treatment stayed in treatment longer (25 days versus 18 days).
Comments by Norma Finkelstein, Ph.D., LICSW:
There is a critical need to develop better polices, programs, and treatment tools to prevent early treatment drop-out and to retain pregnant women in substance abuse treatment. These findings suggest that while behavioral incentives, such as monetary vouchers, might help improve some aspects of treatment attendance, they do not affect early drop-out or retention in later treatment. Therefore, it is worth examining whether addressing other variables, such as co-occurring psychiatric or medical disorders, trauma history, and/or family support might be more critical in preventing early treatment drop-out.