Moving toward trauma-informed practice in addiction treatment: a collaborative model of agency assessment.

Clients in substance abuse treatment need, in addition to evidence-based and sensitive treatment services in general, a system of care that takes into account the impact of trauma and violence in so many of their lives. In addition, services need to be delivered in a way that avoids triggering trauma memories or causing unintentional re-traumatization. To that end, this article describes an agency self-assessment process that combines a trauma-informed assessment, a NIATx process of "walking-through" and use of the Institute of Healthcare Improvement's Plan-Do-Study-Act (PDSA) cycles, and a user-friendly format. The trauma-informed assessment is designed to address issues of safety of clients and staff members, reduction of re-traumatization, consistency in practice, and client empowerment. It brings a non-judgmental, collaborative approach to process and practice improvement. The article describes how the assessment process can be--and has been--used to develop an Action Plan, including trainings and the identification of "trauma champions"; i.e., staff who will continue to spread trauma-informed changes and new evidence-based practices throughout the agency. As we enter a period of healthcare reform, addressing trauma as an integral part of addiction treatment also allows us to better deal with the totality of our clients' health problems.

Urinary tract infection and inflammation at onset of interstitial cystitis/painful bladder syndrome.

OBJECTIVES: Interstitial cystitis/painful bladder syndrome (IC/PBS) is a chronic disease primarily in women that is of low incidence and unknown etiology and manifests as bladder pain and urinary symptoms. Acute urinary tract infection (UTI) is of high incidence in women, presents as dysuria and urinary symptoms, and is caused by uropathogenic bacteria. We hypothesized that UTI is present at the onset of IC/PBS in some women. METHODS: For a case-control study seeking risk factors for IC/PBS, women with IC/PBS symptoms of 12 months or less were recruited and evaluated by interview and medical record review. The date of symptom onset was identified by a six-step process. Three evidence-based methods using culture, urinalysis, and symptoms were used separately and in combination to diagnose UTI at IC/PBS onset. RESULTS: Of 1177 screened women, 314 with recent-onset IC/PBS, including numerous confirming characteristics, were enrolled in the study; 98% of the requested medical records were obtained and reviewed. Evidence of a UTI at the onset of IC/PBS was found in 18% to 36% of women. Common UTI features not used in its diagnosis (short interval to medical care, hematuria, antibiotic treatment, and improvement after antibiotics) were significantly more common in those with onset UTI than in those without. CONCLUSIONS: These retrospective data suggest that a proportion, probably a minority, of women at IC/PBS onset had evidence of UTI or inflammation. Our results indicate that UTI is present at the onset of IC/PBS in some women and might reveal clues to IC/PBS pathogenesis.

Voiding urges perceived by patients with interstitial cystitis/painful bladder syndrome.

AIMS: Interstitial cystitis/painful bladder syndrome (IC/PBS) is a symptom-based diagnosis. We studied the IC/PBS symptom commonly referred to as "urgency" and its relationship to IC/PBS pain in a group of women with recent onset of the disease. METHODS: As part of a case control study to identify risk factors for IC, cases completed a questionnaire including two statements regarding the perceived cause of their urge to void. One was related to fear of incontinence and the other was linked with relief of pain. A Likert scale indicating level of agreement/disagreement comprised the response options. RESULTS: Most respondents (65%) agreed with the statement linking urge with pain relief. A minority (21%) concurred with the fear of incontinence statement. Disagreement for both was found in 19%. A substantial proportion (46%) agreed with pain relief but also disagreed that urge is related to fear of incontinence. Those who reported urge to relieve pain were significantly more likely to report worsened pain with bladder filling and/or improved pain with voiding. There were no such associations with urge to prevent incontinence. Overactive bladder or diabetes prior to IC onset did not confound these results. CONCLUSIONS: At least two distinct experiences of urge to urinate are evident in this population. For most, urge is linked with pain relief and is associated with bladder filling/emptying. About 1/5 reported urge to prevent incontinence. A similar portion did not agree with either urge, indicating that they may experience something altogether different, which requires further inquiry.

Women with co-occurring disorders (COD): treatment settings and service needs.

Over the past two decades, substance abuse and mental health treatment systems have continued to define and refine interventions for co-occurring disorders (COD) for women. However, there is still a need for improvement of treatment and referral services for women with co-occurring disorders. This article presents data from studies of four types of interventions across a continuum of substance abuse treatment settings for women with co-occurring substance abuse and mental health issues. The studies include: (1) local data from the National Women with Co-Occurring Disorders and Violence Study (WCDVS); (2) a study of process improvement changes made to improve treatment access and retention implemented under the Network for the Improvement of Addiction Treatment (NIATx) and SAMHSA/CSAT's Strengthening Treatment Access and Retention (STAR) Program; (3) an examination of selected data collected in a large publicly-funded assessment center for substance abuse and mental health disorders; and (4) a study of postpartum depression within a larger evaluation of a comprehensive treatment model for pregnant/postpartum women with substance abuse disorders. The results from these studies provide information that allows both mental health and substance abuse systems and providers to move toward more effective interventions tailored to specific groups of women with COD. The interventions tested include: centralized screening and assessment centers; trauma-informed, integrated treatment; process improvement strategies to improve retention; and screening for postpartum depression in substance abuse and mental health programs.

Implementing an evidence-based practice: Seeking Safety Group.

This article presents findings from a multisite study on adopting and implementing an evidence-based practice, Seeking Safety, for women with co-occurring disorders and experiences of physical and sexual abuse. It focuses on what implementation decisions different sites made to optimize the compatibility of Seeking Safety with the site's needs and experiences and on issues posed by Rogers (1995) as relevant to successful diffusion of an innovative practice. A total of 157 clients and 32 clinicians reported on satisfaction with various aspects of the model. Cross-site differences are also examined. Results show that Seeking Safety appears to be an intervention that clinicians perceive as highly relevant to their practice, and one that adds value. Clients perceive the treatment as uniquely touching on their needs in a way that previous treatments had not.

Dysuria at onset of interstitial cystitis/painful bladder syndrome in women.

OBJECTIVES: In an ongoing national study of women to identify risk factors for interstitial cystitis/painful bladder syndrome (IC/PBS), dysuria was identified at the onset of IC/PBS in a small majority and the evidence for urinary tract infection was evaluated. METHODS: In women with IC/PBS of 12 months' duration or less, symptoms and pertinent laboratory tests at onset were assessed by telephone interview and medical record review. RESULTS: Of 138 women, 75 (54%) reported that they had started to experience burning or pain on urination at the onset of IC/PBS. Of those with urine cultures, 12 (34%) of 35 women with dysuria versus 1 (5%) of 21 without dysuria yielded a uropathogen (P = 0.01). Similarly, the microscopic white blood cell count and dipstick nitrites and leukocyte esterase were each significantly more common in the urine samples of those with dysuria than in those without. Additionally, 7 of 75 of those with dysuria versus 1 of 62 without dysuria reported chills or fever at the onset of IC/PBS. Using various definitions, the prevalence of urinary tract infection at the onset of IC/PBS, at a minimum, was 16% to 33% of those with dysuria versus less than 2% of those without dysuria (P < or = 0.003). CONCLUSIONS: A slight majority of women with IC/PBS reported dysuria at onset of their IC/PBS symptoms. The available laboratory data have suggested that dysuria may be a sensitive indicator of urinary tract infection at the onset of IC/PBS; however, its specificity is as yet undetermined.

Twelve-month outcomes of trauma-informed interventions for women with co-occurring disorders.

OBJECTIVE: Women with co-occurring mental health and substance use disorders frequently have a history of interpersonal violence, and past research has suggested that they are not served effectively by the current service system. The goal of the Women, Co-occurring Disorders, and Violence Study was to develop and test the effectiveness of new service approaches specifically designed for these women. METHODS: A quasi-experimental treatment outcome study was conducted from 2001 to 2003 at nine sites. Although intervention specifics such as treatment length and modality varied across sites, each site used a comprehensive, integrated, trauma-informed, and consumer-involved approach to treatment. Substance use problem severity, mental health symptoms, and trauma symptoms were measured at baseline, and follow-up data were analyzed with prospective meta-analysis and hierarchical linear modeling. RESULTS: A total of 2,026 women had data at the 12-month follow-up: 1,018 in the intervention group and 1,008 in the usual-care group. For substance use outcomes, no effect was found. The meta-analysis demonstrated small but statistically significant overall improvement in women's trauma and mental health symptoms in the intervention relative to the usual-care comparison condition. Analysis of key program elements demonstrated that integrating substance abuse, mental health, and trauma-related issues into counseling yielded greater improvement, whereas the delivery of numerous core services yielded less improvement relative to the comparison group. A few person-level characteristics were associated with increases or decreases in the intervention effect. These neither moderated nor supplanted the effects of integrated counseling. CONCLUSIONS: Outcomes for women with co-occurring disorders and a history of violence and trauma may improve with integrated treatment.

Outcomes for women with co-occurring disorders and trauma: program and person-level effects.

Six-month outcomes are evaluated from a 9-site quasi-experimental study of women with mental health and substance use disorders who have experienced physical or sexual abuse who enrolled in either comprehensive, integrated, trauma-informed, and consumer/survivor/recovering person-involved services (N = 1023) or usual care (N = 983). Mental health, post-traumatic stress symptoms, and substance use outcomes are assessed with multilevel regression models, controlling for program and personal characteristics. Person-level variables predict outcomes independent of intervention condition and, to a small extent, moderate intervention and program effects. In sites where the intervention condition provided more integrated counseling than the comparison condition, there are increased effects on mental health and substance use outcomes; these effects are partially mediated by person-level variables. These results encourage further research to identify the longer-term effects of integrated counseling for women with co-occurring disorders and trauma histories.

Effects of women-sensitive, long-term residential treatment on psychological functioning of diverse populations of women.

A number of studies have found that women who abuse substances enter treatment with greater psychological problems and more vulnerabilities than men. This article reports on a 5-year study of clients in a comprehensive, residential drug treatment program for women and their children. Psychological assessments on 362 women included the Basic Personality Inventory (BPI), the Center for Epidemiologic Studies Depression Scale (CES-D), and the Luria-Nebraska Neuropsychological Battery, Screening Test (LNNB-ST). Early in the course of treatment, the typical client tends to experience a great deal of distress, as evidenced by scores on the CES-D. Other assessments indicate she is relatively alienated, mistrustful of others, and resentful of rules imposed on her by others. Repeated assessments show that these psychological indicators improve significantly as the client progresses through the treatment program. Additional studies are needed to focus on long-term treatment outcomes of women in programs designed specifically for them.