Karen A. Duncan, M.A., LMFT, LSW
A Partnership in Healing:
Trauma Based Substance Use Treatment for Women
Experiencing Childhood Sexual Abuse
Trauma Based Substance Use Treatment
Childhood sexual abuse trauma (CSAT) is a primary causal factor identified in studies that link symptoms of post-traumatic stress disorder (PTSD) and substance use disorder (SUD) for women. Given the relationship between childhood sexual abuse (CSA) and SUD, it becomes imperative that trauma-based treatment is an inclusive component in SUD programs for women. A trauma-based program for women will need to be gender sensitive, approached in stages, able to assure safety from retraumatization and delivered by clinicians, counselors and medical staff trained in the female experience of CSA.
Trauma Education and Prevention (TEP)
Trauma Education and Prevention (TEP) is a protocol for women that I have developed in my clinical practice over the past twenty years. It is currently being expanded as a pilot program at the Indiana Women's Prison where the majority of women have experienced CSA and other interpersonal traumas and who are incarcerated due to illegal behavior related to substance use.
TEP focuses on education and prevention as a first stage treatment approach adaptable for use within a community based SUD treatment program for women. Trauma education and prevention is an approach that works well with women who are at different stages of recovery from the trauma of CSA, which is often the case when women are entering substance use treatment.
TEP includes six areas of trauma based treatment for women: screening and assessment for trauma, education about female victimization, understanding the prolonged problems from CSA and other interpersonal traumas, the relationship between CSA and substance use, development of a personal plan to prevent future victimization and a review of the overall recovery process to heal the trauma of CSA. Individual sessions are scheduled with women during the TEP program to help process certain aspects of CSA. At least three individual sessions are recommended during TEP.
TEP Screening and Initial Assessment
The TEP program screens for CSA and other interpersonal traumas while also screening for trauma symptoms that includes PTSD symptoms. It takes into consideration that women will present with the more pervasive problems associated with CSA such as substance use, eating disorders and chronic shock symptoms of anxiety, depression and dissociation rather than only PTSD symptoms. TEP recognizes that women do not always present with PTSD symptoms upon entering treatment, and if only PTSD is screened for, rather than specific traumas, then women experiencing CSA or other interpersonal traumas may be overlooked, their trauma symptoms are more likely to be misdiagnosed and other services they might need such as shelter from domestic violence are not identified and included in their aftercare plan.
TEP uses a trauma symptom checklist based on the prolonged problems women experience from CSA. Women complete the CSA-Trauma Symptom Checklist during their first group session. They also complete it again in order to help identify what they are experiencing as they diminish their use of substances. This checklist begins the identification process for women as they begin to make the connection between past traumas and current problems they are experiencing.
Screening for chronic shock symptoms (CSS) of anxiety, depression and dissociation also occurs as CSS often co-occur with substance use. Women report using alcohol and drugs to moderate and diminish symptoms of chronic shock. Assessment identifies if prescription medication is needed for depression and anxiety since these two CSS often increase once a woman begins to diminish her use of alcohol or other substances. Prescription medication is safest when prescribed within an inpatient program so that its use is monitored while a woman is learning to manage the cycle of depression and anxiety from CSA without using the specific substances that brought her to SUD trauma based treatment. If prescription medication was a pattern of substance use then inpatient monitoring becomes even more critical during a woman's first two weeks of trauma based SUD treatment.
When obtaining a woman's history of substance use it is important to ask about the relationship between substance use and child sexual abuse. For example, when the perpetrator(s) introduced the use of substances during or after the sexual abuse, or when a woman used substances to disengage from thoughts or feelings of the sexual abuse on a daily basis, will identify how a pattern of use began. These initial patterns of use can become a connection as to how she continues to use substances to disengage from stressful events. A woman begins to understand her pattern of use in relation to CSA she can learn how to self-soothe in other ways through overwhelming emotions or physical experiences of the sexual abuse that no longer harm her today.
The Group Format for TEP
Size, Length and Time Limit: The optimal group size recommended for TEP is five, which allows for safety, trust and time for discussion. Depending upon the experience, training, skill level and education of the counselor(s) with regard to childhood trauma recovery and working with women an upper limit of ten women is acceptable. It is beneficial to have at least three counselors trained in TEP and that all staff have training on the female experience of childhood sexual abuse trauma and other interpersonal traumas that women experience.
During an inpatient program, one topic of TEP is covered each day over a two-hour period for two weeks. Women have journals to use in-group and to write down questions and thoughts they might have in-between sessions. For an outpatient program, the format would be the same except that women would be meeting for two hours once a week and the group would meet over a six-week period. An aspect of gender sensitive treatment is the need that women have for childcare in order to attend trauma based SUD treatment. When childcare is not provided, a woman may leave treatment prior to completion.
Talking About Sexual Abuse: Women can benefit from a group process in a beginning stage of recovery from both CSA and SUD. However, it is important to identify that the nondisclosure of specific aspects of sexual, emotional and physical trauma that can cause retraumatization to other women be maintained. Disclosure of CSA is an individual process that occurs throughout recovery as a woman gains trust and confidence within the therapeutic relationship. Disclosure is a different process than the general acknowledgement that occurs in TEP. A general acknowledgement is often a first step for a woman that enables her to develop comfort in speaking about sexual abuse as she breaks the silence that has been a part of this trauma for a number of years. “I was sexually abused from age 5 to 11 by my older brother” is an example of a general acknowledgement that is acceptable, safe and encouraged in TEP. It includes information without including details of the specific acts of sexual abuse committed. It is important to remember that for most women this may be their first experience at acknowledging the sexual abuse. Therefore, written guidelines and specific examples on how the group is expect to share and talk about the sexual abuse is helpful and increases the likelihood of women feeling safe to share within the group process.
Boundaries for the Group: Boundaries within a therapeutic intervention are especially important for women who have experienced childhood sexual abuse. Boundaries allow the counselor to have control within the group while creating and modeling an attitude and environment of equality, compassion and respect within relationships. Boundaries center on confidentiality, not being asked intrusive questions and other areas that women identify they need to feel safe within the group.
A Woman's Trauma History: Women complete a social and family history in written form that includes questions about the sexual abuse and other interpersonal traumas which allows the trauma(s) to be understood within the context of a woman's life. The counselor then meets with a woman individually to clarify information or to ask general questions. These questions focus on a general understanding of when and where the traumas were experienced, what symptoms disrupt daily life and the relationship of the perpetrator when the trauma occurred and the relationship today.
A written approach to obtaining a woman's trauma history maintains the therapeutic boundary for the group. A woman can take this written history with her upon completing TEP. Ideally, a woman would transition into a trauma based outpatient program for SUD that would continue to provide her with both individual and group therapy and continue to support prevention from future traumas.
Prevention: Prevention is a key component of TEP. Prevention information allows women to make connections between current or past traumas. TEP helps women to understand the impact that CSA has had upon their choices, their relationships and the lack of safety they have experienced within their lives. The prevention component of TEP can be especially helpful in improving the safety of children whose mothers have experienced CSA. Mothers who have experienced CSA can also experience maternal attachment disorder. Maternal attachment disorder is a woman's inability to emotionally bond and connect to her child. Maternal attachment disorder is linked to an increase risk for a child to experience sexual abuse or other forms of childhood maltreatment and this risk increases if a mother is also using substances. The Right To Be Safe™: Adult Education in the Prevention of Child Sexual Abuse is a key component of prevention education for women. This power point presentation is available free through the internet at www.theright2besafe.org. RTBS can be presented in written form to women as well.
Identifying how a woman's self-concept has been affected by CSA is a critical part of the prevention component of TEP. TEP supports a woman to build a more positive identity through the concrete actions she takes today. This step enables women to identify core issues that contribute to sustaining damaging relationships, identifies what decisions a woman can make today that will restore her self-esteem and create a positive life-sustaining female identity and culminates into the development of a written prevention plan that includes distancing from abusive and violent relationships.
Education: Education is a second key component and focus of TEP that includes four areas of focus. The first focus is to define the types of traumas that women experience, how CSA creates a traumatic pathway to other types of violence and the relationship between trauma, victimization and substance use. The impact of trauma is a second focus that includes how to recognize and self-manage specific trauma effects such as sleep disturbances, anxiety and depression. An overview of how trauma affects memory and how women store, recall and experience memories of CSA. The somatic-sensory experience of CSA and how trauma is stored in the body is also presented.
A third focus is the diversity of prolonged problems associated with sexual trauma. The specific problems that women experience associated with their experience of CSA are identified for discussion during TEP. The specific problems are identified based upon the information women provide within their trauma histories. This approach allows for an individualized focus for each group that is relevant and meaningful for the individual women. The specific relationship between CSA and substance abuse is addressed where women identify their personal pattern of use and discuss their substance use within the context of CSA trauma.
The prevention of future victimization is the fourth focus that identifies the traumatic pathway that leads to future violence. It builds upon the prevention information provided earlier and helps to establish personal boundaries women need to maintain control of their lives and their personal safety. The redefining of family and partner relationships becomes essential as women determine what safety means to them and how to establish and maintain personal safety and self-care. TEP includes how to keep children safe from family perpetrators and preventing the victimization of children into the future. Identifying how they will be challenged in their every day life to maintain their personal regard for self, boundaries and safety helps women to be prepared with responding to these challenges.
Healing CSA Trauma: The final component of TEP is to encourage women to continue their healing by providing them information on what CSA recovery involves, methods for self-soothing, relaxation and self-nurturance, emotional healing and expression and information on healthy family characteristics. Women write a specific relapse prevention plan that includes substance use and victimization prevention and steps they will take to support their personal healing from the trauma of CSA.
Summary
TEP is a first-stage trauma recovery program for women with a focus on prevention and education. It is easily integrated into existing substance use treatment programs. It requires a professional staff committed and trained to work with women who have experienced CSA trauma and substance use disorders. Treatment programs that provide trauma based substance use programs for women will find a positive response among women who seek their services. Given the prevalence that one in three females have experienced some form of child sexual abuse before the age of seventeen an estimated 25.4 million women between the ages of 20 to 59 and 12.6 million female adolescents and children 19 years of age and younger have experienced this trauma. The hope is that with improved prevention education for parents and early intervention programs for families we can stop the intergenerational cycle of child sexual abuse and the substance use that frequently follows. Until then we must meet the growing need to address effectively the dual epidemic of child sexual abuse and substance use in the lives of women and girls.
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