Targeting trauma-related interventions and improving outcomes for women with co-occurring disorders

A Scoping Review of the Trauma Recovery and Empowerment Model (TREM)

The link between interpersonal trauma and negative biopsychosocial outcomes has been well-documented. Integrated treatments that address trauma, mental health, and substance use among women with trauma histories have been found to be more effective than treatments that focus separately on these concerns. Since the early 2000s, the Trauma Recovery and Empowerment Model (TREM) has been described as a "promising" integrated trauma group therapy for women. Despite widespread recognition and implementation of TREM, its effectiveness has not been clearly established. The present scoping review is the first systematic effort to describe the extant literature on TREM and aims to provide an understanding of TREM's effectiveness by organizing and synthesizing the available empirical data. Guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews, a systematic search was conducted using PubMed, PsycINFO, SW Abstracts, Scopus, Embase, and Web of Science. Quantitative dissertation findings not published elsewhere and peer-reviewed journal articles published in English that reported outcomes from TREM intervention research with adult women were included. Twelve of the initial 385 publications identified met the inclusion criteria and reported data from nine studies. TREM demonstrated statistically significant effects on posttraumatic stress disorder, anxiety, psychological/psychosomatic distress, and substance use. A more limited set of findings suggests that TREM may also be associated with additional gains, including self-esteem, relationship power, social support, attachment, and spiritual well-being. Future research should replicate findings, use random assignment to groups, involve larger sample sizes and more representative samples, examine optimal duration, and identify components that facilitate change.

Developing an integrated intervention to address intimate partner violence and psychological distress in Congolese refugee women in Tanzania

BACKGROUND

Multi-sectoral, integrated interventions have long been recommended for addressing mental health and its social determinants (e.g., gender-based violence) in settings of ongoing adversity. We developed an integrated health and protection intervention to reduce psychological distress and intimate partner violence (IPV), and tested its delivery by lay facilitators in a low-resource refugee setting.

METHODS

Formative research to develop the intervention consisted of a structured desk review, consultation with experts and local stakeholders (refugee incentive workers, representatives of humanitarian agencies, and clinical experts), and qualitative interviews (40 free list interviews with refugees, 15 key informant interviews). Given existing efforts by humanitarian agencies to prevent gender-based violence in this particular refugee camp, including with (potential) perpetrators, we focused on a complementary effort to develop an integrated intervention with potential to reduce IPV and associated mental health impacts with female IPV survivors. We enrolled Congolese refugee women with elevated psychological distress and past-year histories of IPV (n = 60) who received the intervention delivered by trained and supervised lay refugee facilitators. Relevance, feasibility and acceptability of the intervention were evaluated through quantitative and qualitative interviews with participants. We assessed instrument test-retest reliability (n = 24), inter-rater reliability (n = 5 interviews), internal consistency, and construct validity (n = 60).

RESULTS

We designed an 8-session intervention, termed Nguvu ('strength'), incorporating brief Cognitive Processing Therapy (focused on helping clients obtaining skills to overcome negative thoughts and self-perceptions and gain control over the impact these have on their lives) and Advocacy Counseling (focused on increasing autonomy, empowerment and strengthening linkages to community supports). On average, participants attended two-thirds of the sessions. In qualitative interviews, participants recommended adaptations to specific intervention components and provided recommendations regarding coordination, retention, safety concerns and intervention participation incentives. Analysis of the performance of outcome instruments overall revealed acceptable reliability and validity.

CONCLUSIONS

We found it feasible to develop and implement an integrated, multi-sectoral mental health and IPV intervention in a refugee camp setting. Implementation challenges were identified and may be informative for future implementation and evaluation of multi-sectoral strategies for populations facing ongoing adversity.

TRIAL REGISTRATION

ISRCTN65771265, June 27, 2016.

Typology of individuals with substance dependence based on a Montreal longitudinal catchment area study

This study sought to develop a typology of individuals with substance dependence (ISD) based on a longitudinal survey (n = 2,434) and 121 ISD. The latter were divided into three groups: newly abstinent individuals, chronic dependents and acute dependents. Individuals' typology was developed by cluster analysis. Newly abstinent individuals had fewer emotional problems and mental disorders in the previous 12 months. Four classes of ISD were identified, labelled respectively "chronic multi-substance consumption and mental disorders comorbidities," "multi-substance consumption," "alcohol and marijuana consumption" and "alcohol consumption only." Strategies adapted to each of these profiles could be promoted for more effective treatment.

Theories and assumptions that inform trauma-specific interventions for incarcerated women

The field of interventional outcomes research in programs designed to treat trauma in correctionally involved women involves contributions from researchers in a variety of disciplines. In this review, we asked how recent interventional studies addressed 3 theoretical touchstones-relational cultural theory, trauma theory, and addiction theory. We found that few outcomes studies engaged theory directly on any of these points and concluded that the opportunity for field-defining debate may risk getting lost in a quest for numbers or outcomes. We recommended that researchers more explicitly position their work, especially with respect to key theories and points of debate.

Differential service utilization associated with trauma-informed integrated treatment for women with co-occurring disorders

Women with co-occurring mental health and substance use disorders and trauma histories vary greatly in symptom severity and use of support services. This study estimated differential effects of an integrated treatment intervention (IT) across sub-groups of women in this population on services utilization outcomes. Data from a national study were used to cluster participants by symptoms and service utilization, and then estimate the effect of IT versus usual care on 12-month service utilization for each sub-group. The intervention effect varied significantly across groups, in particular indicating relative increases in residential treatment utilization associated with IT among women with predominating trauma and substance abuse symptoms. Understanding how IT influences service utilization for different groups of women in this population with complex needs is an important step toward achieving an optimal balance between need for treatment and service utilization, which can ultimately improve outcomes and conserve resources.

Childhood sexual abuse characteristics, intimate partner violence exposure, and psychological distress among women in methadone treatment

Traumatic experiences and their biopsychosocial sequelae present complex challenges in substance use treatment. For women with substance use problems, childhood sexual abuse (CSA), intimate partner violence exposure (IPV), posttraumatic stress disorder (PTSD), and overall psychological distress are often co-occurring concerns. To address gaps in knowledge and to strengthen practice regarding these critical issues in substance use treatment, we drew upon cross-sectional and longitudinal data from baseline and 12-month interviews with a random sample of 416 women in methadone treatment to examine relationships between CSA characteristics, particularly the presence of force and involvement of family, IPV, and mental health concerns. Although CSA involving force and family was not associated with IPV as hypothesized, it was associated with increased risk of PTSD and overall psychological distress. The multivariate findings underscore the psychological vulnerabilities associated with CSA involving force and family and suggest that drug use and financial circumstances may be important targets to reduce IPV risk.

Service Utilization Patterns as Predictors of Response to Trauma-Informed Integrated Treatment for Women With Co-occurring Disorders

OBJECTIVE: The current study examined whether clinical responses to an integrated treatment intervention among women with co-occurring disorders and histories of abuse varied according to their service use patterns at baseline. METHODS: Data were from a national, multi-site, integrated treatment intervention study in 1998-2003. Analyses included 999 study participants assigned to the integrated treatment group and who were symptomatic at baseline. Participants' baseline service use activity was characterized according to five distinct baseline service use clusters. Logistic regression models estimated study participants' odds of good clinical responses to integrated treatment at 12 months across the five service clusters. RESULTS: Participants with high levels of psychotropic medication and medical care use at baseline had significantly lower odds than low-intensity service users of having a good response to integrated treatment at 12 months on mental health, alcohol addiction, and posttraumatic stress measures. A majority of women in this group had serious medical illness or disability and were more likely than their counterparts with other service use patterns to have used homeless or domestic violence shelters. CONCLUSIONS: Women who used high levels of medication and medical services appear to have faced especially difficult barriers in responding well to integrated treatment. Careful assessments of their mental health, trauma, and medical treatment needs may be required as part of integrated treatment in an effort to improve their response to integrated treatment, clinical outcomes and well-being. This information can also be used to target integrated treatment to women who are likely to respond positively and achieve meaningful improvements in their functioning.

The association of trauma and PTSD with the substance use profiles of alcohol- and cocaine-dependent out-of-treatment women

The association of trauma and posttraumatic stress disorder (PTSD) with alcohol and cocaine use is explored to determine if there is additive risk associated with dual dependence. Data were collected from out-of-treatment women enrolled in an HIV-prevention study. Women who experienced a DSM-IV qualifying event (n = 791) were stratified into four substance use groups based on lifetime alcohol and cocaine use. Women with lifetime comorbid alcohol and cocaine dependence experienced significantly more traumatic events and had a higher prevalence of violent events and lifetime diagnosis of PTSD and PTSD-related impairment. There is added risk for associated trauma and subsequent PTSD among women who have dual substance dependence. 

Changes in treatment content of services during trauma-informed integrated services for women with co-occurring disorders

The experience of trauma is highly prevalent in the lives of women with mental health and substance abuse problems. We examined how an intervention targeted to provide trauma-informed integrated services in the treatment of co-occurring disorders has changed the content of services reported by clients. We found that the intervention led to an increased provision of integrated services as well as services addressing each content area: trauma, mental health and substance abuse. There was no increase in service quantity from the intervention. Incorporation of trauma-specific element in the treatment of mental health and substance abuse may have been successfully implemented at the service level thereby better serve women with complex behavioral health histories.