CeDAR, NCAD partner to highlight issues of gender, trauma

The opening plenary speaker for the 2015 National Conference on Addiction Disorders and Behavioral Healthcare Executive Summit (NCAD), Aug. 1-4 in St. Louis, will be women's treatment leader Stephanie S. Covington, PhD, LCSW, co-director, Institute for Relational Development and the Center for Gender and Justice. Covington will speak about the importance of gender and trauma considerations in treatment practices, what it means for programming to be gender-responsive, and how the culture or environment of a program can become trauma-informed. This will kick off the conference's dedicated track on gender and sexuality issues sponsored by The Center for Dependency, Addiction and Rehabilitation (CeDAR).

Covington says women’s services, men’s treatment, adolescent treatment and caring for the transgender population are all relatively new considerations to the addiction field. Over the last 20 years, talking about gender-specific services has really meant services for women. “Finally I think people are paying a bit more attention,” she adds.

While some treatment centers have aligned around offering co-ed services, women’s groups, or even separating male and female clients, Covington says gender-specific treatment is still an issue with which most facilities struggle. “We see many girls that are totally lost in groups that are predominately male-focused,” she says of separating gender within adolescent treatment, which has been historically co-ed. “People in the adolescent treatment field have further to go than some of the adult programs.”

Steven Millette, CeDAR's executive director, has been working with Covington on gender-responsive treatment, clinical protocols and culture in organizations around gender–responsive care since 1999.

“It started with a focus on women and addressing the needs that women have,” he says. “My first day on the job was addressing the attendees at the first Women’s Conference that CeDAR put on in October of 2011. So from relatively early on, it was hugely important to have gender-separate, gender-specific and gender-responsive treatment services.”

In 2013, the decision was made for the conference to address issues involving both sexes. “We divided the conference in half and tried to represent both equally,” Millette says, referring to the shift to Gender Matters. By 2014, the conference was entirely focused on men’s issues and now it will prioritize the gender continuum. . Regarding the decision to partner with NCAD, Millette says it was time to bring these topics to a larger audience.

“Men and women; that’s what most of our culture thinks when they think of gender, but we all know if you dig a little deeper, it’s really a false binary,” he says. “[We’ll be] bringing in the LGBTQ population, NALGAP and looking at gender in a much broader context, because many people express their sense of identity in many different ways. We see the importance of having all three of those frames of reference and understanding our species across a spectrum of preferences, perspectives and biologies.”

Gender Matters aims to drive home the importance of gender-specific and trauma-informed treatment. Millette explains that separating care by gender is inherently a better quality of care, because individuals of whatever gender shouldn’t have to settle for treatment programs that don’t understand their history and needs. A major focus, he says, involves addressing healing in a relational paradigm and giving practical tips and strategies that will be immediately useful to those in attendance.  

Truly trauma-informed
Gender Matters promotes the Substance Abuse and Mental Health Services Administration’s (SAMSHA) value-based services, which emphasizes being gender-responsive, trauma-informed, recovery-oriented and culturally competent.

Millette explains that being trauma-informed as an organization means not only focusing on trauma from a clinical perspective—being trauma-integrated or providing trauma-specific treatment services, assessments and treatment planning—but also from an organizational perspective. It’s important to think in terms of both staff and patients, and commit to five core values: safety, trustworthiness, choice, collaboration and empowerment.

“Those five things need to guide how you run your agency. For many people, this means you have to think about providing services differently,” Covington says.  “Many of the environments that people come into, either to work or for recovery, often are harsh. A lot of places are still very confrontational.”

Being trauma-informed is often easily misunderstood, she adds, but it really means adapting business operations so a trauma survivor can benefit from the services provided. The old mentality of treatment where clients aren’t given choices has to be reconsidered; reshaping environments, attitudes of counselors, and overall management will be key.

Covington recommends management teams role-play a new admission of a patient affected by trauma and do a walk-through of their facilities. “Are there lights on in the parking lot? How does the receptionist talk to you? How do the accounting and billing departments speak to you? All of those things [are important],” she says.

“We’re really working at the meta of cultural competence when we start thinking of being trauma-informed and how that helps shape the way services are designed,” Millette says. “It’s hard to be truly trauma-informed or gender-responsive without the other. They go hand in glove.”

Gender-specific trends
The issue of gender socialization, or the experience of being male or female, is an important consideration when it comes to designing relevant treating programming, Covington adds. For men, it’s about understanding how to counteract the traditional messages received during youth regarding what it means to be masculine. It’s important to pinpoint those messages during treatment and clarify what will need to shift in order for the individual to sustain a healthy recovery, she says.

“Ask for help, show your feelings, don’t do it alone—everything [in recovery] is antithetical to these male messages; it’s a total reversal,” Covington says. “Part of the work with men is to help them look at those messages, keep the ones that really work for them and begin to let go of the ones that don’t.” 

For the last 25 years, boys and girls have used substances at different rates, with girls being historically lower than boys when it comes to drugs and alcohol. Now, Covington says, girls’ use of drugs and alcohol is almost equal to boys, except the stigma is much greater for girls. Girls are also generally more vulnerable to abuse. “Girls do not give drugs to boys [for sexual purposes],” she says.  “It doesn’t work the same way.”

With the women’s population, trauma has been historically talked about more, but Covington says one trend that needs to be considered is looking at prescription drug abuse. While this was studied 20 years ago, new medications have come into play. 

“For women, medication abuse is still high on the list,” she says. “[Also, our] arrest and sentencing laws for drug use have heavily impacted drug-abusing women are becoming involved in the criminal justice system at a higher rate than men.”

For the transgender population, it’s critical to consider where the individual is in their transition process as that’s where challenges often lie. “If someone has transitioned from one sex to another, they need to be in the group as per how they are living, not as per how they were born,” Covington says. “This often becomes complicated for some of the group members because of stigmatization and lack of understanding. Sometimes it’s hard for staff and clients to be understanding and accepting of differences.”

Because of potential reactions from program members, facilities need to adjust and take into consideration whether or not an individual is ready for a group experience, she says. Because fewer transgender individuals are undergoing medical procedures for total transitions, this can be another concern for both patients and staff, especially in residential settings. “However, most concerns are out of prejudice rather than reality,” Covington adds. 

Addressing trauma is an overarching trend for every group. “The majority of people who have addictive disorders also have a trauma history, with some people actually beginning to use alcohol and other drugs as a way to deal with trauma symptoms,” she says. “We’ve known this for at least 30 years, but the mantra was always ‘when you’re clean and sober for a year, then you can focus on the issue.’ Now we’re beginning to understand that it doesn’t work that way. You really can work with addictive disorders and trauma histories at the same time.”

Covington has written several evidence-based programs for women that focus on trauma and teach grounding exercises as well as coping and self-soothing skills, including Beyond Trauma, an 11-session intervention program, and Healing Trauma, an abbreviated 5- intervention program. She recently finished a 6-session brief male intervention called Men in Trauma: Surviving and Thriving with co-author Roberto Rodriguez, who will also be speaking at NCAD. Each program takes gender socialization into consideration while using trauma as a lens. Experiential workshops on these topics will be held throughout the conference.