Becoming Trauma Informed: A Core Element in Women’s Treatment

Over the past thirty-five years, we have greatly improved our understanding of the treatment needs of women who are addicted to alcohol and other drugs. Research reveals that the vast majority of women with addictive disorders have experienced violence and other forms of abuse and that a history of serious traumatic experiences plays an often-unrecognized role in a woman’s physical and mental health problems (Felitti & Anda, 2010; Hien et al., 2010). A history of being abused drastically increases the likelihood that a woman will develop substance use problems.

 

In 2004, the United Nations Office on Drugs and Crime published a monograph on treating drug addictions among women around the world. In the course of developing the monograph, it was discovered that many of the issues with which women with addictions struggle are universal. 

 

These issues are still relevant today: 

 

• Shame and stigma
• Physical and sexual abuse
• Relationship issues
• Fear of losing children
• Fear of losing a partner
• Needing a partner’s permission to obtain treatment
• Treatment issues
• Lack of services for women
• Lack of understanding women’s treatment
• Long waiting lists
• Lack of childcare services
• Systematic issues
• Lack of financial resources
• Lack of clean/sober housing 
• Poorly coordinated services (Covington, 2008a, p. 378)

 

 

Helping professionals around the world report an association between addiction and all forms of violence and abuse—physical, sexual, and emotional—in women’s lives (Tuchman, 2010; United Nations Office on Drugs and Crime, 2004). 

 

More recent research also demonstrates that addiction treatment services for women and girls need to be based on a holistic, female-centered approach that acknowledges women’s psychosocial needs (Prendergast, Messina, Hall, & Warda, 2011). In my writing, “gender-responsive/women-centered services” refers to creating an environment—through site selection, staff selection, program development, and program content and materials—that reflects an understanding of the realities of women’s and girls’ lives and that addresses and responds to their challenges and strengths. 

 

This article discusses the rationale for gender-responsive, trauma-informed practice and describes seven evidence-based and best practices curricula that service providers may find helpful when advocating for and designing treatment and other programs.

 

 

Responding to Gender Differences in Experiences of Violence and Trauma  

 

Risk for abuse is gendered. Both female and male children are at relatively equal risk from family members and people who know them. 

 

In adolescence, boys in the United States and many other white-majority countries are at risk if they are gay, young men of color or gang members. Their risk comes from people who dislike or hate them. As they age, males are more likely to be harmed by enemies or strangers. For an adult man, the risk for abuse comes from being in combat or being a victim of crime.  

 

For a young woman or an adult woman, the primary risk is in her relationship with an intimate partner. This may account for the higher rate of mental health problems among women; it is more confusing and distressing to have the person who is supposed to love and care for you do harm to you than it is to be harmed by someone who dislikes you or is a stranger (Kendall-Tackett, 2004). 

 

Women have different responses to violence and abuse. Some women may not be traumatized by abuse because they have coping skills that are effective for a specific event. Sometimes trauma occurs but is not recognized immediately because the violent event is perceived as normal. Many women who used to be considered “treatment failures” because they relapsed are now recognized as trauma survivors who returned to alcohol or other drugs to medicate themselves from the pain of trauma. By integrating trauma services with addiction treatment, we reduce the risk of trauma-based relapse. 

 

Trauma can skew a woman’s relational experiences and hinder her psychological development. Because it can affect how a woman relates to staff members, her peers, and the therapeutic environment, it is helpful to ask, “Is this person’s behavior linked to her trauma history?” The question becomes “What happened to you?” rather than “What is wrong with you?” However, traditional addiction and mental health treatment often does not deal with trauma issues in early recovery, even though trauma is a primary trigger for relapse among women and may underlie their mental health issues. Many treatment providers do not know what is needed in order to do this work. Here are three important things that can be done in treatment programs to address trauma issues:

 

1. Educate women about to what abuse is, what trauma is, and how abuse can sometimes cause trauma. Women often do not know that they have been abused and they often do not understand posttraumatic stress disorder (PTSD) and other responses to trauma. 
2. Validate women’s reactions. It is important that women learn that their responses are normal, given their experiences. Trauma responses are normal reactions to abnormal or extreme situations.
3. Provide coping skills. There are grounding and self-soothing techniques (e.g., breathing exercises) that women can learn to help themselves cope with their traumatic experiences.

 

 

Avoiding Revictimization and Retraumatization  

 

A woman who has experienced a traumatic event feels more vulnerable. She may have difficulty tolerating, expressing, and/or modulating her emotions. This results in what is called “emotional dysregulation.” An example of this is when she overresponds to neutral cues and underresponds to danger cues. Therefore, traumatized women are at increased risk of similar, repeated revictimization. 

 

“Retraumatization” refers to the psychological and/or physiological experience of being triggered by another abusive experience. A trigger can be a single environmental cue related to the trauma—such as the time of year, a smell or a sound—that can create a full fight-or-flight response. Often, providers of substance abuse treatment hesitate to provide trauma services for women in their programs because of the fear of retriggering them. Although triggers in the environment cannot be completely eliminated, it is important to create a safe environment in which women can learn coping skills. This is the reason that the therapeutic environment is so important for women. They must feel safe.

 

Understanding the impact of trauma and the issue of triggers is particularly important when working with women in the criminal justice system. Unfortunately, standard management practices—such as searches, seclusion, and restraint—may traumatize or retraumatize many women. Experiences in the criminal justice system can trigger memories of earlier abuse. It can be retraumatizing when a survivor of sexual abuse has a body search or must shower with male correctional officers nearby. It can be retraumatizing when a battered woman is yelled at or cursed at by a staff member. Incarceration can be traumatizing in itself, and the racism and class discrimination that are characteristic of the criminal justice system can be even more traumatizing.

 

As the understanding of traumatic experiences increases among clinicians, mental health theories and practices are changing. It is important for service providers to understand trauma theory as a conceptual framework for clinical practice and to provide trauma-informed services for their clients. According to Harris & Fallot, who wrote the foundational text on this topic (2001), trauma-informed services take the trauma into account; avoid triggering trauma reactions or retraumatizing the woman; adjust the behavior of counselors and staff members to support the woman’s coping capacity; and allow survivors to manage their trauma symptoms successfully so that they are able to access, retain, and benefit from the services.

 

The Trauma-Informed Environment  

 

In treatment programs that serve women, sensitivity to trauma-related issues is critical for creating a healing environment. A calm atmosphere that respects privacy and maximizes the choices women can make promotes healing. Staff members should be trained to recognize the effects of trauma, and clients should have a clear understanding of the rules and policies of the program. 

 

A trauma-informed environment includes features such as:

• Attention to boundaries—between staff members and participants, among participants, and among participants and visitors. For example, clients should be given permission to say “no” to hugs. Hugging may be an expression of positive emotion for some women, but for those who have been traumatized it could represent an undesired intrusion into their personal spaces.
• Language that communicates the values of empowerment and recovery. Punitive approaches, shaming techniques, and intrusive monitoring are not appropriate. 
• Staff members who adopt the “do no harm” credo to avoid damaging interactions. Conflict is dealt with through negotiation.
• A feeling of safety for staff members. Women often work in environments in which they feel harassed and/or disrespected. Many female staff members also have histories of abuse.

 

 

 

Assisting Service Providers with Trauma- and Gender-Informed Practice   

 

The recurring theme of the interrelationship between addictive disorders and trauma in women’s lives indicates the need for a multifocused approach to services. I have developed the Women’s Integrated Treatment model (WIT), which is based on four things: the definition of gender-responsive services provided earlier; a theoretical foundation that integrates the theories of addiction, psychological development (relational-cultural theory), and trauma; an understanding of the effects of female socialization; and multidimensional therapeutic interventions. This model is different from most other trauma programs that do not have a gender-specific focus and use a unidimensional cognitive-behavioral approach. 

 

Curricula have also been developed that help service providers bring this theoretically and evidence-based approach to the delivery of trauma-informed (the treatment environment) and trauma-specific (the treatment provided) services. 

 

Seven Gender-Responsive, Trauma-Informed Curricula  

 

In developing gender-responsive services, the material used is a crucial ingredient in the success of treatment. The following are seven manualized curricula I have designed for working with women and girls. They are theoretically based, gender-responsive, and trauma informed. Several are trauma specific. Each includes a facilitator’s guide and a participant’s workbook. Cognitive behavioral, relational, mindful, and expressive-arts techniques are used in each curriculum. These materials not only help to provide services, but also can be used to educate staff members. 

 

Helping Women Recover: A Program for Treating Addiction  

 

This revised resource provides a comprehensive, seventeen-session curriculum that includes the information and tools that counselors, clinicians, mental health professionals, and program administrators need to implement an effective program for women’s recovery in a variety of settings. The Helping Women Recover (Covington, 2008b) resource is organized into four modules that address key areas that women in treatment identify as triggers for relapse: self, relationships, sexuality, and spirituality. The material addresses self-esteem, sexism, family of origin, relationships, domestic violence, and trauma. The curriculum integrates theories of women’s psychological development, trauma, and addiction. There is a step-by-step facilitator’s guide. A participant’s workbook, A Woman’s Journal, is filled with self-tests, checklists, and activities to enable each participant to create a personalized guide to recovery. 

 

The Helping Women Recover program can be implemented by helping professionals with a range of training and experience. It is widely used in addiction treatment programs, mental health clinics, eating disorder programs, and domestic violence services. There also is a special edition for women in the criminal justice system. This version provides specific information about women in correctional settings to staff members working in such programs. In addition, Helping Men Recover (Covington, Griffin, & Dauer, 2012) is the first gender-responsive and trauma-informed treatment program for men.

 

Beyond Trauma: A Healing Journey for Women  

 

Beyond Trauma (Covington, 2003a) is also designed for counselors to use in any setting—outpatient, residential, therapeutic community, criminal justice or private practice—to help women understand trauma and its impact and to develop coping strategies. It includes a facilitator’s guide and a workbook for women, as well as facilitator training DVDs and a client DVD. 

 

The curriculum’s eleven sessions cover topics such as the connections between violence, abuse, and trauma; reactions to trauma; grounding skills; the mind-body connection; and healthy relationships. The curriculum draws on psychoeducational, cognitive behavioral, mindful, expressive-arts, and relational therapeutic approaches to support a strengths-based framework that is responsive to women’s gender-specific needs for healing and support. 

 

The Beyond Trauma curriculum is designed to be used alone or along with the Helping Women Recover curriculum to expand and deepen the trauma work in that curriculum.

 

Healing Trauma: Strategies for Abused Women  

 

Healing Trauma (Covington, 2011) is an adaptation of Beyond Trauma. It is particularly designed for settings requiring a shorter intervention, such as short-term addiction treatment, domestic violence agencies, sexual assault services, and jails. This five-session intervention is designed for women who have been abused. There is introductory material on trauma for the facilitator and detailed instructions (specific lesson plans) for the group sessions. 

 

The session topics include the process of trauma, power and abuse, grounding and self-soothing techniques, and healthy relationships. There is a strong emphasis on grounding skills. The facilitator guide and participant handbook focus on the three core elements that both staff and clients need to know: an understanding of what trauma is, its process, and its effect on both the inner self (thoughts, feelings, beliefs, and values) and the outer self (behavior and relationships). The facilitator guide and workbook are available in English and Spanish and are on a CD-Rom for ease of duplication.

 

Voices: A Program of Self-Discovery and Empowerment for Girls  

 

Voices (Covington, 2004) was created to address the unique needs of adolescent girls and young women. It encourages them to seek and celebrate their true selves by providing a safe space, encouragement, structure, and the support they need to embrace their journeys of self-discovery. The program includes modules on self, connecting with others, healthy living, and the journey ahead. These can be delivered in eighteen group sessions. Each session has an opening section, a teaching on a topic, an interactive element (discussion of issues, questions, etc.), an experiential component (activities to try out new skills and learning), and a closing section to facilitate reflection. The program’s theoretical foundations are in gendered psychological development, attachment, resilience, addiction, and trauma. Trauma is addressed in the program both explicitly and implicitly through attention to issues such as self-esteem, connections with others, body image, emotional wellness, and good decision-making. 

 

Voices is used in many settings, such as outpatient and residential substance use treatment, schools, juvenile justice, and private practice. It includes a facilitator’s guide and a participant’s journal. The participant’s journal uses a research-based process called “interactive journaling.” In the context of girls’ lives, structured journaling provides an outlet for creativity, personal expression, exploration, and the application of new concepts and skills.

 

A Woman’s Way through the Twelve Steps  

 

A Woman’s Way through the Twelve Steps (Covington, 1999, 2003b, 2009) includes the original self-help book based on interviews with recovering women about their experiences and understanding of the Twelve Steps, plus a participant’s workbook, a facilitator’s guide, and a DVD for clients, family members, and facilitators who want to learn how women and girls can use the Twelve Steps in a safe, nurturing way. The book and workshop are available in English and Spanish.

 

The facilitator’s guide to A Woman’s Way through the Twelve Steps describes a thirteen-session program that includes an opening session followed by one session for each of the Twelve Steps of Alcoholics Anonymous. It uses interactive activities and exercises to help women understand the principles or themes in each step. Staff who participate in A Woman’s Way training groups are able to develop a deeper understanding of the basic tools for living that are embedded in the steps.

Beyond Violence: A Prevention Program for Criminal Justice-Involved Women  

 

Beyond Violence (Covington, 2013) was developed for women who commit violent or aggressive crimes. The curriculum consists of twenty sessions (two hours per session), and the program materials include a facilitator’s guide, a participant’s workbook, and a DVD. The focus is on the violence or aggression that the women have experienced as well as on what they have perpetrated. The interactive activities are based on cognitive behavioral, relational, and experiential therapeutic approaches.

 

Beyond Violence uses a social-ecological model (Dahlberg & Krug, 2002) to contextualize and explain violence. This model considers the complex interplay between the individual, relationship, community, and societal factors that put people at risk for experiencing and/or perpetuating violence. Applying a gender lens to the social-ecological model results in a program that is specific to women’s life experiences.

 

This is the first researched-based curriculum on this topic. It is suitable for use in domestic violence agencies and community corrections as well as in institutional settings.

 

Beyond Anger and Violence: A Prevention Program for Women  

 

Beyond Anger and Violence (Covington, 2014) was developed for women who are struggling with the issues of anger and violence in their lives but are not involved in the criminal justice system. It is an adaptation of the Beyond Violence program and uses the social-ecological model to contextualize violence. It also incorporates information on gender differences in the expression and acceptability of anger. The focus is on both the anger and aggression that women feel and the aggression or violence they have experienced. The curriculum is designed for use in a variety of community-based settings, such as anger management programs, substance abuse treatment, domestic violence programs, VA hospitals, and other mental health settings. 

 

Learning the Curricula: Staff Development  

 

If a program uses a specific curriculum with women, one of the best ways to train staff members, supervisors, and administrators is to have them participate in the curriculum themselves as a group. This has been done in a variety of settings, including residential, outpatient, and correctional programs. An hour or an hour-and-a-half session can be conducted in a weekly staff meeting or over lunch, with a different staff member facilitating each week. For the program director, these sessions offer a team-building tool and also help to reveal staff members’ strengths and challenges.

 

When planning to implement this process, it is important to be able to explain the differences between a therapy group and a learning (training) group.  

 

In a therapy group, the focus is on individual growth, using the group to recreate family-of-origin dynamics, using the group for support for individual issues, and the process. In a training group, however, the focus is on learning as a group, using the group for experiential learning by means of activities, having support from outside the group (for individual issues), and sequential learning.

 

Conclusion  

 

Historically, treatment programs for addiction disorders were designed for the needs of a predominantly male client population. Over the past four decades, researchers and treatment providers have begun to identify the characteristics and components of successful treatment programs for women. A solid body of knowledge has now been developed that reflects the needs of women in treatment, and there is both a definition of and principles for the development of gender-responsive treatment. 

 

Women’s exposure to violence has emerged as a core element in treatment. For both service providers and the women survivors who access services, it is important to understand what trauma is, its process, and its impact on thoughts, feelings, beliefs, values, behavior, and relationships. Therefore, it is imperative that addiction treatment services become integrated, incorporating what we have learned from relational-cultural theory (women’s psychosocial development), addiction theory, and trauma theory. A gender-responsive and trauma-informed program can provide the safe, nurturing, and empowering environment that women need to find their inner strengths, to heal, and to recover. 

 

 

Acknowledgements: Part of this article was adapted from S. Covington (2012), Curricula to Support Trauma-Informed Practice with Women. In N. Poole & L. Greves (Eds.), Becoming Trauma Informed. Toronto, Ontario, Canada: Centre for Addiction and Mental Health (CAMH).

 

 

 

References  

 

Covington, S. (1999). A woman’s way through the twelve steps. Center City, MN: Hazelden.

 

Covington, S. (2003a). Beyond trauma: A healing journey for women. Center City, MN: Hazelden.

 

Covington, S. (2003b). A woman’s way through the twelve steps: Workbook. Center City, MN: Hazelden.

 

Covington, S. (2004). Voices: A program of self-discovery and empowerment for girls. Carson City, NV: The Change Companies.

 

Covington, S. (2008a). Women and addiction: A trauma-informed approach. Journal of Psychoactive Drugs, (SARC Suppl. 5), 377–85.

 

Covington, S. (2008b). Helping women recover: A program for treating addiction (rev. ed.). San Francisco, CA: Jossey-Bass.

 

Covington, S. (2009). A woman’s way through the twelve steps: Facilitator guide and DVD. Center City, MN: Hazelden.

 

Covington, S. (2011). Healing trauma: Strategies for abused women. [CD-ROM]. Center City, MN: Hazelden.

 

Covington, S. (2013). Beyond violence: A prevention program for criminal justice-involved women. Hoboken, NJ: Wiley.

 

Covington, S. (2014). Beyond anger and violence: A program for women. Hoboken, NJ: Wiley.

 

Covington, S., Griffin, D., & Dauer, R. (2012). Helping men recover: A program for treating addiction. Hoboken, NJ: Wiley.

 

Dahlberg, L. L., & Krug, E. G. (2002). Violence: A global public health problem. In E. Krug, L. L. Dahlberg, J. A. Mercy, A. B. Zwi, & R. Lozano (Eds.), World report on violence and health (pp.1–19). Geneva: World Health Organization.

 

Felitti, V. J., & Anda, R. F. (2010). The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders, and sexual behaviour: Implications for healthcare. In R. A. Lanius, E. Vermetten, & C. Pain (Eds.), The impact of early life trauma on health and disease: The hidden epidemic (pp. 77–87). New York, NY: Cambridge University Press. 

 

Harris, M., & Fallot, R. D. (2001). Using trauma theory to design service systems. San Francisco, CA: Jossey-Bass.

 

Hien, D. A., Jiang, H., Campbell, A. N., Hu, M. C., Miele, G. M., Cohen, L. R., . . . Nunes, E. V. (2010). Do treatment improvements in PTSD severity affect substance use outcomes? A secondary analysis from a randomized clinical trial in NIDA’s clinical trials network. American Journal of Psychiatry, 167(1), 95–101. 

 

Kendall-Tackett, K. (2004). Introduction: Women’s experiences of stress and trauma. In K. Kendall-Tackett (Ed.), Handbook of women, stress, and trauma (pp. 1–5). New York, NY: Brunner-Routledge. 

 

Prendergast, M. L., Messina, N. P., Hall, E. A., & Warda, U. S. (2011). The relative effectiveness of women-only vs. mixed-gender treatment for substance abusing women. Journal of Substance Abuse Treatment, 40(4), 336–48.

 

Tuchman, E. (2010). Women and addiction: The importance of gender issues in substance abuse research. Journal of Addictive Diseases, 29(2), 127–38.

 

United Nations Office on Drugs and Crime. (2004). Substance abuse treatment and care for women: Case studies and lessons learned. Retrieved from http://www.unodc.org/pdf/report_2004-08-30_1.pdf