Integrative Treatment Pilot Study:
An Extended Care Holistic Treatment Facility for Women with Co-occurring Disorders
Tricia Chandler, PhD, LPC, BCPC
Consulting Clinical Director and Researcher
Key Words: Integrated care, co-occurring disorders, addiction, mental illness, complementary therapies
1. Discuss the differences in needs of women from men in treating addiction issues and underlying co-occurring disorders.
2. Describe integrative treatment modalities.
3. Explain the role and significance of personal relationships in women’s lives.
4. Compare the relevance and presence of various caregiver roles that women assume throughout their lives.
5. Discuss the unique medical issues facing women with co-occurring disorders.
6. Explain positive psychology and the movement toward wellness and its implications for treatment modalities.
7. Describe therapeutic modalities that have demonstrated efficacy in treating mood disorders and addiction issues.
A longitudinal pilot study conducted in 2011/2012 researched the efficacy of an integrated protocol that provided treatment to women with co-occurring disorders in an extended-care group home environment. Eight women who had been referred from in-patient thirty-day substance abuse facilities participated in the study while receiving holistic care that included: recovery groups, somatic experiencing, dialectic behavioral therapy, individual psychotherapy, mindfulness groups, yoga, acupuncture, Reiki, massage, art therapy, vocational assistance, nutrition and exercise, along with daily AA/NA meetings. Assessment measurements included the Beck Depression Inventory, Purpose in Life Questionnaire, URICA inventory on stages of change, and an Anxiety Scale. These were administered at intake, discharge, three-months after discharge and at the twelve-month interval to examine long-term efficacy of the model. Results demonstrated positive change from baseline to discharge. Gains were maintained at the three-month interview and continued to show improvement at the twelve-month interview for those women that participated.
Historical Context for Protocol
Over the past twenty years research has begun examining the differences in regards to how and why men and women develop addictions. This research has concluded that women have special needs within substance abuse treatment. This research has produced a great deal of information into the differences in physiology, interpersonal issues and risk factors relating to women with these issues (Becker, 2011; Gudrais, 2011; Kauffman et al, 1997). The Substance Abuse and Mental Health Services Administration (SAMHSA, 2011) has noted specific “risk factors associated with substance abuse” in women include:
• Eating disorders
• Posttraumatic stress
Further research suggests these additional risks are due to histories of trauma and childhood sexual abuse, as well as interpersonal abuse and socioeconomic issues all relating to the issues of regulating affect (Bloom and Covington, 1998; Chandler, 2010; Manhal-Baugus, 1998; Najavits, 2002; Nelson-Zlupko et al, 1995; US Dept of Health and Human Services, 2000, 2003; SAMHSA, 2011).
Two different research studies by Engstom et al (2002/2008) at the University of Chicago Center for Health and Social Sciences, found that in over 400 women being treated for opiate addiction in a methadone clinic, 58% had experienced childhood sexual abuse, 90% had experienced intimate partner violence and 29% met the criteria for posttraumatic stress disorder. Similar findings have been substantiated by Robert Jamison (2011), a clinical psychologist at Harvard Brigham and Women’s Hospital, who discovered correlations between women who abuse pain medications having sexual and/or physical abuse histories, as well as psychological distress as motivating factors for their drug misuse. These findings further substantiate the complicated relationship between trauma and substance abuse for women that were included in the research conducted by this writer in relation to determining resiliency in women with childhood sexual abuse histories (Chandler, 2010).
Based upon years of research into the special needs females in substance abuse treatment, SAMHSA has identified core principles for gender responsive treatment. These core principles include:
• Recognizing the role and significance of personal relationships in women’s lives
• Addressing the unique health concerns of women
• Acknowledging the role and importance of different socioeconomic issues among women
• Promoting cultural competency that is specific to women
• Endorsing a developmental perspective
• Attending to the relevance and presence of various caregiver roles that women assume throughout their lives (SAMHSA, 2011/PIT 51)
Although the reasons behind substance abuse have been acknowledged as being different for women than for men (Kauffman et al, 1997), treatment protocols have been slow to acknowledge this difference and to change in accordance with the need for integrative treatment protocols specific to women’s needs. Traditionally substance abuse treatment has offered a specialized treatment protocol that has been provided for both women and men in the same facility.
While primary residential facilities state that women and men are treated separately, in actuality most of these facilities intermingle groups, resulting in findings that women have greater risk for relapse after completing treatment in these environments (Gudrais, 2011). And, although men and women are housed in different wings of the same facility although they have access to one another in group interactions and within a social context.
The normal length of stay to address the substance abuse issue for both genders is usually thirty days. Primary treatment has traditionally included cognitive therapy and recovery based protocols with a strong element of 12-step indoctrination aimed solely at the substance abuse issue, while deferring additional issues that the individual may have.
Programs that do attempt to incorporate an integrative approach are extremely expensive and are not accessible to individuals without significant financial resources. Funding grants from SAMHSA for substance abuse treatment is less than it was seven years ago, when considering inflation, per Harold Pollack, faculty chair at the Center for Health Administrative Studies. This adds to the difficulty in accessing appropriate substance abuse treatment (SAMHSA, 2011).
While the need for gender specific treatment has been identified, few protocols have been identified to treat the whole person relating to the issues that women have in substance abuse treatment. One 12-week pilot study of substance abuse treatment done by Shelly Greenfield, in connection with Harvard Medical School, found that women’s self-efficacy improved with a combined woman-centered approach and group dynamics in treatment (Gudrais, 2011). This writer’s research in what methods assist in reclaiming resiliency in women with childhood sexual abuse histories uncovered a variety of modalities that work to treat all issues simultaneously and this became the basis of a truly integrative approach to healing. This preliminary research provided the data used in a structured protocol that was utilized within a longitudinal pilot study for an extended care residential facility for women with co-occurring disorders in 2011.
Pilot Study: Extended Care Program
Over the course of seven months, eight women with co-occurring disorders of substance abuse and psychological disorders moved through a suggested ninety-day treatment facility that provided holistic integrative treatment modalities designed to treat the whole woman. Each of these women had been referred for extended treatment from a primary residential facility after completing a thirty-day program to regain sobriety.
Demographics concluded that all of these women were Caucasian from middle to upper-middle class socioeconomic status. The average age of the women was 39 years, with a range from 21 to 58 years of age. Most of the women had college educations, although only two of the women had careers that were not adversely affected by their co-occurring disorders. All of the women had some family support, but it was tenuous at best.
Each of the women had been treated for a variety of substance addictions that included alcohol, opioids, methamphetamine, and in a few women, poly-substance abuse. In addition, each of the women had co-occurring diagnoses of major depression and anxiety, and three of the women had an eating disorder diagnosis. Physical problems included chronic pain, fibromyalgia, reoccurring benign tumors, and one woman was aware she carried the gene for a life-threatening genetic disorder.
Additional, all of the women had severe interpersonal problems, six of them had experienced trauma in the form of physical, emotional, spousal or sexual abuse, and all of them were facing legal issues related to substance abuse. When admitted, four of the women were dealing with marriage issues and the potential loss of their custodial rights to their children.
The treatment protocol included a thorough assessment, including having the women complete a psych-social-medical history at intake. The Beck Depression Scale, the Purpose in Life Inventory, the URICA Inventory on stages of change, and an Anxiety Scale were completed at intake, discharge, and after discharge at three months and twelve months. The assessments led to the development of individualized treatment plans based upon clients’ specific issues.
The women lived in a house within a middle-class community and were provided some form of round-the-clock supervision and holistic services that addressed all areas of functioning. The house was run like a home, with the women specifying their food preferences, planning menus, and helping with shopping. They were responsible for cooking as a community and for maintaining the cleanliness of the house. Once per week a professional chef came and the women helped him prepare a family meal with their children and spouses, or other family members who were welcome to share in the meal. Sundays were allocated for family visits and the women could go off site for those visits. Family and couple counseling was provided during the week and community outings occurred on Friday nights.
Clinical and healing services included:
• Three 60-minute individual sessions per week
• Three 90-minute recovery groups that included: Somatic Experiencing, Dialectic Behavioral Therapy, and Addiction Recovery themes
• Three to five 90-minute psychotherapy groups on mindfulness, guided visualization, identifying and developing personal spiritual values and practices, positive cognitive therapy, vocational/educational planning, and budgeting skills
• Two 90-minute acupuncture sessions that included National Acupuncture Detoxification Association (NADA) protocols, Emotional Freedom Therapy (EFT) and/or Psy K
• Two 120-minute expressive art therapy sessions
• One 60-minute massage (and/or Reiki) weekly
• An initial nutritional assessment and follow up as needed.
• One 90-minute yoga session weekly
• Daily AA/NA meetings
In addition, a gym membership was made available to the clients that included yoga, a pool, weights and a climbing wall. As women progressed through the program, if they had careers or jobs, they were allowed to pursue those vocations and eliminate some parts of the program. If they needed vocational counseling or resumes updated they were assisted with those endeavors and/or volunteering at some community projects was made available one to two times per week. Transportation was provided until they had moved into the status of using their own forms of transportation.
Rationale for the Modalities of Treatment
Protocols were based upon a holistic or transpersonal model of care with the idea that treating the whole person simultaneously is the most efficient and efficacious way to help people heal from the multiple problems that lead to substance abuse. Positive psychology has developed a ‘wellness’ philosophy over the past few decades that build upon clients’ strengths as opposed to just focusing on pathology (Seligman, Stein, Parks, & Peterson, 2005).
Research in regards to which attributes support having good life outcomes for people who have experienced serious adversity in life, strongly endorses resilience as a key factor (Bogar & Hulse-Killacky, 2006; Valentine & Feinauer, 1993; Chandler, 2010). Resilience has been associated with stable characteristics such as wellbeing, optimism, faith, wisdom, creativity, self-control, morality, gratitude, forgiveness, and hope (Liem et al, 1997; Werner & Smith, 2001). Thus the treatment modalities used in the pilot study were meant to provide clients with positive psychotherapy and recovery modalities, mindfulness training within both a cognitive and spiritual framework, outlets for creativity, somatic therapies to help with balancing and integrating both hemispheres of the brain, energetic healing modalities to assist with activating the client’s own immune systems, and practical skills to develop self-control, self-efficacy, and to build self-esteem.
Cognitive Based Mindfulness Therapies
Mindfulness-based cognitive approaches are a departure from traditional, cognitive-behavioral treatment. Cognitive-behavioral therapy includes a clear goal of changing negative behaviors and irrational thinking patterns, while mindfulness practice suggests that clients observe their thoughts as impermanent and refrain from judging them. Mindfulness-based stress reduction, and dialectical behavior therapy (DBT) have shown promise as therapies that support women with trauma histories and co-occurring disorders to focus on strategies that support improved health.
Dialectical behavior therapy (DBT) is one example of a cognitive approach that embraces humanistic principles toward personal growth (Baer, 2003; Hayes & Shenk, 2004). DBT is a multifaceted approach that was initially conceptualized as a treatment for individuals diagnosed with borderline personality disorder but has been expanded to use with addictive behaviors (Baer, 2003; Hayes, et al., 2004). Clients in the study learned mindfulness practices including nonjudgmental observation of thoughts, emotions, sensations, environmental stimuli, acceptance of personal histories and current situations while working to change behaviors and environments that support building better lives.
Mindfulness-based stress reduction has demonstrated its effectiveness for treating anxiety and panic (Kabat-Zinn et al., 1992; Miller et al., 1995). A meta-analysis of 20 empirical studies suggested that mindfulness-based stress reduction help individuals cope with depression, anxiety, pain, cancer, and heart disease (Grossman et al., 2004). By integrating cognitive behavioral approaches with humanistic, transpersonal theories, and mindfulness practices, creative healing strategies are promoting wellness.
These treatment modalities show promise as therapies that support women with trauma histories by helping them to integrate their past abuse experiences with their current substance abuse issues and encouraging them to focus on strategies that support improved health.
Consciousness and Developing Spiritual Practices
Consciousness has been linked with awareness, attention, and memory (Farthing, 1992) and has been highly correlated with resiliency (Liem et al., 1997; Werner & Smith, 2001). Jungian theory suggests that the unconscious mind retains information not readily available to the ego. While the personal unconscious holds repressed memories, the collective unconscious contains dreams, visions, religious experiences, and the myths of all cultures throughout the ages.
Murphy (1963) wrote that the unconscious mind possesses infinite wisdom that is available to the conscious mind when it is open and receptive. Thus human consciousness can be viewed from a multidimensional perspective that includes both a psychological and a spiritual context (Chandler, 2010). While we have access to our everyday consciousness to assist us in dealing with daily activities, we can be adversely impacted by what lies in the repository of our personal unconsciousness, of which we may be totally unaware (Chandler, 2010). Traumatic events narrow the focus of consciousness, and “the mind at large has to be funneled through the reducing valve of the brain and nervous system” (Huxley, 1954, p. 23). Meditation and other mindfulness techniques have been shown to lessen the hypervigilance, restlessness, anxiety, and fear associated with severe trauma (Miller, 1993).
In researching what practices and therapies helped abused women regain resiliency, personal spiritual practices were endorsed as providing meaning, hope, increased self-esteem and a sense of belonging (Chandler, 2010). Additionally, research is integrating spiritual practices with science such is seen with power of prayer (Bensen, 2006; Byrd, 1988; Krucoff & Crater, 2001) and other nonlocal healing techniques to assist in healing a variety of medical issues (Achterberg, et al., 2005; Chandler, 2010; Shealy, 1999; Shealy & Myss, 1988).
While organized religions have been found to be detrimental for certain trauma survivors (Chandler, 2010), the development of a spiritual practice can significantly aid in one’s search for meaning and purpose (Ryan, 1998), which echoes Frankl’s (1962) position that the way a person deals with suffering is a key to adding deeper meaning to life. Jaffe (1985) further asserted that adversity might become the cornerstone of a new identity, as a person discovers meaning in life’s struggles. It is, therefore, important for counselors to assess clients’ spiritual functioning and assist them in addressing spiritual concepts while searching for meaning in traumatic life experiences (Ganje-Fling & McCarthy, 1996).
Creativity and Expressive Arts
Sikes (2001) suggests that creativity plays a central role in the healing process. Creativity has been cited as one of the factors that assisted in the maintenance of resiliency (Seligman et al., 2005). Creativity embodies our natural impulse for change, without which stagnation would occur (Sikes, 2001). Throughout human history, people have used creativity to adapt and recover from stress, loss, trauma and pain. Seeking meaning (Frankl, 1962) is vital to the healing process, and humans have always found a structure in which to contain difficult experiences such as through rituals, ceremonies, storytelling, and songwriting (Sikes, 2001). Creating art has an established history of being a helpful adjunct therapy for working with psychological and physiological disorders, as well as for its cathartic properties (Chandler, 2010; Lusebrink, 1990/2004; McNiff, 1992).
Bessel van der Kolk, the medical director of the Trauma Center in Boston, found evidence that trauma affects the entire person and that treatment is most effective when it integrates psychotherapy with somatic, body-memory treatment such as EMDR, art therapy, and massage (Collinge et al., 2005, van der Kolk, 1994/1996). Van der Kolk’s findings concurred with Burgess, Watkinson, Elliot, MacDermott, and Epstein’s (2003) similar research.
Field (2000) demonstrated that massage benefits the musculoskeletal, circulatory, lymphatic, and nervous systems, and mental disorders associated with sexual abuse (Field, 2000). In studies of PTSD, depression, and anxiety, massage was shown to decrease symptoms and to improve mood and behavior. A chronic fatigue study concluded that massage decreased depression, anxiety and pain, and improved immune function (Field, 2009).
Although research on the treatment of trauma with alternative medicine is limited, studies on the neurobiological findings of trauma support the need for an integration of both somatic and cognitive therapies to treat the layers of problems that affect victims with trauma histories and subsequent co-occurring disorders (Chandler, 2010).
Somatic experiencing, a mind/body modality developed initially by Peter Levine (1997), is a modality in the mental health field that goes beyond talk therapy. It teaches ways of recognizing, reducing, and discharging stressful energy from the nervous system. It helps the client understand exactly how the body is managing overwhelming, stressful, or traumatic events. In a gentle, yet powerful way, somatic experiencing helps people to let go of accumulated trauma in the body and allows the body to regain its innate ability to self-regulate and be resilient.
Three studies were found on the use of somatic experiencing method by social workers who had worked to help victims of both Hurricane Katrina and Rita. According to the authors of the study, the treatment group showed statistically significant gains in resiliency indicators and decreases in symptoms of PTSD. Although psychological symptoms had increased in both groups at the three to four month follow-up, the treatment group’s psychological symptoms were statistically lower than those of the comparison group (Leitch, Vanslyke, & Allen, 2009). The limbic center of the brain is where the pain and pleasure center is located that is affected by trauma and substance abuse and it appears to be another powerful technique for helping individuals with both disorders.
Acupuncture and Energy Medicine
The National Acupuncture Detoxification Association (NADA) was developed in the 1970s when it was discovered that a five-needle ear protocol was effective in reducing tremors, shakes, and both physical and mental agitation in heroin addicts while in detoxification units (Huff, 2007). Although the results of clinical studies have been mixed on demonstrated effectiveness for addiction treatment using the NADA protocol, more than 1,500 clinical sites around the world currently use these protocols.
The NADA protocols began to be used with traumatized populations in New York after the September 11, 2001 attacks. The group Acupuncturists Without Borders has been going to natural disaster sites since then to provide trauma relief using the NADA protocols (Huff, 2007). A pilot study by Hollifield, Sinclair-Lian, Warner, and Hammerschlag (2007) at the University of Louisville School of Medicine in Kentucky examined the effects of acupuncture on depression and anxiety in 73 individuals diagnosed with PTSD. During a 12-week period, participants were assigned to acupuncture, cognitive-behavioral, or wait-list groups. Both acupuncture and cognitive-behavioral groups had similarly improved symptoms that were superior to those of the wait-list control group and maintained the effects for three months after the end of treatment (Hollifield, Sinclair-Lian, Warner, and Hammerschlag, 2007).
Charles Engel, MD at the U.S. Army Walter Reed Medical Center, has been conducting an on-going randomized, wait list controlled trial from 2006 through 2008 to evaluate the efficacy of acupuncture for PTSD based upon the reported results on the study by Hollifield, Sinclair-Lian, Warner, and Hammerschlag (2007) stating that acupuncture improved wellbeing, stress, anxiety, sleep, digestion, and pain conditions, and that it held promise as a treatment option for PTSD.
Reiki, which means universal energy in Japanese, is a nonintrusive, hands-on and distance healing technique, which originated in Japan by Dr. Mikao Usui (1865-1926) at the beginning of the 20th century. Research on Reiki healing shows it to be effective in treating emotional trauma, releasing toxins, reducing side effects of drugs after surgery or chemotherapy, improving immune system function, increasing vitality, creating deep relaxation, and releasing stress and tension (Chandler, 2010).
Quantum physicists have acknowledged that the human body generates an electromagnetic field and that negative emotions that occur in response to trauma, influence the physical tissue in the body (Oschman, 2000; Smith, 1988, 1994; Tiller, 1997). Acceptance of Reiki in the medical world has been limited by a lack of empirical investigations, but professional nurses have recently led the way in exploring Reiki’s healing benefits (Oschman, 2000; Vitale, 2007).
Two Reiki studies of surgical patients showed less use of pain medications and quicker recovery with Reiki treatments (Alandydy & Alandydy, 1999; Motz, 1998). A study at St. Vincent’s Medical Center in New York demonstrated that Reiki lowered anxiety in 30 heart patients (Rand, 2009). Three cancer studies found Reiki to be useful for palliative care and pain management (Bullock, 1997; Burden, 2005; Olson & Hanson, 1997). The Department of Veterans Affairs uses Reiki in their Hepatitis C treatment program, and most recipients report a peaceful sense of relaxation and reduction in pain, anxiety, fear, and anger.
Further findings have suggested that Reiki fits easily within a harm-reduction model and can be used successfully as self-treatment by people with HIV, in conjunction with appropriate medical and/or psychiatric care (Miles & True, 2003). Reiki was found to be a helpful treatment modality for women with childhood sexual abuse histories in the Burgess Watkinson, Elliot, MacDermott, & Epstein (2003) study. Additional research into the efficacy of this treatment modality specific to treating women with co-occurring disorders is indicated.
Based upon the collective research being done to validate the efficacy of all these healing and mindfulness modalities with a variety of psychological, physiological, and substance abuse issues, they were all included in the extended care facility’s regimen. Each woman had an individualized treatment plan that included access to consistent use of treatment modalities that fell within the body-mind-spirit continuum to fully explore the core principles of integrated treatment as stated by the SAMHSA findings (SAMHSA/PIT 51).
Results of Longitudinal Research
While this was a small sampling of women with co-occurring disorders in an extended care facility, the results were encouraging that a holistic, integrated treatment model is an effective strategy. Using the self-administered Beck Depression Scale, an Anxiety Scale, the Purpose in Life Inventory, and the URICA Inventory of Stages of Change to quantify baseline, discharge, three months after discharge, and twelve months after discharge provides some statistical data to substantiate findings.
Beck Depression Scale – 20% is considered significantly depressed.
Baseline Discharge 3-Months 12-Months
AVG. 20.38 8.38 3.3 .75
At intake the average depression rating for the women was 20.38%, which is considered significantly depressed. The average depression scaled diminished over the ninety-day stay to 8.38%, which indicates minimal if any clinical depression, and the average percentage continued to decrease among the women.
Anxiety Scale – Five-point scale with 5 being the worst.
Baseline Discharge 3-Months 12-Months
4.75 2.63 .5 >.25
All of the women indicated high anxiety upon intake, with the average point distribution being 4.75%. This scale related to how effective acupuncture was in addressing anxiety symptoms. After three months of weekly acupuncture sessions, the average anxiety scale for the women was 2.63% and anxiety levels continued to decrease after discharge from the program.
Purpose in Life Inventory – Below 90 = No Purpose; Over 112 = Definite Purpose
Baseline Discharge 3-Months 12-Months
88.25 103 114 119
The Purpose in Life Inventory rates sense of purpose, which is tied to resiliency and hope for recovery. The survey’s instructions state that a score below 90% indicates the individual feels she/he has no purpose in life. At intake the baseline average of the women who participated in the treatment protocol was 88.25%. At discharge average scores were 103%, which is in the contemplation or more hopeful stage, and this score continued to increase on average to the women feeling they had renewed purpose in life.
Precontemplative Contemplative Action Maintenance
Baseline Discharge 3-Months 12-Months
AVG. P/C C/A A/M M
The URICA inventory suggests where the individual sees herself in relation to recovery from substance abuse. At intake the women were pre-contemplative or contemplative about their ability to recover from substance abuse/dependence. At discharge all of the women had developed action plans to maintain the sobriety they had developed through treatment. By the twelve-month follow up, those that were willing to be interviewed had maintained sobriety and were actively pursuing lifestyles that supported their continued sobriety.
The findings at baseline were that even after a thirty-day primary inpatient program the majority of the women were still depressed, extremely anxious, had a low score on purpose in life inventory, and ranged in the pre-contemplative to contemplative range on wanting to maintain recovery from substance abuse. All of the women came into the extended program with a sense of being overwhelmed with their lives and some sense of hopelessness that they could not improve the quality of their lives and build their self-esteem. The average length of stay for the eight women was 2.75 months. Only five of the original eight women could be reached at the twelve-month mark, but those that were contacted had maintained the gains made and, in some measures, continued to improve.
During the stay in the extended care house, three of the four married women resolved that divorce was inevitable and began that process. They felt empowered to take the necessary steps to provide for joint-custody of their children, and they were able to advocate appropriately for themselves with their ex-husbands. The one woman that remained married continued in outpatient therapy and marriage counseling, and determined after several months of both, that enough growth in the relationship had occurred to warrant staying in the marriage.
The women that had careers resumed those careers and were among the ones that responded at the twelve-month mark. Three of the women began to explore how to re-vitalize their careers and two of the women began to explore returning to college. The women who had struggled with dysmorphic body image issues and eating disorders were able to develop healthy eating strategies through proper nutrition, regular exercise programs, and somatic/mindfulness therapies such as yoga and meditation.
Of the group, the two women under 30-years-old had the hardest time committing and staying committed to their sobriety. They each committed to stepping down in treatment to sober living facilities and extensive outpatient programs to continue their therapeutic work. In addition, several of the women developed a real bond with one another and maintained that connection, even at the twelve-month mark.
As a small pilot study, there were not sufficient participants for the results of the study to be considered quantifiably significant. In addition, the integrative techniques were offered collectively along with traditional therapeutic approaches, which do not expressly demonstrate how any of these therapies offered exclusively would or would not be beneficial in additional studies. Thus, from a scientific method perspective, validity or reliability cannot be established for retest possibility. The premise of this study was to provide a variety of holistic services in a clinical setting and to monitor the progress of clients from a longitudinal perspective to determine efficacy of the whole program to affect positive change in clients.
As a clinical treatment protocol, a major issue with this program was cost and the lack of insurance carriers that would pay for the program. Insurance carriers that were approached would not consider the whole program, and would only consider paying piecemeal to practitioners that were on their specific insurance panel, and in this, effectively managed to discount the program.
While considering the nature of the program received, as well as room and board, the cost was $7500 per month, which is about half the cost of a month in a primary treatment facility in the same geographical area. However the reality is that the majority of families with this need cannot afford even one month of this cost, much less three months. This dilemma suggests that a comprehensive, integrative program would need to be funded through federal grants to continue research into its efficacy, and developed as a teaching model to take into the non-profit sector.
In this way the efficacy of therapies could be further tested with individuals that currently do not have access to alternative therapies and may be of diverse cultures and economic statuses. The pilot study may provide opportunities to develop research protocols to further elucidate efficacy of therapies in other settings such as in community mental health settings and in traditional residential treatment facilities for the treatment of substance abuse. While providing therapies piecemeal has been the way co-occurring disorders have been traditionally treated, this might be an appropriate way to begin incorporating some of the other therapies into mainstream treatment facilities.
The outcomes for the eight women in the three-month pilot study into integrative holistic treatment for co-occurring disorders was a reduction in depression and anxiety, a renewed sense of purpose, raised self-esteem, and the ability to face interpersonal and legal problems with increased self-efficacy. Of the five women that responded to repeating the assessment measurements a year after treatment, all of them maintained and increased gains of treatment, which provides encouragement for potentials of integrative treatment.
Additionally the interpersonal, vocational, legal, medical, and Axis I issues of each individual were addressed in a comprehensive and holistic program, which encouraged more research into integrative care. Even with the inherent problems of developing funding for a change in rationale from piecemeal treatment protocols to an integrative model, the encouraging trend noted in this pilot study suggests that the overall problems of recidivism for substance abuse and the underlying gestalt of co-occurring issues in women being treated simultaneously with a holistic model may produce more lasting and effective changes.
Further research is needed in integrative and alternative therapies for the treatment of mental illness and co-occurring substance abuse disorders. There may be ways to do additional research within community mental health and substance abuse treatment facilities to elucidate efficacy of treatment modalities. Specific treatment modalities could be provided in set participant groups to determine treatment efficacy for those modalities. From the clinical perspective of holistic care, it is not one or two therapies that provided the treatment outcomes, but the therapeutic perspective of a holistic and fully integrated treatment program that treated the whole person that made the difference.
Providing specific care to women with co-occurring disorders from the holistic perspective suggests a need to consider the relational issues that may be causal to women becoming dependent upon substances, along with co-occurring disorders, and the core principles noted in SAMHSA for gender differences to develop protocols that lead to healing.
Achterberg, J., Cooke, K., Richards, T., Standish, L. J., Kozak, L., & Lake, J. (2005). Evidence for correlations between distant intentionality and brain function in recipients: A functional magnetic resonance imaging analysis. The Journal of Alternative and Complementary Medicine, 11(6), 965-972.
Alandydy, P., & Alandydy, K. (1999). Using Reiki to support surgical patients. Journal of Nursing Care Quality, 13(2), 89-91.
Baer, R. A. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and practice, 10(2), 125-143.
Becker, (2011). Differences of treatment amongst men and women. Retrieved on 10/1/2011. http://abcnews.go.come/Health/story?id=116913&page=1
Bensen, H. (2006). Study of the therapeutic effects of intercessory prayer (STEP) in cardiac bypass patients: A multicenter randomized trial of uncertainty and certainty of receiving intercessory prayer, American Heart Journal, 151, 934-942.
Bloom, B., and Covington, S. (1998) “Gender-specific programming for female offenders: What is it and why is it important?” Paper presented at the 50th annual meeting of the American Society of Criminology, Washington, DC.
Bogar, C. B., & Hulse-Killacky, D. (2006). Resiliency determinants and resiliency processes among female adult survivors of childhood sexual abuse. Journal of Counseling and Development, 84, 318-327.
Bullock, M. (1997). Reiki: A complementary therapy for life. American Journal of Hospice and Palliative Care, 14(1), 31-33.
Burden, B., Herron-Marx, S., & Clifford, C. (2005). The increasing use of Reiki as a complementary therapy in specialist palliative care. International Journal of Palliative Nursing, 11(5), 248-253.
Burgess, S., Watkinson, A. M., Elliot, A., MacDermott, W., & Epstein, M. (2003). I couldn’t say anything so my body tried to speak for me: The cost of providing health care services to women survivors of childhood sexual abuse. Retrieved April 10, 2007, from http://www.uwinnipeg.ca/admin/vh_external
Byrd, R. (1988). Positive therapeutic effects of intercessory prayer in a coronary care unit population. Southern Medical Journal, 81(7), 826-829.
Chandler, P. (2010). Resilience in healing from childhood sexual abuse. (Dissertation presented to faculty at Saybrook University for partial fulfillment of requirements for the Degree of Doctor of Philosophy (Ph.D.) in Psychology. UMI Dissertation Services.
Collinge, W., Wentworth, R., & Sabo, S. (2005). Integrating complementary therapies into community mental health practice: An exploration. The Journal of Alternative and Complementary Medicine, 11(3), 569-574.
Engstrom, M., El-Bassel, N., Go, H., & Gilbert, L. (2008). Childhood sexual abuse and intimate partner violence among women in methadone treatment: A direct or mediated relationship? Journal of Family Violence 23(7): 605-617.
Farthing, G. W. (1992). The psychology of consciousness. Englewood Cliffs, NJ: Prentice-Hall.
Field, T. (2000). Touch therapy. London: Harcourt.
Field, T. (2009). Complementary and alternative therapies: Research. Washington, DC: American Psychological Association.
Frankl, V. (1962). Man’s search for meaning. Boston, MA: Beacon Press.
Gange-Fling, M. A., & McCarthy, P. (1996, January/February). Impact of childhood sexual abuse on client spiritual development: Counseling implications. Journal of Counseling and Development, 74, 253-258.
Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress reduction and health benefits: A meta-analysis. Journal of Psychosomatic Research, 57(1), 35-43.
Gudrais, E. (July-August, 2011). Women and alcohol. Harvard Magazine.
Hayes, S. C., & Shenk, C. (2004). Operationalizing mindfulness without unnecessary attachments. Clinical Psychology: Science and Practice, 11(3), 249-254.
Hayes, S. C., Bissett, R., Korn, Z., Zettle, R. D., Rosenfarb, I., Cooper, L., et al. (1999). The impact of acceptance versus control rationales on pain tolerance. The Psychological Record, 49, 33-47.
Hayes, S. C., Wilson, K. G., Gifford, E. V., Bissett, R., Piasecki, M., Batten, S. V. et al. (2004). A preliminary trial of twelve-step facilitation and acceptance and commitment therapy with polysubstance-abusing methadone-maintained opiate addicts. Behavior Therapy, 35, 667-688.
Hollifield, M., Sinclair-Lian, N., Warner, T. D., & Hammerschlag, R. (2007). Acupuncture for posttraumatic stress disorder: A randomized controlled pilot trial. Journal of Nervous and Mental Disorders, 195(6), 504-513.
Huang, C. (1995). Hardiness and stress: A critical review. Maternal-Child Nursing Journal, 23, 82-89.
Huff, M. (May 2007). Montpelier acupuncturists hope to help Iraq vets with posttraumatic stress. [Vermont] Times Argus. Retrieved March 31, 2010, from: http://www.timesargus.com/apps/pbcs.dllarticle?AID=/2007507/NEWS02/705070358/1003/NEWS02
Huxley, A. (1954). The doors of perception. New York: Harper & Row.
Jaffe, D. (1985). Self-renewal: Personal transformation following extreme trauma. Journal of Humanistic Psychology, 25(4), 99-124.
Jamison, R. N. (2011). Just how do gender differences show up relative to a particular
drug that’s abused? http://www.healthfinder.gov/News/newsstory.aspx?docid=638574
Kabat-Zinn, J., Massion, A. O., Kristeller, J., Peterson, L. G., Fletcher, K. E., Lenderking, W. R., et al. (1992). Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. American Journal of Psychiatry, 149, 936-943.
Krucoff, M. W., & Crater, S. W. (2005). Music, imagery, touch, and prayer as adjuncts to interventional cardiac care: The monitoring and actualization of noetic training (MANTRA II) randomized study. Lancet, 366, 211-217.
Liem, J. H., James, J. B., O’Toole, J. G., & Boudewyn, A. C. (1997). Assessing resilience in adults with histories of childhood sexual abuse. American Journal of Orthopsychiatry, 67(4), 594-606.
Leitch, L., Vanslyke, J., & Allen, M. (2009). Somatic experiencing treatment with social service workers following hurricanes Katrina and Rita. Retrieved January 5, 2010, from http://www.traumahealing.com/somatic-experiencing/the-faculty.html
Levine, P. A. (1997). Waking the tiger: Healing trauma. Berkeley, CA: North Atlantic Books.
Lusebrink, V. B. (1990). Imagery and visual expression in therapy. New York, NY: Plenum Press.
Lusebrink, V. B. (2004). Art therapy and the brain: An attempt to understand the underlying processes of art expression in therapy. Art Therapy: Journal of American Art Therapy Association, 21(3), 125-135.
Kauffman, S.E., Silver, P., and Poulin, J. (1997). Gender differences in attitudes toward alcohol, tobacco, and other drugs, Social Work, (42) 3, 231-241.
Manhal-Baugus, M. (1998). The self-in-relation theory and women for sobriety: Female specific theory and mutual help group for chemically dependent women, Journal of Addictions and Offender Counseling, (18) 2, 78-85.
McConnaughy, E. N., Prochaska, J. O., & Velicer, W. F. (1983). Stages of change in psychotherapy: Measurement and sample profiles. Psychotherapy: Theory, Research and Practice, 20, 368-375.
McNiff, S. (1992). Art as medicine: Creating a therapy of the imagination. Boston, MA: Shambala.
Miles, R., & True, G. (2003). Reiki-review of a bio-field therapy: History, theory, practice, and research. Alternative Therapies, 9(2), 62-72.
Miller, J. J. (1993). The unveiling of traumatic memories and emotions through mindfulness and concentration meditation: Clinical implications and three case reports. The Journal of Transpersonal Psychology, 25(2), 169-180.
Miller, J. J., Fletcher, K., & Kabat-Zinn, J. (1995). Three year follow up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. General Hospital Psychiatry, 17(3), 192-200.
Motz, J. (1998). Hands of Life. New York, NY: Bantam.
Murphy, J. (1963). The power of your subconscious mind. Englewood Cliffs, NJ: Prentice-Hall.
Najavits, L. M. (2002). “Seeking safety:” Therapy for trauma and substance abuse.
Corrections Today, (64)6, 136-139.
Nelson-Zlupko, L., Kauffman, E., & Dore, M. M. (1995). Gender differences in drug addiction and treatment: Implications for social work intervention with substance-abusing women, Social Work, (40)1, 45-54.
Olson, K., & Hanson, J. (1997). Using Reiki to manage pain: A preliminary report. Cancer Prevention Control, 1(2), 108-113.
Oschman, J. L. (2000). Energy medicine: The scientific basis. London, England: Churchill Livingston.
Ryan, P. L. (1998a). Spirituality among adult survivors of childhood violence: A literature review. The Journal of Transpersonal Psychology, 30(1), 39-51.
Ryan, P. L. (1998b). An exploration of the spirituality of fifty women who survived childhood violence. The Journal of Transpersonal Psychology, 30(2), 87-102.
SAMHSA, (2011). Women have special needs in substance abuse treatment. Treatment
Improvement Protocols (TIP) 51. The Substance Abuse and Mental Health Services Administration (SAMHSA). Retrieved on 10/10/2011. http://ncadistore.samhsa.gov/catalog/productDetails.aspx?ProductID=18244
Schiff, M., El-Bassel, N., Engstrom, M. & Gilbert, L. (2002). Psychological distress and intimate physical and sexual abuse among women in methadone maintenance treatment programs. Social Service Review 76(2): 302-320.
Seligman, M. E. P., Steen, T. A., Park, N., & Peterson, C. (2005). Positive psychology progress: Empirical validation of interventions. American Psychologist, 6(5), 410- 421.
Shealy, C. N. (1999). Sacred healing: The curing power of energy and spirituality. Boston, MA: Element Books.
Shealy, C. N., & Myss, C. M. (1988). The creation of health: The emotional, psychological, and spiritual responses that promote health and healing. Walpole, NH: Stillpoint.
Sikes, C. (2001, August 24). Creativity: Its role in healing and place in positive psychology. Paper presented at the Annual Conference of the American Psychological Association, San Francisco, CA.
Smith, C. W. (1988). Electromagnetic effects in humans. In H. Frohlich (Ed.), Biological coherence and response to external stimuli (pp 205-232). Berlin, Germany: Springer-Verlag.
Smith, C. W. (1994). Biological effects of weak electromagnetic fields. In M. W. Ho, F. A. Popp, & U. Warnke (Eds.), Bioelectrodynamics and Biocommunication (pp.1-17). Singapore: World Scientific.
US Department of Health and Human Services. (2000). Gender differences in drug abuse risks and treatment. Rockville, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse.
US Department of Health and Human Services. (2003). Treatment methods for women.
Rockville, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse.
Valentine, L., & Feinauer, L. L. (1993). Resilience factors associated with female survivors of childhood sexual abuse. The American Journal of Family Therapy, 21(3), 216-224.
van der Kolk, B. A. (1994). The body keeps the score: Memory and the evolving psychobiology of posttraumatic stress. Harvard Review of Psychiatry, 1, 253-265.
van der Kolk, B. A., McFarlane, A. C., & Weisaeth, L. (1996). Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York, NY: Guilford Press.
Vitale, A. (2007). An integrative review of Reiki touch therapy research. Holistic Nursing Practice, 21, 25-31.
Werner, E. E., & Smith, R. S. (2001). Journeys from childhood to midlife: Risk, resilience, and recovery. Ithaca, NY: Cornell University Press.
About The Author
Dr. Tricia Chandler, PhD, LPC, BCPC, has been working in the field of psychology for the past nineteen years as a Licensed Professional Counselor and Art Therapist with children, youth, and adults in a variety of milieus. This has created the opportunity to research and develop holistic therapeutic practices for individuals with considerable trauma histories and co-occurring disorders. Dr. Chandler has trained in transpersonal psychology, energy medicine, personal spiritual/mindfulness practices, and somatic therapies she researched resiliency in healing from childhood sexual abuse for her dissertation in 2010 and developed a holistic model to treat women with co-occurring disorders after noting that therapeutic techniques for women lack an understanding of the multiple problems that face women seeking treatment for addiction issues. In addition to completing the longitudinal research presented in this paper, Dr. Chandler has a private practice and teaches graduate counseling and psychology students in online format for three universities where she teaches diagnostic psychopathology, family systems, biological basis of behavior, introduction to addiction counseling, counseling theories, advanced research, and professional ethics.