Exploring the Dynamics of High-Challenge Encounters in Residential Substance Abuse Treatment Settings

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Doctor of Social Work (DSW)
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Counselor Education
Inequality and Stratification
Medicine and Health
Social and Behavioral Sciences
Social Control, Law, Crime, and Deviance
Social Work
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In 2012, 4 million people aged 12 or older received help for alcohol and illicit drug use in the United States with approximately 2.5 million treated as inpatients (SAMHSA, 2012). Studies show the majority of women, men, and adolescents obtaining substance abuse residential treatment have been traumatized before entering treatment. Traumatic events span past sexual abuse, physical abuse and victimization from violence; trauma also include experiences from disasters and war. Yet, trauma-informed treatment is not mandated for substance abuse treatment facilities, and the manner in which clients are handled upon entering substance abuse residential treatment facilities is largely unknown. In a survey reflecting the most comprehensive national data on treatment delivery, Capezza and Najavits (2012) found that 66% of the 13,233 substance abuse treatment facilities examined reported the use of trauma-related counseling with clients. However, a considerable 33.4% of these facilities rarely or did not provide trauma counseling. Alarmingly, similar residential structures such as nursing homes report rising annual abuse of patients while in care in a third of their institutions throughout the U.S. (U.S. House of Representatives, 2001), and client re-traumatization has been documented in psychiatric inpatient wards (Cusack et al., 2003; Freuh et al., 2000). This dissertation explores the triggers and consequences of high-challenge moments that occur within residential drug treatment settings; high-challenge moments are escalated moments between staff and clients that result in potential emotional and/or physical harm to clients. Client harm from high-challenge moments appears related to the absence of trauma-informed facilities, lack of staff training in client symptomatology, enactment of authoritarianism by staff, and inappropriate maintenance of staff-client boundaries. A qualitative study was conducted in which nine staff members working for at least six months in adult and adolescent residential substance abuse treatment milieus of varying treatment lengths engaged in intensive semi-structured interviews. Data were analyzed utilizing open-coding and category formation from grounded theory and theme formation surrounding a common concept from phenomenology. Subjects confirmed high-challenge moments do occur in residential substance abuse treatment settings. Results signify training as useful in preventing re-traumatization, overidentification, lack of staff understanding of trauma, client exploitation, use of shame, and excessive enforcement of residential setting rules. Implications indicate a need for trauma-informed facilities in treating substance abuse and an emphasis on changing hiring practices, training, supervision, and client treatment.

Lani Nelson-Zlupko
Andrea Doyle
Jim McKay
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