WELL Project

The WELL Project was one of the sites of the Women, Co-Occurring Disorders and Violence Study, funded by the Substance Abuse and Mental Health Services Administration. This Study included a two-year planning and systems development phase (1998-2000), and a three-year implementation phase (2001-2003).

The WELL Project was a collaboration of the Institute for Health and Recovery with four geographically diverse community-based organizations. CAB Health and Recovery, Gosnold, and Stanley Street Treatment and Resources served as intervention sites and Spectrum Health Systems, Inc. served as the comparison site. In addition, Health and Addictions Research Inc., was responsible for conducting the research portion of the project.

At the intervention sites, the three local organizations worked with other service providers in their community to deliver trauma-informed, integrated care to women with co-occurring mental health and substance abuse disorders and histories of being physically or sexually abused and their children. The project funded “Integrated Care Facilitators” in each community, who assisted the three local organizations in developing plans for improving services to this population. Each organization also received two hours per month of “integrated supervision” to support site clinicians in providing integrated, trauma-informed care. In addition, in each community, Local Leadership Councils (LLCs) were formed that included service providers, advocates and consumers. LLCs discussed the needs of families affected by violence, substance abuse and mental illness and identified services available in their community and those that are needed but not available. LLCs developed projects to address gaps as well as making recommendations for state policy changes and pilot projects that were forwarded to the State Leadership Council described below. A subset of LLCs, Resource Coordination Councils, developed procedures for cross-referral, information-sharing and interagency service planning to enhance coordination when families receive services from more than one agency.

At the state level, representatives from key state agencies, advocacy organizations and consumer/advocates convened as a State Leadership Council to identify barriers to integration at the state level, review the process and products developed in the process of service integration at the three local sites and use local experiences to make recommendations for changes in the operations of state systems. The SLC also developed Principles for the Trauma-Informed Treatment of Women with Co-Occurring Mental Health and Substance Abuse Disorders along with a Tool Kit that can be used by organizations that wish to become more trauma-informed.

Organizations participating in the LLCs and SLC received cross-training based on the WELL Project Training Curriculum for Providers: Developing Integrated Services for Women with Substance Abuse, Mental Illness and Trauma. This curriculum was developed by a group of Clinical Experts/Trainers from a variety of disciplines including mental health, substance abuse, violence and children's services. Members included: June Cooper, MSP, President of Cooper & Associates; Margaret Cramer, Ph.D., Independent Consultant; Phyllis Dixon, MSW, Director of Mental Health and Addiction Services of the Fenway Community Health Center; Maxine Weinreb, Director of Training and Education of the Child Witness to Violence Project at Boston Medical Center; Mary Harvey, Ph.D., Director of the Victims of Violence Program at Cambridge Hospital; Shiela Moore, Executive Director and Debra Robbins, Director of Training of Casa Myrna Vasquez, Inc.

The project used as its theoretical bases:

The Relational Model of Women's Psychological Development.
Minkoff's concept of integrated treatment for co-occurring disorders.
Herman's model of Trauma Recovery.
Browne's strengths model.
Harvey's ecological model.
The transtheoretical model of stages of change.

Combining these elements was the basis for creating a new framework that acknowledges the complex relationship of gender, culture, and family in women's lives, along with the central role that violence plays in the development of mental health and substance abuse problems for women.

The national cross-site Women, Co-Occurring Disorders and Violence Study, of which the WELL Project was part, compared outcomes for women receiving integrated trauma-informed care with outcomes for women receiving services as usual at a comparison site. Women were interviewed every three months for a one year period to document their progress and use of services. Women in the WELL Project received the following services:

Resource Coordination and Advocacy for the woman and her family.
Interagency Service Planning through the Resource Coordination Councils.
Seeking Safety- a skill building group intervention for women with substance abuse difficulties or co-occurring disorders who have histories of violence developed by Lisa Najavits, Ph.D.
Nurturing Families Affected by Substance Abuse, Mental Illness and Trauma- The Institute for Health and Recovery’s parenting intervention for women with co-occurring disorders and histories of violence.
WELL Recovery- a peer-run self/mutual help group specifically for women with co-occurring disorders and histories of violence developed by the Institute for Health and Recovery and the Peer Educators Project of Vinfen, Inc.

The outcomes of women receiving these services at the intervention site were compared with outcomes of women receiving services as usual at Spectrum Health Systems, Inc.

Findings

Systems Change Findings at the Local (Regional) Level

The WELL Project used interorganizational network analysis (Morrissey et al.), a method for quantifying and mapping relations across organizations in a given area. Two waves of standardized interviews with representatives of agencies in each of 3 Local Leadership Councils gathered information on whether and to what degree their agency shared clients, funding, and information with each of the other agencies in the local area. The data collected in each wave of interviews (1999 and 2003) were compared to reveal changes in network structure. Findings indicated a shift toward greater centrality of violence service providers in the client referral network. In one region, the shift was statistically significant (p<.o5) and in another region it was marginally significant. This shift was corroborated by an increased proportion in each local area network of core agencies that are violence service providers. Because of the relatively low number of violence service providers involved, this measure only attains marginal significance in two networks.

Client Outcomes

Women, Co-Occurring Disorders and Violence Study Cross-Site (National) Outcomes

At 6 months, women in both experimental and comparison conditions had decreased symptoms on the four major outcomes of alcohol use, other drug use, mental health symptoms, and trauma symptoms.

On two of the four measures (drug use severity and trauma symptoms) women in the experimental condition showed significantly greater improvement than those in the comparison condition.

On mental health symptoms, greater improvements among women in the experimental condition almost reached statistical significance.

WELL Project Outcomes

Among women who were most likely to be younger, White, employed, primary alcohol users, and to have reported having had a mental health problem before age 13, women in the intervention condition tended to have more favorable alcohol use scores than those in the comparison condition. Interaction between the women’s characteristics and the study condition was statistically significant (p<.02).

Among women who were most likely to be older, non-White unemployed, primary heroin users, and reported having had no mental health problems before age 13, women in the intervention condition tended to have more trauma symptom reduction than those in the comparison condition. Interaction between women’s characteristics and study condition was statistically significant (p<.04).

There were no significant interaction effects for the drug use or mental health symptom measures.