RESEARCH WITH WOMEN WHO USE DRUGS: APPLYING A TRAUMA-INFORMED FRAMEWORK

Abstract

Women who use drugs (WWUD) experience high rates of trauma. The complex impacts of trauma can act as a barrier to accessing substance use and harm reduction services, and to participation and representation within substance use research. Trauma-informed practice is an evidence-based approach for improved clinical care among WWUD, the principles of which can be applied to substance use research. Many researchers are integrating trauma-informed approaches across research settings, yet these principles are often not referenced specifically within publications, and there is a lack of comprehensive guidance regarding integration of trauma-informed methods across different research designs and methodologies. This commentary describes and discusses the merits of applying the 4 principles of trauma-informed practice - trauma awareness, safety and trustworthiness, choice collaboration and connection, and strengths-based and skills building - to promote safety and inclusion of WWUD in substance use research.

The complex impacts of trauma among women who use drugs (WWUD) are well established in the literature.^1,2 Although selection effects preclude a precise understanding of the prevalence of trauma among WWUD, existing research estimates gender-based violence, trauma, and post-traumatic stress disorder occurs among 40% to 90% of WWUD,^2,3 and is frequently normalized and unreported.^3,4 WWUD cite trauma coupled with the lack of safe, gender-responsive programs as barriers to accessing substance use and harm reduction services.^4,5 Of particular relevance is the potential for mistrust due to past interactions with healthcare or government systems, as research is not necessarily seen by WWUD as distinct from these institutions.⁶ These experiences may contribute to underrepresentation of diverse WWUD within substance use research by acting as barriers to engagement and retention. Novel research approaches that integrate trauma-informed principles could better address trauma-related barriers, thereby improving participation and representation and increasing relevance of intervention, programmatic, and policy reforms for WWUD.

Trauma-informed practice (TIP) is an internationally recognized effective clinical approach, where an understanding of the prevalence and effects of trauma is applied to all aspects of service delivery, and priority is placed on an individual’s safety, choice, and control.^1,2,7 TIP with WWUD gained traction in the early 2000s following the multi-site, longitudinal Women, Co-occurring Disorders and Violence Study, which showed integrated, trauma-informed substance use services reduced post-traumatic stress disorder symptoms and substance use among WWUD.⁷ Further research has shown that TIP improves service access, engagement, and health equity for WWUD^1,2,8–10 yet, to our knowledge, comprehensive and explicit implementation of TIP principles to substance use research itself has not been systematically implemented.⁹

Substance use researchers are integrating trauma-informed approaches within research settings. However, these principles are often not referenced specifically within publications and there is a lack of comprehensive guidance regarding integration of trauma-informed methods across research.⁹ When considering the absence of explicit TIP in substance use research alongside increased calls for trauma-informed research emerging within social work,¹¹ health-equity,^9,10 and trauma-specific¹² literature, we believe there is an opportunity to improve the incorporation and application of TIP in knowledge production processes. Therefore, we describe and discuss the merits of creating and applying a trauma-informed framework to promote safety and inclusion of WWUD in substance use research by drawing on the four core principles of TIP: trauma awareness, safety and trustworthiness, choice, collaboration and connection, and strengths-based and skill-building.^2,8 In doing so, we seek to provide practical strategies for how more researchers can incorporate TIP systematically in the development of research methodologies, and highlight the merits of creating a TIP guide for substance use research.

TRAUMA AWARENESS

Trauma awareness means recognizing and responding to the high prevalence and diverse experiences of trauma among WWUD, multifaceted impacts of trauma on physical and mental health, and bidirectional relationship between trauma and substance use.^1,2 TIP also recognizes the impacts of collective and intergenerational trauma, on individuals, communities and cultures.^1,2,8 As such, trauma-informed education can prepare researchers and ethics boards to critically examine the relationship between WWUD’s experiences of trauma and study participation’ and adapt research protocols accordingly.

Importantly, engaging in trauma-informed research does not require eliciting trauma-specific information, but rather, approaching research with “universal precautions,” assuming all participants have a trauma history’ and shaping research to minimize negative impacts.^7,8 To that end, data should be collected by trained staff, able to recognize and respond to participants who may be triggered and operating in a fight/flight/freeze response.^1,2,8 For example, in study sessions with participants experiencing incarceration, social work researchers began by intentionally establishing rapport, and ended with grounding exercises to reset mind-body connection.¹¹ Moreover, data should be gathered in the most effective, least intrusive method to meet study objectives. For example, when working with WWUD of childbearing age, or who are pregnant or parenting, exploring substance use patterns retrospectively, using de-identified samples, and/or incorporating Certificates of Confidentiality may help safeguard participant information and avoid unintended criminal and child welfare implications.¹³ Incorporating trauma awareness across research design and operations, supports WWUD’s engagement and retention while reducing the risk of re-traumatization.

SAFETY AND TRUSTWORTHINESS

Creating safety and trust is essential to research with WWUD, who often navigate complex risk environments such as unsafe relationships, spaces, and social policies,⁴ which erode WWUD’s emotional, physical, and cultural safety, and make reserving trust a mechanism of survival.⁸ TIP improves safety and trustworthiness via reflexivity, engagement, and consultation.

Reflexivity encourages researchers to consider how one’s intersectional identity and experiences impact all aspects of the research process, including power dynamics among personnel and between participants and staff, data interpretation and engagement with participants.^8,10 Engagement with WWUD on how to make interpersonal, spatial, and environmental aspects of research welcoming and gender-responsive may increase safety and promote participation.^1,8 Examples include providing self-identified women-only days, alternative exits for participants, and access to transportation and childcare. Consulting with community organizations supporting WWUD may improve trustworthiness.⁶ In a study exploring ethical research with WWUD, participants expressed that recruitment through their “own network or community,” not only supported meaningful participation, but also promoted trust that research outcomes would benefit their communities.⁶ By improving trust and safety with WWUD, TIP methods support engagement and retention.

CHOICE, COLLABORATION, AND CONNECTION

Experiences of trauma among WWUD are often coupled with lack of control or connection.^2,4 Researchers are working to make informed consent more dynamic, collaborative, and inclusive⁶ by providing small amounts of information at one time to avoid cognitive overload,¹¹ explaining “why” before doing something,² and providing reminders of participant’s rights, including study withdrawal, throughout a visit.¹² Clarity surrounding limits to confidentiality,¹² including reporting requirements to child welfare or workplaces, allows WWUD to determine if participation is in their best interest.⁶ In sum, although more gender-specific guidance on the consent process is needed, offering WWUD choice at different junctures can improve participant control and empowerment.⁶

Beyond consent, and in accordance with community-based participatory research (CBPR) and health-equity research, including peers with lived/living experience throughout the research process increases relevance of research questions, promotes collaborative, non-judgmental interactions, and facilitates access to knowledge.^9,10,14 For example, a CBPR study exploring WWUD’s experiences accessing a women’s overdose prevention site found that a diverse gender-responsive peer-led model reduced fatal overdoses, and improved safety and access for participants.⁵ Furthermore, this research was carried out by a team that included peer researchers who contributed to fieldwork, recruitment, and manuscript authorship.⁵ From a trauma-informed standpoint, peer research involvement has potential to be empowering for peers themselves^1,2,14 and can reduce stigma¹⁴ and improve connectedness for participants.² Concurrently, trauma-informed peer research involvement demands effective support for peers, including supervision, leadership opportunities, and space for dissent.¹⁴ In short, addressing choice, collaboration and connection can increase research inclusion of WWUD.

STRENGTHS-BASED AND SKILL-BUILDING

Strengths-based, skill-building research with WWUDs views coping with trauma as a dynamic process influenced across the ecological model,¹⁵ and considers how research itself contributes to tangible, meaningful change.^1,8 Techniques for highlighting WWUD’s strengths can be implemented throughout the research process. For example, mixed methods approaches nesting qualitative methods into quantitative or experimental studies center WWUD’s perspectives and amplify participant’s voices. Prioritizing asset-based, rather than deficit-based analytic approaches emphasizes participant’s strengths.^11,15 When evaluating substance use, consider using more inclusive, harm-reduction oriented outcomes to measure success and change, such as quantity, frequency, and safe use strategies that move beyond binary, abstinence-based measures, such as urine-drug screens.¹⁵ Finally, using empowering, change-oriented techniques to interview participants, including Motivational Interviewing² and positive affirmations,¹¹ may enhance WWUD’s motivation and confidence to work towards goals.

Trauma-informed research also considers how study participation and results can contribute to policy change.^14,16 Integrative Knowledge Translation, or engaging stakeholders throughout the research process to address barriers to the uptake of findings, creates meaningful interactions between researchers and stakeholders in service of reciprocal learning.¹⁶ Integrative Knowledge Translation can be used in experimental and community-based research and aligns with results from a CBPR study, in which WWUD highlighted the need for concrete research outcomes to raise their standard of living.⁶ Engaging in strengths-based research that furthers capacity-building and policy change creates a positive feedback loop, increasing the inclusion and agency of WWUD and encouraging reciprocity among researchers, stakeholders, and communities.

MOVING FORWARD

By explicitly incorporating TIP approaches in knowledge production, researchers will be better equipped to recognize and respond to the pervasive experiences of trauma impacting WWUD and reduce the risk of unintentional re-traumatization. Researchers can improve trust and safety through researcher reflexivity, participant consultation, and collaboration with community organizations. Dynamic informed consent and peer involvement can improve participant choice, connection, and collaboration. Finally, in taking a strengths-based, skill-building approach, researchers can support meaningful individual and community level change.

A trauma-informed framework needs to be versatile: it must adapt to qualitative and quantitative designs, observational and intervention studies, and be complimentary to feminist,⁵ participatory,¹⁴ harm reduction,⁹ and strengths-based^11,15 approaches. Furthermore, researchers must recognize TIP’s western, colonial origins and move beyond these to include decolonizing and Indigenous approaches to research practice.⁹ Building a trauma-informed research framework will be a collaborative, iterative effort. By enhancing research representation of WWUD, a trauma-informed framework holds promise to improve applicability, relevance, and trust in evidence-based interventions affecting WWUD.