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Seeking Safety in Methadone Maintenance Treatment: A Model for Treating Trauma and Opioid Dependence Marshall Rosier, MS Connecticut Counseling Centers, Inc. Alan Lee Nolan, LCSW Connecticut Counseling Centers, Inc. Lisa Najavits, Ph.D. Department of Psychiatry Harvard Medical School, McLean Hospital Diane Heyward, MS Connecticut Counseling Centers, Inc. Michael Freeman, MS, LADC Connecticut Counseling Centers, Inc. 2004 COPYRIGHT M. Rosier, MS 1 Goals of Presentation Introduce the Connecticut Trauma Initiative Discuss psychological trauma and PTSD Outline several features of Seeking Safety Discuss the technology transfer process Share lessons learned 2004 COPYRIGHT M. Rosier, MS 2 Celebrating 20 years of Treatment Excellence 1984 -2004 JCAHO Accredited • Middlebury – Executive Offices – Executive Director, Richard Bilangi, MS 203.577.5320 e-mail:[email protected] • Waterbury Clinic – Program Director, Michael Freeman, MS, LADC • Norwalk Clinic – Program Director, Robert Lambert, MA, LADC • Danbury Clinic (Opening February 2005) 2004 COPYRIGHT M. Rosier, MS 3 Celebrating 20 years of Treatment Excellence 1984 -2004 JCAHO Accredited Mission Statement: CCC, Inc. is a not-for-profit corporation that provides a full range of licensed outpatient substance abuse and mental health prevention, education and treatment services to assist adults in becoming productive members of society. 2004 COPYRIGHT M. Rosier, MS 4 Waterbury Clinic JCAHO Accredited Patient Demographics: 825 Methadone Maintenance Patients 46% Women 54% Men 56% Caucasian 28% Hispanic 12% African American 4% Other 2004 COPYRIGHT M. Rosier, MS 5 Behavioral Health Care Services JCAHO Accredited – Opiate Withdrawal Programs – Methadone Maintenance Treatment Programs – Intensive Outpatient Program – Partial Hospitalization Program – Dual Diagnosis Treatment and Services – Non-Chemically Supported Outpatient Treatment Program – Mental Health Treatment and Services 2004 COPYRIGHT M. Rosier, MS 6 Behavioral Health Care Services JCAHO Accredited – Pregnant Addict Care Programs – Women Centered Treatment Services – Patient Transportation – HIV, TB, HEP A, B, and C • Screening, Education & Counseling – Research Department • NIDA Clinical Trails Network NEW ENGLAND Node / Yale University – Suboxone - Bupenorphine Clinical Trial 2004 COPYRIGHT M. Rosier, MS 7 Connecticut Trauma Initiative: Department of Mental Health and Addiction Services Source: http://www.dmhas.state.ct.us/trauma/overview.htm Goals of the Initiative Promote co-occurring PTSD competency Link resources to system-wide care in public sector Develop partnerships Criteria for Treatment Models Representative target population Cultural diversity Evidence-based Gender-sensitive Skills-based rather than exposure-based Empowering to survivors Compatible with treatment needs and clinicians 2004 COPYRIGHT M. Rosier, MS 8 Posttraumatic Stress Disorder (PTSD) DSM-IV-TR (2000) American Psychiatric Association Exposure to a traumatic event – Experienced, witnessed or was confronted with traumatic event or events that involved • Actual or threatened death or serious injury • Threat to the physical integrity of self or others – Response involved • Intense fear, helplessness, or horror Intrusion Avoidance Arousal 2004 COPYRIGHT M. Rosier, MS 9 Posttraumatic Stress Disorder (PTSD) DSM-IV-TR (2000) American Psychiatric Association Intrusion Event is persistently reexperienced – Distressing recollections such as images, thoughts, or perceptions – Recurrent dreams – Acting or feeling as if event were recurring – Distress or reactivity to exposure of internal or external cues that symbolize an aspect of the trauma 2004 COPYRIGHT M. Rosier, MS 10 Posttraumatic Stress Disorder (PTSD) DSM-IV-TR (2000) American Psychiatric Association Avoidance Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness – Efforts to avoid thoughts, feelings or conversations associated with trauma – Efforts to avoid activities, places or people that arouse recollection of trauma – Inability to recall important aspects of trauma – Markedly diminished interest or participation in significant activities – Feelings of detachment or estrangement from others – Restricted range of affect – Sense of foreshortened future 2004 COPYRIGHT M. Rosier, MS 11 Posttraumatic Stress Disorder (PTSD) DSM-IV-TR (2000) American Psychiatric Association Arousal Persistent symptoms of increased arousal – – – – – Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hypervigilance Exaggerated startle response 2004 COPYRIGHT M. Rosier, MS 12 Co-Occurring Psychiatric & Substance Use Disorders Getting Better: A Study of Addiction Services in Connecticut. DMAHS & UCONN Men and Women Entering Addiction Treatment in Connecticut 60 50 40 53.2 37 37.8 26 30 21.9 20 13.3 19.4 12.2 10 0 Any Disorder Depression Men Anxiety Women 2004 COPYRIGHT M. Rosier, MS PTSD 13 Seeking Safety: A Psychotherapy for Trauma/PTSD and Substance Use Disorders Seeking Safety is a present-focused therapy to help people attain safety from both PTSD and substance abuse. The treatment was designed for flexible use. It has been conducted in group and individual format; for women, men, and mixed-gender; using all topics or fewer topics; in a variety of settings (e.g., outpatient, inpatient, residential); and for both substance abuse and dependence. It has also been used with people who have a trauma history, but do not meet criteria for PTSD. www.seekingsafety.org 2004 COPYRIGHT M. Rosier, MS Lisa Najavits, Ph.D. Picture courtesy of NIDA 14 Principles of Seeking Safety: Safety is the fundamental treatment goal “When a person has both active substance abuse and PTSD, the most urgent clinical need is to establish safety.” Najavits, 2002 “Seeking safety refers to helping patients free themselves from such negative behaviors and, in so doing, to move toward freeing themselves from trauma at a deep emotional level.” Najavits, 2002 Seeking Safety: A Treatment Manual for PTSD and Substance Abuse Najavits (2002) The Guilford Press, New York www.guilford.com 2004 COPYRIGHT M. Rosier, MS 15 Principles of Seeking Safety: Five Central Ideas Safety is the priority of first-stage treatment Integrated treatment for trauma and substance use disorders A focus on ideals Four content areas: cognitive, behavioral, interpersonal and case management Various therapist processes emphasized such as building therapeutic alliances, using coping skills, giving patients control, modeling positive behavior and asking for patient feedback 2004 COPYRIGHT M. Rosier, MS 16 Principles of Seeking Safety: Safety is the fundamental treatment goal Safety is an umbrella term that signifies various elements: Discontinuing substance use Reducing suicidality Minimizing exposure to HIV risk Letting go of dangerous relationships Gaining control over extreme symptoms Stopping self-harm behaviors Najavits, 2002 2004 COPYRIGHT M. Rosier, MS 17 Principles of Seeking Safety: Additional Features of Treatment Focus on potential rather than pathology Attention to language Emphasis on practical solutions Relating the material to patient’s live Making the treatment interesting to patients Substance abuse as a priority Patients do not necessarily need to meet formal criteria for PTSD 2004 COPYRIGHT M. Rosier, MS 18 Principles of Seeking Safety: Recommended Session Format Check-in Quotation Session Topic Check-Out End of Session Questionnaire 2004 COPYRIGHT M. Rosier, MS 19 Principles of Seeking Safety: Recommended Session Format Check-in How are you feeling? What good coping have you done? Any substance use or unsafe behavior? Did you complete your commitment? Community resource update? 2004 COPYRIGHT M. Rosier, MS 20 Principles of Seeking Safety: Recommended Session Format Quotation The purpose of the quotation Engage patient emotionally Provide inspiration Offer treatment reference for future good coping 2004 COPYRIGHT M. Rosier, MS 21 Principles of Seeking Safety: Sample Quotation “Let your heart guide you. It whispers, so listen closely” -Molly Goode (20th-century American writer) Taken from Seeking Safety – Setting Boundaries in Relationships (page 271) 2004 COPYRIGHT M. Rosier, MS 22 Principles of Seeking Safety: Recommended Session Format Session Topic Ask patients to review written materials Relate material to current and specific issues Ask patients what they find to be most relevant Identify patient issues to process Mention PTSD and Substance Abuse Encourage patients to generate options 2004 COPYRIGHT M. Rosier, MS 23 Principles of Seeking Safety: Recommended Session Format Check-Out Name one thing that you got out of today’s session? Any problems with the session? What is your new commitment? Encourages the patient to keep moving forward Viable and realistic Patient oriented What community resource will you contact? 2004 COPYRIGHT M. Rosier, MS 24 Principles of Seeking Safety: Recommended Session Format End of Session Questionnaire Ask patients to complete feedback questionnaire Benefits of anonymous feedback Patients are empowered Patients feel valued Helpful in planning future sessions 2004 COPYRIGHT M. Rosier, MS 25 Seeking Safety: Sample Treatment Topics Essential first steps… Introduction to Treatment/Case Management Safety PTSD: Taking Back Your Power Detaching from Emotional Pain (Grounding) Taking Care of Yourself Asking for Help Setting Boundaries in Relationships Coping with Triggers 2004 COPYRIGHT M. Rosier, MS 26 Technology Transfer Process: Research to Practice Technology Transfer “Involves creating a mechanism by which a desired change is accepted, incorporated and reinforced at all levels of an organization or system.” The Change Book: A Blueprint for Technology Transfer (2000) See www.nattc.org/resPubs/changeBook.html Goal of Technology Transfer To integrate technology, research and innovation not only into the practices and policies, but into the culture, of the organization 2004 COPYRIGHT M. Rosier, MS 27 Technology Transfer Process: Research to Practice Other Issues for Consideration Institutional Supports Barriers to Change Readiness for Change Climate for Change Resources Quality Improvement Process and Assessment Dwayne Simpson (2002) 2004 COPYRIGHT M. Rosier, MS 28 Seeking Safety: Research to Practice Fall 2002: Seeking Safety two-day training Dr. Lisa Najavits The Women’s Consortium New Haven, CT Discussed trauma and Posttraumatic Stress Disorder Reviewed history of trauma treatment Discussed current theories and treatment Introduced the Seeking Safety model Integrated case studies, research findings and clinical techniques in providing Seeking Safety treatment 2004 COPYRIGHT M. Rosier, MS 29 Seeking Safety: Research to Practice • One year consultation with Lisa Najavits, Ph.D. and Martha Schmitz, Ph.D. • Weekly phone and once a month on-site consultations with clinical team • Referrals to Seeking Safety sessions reviewed by clinical team • Seeking Safety sessions scheduled in both the AM and PM clinics 2004 COPYRIGHT M. Rosier, MS 30 Seeking Safety: Research to Practice Clinical Practice Challenges Systemic Environmental Economic Program Policies and Procedures Clinical Staff Recruitment Clinical Orientation Patient Education 2004 COPYRIGHT M. Rosier, MS 31 Seeking Safety: Women’s Group Nearly 1 in 4 women from the MMTP participated in Seeking Safety groups 7 groups with female clinical co-facilitation Groups served between 5 – 12 women Most groups 26 weeks or more in duration Weekly group meetings Sessions lasted between 1 and 1 ½ hours Relationship issues, boundaries and anger management 2004 COPYRIGHT M. Rosier, MS 32 Seeking Safety: IOP/PHP Group Seeking Safety has been integrated into the IOP/PHP program for all women 2 groups with female clinical co-facilitation Twice weekly group meetings Sessions last 1 hour with extended application through out IOP/PHP program Greater emphasis on skills application into life experiences due to increased exposure Beneficial cohort effects = Increased comfort 2004 COPYRIGHT M. Rosier, MS 33 Seeking Safety: HIV Positive Group Safety and Case Management have been the central themes 1 Women’s group and 1 Men’s group Co-facilitated by female clinicians Bi-weekly for 1 ½ hours Safe coping and skills building focused Commitments tended to focus on medical issues, healthy behaviors and lifestyle 2004 COPYRIGHT M. Rosier, MS 34 Seeking Safety: Men’s Group Men’s Group remained active for over 2 years 2 groups with male clinician co-facilitation Groups served 12 men – 8 consistently Weekly group meetings Sessions lasted 1 ½ hours Termination was particularly challenging 2004 COPYRIGHT M. Rosier, MS 35 Seeking Safety: Implementation Issues Length of Session Length of Treatment 60 vs. 90 minutes Group Composition Mixed vs. Same Gender Clinician Representation Topic Selection Female vs. Male 1 vs. 2 Choice vs. Assigned Session Format Structured vs. Fluid Level of Care Entry vs. Maintenance Open vs. Closed 2004 COPYRIGHT M. Rosier, MS 36 Seeking Safety: Implementation Issues Expert Consultation On site and electronic/phone Structured Weekly Peer Supervision Ongoing Training and development Top-Down Administrative Support Utilization of Consumer Feedback Data Collection 2004 COPYRIGHT M. Rosier, MS 37 Seeking Safety: Benefits of Treatment Patients’ Self-Reported Improvements Reduced Substance Use Fewer Psychiatric Symptoms Less Hopelessness and Depression Improved Psychological Functioning Higher Quality Interpersonal Relationships 2004 COPYRIGHT M. Rosier, MS 38 Seeking Safety: Benefits of Treatment Observed Benefits of Treatment Flexible Treatment Model Increased Treatment Satisfaction Improved Problem Solving and Help Seeking Increased Ownership and Empowerment of Recovery 2004 COPYRIGHT M. Rosier, MS 39 Seeking Safety: Future Directions Treatment Outcome Research Expanded Treatment Inter-Agency Collaboration Evolution of the CT State Trauma Initiative Community Education and Awareness Continuity of Care Community Resources Database 2004 COPYRIGHT M. Rosier, MS 40 Summary People entering treatment for substance use disorders are very likely to have a trauma history Evidence-based practices now exist to effectively treat co-occurring psychological trauma/PTSD and substance use disorders Seeking Safety is a flexible, highly acceptable and feasible treatment for people with Opioid Use Disorders Seeking Safety can be implemented into the existing clinical practices of MMTPs to provide beneficial treatment that improve patient outcomes and satisfaction 2004 COPYRIGHT M. Rosier, MS 41 Presenter’s Contact Information Marshall Rosier, MS [email protected] (203) 755-8874 Alan Lee Nolan, LCSW [email protected] Lisa Najavits, Ph.D. www.seekingsafety.org Diane Heyward, MS [email protected] Michael Freeman, MS, LADC [email protected] 2004 COPYRIGHT M. Rosier, MS 42