Download Treating Offenders with Substance Abuse and Posttraumatic

TREATING OFFENDERS WITH
SUBSTANCE ABUSE AND
POSTTRAUMATIC STRESS DISORDER
Douglas L. Delahanty
Kent State University
Alec Boros
Oriana House
Overview
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Introduction to PTSD
Comorbidity of PTSD/SUD
Intervention: Prolonged Exposure
Using PE with SUD Clients
The KSU-Oriana House Studies on PTSD
Challenges of treating offenders in community
corrections
Alternatives for treatment in Community
Corrections
Introduction to PTSD
DSM-IV Diagnostic Criteria for
PTSD
 Exposure to a traumatic event in which the person:
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experienced, witnessed, or was confronted by death or serious
injury to self or others AND
responded with intense fear, helplessness, or horror
 Symptoms
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appear in 3 symptom clusters: re-experiencing,
avoidance/numbing, hyperarousal
last for > 1 month
cause clinically significant distress or impairment in functioning
American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders, 4th ed. 1994.
DSM-IV Diagnostic Criteria for
PTSD
 Reexperiencing
 Persistent re-experiencing of  1 of the following:
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recurrent distressing recollections of event
recurrent distressing dreams of event
acting or feeling event was recurring
psychological distress at cues resembling event
physiological reactivity to cues resembling event
American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders, 4th ed. 1994.
DSM-IV Diagnostic Criteria for
PTSD
 Avoidance and Numbing
 Avoidance of stimuli and numbing of general
responsiveness indicated by  3 of the following:
 avoid thoughts, feelings, or conversations
 avoid activities, places, or people
 inability to recall part of trauma
  interest in activities
 estrangement from others
 restricted range of affect
 sense of foreshortened future
American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders, 4th ed. 1994.
DSM-IV Diagnostic Criteria for
PTSD
 Hyperarousal
 Persistent symptoms of increased arousal  2:
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difficulty sleeping
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders, 4th ed. 1994.
DSM 5 PTSD Criteria
 As of May 2013, the DSM 5 has contained slightly different
PTSD diagnostic criteria
 Symptoms are mostly the same
 The 3 clusters of DSM-IV symptoms will be divided into 4 clusters in
DSM-5: intrusion symptoms, avoidance symptoms, arousal/reactivity
symptoms and negative mood and cognitions.
 Criterion A2 (requiring fear, helplessness or horror happen
right after the trauma) will be removed.
 Based on the proposed DSM-5 criteria, the prevalence of
PTSD will be similar to what it is currently in DSM-IV.
Incidence of PTSD
 69% of civilians report experiencing a traumatic event (Norris,
1992; Resnick et al., 1993)
 Affects more than 10 million American children or adults
(National Center for PTSD, 2001)
 Lifetime prevalence in the U.S. is 6.8%, making it the third
most common anxiety disorder (Kessler et al., 2005)
 Females are at approximately 2x greater risk than males
Prevalence of Trauma and
Probability of PTSD
40
Prevalence of Trauma
Male
Female
30
%
20
10
0
Witness
Accident
Threat w/
Weapon
Combat
Rape
Accident Threat w/ Physical Molestation Combat
Weapon
Attack
Rape
70
60
50
% 40
30
20
10
0
Physical
Attack
Molestation
Probability of PTSD
Witness
Kessler R et al. J Clin Psychiatry. 2000;61(Suppl 5):4-14.
Kessler R et al. Arch Gen Psychiatry. 1995;52:1048-1060.
Consequences of PTSD
 Negative impact on affect regulation, attention,
cognition, interpersonal relationships and
neuroendocrinology (Hart et al.,1995; Maughan & Cicchetti, 2002;
Putnam et al., 1997)
 Increased risk for:
 Physical health problems (Pacella, Hruska, & Delahanty, 2013)
 Unemployment (Smith, Schnurr, Rosenheck, 2005)
 Relationship problems (Riggs, Byrne, Weathers, & Litz, 1998)
 Suicide (Marshall et al., 2001)
Psychiatric Comorbidity in PTSD
Psychiatric Comorbidity in PTSD
(Pietrzak, Goldstein, Southwick, & Grant, 2011)
Psychiatric Comorbidity in PTSD
Males
Females
Comorbidity (%)
60
50
40
30
20
10
0
Major
Depressive
Episode
GAD
Panic
Disorder
Social
Drug
Anxiety Agora Alcohol
Abuse/
Disorder phobia Abuse/
Dependence Dependence
Kessler R et al. Arch Gen Psychiatry. 1995; 52:1048-1060.
SUD-PTSD Comorbidity
 46.4% of people with PTSD meet criteria for one or more SUDs
(Pietrzak, Goldstein, Southwick, & Grant, 2011)
 Comorbidity rates of substance abuse/dependence in PTSD are
high (up to 43%) (Breslau, Davis, & Schultz, 2003; Deering, Glover, Ready,
Edelman, & Alarcon, 1996; Friedman, 1991; Friedman & Yehuda, 1995; Kessler,
Sonnega, Bromet, Hughes, & Nelson, 1995).
 PTSD rates range from 30-50% in substance abusers (Dansky,
Roitzsch, Brady, & Saladin, 1997; Mills, Lynskey, Teesson, Ross, & Darke, 2005)
 253 Australian detox inpatients (Dore et al., 2012)
 80% experienced > 1 trauma
 45% screened for PTSD
PTSD-SUD is associated with
significant impairment
 More severe alcohol problems
(McFall, MacKay, & Donovan, 1992)
 Greater utilization of addiction treatment services
(Brown,
Stout, & Mueller, 1999)
 Higher relapse rates, poorer treatment outcomes (Jacobsen et al., 2001; Read et al.,
2004)
 More severe PTSD symptoms
(Hien, Campbell, Ruglass, Hu, &
Killeen, 2011; Saladin, Brady, Dansky, & Kilpatrick, 1995)
PTSD-SUD is associated with
significant impairment, cont’d
 Less successful PTSD treatment
(Perconte & Giger, 1991)
 Greater medical, social and employment costs than
either disorder alone (Neuman et al., 2012; Brady et al., 2004; Brown et al.,
1994)
 Psychiatric comorbidity in SUD patients can serve as a
barrier to successful SUD engagement and treatment at
every stage of the process
Theories of Comorbidity: SUD and PTSD
 The self-medication hypothesis
 The high risk hypothesis
 The susceptibility hypothesis
 The substance-induced anxiety enhancement
hypothesis
 The shared vulnerability hypothesis
Stewart & Conrod, 2008; Hruska and Delahanty, in press
Comorbidity Theory:
Self-Medication Hypothesis
 PTSD temporally precedes SUD and leads to
the development of substance use problems as
the individual attempts to self-medicate the
negative affect associated with their trauma
symptoms.
Comorbidity Theory:
High Risk Hypothesis
 Substance use puts one at risk for exposure to
traumatic events and subsequently, PTSD.
Substance use precedes PTSD.
Comorbidity Theory:
Susceptibility Hypothesis
 The use of substances increases the likelihood of
developing PTSD following a traumatic event.
Substance use precedes PTSD.
Comorbidity Theory:
Substance-induced anxiety enhancement hypothesis
 SUD leads to the development of PTSD symptoms
following trauma because SUDs affect the
functioning of the body’s stress response system
Comorbidity Theory:
Shared vulnerability hypothesis
 PTSD and SUD onset occur near the same time due
to a shared vulnerability (genetic/physiological/
underlying risk factors) common to the development
of both disorders
Tension Reduction Model
 Neuroendocrine, neuroanatomical, and genetic research
support the tension reduction model (Hruska & Delahanty, in press)
 Trauma or PTSD diagnosis precedes the onset of alcohol or
substance abuse (Bremner et al., 1996; Clark & Jacob, 1992; Davidson et al.,
1985, 1990)
 Having PTSD increased the risk of developing a subsequent
SUD, but presence of drug abuse or dependence did not
substantially increase risk for developing PTSD (Chilcoat and Breslau,
1998)
 PTSD symptoms mediate the relationship between prior
trauma and alcohol use in adult women (Epstein, Saunders, Kilpatrick, &
Resnick, 1998).
Tension Reduction Model
 As trauma victims with PTSD may self-medicate with substances to
decrease the intensity of PTSD symptoms, decreasing PTSD
symptoms through empirically supported therapies may be
associated with a decrease in substance use/abuse.
 Failure to address underlying PTSD symptoms results in greater
SUD relapse rates, further reinforcing the importance of
addressing psychopathological barriers to SUD treatment success
(Brown et al., 1999)
Intervention: Prolonged Exposure
Prolonged exposure therapy (PE)
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PE therapy has been found to be effective in the
treatment of PTSD and comorbid symptoms across
several controlled studies
Most appropriate form of treatment for PTSD
(Ballenger et al., 2000)
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PE aims to reduce the fear or anxiety associated
with the trauma by encouraging patients to
repeatedly confront fear-evoking stimuli (Foa et al.,
2007)
PE: Mechanisms
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Repeated imaginal exposure facilitates habituation and
reduction of anxiety associated with the traumatic memory
By imagining and discussing the traumatic event with a
supportive therapist, the patient begins to realize that thinking
about the trauma is not dangerous
PE: Mechanisms
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Through imaginal exposure to the trauma memory and in vivo
exposure to external cues, the patient begins to differentiate
the traumatic event from other situations, decreasing
generalization of fear responses
Following repeated exposure, the patient achieves a sense of
mastery that contradicts the typical view of symptoms reflecting
weakness
Prolonged Exposure
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Equally efficacious in African-Americans and Whites
Effective in treating victims from a wide range of traumas
including war experiences, rape, assault, crime, and
samples including victims of a variety of different traumas
Effective in treating individuals who have been multiply
traumatized and patients who suffer from complex PTSD
PE compared to other approaches
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PE is more effective and efficient than:
 relaxation
training
 eye movement desensitization and reprocessing (EMDR)
 counseling
 stress inoculation training (SIT)
 combination therapy involving both PE and SIT, especially
at longer-term follow-up assessments
Prolonged Exposure
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10 sessions conducted twice per week for 5 weeks.
Each session lasts between 90-120 minutes.
Include education about common reactions to
trauma, breathing retraining, prolonged (repeated)
imaginal exposure to trauma memories, repeated in
vivo exposure to situations the client is avoiding due
to trauma-related fear, and discussion of thoughts
and feelings related to exposure exercises.
Session 1
Begins with an overview of the treatment program
and a general rationale for exposure. The therapist
gathers information focusing on the client’s
symptoms, details of the trauma, history of previous
trauma, and social and occupational functioning.
Breathing retraining is introduced and the client
practices breathing techniques. Homework consists
of daily breathing exercises, listening to the tape of
the session, and reviewing the "Rationale for
Treatment" handout.
Session 2
Focuses on education, treatment planning, and
development of the in vivo exposure hierarchy. The
therapist provides an explanation of PTSD, discusses
common reactions to trauma, discusses a rationale
for the treatment, and provides a description of
each treatment component. The use of Subjective
Units of Distress (SU) ratings is explained. A list of
avoided situations is compiled and an exposure
hierarchy is developed.
Session 3
Reviews the rationale for PE and introduces
prolonged imaginal exposure. The client is guided
through 60 minutes of imaginal reliving of the focal
trauma. The client is instructed to relive the trauma
as vividly as possible, and to recount it aloud in the
present tense. This procedure is repeated until the
exposure period is expended. SU ratings are
obtained every 5 minutes and vividness ratings are
taken every 10 minutes.
Sessions 4-9
Focus on imaginal exposure for 45-60 minutes,
followed by discussion of any thoughts and feelings
provoked by the reliving. During imaginal exposure,
the therapist asks specific questions to clarify the
client's thoughts, feelings, and physical reactions while
reliving the trauma to facilitate confrontation with
fear-evoking cues. The parts of the scenario that are
the most anxiety-producing for the client are identified
and emphasized in repeated exposure.
Session 10 (Termination)
Imaginal exposure lasts 30 minutes. The therapist
and client review treatment progress and discuss
applications of treatment principles to daily life.
This discussion will address the potential for
temporary increases in PTSD symptoms, and how
these can be managed. At this time, the therapist
and client will evaluate progress and determine
whether additional sessions or referral may be
worthwhile.
Using Prolonged Exposure for individuals
with PTSD and Substance Abuse
PE in SUD populations
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Initial concern was risk for substance use relapse
 six
male veterans undergoing imaginal flooding
therapy for PTSD, 3 out of 4 of the patients with current
or past histories of alcoholism relapsed to alcohol
abuse (Pitman et al., 1991)
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More recent examinations of the efficacy of PE
have not found consistent relationships between
substance use and treatment outcome or dropout
PE in SUD populations (Cont,d)
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Interventions developed to treat comorbid SUD and
PTSD have incorporated imaginal exposure
Exposure therapies have demonstrated efficacy in
reducing PTSD severity in SUD-PTSD patients
Patients who have received PE reported fewer
cravings than those who did not
We have also demonstrated the efficacy of PE in a
study of HIV+ individuals, 60% of whom reported
substance use at the start of the protocol
PEACH Study (Pacella et al., 2012)
 Examine the efficacy of PE at:
 Reducing HIV related and non- HIV related PTSD
symptoms in PLWH
 Reducing depressive symptoms
 Increasing adherence
Participants
 43 participants
 Age (M = 46.39)
 29 Males; 14 Females
 49% African American; 45.1% Caucasian; 5.9% Hispanic
 Years living with HIV (M = 13.1; range: 1-27 years)
 Income: 84% Under $20,000
Pre-Screen (N = 99)
Eligible (N = 65)
Ineligible (N = 34)
Intervention
Weekly monitoring
control group
Baseline (N = 34)
Baseline (N = 25)
Post-intervention (N = 24)
Post-intervention (N = 23)
3-month Follow-up
(N = 19)
3-month Follow-up
(N = 24)
Treatment Conditions
 Prolonged Exposure:
 Focused on the most traumatic event they’ve
experienced
 10 sessions; 5 weeks
 Weekly Monitoring/Wait-list group
HIV related PTSS
30
Control
Experimental
HIV related PTSS
25
20
15
10
5
0
Baseline
Post-intervention
3-month follow-up
Non-HIV related PTSS
35
Control
Non-HIV related PTSS
30
Experimental
25
20
15
10
5
0
Baseline
Post-intervention
3-month follow-up
Depression
30
Control
Experimental
25
Depression
20
15
10
5
0
Baseline
Post-intervention
3-month follow-up
Peach Study (Pacella et al., 2012):
Conclusions
 Overall, PE was readily accepted by PLWH and was
efficacious in reducing symptoms of:
 PTSS for HIV and non-HIV related trauma
 Depressive symptoms
 PE was not associated with exacerbation of self-reported
substance use (SU). The control group went from an
average of 7 instances of SU in the last week at baseline to 2
at post-intervention to 7 at 3-month follow-up, while the PE
group went from 3 at baseline to 2 at post-intervention to 4.5
at 3-month follow-up.
 PE and control participants did not significantly differ on
adherence variables
The KSU-Oriana House Studies
on PTSD
The KSU-Oriana House Studies
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Detox patient studies:
The KSU- Summit County ADM Crisis Center Study (Hruska et
al., in press)
 The Life Experiences and Drug Dependence Study (Ongoing)
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Prolonged Exposure and Motivational Interviewing Study (PE-MI)
Residential
 Community Based Correctional Facility (Just started)
Non Residential
 Summit County Felony Drug Court (grant funded, started in 2013)
KSU-Oriana House Studies on Detox
Populations
Prevalence of Trauma in Detox studies
%
Studies on Detox Populations
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For the first two detox studies… 42.2% (195/462) meet criteria
for PTSD
The incidence of trauma is significantly greater in detox than in the
general population
On the average, a detox clients experiences seven different types
of trauma
Studies on Detox Populations
Those with PTSD experience greater
impairment in a variety of domains
Detox
Clients
with PTSD
Detox
Clients w/o
PTSD
Experience more traumatic events
9.5
5.6
More likely to have depression
56.6
28.2
Report worse alcohol withdrawal symptoms
14.6
10.4
Report worse opiate withdrawal symptoms
28.5
23.5
Report more severe negative consequences due to their addiction
120.9
92.8
Using a greater number of addictive substances
39.8
32.4
Prolonged Exposure and Motivational
Interviewing Study (PE-MI) at Detox
• Where: ADM Crisis Center Detox facility
• Purpose: To implement intervention to clients
during wait period for substance use treatment
• Intervention: Conduct 9-10 PE sessions with two
MI sessions before entering SUD treatment
Detox PE-MI Study, cont’d
 Difficult to implement
 19 total participants recruited
 1 did not meet PTSD criteria
 5 excluded for bipolar disorder, suicidality
and/or current DV relationship
 5 completed first or second session only
 5 never showed for first appt.
 2 completed more than 5 sessions
Detox PE-MI Study, cont’d
• Challenges to PE-MI study
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•
•
•
Transportation
Chaotic lifestyles
Lack of means to communicate (cell phone, email, etc.)
Lack of case management
– Needed help obtaining housing, food, clothing etc.
– Majority of clients were homeless and didn’t have any
support
– Difficult to implement intervention when basic needs aren’t
being met
Prolonged Exposure Treatment
Engagement study (PETE)
• Where: Male and female CBCF facilities in
Akron, OH
• Purpose: Remove trauma-related
psychological barriers to engagement in
substance use treatment
• Intervention: Implement 10 sessions of PE to
clients prior to beginning their SUD treatment
within the facility
PETE study, cont’d
 Why is a correctional setting better?
 Removal of basic barriers to treatment(i.e. shelter,
food, clothing)
 No need for transportation
 Have social support within facility
 Limited access to the outside, allowing for focus of
developing skills to manage stress
 Limited wait period to begin substance use
treatment
The Summit County Felony
Drug Court Program (SCFDC)
 Summit County Felony Drug Court (SCFDC) started in 2002
 931 participants as of 2012
 Caucasian = 77%
 Male= 65%
 Unemployed= 58%
 Average age= 33
SCFDC, cont’d
 Enhancement Grant from BJA and SAMHSA in 2013
 Three Enhancements
 Opiate Specific Track
 Suboxone program for those opiate users that are
interested
 PTSD Track
SCFDC: Screening Assessment Process
All Drug Court
Clients
N=110
17
PCL
Assessment
Continued
Observation
n=40
No further
follow-up
n=47
Met less strict
criteria for PTSD
n= 6
85
Screened as
indicating PTSD
n=23
CAPS
Assessment
Individual
Counseling
n= 14
Not meeting
PTSD criteria
n= 1
44
Met strict
criteria for PTSD
n= 5
Refused further
assessment or
not yet
assessed
n= 11
SCFDC: PTSD Screening and Gender
Females
n=44
Females:
Screened positive
for PTSD
n=12 (27.3%)
Males
n= 56
Females:
Monitored based on
clinical judgment for
PTSD
n=18 (40.9%)
Females:
no intervention
needed
n=14 (31.8%)
Males:
Screened positive
for PTSD
n=11 (19.6%)
Males:
Monitored based on
clinical judgment for
PTSD
n=22 (39.3%)
Males:
no intervention
needed
n=23 (41.1%)
Challenges of treating offenders in
a community corrections
Challenges, cont’d
 Therapist Gender Issues
 Addressing Comorbidities in a correctional population
 Issue: Alcohol and Drugs
 Issue: Bipolar Disorder
 Cost of Therapist
 Inability to sanction clients for not attending PE sessions
 Private Space for homework
Challenges, cont’d
 Time Factor
 Issue: Other demands on time
 Cognitive skills (criminal thinking errors)
 Substance abuse
 Employment (restitution, court costs, child support)
 Other day-to-day issues
 Issue: When should the screening tool and assessments be given
 Upon entrance to Drug Court may not be the best time
 Effects of recent drug use
 Issue: When should Prolonged Exposure be placed in the
pecking order of other treatment and correctional demands?
Challenges of treating offenders in
a community corrections
Alternatives for treatment in
Community Corrections
 Recent Adjustments to Accommodate Felony Drug Offenders
 Transitioning clients that would benefit from PE
 Currently use individual counseling sessions and active review
and check-up with patients to discuss substance abuse and PTSD
issues
 Potential Adjustments to Accommodate Felony Drug Offenders
 Requiring clients who are diagnosed with PTSD to attend at least
the first two sessions of PE
 Clinical judgment and patient must agree to attend further
sessions
 If not, other PTSD treatments may be offered such as Seeking
Safety
Alternatives for treatment in
Community Corrections
 Potential Adjustments: Seeking Safety curriculum
 help transition clients into PET
 Developed in early 1990’s
 Addresses both trauma/PTSD and substance abuse
 25 topics usually given over 12-weeks
Alternatives for treatment in
Community Corrections
Advantages of using Seeking Safety:
 Group and individual
 Either gender, adults/adolescents
 Substance abuse/ substance dependence
 Can be used for clients with trauma history but meeting PTSD
criteria
 Can be conducted as an open group
 Lessons can be given in any order
Has QA/CQI tools to be used to measure clinicians adherence to
program
More information at www.seekingsafety.org
Questions?
Douglas L. Delahanty
Department of Psychology
Kent State University
P.O. Box 5190
Kent, OH 44242
[email protected]
Alec P. Boros
Research Manager
Oriana House, Inc.
P.O. Box 1501
Akron, OH 44309
[email protected]