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Transcript
Treatment for Co-occurring PTSD
and Substance Use Disorders:
State of the Science
Lisa R. Cohen, PhD
Columbia University School of Social Work
ISTSS
November 6, 2006
Hollywood, CA
Scope of the Problem

As many as 80% of women
seeking SUD treatment report
histories of sexual and physical
assault (Brady et al., 1994; Dansky et al., 1995;
FuIlilove et al., 1993; Hien & Scheier, 1996; Miller et al.
1993)

Among substance abusers, lifetime
rates of PTSD range from 14-60%
(Triffleman, 2003; Donovan et al., 2001; Najavits et al.,
1997; Brady et al., 2001)

Among PTSD populations, cooccurring substance use disorders
may occur in 60-80% of
individuals (Donovan et al., 2001)
Clinical Profile:
Women with PTSD/SUD




Majority are victims of childhood abuse
and repeated trauma
Present to treatment with high rates of
other co-morbid disorders
Have interpersonal, behavioral and
emotion regulation deficits
Abuse the most severe substances
Self-Perpetuating Cycle
Substance Use
Interpersonal
difficulties, no anger
management,
increased isolation
Complicated
Depression
Increased sleep
disturbance &
irritability
Pandora
The first woman, created by
Hephaestus (God of Fire),
endowed by the gods with all
the graces and treacherously
presented with a box in
which were confined all the
evils that could trouble
mankind.
As the gods had anticipated,
Pandora opened the box,
allowing the evils to escape.
Clinical Challenges in the Treatment
of Traumatic Stress and Addiction


Abstinence may not
resolve comorbid
trauma-related
disorders – for some
PTSD may worsen
Confrontational
approaches typical in
addictions settings
frequently exacerbate
mood and anxiety
disorders


12-Step Models often
do not acknowledge
the need for
pharmacologic
interventions
Treatments for PTSD
only —such as
Exposure-Based
Approaches often
may not be advisable
to treat women with
addictions or may be
marked by
complications
PTSD/SUD Treatments


ATRIUM: Addictions and Trauma Recovery
Integrated Model (Miller & Guidry, 2001)
Concurrent Treatment of PTSD and Cocaine
Dependence (Back et al., 2001)

Seeking Safety

SDPT: Substance Dependence PTSD Therapy
(Najavits, 1998; www.seekingsafety.org)
(Triffleman et. al, 1999)


TARGET - Trauma Affect Regulation: Guidelines for
Education and Therapy (Ford; www.ptsdfreedom.org)
Transcend
(Donovan et al., 2001)
Treatments for co-morbid PTSD
vs. PTSD only treatments

Addition of components specifically designed to
deal with coping and cognitive restructuring
related to substance use (cravings and relapse
triggers)

Concurrent Model : Additional components may
be integrated and delivered concurrently

Sequential Model: Initial phase may focus on
substance abuse related symptoms in preparation for
working on trauma related symptoms later
Seeking Safety








Developed as a group treatment for PTSD/SUD women
Structured with flexibility
Educates patients about PTSD and SUD’s and their
interaction
Based on CBT models of SUDs, PTSD treatment, women’s
treatment and educational research
Goals include abstinence and decreased PTSD symptoms
Focuses on enhancing cognitive and interpersonal coping
skills, safety and self-care
Therapist is active: teaches, supports and encourages
Includes case management component
Najavits, 2002; www.seekingsafety.org
Comparison
of Existing
Trauma and
Substance
Use
DisorderFocused
Treatment
Research
Najavits,
1998
N
27 women
17 (6 or more
sessions)
No Control
24 group
Sessions, 3
months,
2x/wk, 90min/group
TX
Seeking
Content Safety: Cog
Behavioral
Interpersonal
coping skills
Length
of TX
Follow
Up
Results
3 mo post
Improvement
on SU,
PTSD,
Depression,
increase in
somatization
Variable SU, PTSD,
Psych, Cog
Limits Small N, No
Control, Did
not follow up
Drop-outs
Triffleman,
2000
19 (10
women)
Brady,
2001
Donovan,
2001
Hien,
2004
39 (82%
women)
15 (10 or
more
sessions)
No Control
16 sessions,
individual, 90
min sessions
46 men
107 women
No Control
12 weeks,
partial hosp,
10 hrs/week
RCT
3 months,
individual
SDPT
(Coping,
CBT, Stress
Inoc, In Vivo,
RP-2 phase)
vs 12 step
1 mo post
Exposure
Therapy &
CBT
CBT, RP &
peer social
support (2phase)
Seeking
Safety/CBT
vs RPT vs
TAU
6 mo post
6/12 mo post
6/9 mo post
Improvement
on SU,
PTSD,
psych, No
gender
differences
SU, PTSD,
ASI psych
Small N,
Short FU
period
Improvement Improvement Improvement
in SU, PTSD in PTSD, SU @ 6 mo,
&
diminished
Depression
at 9 mo, no
diff b/t exp
and control
SU, PTSD,
SU, PTSD
SU, PTSD,
Depression
Psych
Small N, No
Small N, No
NonControl, large Control, 30
randomized
drop out rate
day
TAU
abstinence
required, one
site
RCT
5 months (20
wks), 2x/wk,
individual
Women, Co-occurring Disorders &
Violence Study (SAMHSA)

Multi-site national trial (9 sites) examining

Core Treatment Components
implementation and effectiveness of treatment modalities
for women with mental health, substance use and trauma
histories








Outreach and engagement
Screening and assessment
Treatment activities
Parenting skills
Resource coordination and advocacy
Trauma-specific services
Crisis intervention
Peer-run services
Summary




CBT, including exposure therapy, shows promise
in treating PTSD/SUD
PTSD treatments did not make patients worse,
improved PTSD, substance use and general
psychiatric symptoms
Integrated counseling may be one of the key
program features that impacts outcomes.
More research needed to examine the duration,
scope, timing and combination of components to
identify optimal model of PTSD/SUD treatment
integration
Challenges to Implementing
Trauma-focused Interventions
in Substance Abuse
Treatment Programs
Lisa Caren Litt, Ph.D.
Columbia University College of Physicians and Surgeons
Women’s Health Project Treatment and Research Center
ISTSS, November 6, 2006
Hollywood, CA
Integrating Trauma
Treatment
Trauma-Informed Treatment
vs.
Trauma-Specific Treatment
Trauma-specific treatment
is not enough.
Creating a Trauma-Informed
Addiction Treatment System
Lessons from the WCDVS*




Outreach and
Engagement
Screening and
Assessment
Substance Abuse and
Mental Health
Treatment
Parenting Skills




Resource Coordination
and Advocacy
Trauma-specific Services
Crisis Intervention
Peer-Run Services
(Consumers / Survivors / In
Recovery)
*WCDVS information is drawn from www.prainc.com/wcdvs.
Trauma-Informed Services:
Characteristics (WCDVS)

Aware of the role of violence and victimization in
women’s lives .

Minimize victimization and re-victimization.

Hospitable and engaging for survivors.

Facilitate recovery.

Empower.

Respect a woman's choices and control over her
recovery.

Goals are mutual and collaboratively established.

Emphasize women’s strengths.
Trauma-Informed Services:
Principles (WCDVS)


Respect trauma as a central concern in a
woman’s life.
Symptoms are adaptations to traumatic
experiences.

Reframe ‘Adaptive’ behavior as positive coping.

Violence and trauma have broad impact.

Providers need to meet the woman where she
is.
Introducing
Trauma-Specific Treatment






Counselor Buy In
Challenges to Agency and Treatment
Philosophies
Protocol Training
Safety
Supervision
Counselor Self-care
Should I or Shouldn’t I?

Why counselors may be hesitant to provide
trauma treatment

Pandora’s box: Fear
Clients and/or Counselors will become overwhelmed.
 Clients will relapse, act out or drop out.
 Clients will become threatening or destructive to self or
others.

Should I or Shouldn’t I?

Why counselors may be hesitant to provide
trauma treatment

Personal history
Addiction history and recovery
 Survivors of trauma themselves; increased
vulnerability

What do Counselors
Need to Learn?
Try Something New

Treatment that differs from the Counselor’s own
past treatment.



Treatment is not one-size-fits-all.
Addiction treatment that pays attention to
abuse.
Treatment that challenges traditional substance
abuse treatment models

Medical (Disease) Model

12 Step Model

Confrontational Methods
Difficult 12 Step Concepts for
Survivors in Recovery

Surrender your power.

Surrender to a higher power.

Get off your pity potty.
Philosophical Differences

Abstinence vs. Harm Reduction



What is the Agency response to
lapse/relapse?
Harm reduction can be a path to Abstinence
Compassion and collaboration
Why Use Manualized
Trauma Treatment?

Psychoeducation for survivors

Structure for Clients and Counselors

Less opportunity to go too deep

Time-limited possibilities
Developing a New Stance

Identify Counselor skills sets.

Collaborate, Don’t Dominate.

Validate and support.

Notice non-verbal communication.

In group, keep members safe.

Work within the “therapeutic window” (Briere).

Motivational interviewing strategies are helpful,
and not just for substances.
Client and Counselor Safety

Managing an angry and aggressive client

“Tool box” not Pandora’s box

Child welfare involvement

Intimate partner violence
The Counselor Should Not
Feel Alone

Trauma specialists



In Agency
In the Community
Get the client off to a good start



Attending to trauma as part of recovery
Stabilize
Most trauma processing will follow
Potential for
Vicarious Traumatization



Sensitivity for Counselor survivors
Conducting trauma treatment should be
voluntary
Supportive environments


Moderate caseloads
Regular supervision
Supervision is Critical

Protocol training is only the beginning.

A safe place.

Individual or group supervision.

Should not be on the ‘back burner’.

Ensure fidelity to the treatment.

Are audio or video recordings possible?
About Direct Observation

“It seems very frightening at first—you
risk being naked in front of your peers—
but, if the people watching you are
generous and supportive, it is actually a
great relief. You discover that you don’t
really have to hide anything; your work
has been seen and validated, which is
something you can carry with you for the
rest of your life.”
David Treadway, quoted in Wylie & Markowitz, 1992, p.29
Counselor Self-Care

Practice what you preach

Rest and exercise

Opportunities for personal renewal

Personal therapy
NIDA Clinical Trials Network
Women’s Treatment for Trauma
and Substance Use Disorders:
Issues in Training and Assessment
Aimee Campbell, MSW
Columbia University School of Social Work
ISTSS, November 6, 2006
Hollywood, CA
NIDA Clinical Trials Network
Women & Trauma Sites
Washington Node
Residence XII
New England Node
LMG Programs
Ohio Valley Node
Maryhaven
New York Node
ARTC
Long Island Node
Lead Node
South Carolina Node
Charleston Center
Florida Node
Gateway Community
Florida Node
The Village
Pre-Post Control Group Design
Pre-Treatment
1 - 4 Weeks
Pre-screening, Screening, Baseline,
Randomization, Individual
Counselor Session
Treatment
6 Weeks
Post Treatment
Follow-up
46 Weeks
12 Twice Weekly Group Sessions
1 Week
3 Month
6 Month
12 Month
Participant Eligibility Criteria
Inclusion
 female, 18 - 65 years old
 used an illicit substance within the past six months and have a
current diagnosis of illicit drug/alcohol abuse or dependence
 PTSD or Sub-threshold PTSD
 enrolled at participating community treatment program
Exclusion
 advanced stage medical disease (AIDS, TB)
 impaired mental status (MMSE: less than or equal to 21)
 significant risk of suicidal/homicidal intent or behavior
 history of schizophrenia-spectrum diagnosis
 active psychosis (prior 2 months)
 involved in PTSD-related litigation
 refuses to be audio or videotaped
Assessment Measures











Demographics
Substance Abuse/Dependence Diagnosis (CIDI)
Substance Use (past 7, 30 days (ASI, SUI)
Biological Measures of Substance Use
PTSD Diagnosis (CAPS)
PTSD Symptom Severity (PSS-SR)
Psychiatric Symptoms (BSI)
Other Service Utilization (medication)
General Health, Social Network
HIV Risk Behaviors
Child/Adult Physical/Sexual Violence
PTSD Assessment

Clinician Administered PTSD Scale (CAPS)

DSM-IV symptom clusters
A: Exposure
 B: Re-experiencing
 C: Avoidance
 D: Arousal



Subthreshold PTSD: criteria A, B, C or D, E
(duration of at least 1 month) and F (clinically
significant impairment).
Independent assessor training and ongoing
supervision and adherence monitoring by
expert supervisor
Blake, D.B., Weathers, F.W., Nagy, L.M., Kaloupek, D.G., Gusman, F.D., Charney, D.S., Keane, T.M., 1995. The development of a
Clinician-Administered PTSD Scale. J Trauma Stress. 8, 75-90.
Enrollment
Initial Screen
N=1,963
Ineligible
N=751
Eligible
N=1,212 (62%)
No Full Screen
N=751
Completed Full Screen
N=541
Ineligible
N=162
Eligible
N=379 (70%)
Not Randomized
(multiple reasons)
Randomized
N=353 (93%)
N=26
Sample Characteristics (N=353)
Variable
percent or M (S.D.)
Age (years)
Race/ethnicity
39.2 (9.3)
Hispanic or Latino
Black/African American
White
Mixed
Other
6.5
34.0
45.6
13.3
0.6
Married
Widowed/Divorced
Never Married
33.3
29.3
37.4
Marital status
Sample Characteristics (n=353)
Variable
percent or M (S.D.)
Monthly income ($)
Education level (years)
Employment
539.4 (1176.9)
12.6 (2.4)
Employed
Unemployed
Student
Retired or Disabled
Number children living with
Number previous treatment episodes (lifetime)
Controlled environment (past 30 days)
Days in a controlled environment (past 30 days)
40.5
54.6
1.4
3.5
0.7 (1.1)
5 (7.9)
25.6
13.9 (8.9)
PTSD Diagnosis and Severity
at Baseline (n=353)
PTSD Diagnoses and Severity Scores
Current Full PTSD
Current Subthreshold PTSD
CAPS Total Score
Subscale B (re-experiencing)
Subscale C (avoidance)
Subscale D (hyperarousal)
percent or M (S.D.)
80.4
19.6
62.8 (19.4)
16.9 (6.8)
25.6 (10.2)
20.3 (7.6)
Substance Use Disorders
at Baseline (n=353)
Substance Use Diagnosis
Current Alcohol Use Disorder Diagnosis
Current Marijuana Use Disorder Diagnosis
Current Opioid Use Disorder Diagnosis
Current Cocaine Use Disorder Diagnosis
Current Stimulant Use Disorder Diagnosis
percent
62.0
35.4
33.1
72.8
8.2
Lifetime Trauma Exposure
(n=353)
Lifetime Traumatic Experiences
Natural Disaster
Transportation Accident
Physical Assault
Childhood Physical Abuse
Lifetime Physical Abuse
Sexual Assault
Childhood Sexual Abuse
Lifetime Sexual Violence
Captivity
Life-threatening Illness
Sudden, Violent Death
percent
53.1
72.7
58.7
93.8
70.1
89.5
40.3
39.8
19.3
Treatment Groups

Seeking Safety (SS; Najavits, 1998)
Short term, manualized treatment
 Cognitive Behavioral
 Focused on addiction and trauma


Women’s Health Education (WHE)
Short term, manualized treatment
 Pyschoeducational, didactic
 Focused on understanding women’s health
issues and empowerment

Seeking Safety Topics






Safety
PTSD: Taking Back Your
Power
Detaching from Emotional
Pain
When Substances Control You
Taking Good Care of Yourself
Compassion






Red and Green Flags
Honesty
Integrating the Split
Self
Creating Meaning
Setting Boundaries in
Relationships
Healing from Anger
Women’s Health Education Topics






Body Systems
Female anatomy
Breast care
Infections
HIV
Contraception






Pregnancy
STDs
Nutrition
High Blood Pressure
Diabetes
Menopause
Who were the clinicians?




All female staff
Agreed to randomization, videotaping and
research monitoring
Demonstrated ability to conduct
manualized, problem-solving session prior
to randomization
Had no prior experience with study
interventions
Counselor and Supervisor
Demographics
Counselors
n=18
Supervisors
n=18
38.0
41.8
9 (50.0)
5 (27.8)
4 (22.2)
12 (66.7)
5 (27.8)
1 (5.5)
Yrs in Substance Abuse: M
4.8
9.0
Years at Program: M
3.9
4.8
1 (5.5)
7 (38.9)
10 (55.6)
1 (5.5)
2 (11.1)
15 (83.3)
13 (72.3)
4 (22.2)
1 (5.5)
15 (83.3)
2 (11.1)
1 (5.5)
Age: M
Race: N (%)
White
Black/African American
Hispanic/Latina
Highest Degree: N (%)
>Bachelors Degree
Bachelors Degree
Master’s Degree/Doctorate
In Recovery: N (%)
No
Yes
Prefer not to answer
Intervention-Specific
Training Elements



3-day group training
Explanation, demonstration and role-play
Post-training certification



Counselors and supervisors conducted pilot
groups
Supervisors coded counselors’ sessions and
compared ratings with lead experts
Train-the-trainer model

Used for supervisor training
Research-within-Practice
Challenges

The Therapeutic Misconception



Research is not treatment
Protocol adherence is key
Avoiding cross-contamination


Need to keep interventions separate
Can’t share information with other colleagues
or clients
Ongoing Supervision and
Monitoring


Supervisors attended weekly supervision
teleconferences with Lead Node experts in
the respective intervention
Calls included discussion of specific issues,
review of session tapes and adherence
ratings
Adherence Monitoring

Counselors



Supervisors rated 50% of cases and gave
feedback based on ratings
Cut-offs for continued participation in trial and
guidelines for retraining
Supervisors

Lead node experts rated 25% of sessions
rated by local supervisors and gave feedback
on level of agreement
Treatment Fidelity
Site Adherent
(%)
Lead Adherent
(%)
Site/Lead
Adherence
Agreement
N (%)
SS
60.0
78.3
60 (68.3)
267 (73.8)
WHE
80.3
80.3
71 (94.4)
206 (90.3)
Total Adherent
at Site
N (%)
Treatment Attendance
Treatment
Group
N
Mean
SD
Median
SS
170
6.3
4.4
7
WHE
172
5.9
4.3
6.5
Counselor and Supervisor
Benefits



Expanded skills in delivering and
supervising interventions
Became more comfortable using treatment
manuals and working explicitly with
women with co-occurring disorders
Sustainability and interest after conclusion
of trial
Counselor and Supervisor
Challenges



Rolling admission groups and no-shows led
to delays in providing interventions
TTT model led to counselors feeling less
involved in the process
Adherence monitoring




Counselor issues
Supervisor issues
Participant characteristics
Time commitment
Summary



Training, supervision and implementation
require time and commitment from all
levels of staff
Involve counselors and supervisors in
ongoing supervision from “lead node”
Ensure adequate training in research
process, procedures and special need of
patient population
Summary
Consistent across sites:
 High levels of multiple trauma exposure with
clinically significant PTSD symptoms.
 High percentage of sexual assaults (range=85%100%).
Differences across sites:
 Types of other traumatic experiences reported.
 Types of drugs used and drug diagnosis.
 Continued levels of substance use.
 Recruitment success linked to type of CTP
population and number of available intakes.
Implications


Though all participants met PTSD and SUD
diagnoses as per study inclusion criteria, findings
show that within this sample population there was
substantial variability across sites in terms of types
of trauma exposure, types of drugs used and
specific drug use diagnoses.
Clinicians and researchers need to be aware of the
potential for such differences when developing or
delivering treatment interventions so as to best
meet needs of this heterogeneous group.
Support

Participation in this study made possible by:



NIDA CTN Long Island Regional Node
NIDA/NIH Grant U10 DA13035
We would like to acknowledge the
dedication of staff and resilience and
strength of the participants who made this
study possible.