Treatment for Co-occurring PTSD and Substance Use Disorders: State of the Science

1
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

2
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, co-occurring substance
  use disorders may occur in 60-80 of individuals
  (Donovan et al., 2001)

3
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

4
Self-Perpetuating Cycle
Substance Use
Interpersonal difficulties, no anger management,
increased isolation
Complicated Depression
Increased sleep disturbance irritability
5
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.

6
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

7
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 (Najavits, 1998
  www.seekingsafety.org)
• SDPT Substance Dependence PTSD Therapy
  (Triffleman et. al, 1999)
• TARGET - Trauma Affect Regulation Guidelines for
  Education and Therapy (Ford www.ptsdfreedom.org)
• Transcend (Donovan et al., 2001)

8
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

9
Seeking Safety

• Developed as a group treatment for PTSD/SUD women
• Structured with flexibility
• Educates patients about PTSD and SUDs and their
  interaction
• Based on CBT models of SUDs, PTSD treatment,
  womens 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
10
Comparison of Existing Trauma and Substance Use
Disorder- Focused Treatment Research
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Women, Co-occurring Disorders Violence Study
(SAMHSA)

• Multi-site national trial (9 sites) examining
  implementation and effectiveness of treatment
  modalities for women with mental health,
  substance use and trauma histories
• Core Treatment Components
• Outreach and engagement
• Screening and assessment
• Treatment activities
• Parenting skills
• Resource coordination and advocacy
• Trauma-specific services
• Crisis intervention
• Peer-run services

12
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

13
Challenges to Implementing Trauma-focused
Interventions in Substance Abuse Treatment
Programs

• Lisa Caren Litt, Ph.D.
• Columbia University College of Physicians and
  Surgeons
• Womens Health Project Treatment and Research
  Center
• ISTSS, November 6, 2006
• Hollywood, CA

14
Integrating Trauma Treatment

• Trauma-Informed Treatmentvs.
• Trauma-Specific Treatment

15

• Trauma-specific treatment
• is not enough.

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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.
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Trauma-Informed Services Characteristics (WCDVS)

• Aware of the role of violence and victimization
  in womens 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 womens strengths.

18
Trauma-Informed Services Principles (WCDVS)

• Respect trauma as a central concern in a womans
  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.

19
Introducing Trauma-Specific Treatment

• Counselor Buy In
• Challenges to Agency and Treatment Philosophies
• Protocol Training
• Safety
• Supervision
• Counselor Self-care

20
Should I or Shouldnt I?

• Why counselors may be hesitant to provide trauma
  treatment
• Pandoras 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.

21
Should I or Shouldnt I?

• Why counselors may be hesitant to provide trauma
  treatment
• Personal history
• Addiction history and recovery
• Survivors of trauma themselves increased
  vulnerability

22

• What do Counselors
• Need to Learn?

23
Try Something New

• Treatment that differs from the Counselors 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

24
Difficult 12 Step Concepts for Survivors in
Recovery

• Surrender your power.
• Surrender to a higher power.
• Get off your pity potty.

25
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

26
Why Use ManualizedTrauma Treatment?

• Psychoeducation for survivors
• Structure for Clients and Counselors
• Less opportunity to go too deep
• Time-limited possibilities

27
Developing a New Stance

• Identify Counselor skills sets.
• Collaborate, Dont 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.

28
Client and Counselor Safety

• Managing an angry and aggressive client
• Tool box not Pandoras box
• Child welfare involvement
• Intimate partner violence

29
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

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Potential for Vicarious Traumatization

• Sensitivity for Counselor survivors
• Conducting trauma treatment should be voluntary
• Supportive environments
• Moderate caseloads
• Regular supervision

31
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?

32
About Direct Observation

• It seems very frightening at firstyou risk
  being naked in front of your peersbut, if the
  people watching you are generous and supportive,
  it is actually a great relief. You discover that
  you dont 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
33
Counselor Self-Care

• Practice what you preach
• Rest and exercise
• Opportunities for personal renewal
• Personal therapy

34
NIDA Clinical Trials Network Womens 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

35
NIDA Clinical Trials Network Women Trauma Sites
Washington Node Residence XII
New England Node LMG Programs
New York Node ARTC
Ohio Valley Node Maryhaven
Long Island Node Lead Node
South Carolina Node Charleston Center
Florida Node Gateway Community
Florida Node The Village
36
Pre-Post Control Group Design
Pre-screening, Screening, Baseline,
Randomization, Individual Counselor Session
Pre-Treatment 1 - 4 Weeks
Treatment 6 Weeks
12 Twice Weekly Group Sessions
Post Treatment Follow-up 46 Weeks
1 Week
3 Month
6 Month
12 Month
37
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

38
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

39
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.
40
Enrollment
Initial Screen N1,963
Ineligible N751
Eligible N1,212 (62)
No Full Screen N751
Completed Full Screen N541
Ineligible N162
Eligible N379 (70)
Not Randomized (multiple reasons) N26
Randomized N353 (93)
41
Sample Characteristics (N353)
42
Sample Characteristics (n353)
43
PTSD Diagnosis and Severity at Baseline (n353)
44
Substance Use Disorders at Baseline (n353)
45
Lifetime Trauma Exposure (n353)
46
Treatment Groups

• Seeking Safety (SS Najavits, 1998)
• Short term, manualized treatment
• Cognitive Behavioral
• Focused on addiction and trauma
• Womens Health Education (WHE)
• Short term, manualized treatment
• Pyschoeducational, didactic
• Focused on understanding womens health issues
  and empowerment

47
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

48
Womens Health Education Topics

• Body Systems
• Female anatomy
• Breast care
• Infections
• HIV
• Contraception

• Pregnancy
• STDs
• Nutrition
• High Blood Pressure
• Diabetes
• Menopause

49
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

50
Counselor and Supervisor Demographics
Counselors n18 Supervisors n18
Age M 38.0 41.8
Race N () White Black/African American Hispanic/Latina 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
Highest Degree N () gtBachelors Degree Bachelors Degree Masters Degree/Doctorate 1 (5.5) 7 (38.9) 10 (55.6) 1 (5.5) 2 (11.1) 15 (83.3)
In Recovery N () No Yes Prefer not to answer 13 (72.3) 4 (22.2) 1 (5.5) 15 (83.3) 2 (11.1) 1 (5.5)
51
Intervention-SpecificTraining 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

52
Research-within-Practice Challenges

• The Therapeutic Misconception
• Research is not treatment
• Protocol adherence is key
• Avoiding cross-contamination
• Need to keep interventions separate
• Cant share information with other colleagues or
  clients

53
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

54
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

55
Treatment Fidelity
Site Adherent () Lead Adherent () Site/Lead Adherence Agreement N () Total Adherent at Site N ()
SS 60.0 78.3 60 (68.3) 267 (73.8)
WHE 80.3 80.3 71 (94.4) 206 (90.3)
56
Treatment Attendance
Treatment Group N Mean SD Median
SS 170 6.3 4.4 7
WHE 172 5.9 4.3 6.5
57
Counselor and SupervisorBenefits

• 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

58
Counselor and SupervisorChallenges

• 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

59
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

60
Summary

• Consistent across sites
• High levels of multiple trauma exposure with
  clinically significant PTSD symptoms.
• High percentage of sexual assaults
  (range85-100).
• 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.

61
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.

62
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.