Treating Trauma and Addiction: The CTN Women and Trauma Study

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Treating Trauma and Addiction The CTN Women
and Trauma Study

• Denise Hien, Ph.D.
• Research Scholar, Columbia University School of
  Social Work
• Executive Director, Womens Health Project
  Treatment and Research Center, Dept of
  Psychiatry, St. Lukes\ Roosevelt Hospital Center
• Gloria Miele, Ph.D.
• Training Director, New York State Psychiatric
  Institue, Columbia University
• Greg Brigham, Ph.D.
• Chief Research Officer, Maryhaven
• National Conference on Women, Addiction and
  Recovery News You Can Use
• Anaheim, CA, July 14, 2006

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Overall Presentation Objectives

• Participants will gain an overview of specific
  treatment approaches for women with trauma and
  substance use disorders based upon our collective
  work with CTNs Women and Trauma Study.
• Participants will learn important descriptive
  characteristics of women with trauma who attend
  outpatient substance abuse treatment.
• Participants will gain knowledge about training
  and supervision required when using empirical
  approaches to treating women with trauma.
• Participants will learn the benefits and
  challenges to implementing empirical approaches
  to treating women with trauma in community
  treatment programs.

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Historical Context for the Study of Trauma and
Addiction

• Womens Movement and Grassroots Advocacy for
  Battered Women in 1970s.
• Crack/ Cocaine epidemic DSM-IIIR broadens
  criteria for PTSD PTSD studies in Vets and Non
  Substance Abusers Fulliloves Snowball Sample,
  Millers work with criminal justice population in
  mid-late 1980s.
• Surgeon General Koop declares Violence a Public
  Health Epidemic in 1991.
• Judith Hermans book Trauma and Recovery
  published in 1992.

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Historical Context for the Study of Trauma and
Addiction (contd.)

• Epidemiology from cross-disciplinary research
  over the late 80s and 90s establishes high
  ratessurpassing normal population estimatesfor
  childhood abuse, domestic violence, crime
  victimization and PTSDespecially for women.
• Chilcoat and Breslau identify support for
  self-medication model in 1998 Kendler and
  colleagues publish first co-twin study
  demonstrating causal link between childhood abuse
  and substance use disorders in 2000.
• National consciousness of PTSD and addiction
  links following September 11, 2001.

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DSM-IV Criteria for Posttraumatic Stress
Disorder (PTSD)

• The person has been exposed to a traumatic event
• Event involved actual or threatened death or
  serious injury, or a threat to the physical
  integrity of self or others
• The persons response involved intense fear,
  helplessness, or horror
• The traumatic event is persistently
  re-experienced
• Avoidance of stimuli associated with the trauma
  and numbing of general responsiveness
• Persistent symptoms of increased arousal,
  including difficulty falling or staying asleep,
  irritability or outbursts of anger, difficulty
  concentrating, hypervigilance, exaggerated
  startle response

(American Psychiatric Association, 1994)
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PTSD vs. Complex Trauma

• PTSD typically develops from one incident,
  usually experienced as an adult.
• Complex Trauma (DESNOS) is associated with
  repeated incidents (domestic violence or ongoing
  childhood abuse).
• Broader range of symptoms self-harm, suicide,
  dissociation (losing time) problems with
  relationships, memory, sexuality, health, anger,
  shame, guilt, numbness, loss of faith and trust,
  feeling damaged.

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Pathways Between Trauma-related Disorders and
Substance Use
SUD
PTSD
TRAUMA
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Clinical Challenges in the Treatment of Traumatic
Stress and Addiction

• Abstinence may not resolve comorbid
  trauma-related disorders
• for many patients the PTSD worsens
• Women with PTSD abuse the most severe substances
  and are vulnerable to relapse for both
  conditions, as well as repeated trauma
• Confrontational approaches typical in addictions
  settings frequently exacerbate mood and anxiety
  disorders
• 12-Step Models often do not acknowledge the need
  for pharmacologic interventions

• Treatment programs often do not offer integrated
  treatments for Substance Use and PTSD
• Treatments for only one disordersuch as
  Exposure-Based Approaches are often marked by
  complications
• treatments developed for PTSD alone may not be
  advisable to treat women with addictions

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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.

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Spiral of Addiction and Recovery (Covington, 1999)
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Other Relevant Treatment Models

• Linehan Dialectical Behavioral Therapy (DBT)
• Cloitre Skills Training in Affective and
  Interpersonal Regulation (STAIR/STAIR-PE)
• TREM

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Comparison of Existing Trauma/ SUD- Focused
Treatment Research
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NIDA Clinical Trials Network Women Trauma Sites
Washington Node Residence XII
Ohio Valley Node Maryhaven
New England Node LMG Programs
New York Node ARTC
Long Island Node Lead Node
South Carolina Node Charleston Center
Florida Node Gateway Community
Florida Node The Village
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CTN Long Island Node Team

• Denise Hien, Lead Investigator
• Edward Nunes, Node PI
• Gloria Miele, Training Director
• Lisa Cohen, Protocol Manager
• Aimee Campbell, Project Director
• Jennifer Lima, Node Coordinator
• Eva Petkova, Lead Statistician
• David Liu, NIDA Liaison

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Participating Nodes and CTPs
Node Node PI(s) Protocol PI CTP Site PI Location
Florida Jose Szapocznik Daniel Santisteban Lourdes Suarez-Morales The Village Michael Miller Miami, FL
Florida Jose Szapocznik Daniel Santisteban Lourdes Suarez-Morales Gateway Community Candace Hodgkins Jacksonville, FL
New England Kathleen Carroll Melissa Gordon LMG Programs Samuel Ball Stamford, CT
New York John Rotrosen Marion Schwartz Addiction Research Treatment Corporation Robert Sage Brooklyn, NY
Ohio Valley Gene Somoza Greg Brigham Maryhaven Greg Brigham Columbus, OH
South Carolina Kathleen Brady Therese Killeen Charleston Center Mark Cowell Charleston, SC
Washington Dennis Donovan Betsy Wells Betsy Wells Residence XII Karen Canida Kirkland, WA
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Seeking Safety is in the Community

• In the CSAT study on Women and Violence, nine
  sites were offered a choice of three treatment
  models for PTSD/SUD more chose SS than any other
  treatment model.
• The Veterans Affairs 10-site project on homeless
  women veterans selected SS as the sole treatment
  to be compared to treatment-as-usual.
• The State of Connecticut trauma initiative
  selected SS as one of three trauma treatments.
  Seven agencies chose SS for this year-long
  project.

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Study Aims

• To assess the effectiveness of adding Seeking
  Safety (SS) to standard substance abuse treatment
  (TAU).
• To evaluate the transportability of a 12- session
  group version of SS in community drug/alcohol
  treatment settings.

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Treatment Groups

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

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Stages of Healing

• 1. SAFETY This is the phase you are in now.
  The goals are to free yourself from substance
  abuse, stay alive, build healthy relationships,
  gain control over your feelings, learn to cope
  with day-to-day problems, protect yourself from
  destructive people and situations, not hurt
  yourself or others, increase your functioning,
  and attain stability.
• 2. MOURNING Once you are more safe, you may
  need to grieve about the past, about what your
  trauma and substance abuse did to you. You may
  need to cry deeply to get over the losses and
  pain you experienced loss of innocence, loss of
  trust, loss of time.
• 3. RECONNECTION After letting yourself
  experience mourning, you will find yourself more
  willing and able to reconnect with the world in
  joyful ways thriving, enjoying life, able to
  work and relate well to others. You will get to
  this stage if you can establish safety now.

Adapted from Herman, Trauma and Recovery, 1992
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Seeking Safety

• Developed as a group treatment for PTSD/SUD women
• Based on CBT models of SUDs, PTSD treatment,
  womens treatment and educational research
• Educates patients about PTSD and SUDs and their
  interaction
• Goals include abstinence and decreased PTSD
  symptoms
• Focuses on enhancing coping skills, safety and
  self-care
• Active, structured treatment - therapist
  teaches, supports and encourages
• Case management

Najavits, 2002 www.seekingsafety.org
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Key Treatment Concepts

• Safety first
• From substances and harmful situations
• Safe Coping Skills
• Anticipating dangerous situations
• Red Flags/Green Flags
• Setting boundaries
• Anger management
• Affect regulation skills

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Womens Health Education

• Empowerment
• Information is empowering
• Self-care
• Substance abuse and trauma interfere with ability
  to care for oneself
• Exposure to traumatic stress can affect people on
  many different levels of functioning including
• emotional
• behavioral
• cognitive
• characterological
• somatic
• There is significant overlap of PTSD and physical
  symptoms
• In the national comorbidity survey, use of
  medical care services was highest in PTSD and
  panic disorder patients

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CTP Criteria for Study Inclusion

• Outpatient Program
• Length of program stay at least 10 weeks
• Average 2-3 new female intakes per week
• At least 4 interested counselors/therapists
• Ability to accommodate 2 groups conducting twice
  weekly sessions over 1 year

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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
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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 CTP
• 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

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Assessment Measures

• Demographics
• Substance Abuse/Dependence Diagnosis
• Substance Use (past 7, past 30 days/biological)
• PTSD Symptoms (CAPS, PSS-SR)
• Psychiatric Symptoms (BSI)
• Other Service Utilization (medication)
• Health Related Questions
• HIV Risk Behaviors
• Child/Adult Physical/Sexual Violence

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Primary Outcomes(baseline, 1week post, 3-, 6-,
12-month follow-up)

• PTSD Symptoms (CAPS)
• Biologically Confirmed Substance Abstinence
• Substance Use Inventory (SUI)
• Urine Drug Screen (UDS)
• Saliva Alcohol Screen (ST)

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Secondary Analyses

• Site characteristics
• Frequency and length of TAU
• Group sizes
• Type of treatment and modality
• Proportion of patients on medication
• Gender/Trauma specific interventions
• Individual baseline characteristics
• Severity, type, duration of substance use/PTSD
• Psychotropic medication use
• Drug use and PTSD symptoms over time

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Enrollment

• Initial Screen
• 1,963 Completed
• 1,212 (62) Eligible
• Screening Interviews
• 541 Completed
• 379 (70) Eligible
• 353 (93) Eligible Pts. Randomized

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Eligibility of Screened Sample (N541)
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Randomization (N353)
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Sample Characteristics (N353)
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ASI Alcohol Drug Composite Scores (N353)
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Trauma Characteristics (N353)

• Partner Violence
• 261 (73.9)
• Partner Sexual Violence
• 117 (33.1)
• Childhood Physical Abuse
• 205 (58.1)
• Childhood Sexual Abuse
• 244 (69.1)

• Traumatic Events
• Physical Assault 91.8
• Sexual Assault 89.2
• Other Unwanted Sexual Experience 81.9
• Sudden Unexpected Death 79.0
• Transportation Accident 72.5
• Assault with Weapon 71.7

Taken from the Life Events Checklist
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Trauma Exposure (N353)
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PTSD Diagnosis Full vs Subthreshold (N353)
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PTSD Symptom Severity (CAPS Subscales) (N353)
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Summary

• Consistent across sites
• High levels of multiple trauma exposure with
  clinically significant PTSD symptoms.
• High percentage of sexual assaults
  (range85-100).
• High rates of service utilization (i.e. 12 step,
  medical and mental health visits).
• Low overall depression levels, but with
  clinically significant subgroup with higher
  depression scores.
• Differences across sites
• Types of other traumatic experiences reported.
• Types of drugs used and drug diagnosis.
• Recruitment success linked to type of CTP
  population and number of available intakes.

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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.

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Implementation Issues

• Intervention Delivery
• Weeks in treatment
• Number and type of sessions received
• Number of participants in each group session
• Session length
• Therapist
• Characteristics
• Adherence Levels
• Race/Ethnicity
• Alliance
• Treatment as Usual
• Gender/Trauma services

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Additional Challenges

• Training and re-training replacements
• Varied levels of experience and education
• Slow start up
• Slow recruitment
• Adherence levels (Seeking Safety)
• Multi-site communication

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Overview of Stage of Science

• Treatment outcome research which examines
  longer-term interventions is urgently needed.
• Improving retention remains a clinical challenge.
• Studies are needed which test effects of elements
  such as
• timing of sessions in the context of substance
  abuse treatment,
• optimal dose,
• combination psychopharmacology and behavioral
  interventions,
• mechanisms/mediators of treatment outcomes (i.e.,
  emotion regulation)
• how and when to add other behavioral approaches
  such as exposure therapy.

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Support

• Participation in this study made possible by
• NIDA CTN Long Island Regional Node
• NIDA/NIH Grant U10 DA13035
• We would like to acknowledge all of the staff and
  participants who made this study possible.

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