1. Janet C. Titus, Ph.D. Chestnut Health Systems
Community Corrections and Offender Reentry Program Grantee Meeting May 3, Denver, Co Janet C. Titus, Ph.D. Chestnut Health Systems, Normal, IL Trauma-Informed Interventions for the Treatment of Co-occurring Trauma and Substance Use Disorders
Janet C. Titus, Ph.D.
Chestnut Health Systems

2. Presentation Roadmap
Brief review -- What is “trauma” and how is it linked to substance abuse?
What are some current and promising trauma-informed or integrated treatments for co-occurring PTSD/trauma and substance abuse?

3. Defining Trauma Trauma = Traumatic Event + Stress Reaction
Traumatic events (trauma exposure)
Experiencing a serious injury or witnessing a serious injury to or death of someone else
Facing actual threats of serious injury or death to yourself or others
Learning about unexpected or violent death, harm, or threat of death/harm to someone close
Stress reaction
Intense fear
Helplessness
Horror
Disorganized or agitated behavior (children)

4. Types of Traumatic Events
Child abuse (physical, sexual, emotional) and neglect
Traumatic loss & grief
Domestic violence
Community and school violence
Complex trauma
Medical trauma
Refugee and war zone trauma
Natural disasters
Terrorism

5. Acute vs. Chronic Traumatic Events
Occur at a particular time and place
Usually short-lived
Examples – school shootings, gang violence, terrorist attacks, natural disasters, serious accidents, sudden or violent loss, physical or sexual assault
Chronic
Occur repeatedly over long periods of time
A “lifestyle” that leads to intense fear, loss of trust, decreased sense of safety, guilt, shame
Examples – some forms of physical abuse, long-standing sexual abuse, domestic violence, wars and political violence

6. The body’s acute physical response to trauma
Physical response: Fight, flight, or freeze >> The body’s reaction to perceived threat or danger.
Fight – fighting off an attacker
Flight – running away from danger
Freeze – going “dead” such as during rape
Dissociation (a kind of Flight) – out of body experiences
Adrenalin and cortisol are released to give the body a burst of energy and strength

7. Physical Sensations Heart pounding Palpitations Fast pulse Nausea
Knot in stomach
Dry mouth and throat
Difficulty swallowing
Sweating
Clammy feeling
Cold hands
Pale face and skin
Blurred vision
Light seems brighter
Feeling detached from self or surroundings
Feeling frozen or immobile
Feeling spaced out or in another world

8. The body’s acute mental response to trauma
Mental response: Primitive auto-pilot >>
The usual mental mechanisms that help us make everyday decisions are temporarily shut down.
This response enables us to make more primitive responses and take quick action rather than to think carefully about the situation at hand.

9. Trauma Reminders
The body’s alarm reaction can be triggered by situations that remind us of the trauma, even if we are no longer in a truly dangerous or threatening situation.
These trauma reminders, or triggers, might include situations that have something in common with the traumatic event, but they could also include thoughts or memories about what happened.
Even when we are no longer in danger, our body’s alarm response could become activated as if we were experiencing the trauma all over again.

10. Substance Use Triggers and Cravings
A “trigger” is a stimulus which has been repeatedly associated with the preparation for, anticipation of or the use of drugs and/or alcohol.
These stimuli include people, things, places, times of day, and emotional states.
Substance use “craving” refers to the very strong desire for a psychoactive substance or for the intoxicating effects of that substance.
Cravings include thoughts (about the urge to use), physical symptoms (heart palpitations), and behaviors (pacing).

11. Connection Between Trauma and Substance Use
Bad coping/
Avoidant response
Trigger/
Reminder/Signal
Emotional/Physical
Reaction
Sadness, anger,
anxiety, guilt, shame
Craving
Substance use

12. Characteristics of Individuals with Traumatic Stress and Substance Abuse
Emotional and behavioral dysregulation
Coping deficits
Family strain
Environmental stress
Academic & vocational difficulties
Health problems
Involvement with multiple service systems (legal system, social services, mental health, substance abuse, special education)

13. Setting the Stage for PTSD
Lifetime exposure to trauma is common.
Only a fraction of trauma-exposed individuals will go on to develop PTSD or a sub-clinical variation of it (complex trauma response, DESNOS, partial PTSD).
Strongest risks for exposure turning into PTSD…
Sexual assault, physical assault (“of human design”), frequency of exposure, high subjective distress (Frans, Rimmo, Aberg, & Fredrickson, 2005).
What happens during and after exposure (greater trauma severity, lack of social support, subsequent stress) (Brewin, Andrews, & Valentine, 2000).

14. Posttraumatic Stress Disorder
A set of characteristic symptoms that can develop when trauma overwhelms the person’s ability to cope
Re-Experiencing the traumatic event through intrusive thoughts or dreams of the event, or intense psychological distress when exposed to reminders of the event
Avoidance of thoughts, feelings, images, or locations that remind one of or are associated with the traumatic event
Increased arousal such as hyper-vigilance, irritability, exaggerated startle response, and sleeping difficulties 14

15. The Whole is Greater than the Sum of its Parts…
The presence of traumatic stress or PTSD greatly complicates the recovery process in individuals with substance use disorders.
Exposure to trauma or trauma triggers has been shown to increase drug cravings in people with co-occurring trauma and substance abuse.
When substance abuse and traumatic stress are treated separately, individuals with co-occurring disorders are more likely to relapse and revert to previous maladaptive coping strategies.
Successful treatment must address challenges of both disorders… yet services are largely fragmented.

16. Co-occurring SUD & PTSD/trauma
Integrated Treatment
Co-occurring SUD & PTSD/trauma

17. Trauma vs. Trauma-Informed Substance Abuse Treatment
Trauma-Informed Substance Abuse Tx
Trauma Tx
CBITS
SPARCS
Trauma Systems Tx (TST)
TARGET-A
TF-CBT
I-CARE (TST-SA)
RRFT
Seeking Safety
Cognitive Processing Therapy (CPT)
Prolonged Exposure (PE)
EMDR
Cognitive Restructuring
Stress Innoculation
Relaxation
ATRIUM
ARTS
TREM
Concurrent Tx of PTSD/Cocaine Dep
Transcend
Youth
Adults

18. Trauma-Specific Components
Learn to recognize and consciously regulate (rather than avoiding and being controlled by) current post-traumatic symptoms.
Formulate constructive ways to handle symptoms, triggers, and distress without substance use

19. Trauma-Specific Components
Help trauma survivors understand how trauma changes the body and brain's normal stress response into an extreme survival-based alarm response
Skills to gain control over the intense survival alarm signals that cause confusion, overwhelming negative emotions, and reactive behaviors.
Relaxation, bodily self-regulation, affect regulation, memory/information processing, interpersonal problem solving, and stress management.

20. Substance Abuse Components
Help identify triggers and manage cravings
Relapse prevention: Acknowledge and prepare for the role of stress and trauma on relapse
Drug refusal skills
Motivational interviewing

21. Essential Components of Integrated Treatment
Therapeutic relationship that is consistent, trusting, and collaborative
Motivational enhancement strategies (Miller & Rollnick) focused on engagement/participation in treatment; safety; reduction of harm/risk, use, truancy, delinquency
Stress management skills such as relaxation and positive self-talk
Emotion regulation skills such as the identification, expression, and modulation of negative affect

22. Essential Components of Integrated Treatment
Cognitive restructuring such as recognizing, challenging, and correcting negative cognitions
Increasing problem-solving, drug refusal, and safety skills
Social skills training
Gradual exposure to achieve desensitization to trauma reminders
Adapted from Cohen, Mannarino, Zhitova, & Capone (2003)

23. Essential Components of Integrated Treatment
Parental involvement in treatment
Parenting skills (behavioral management strategies, increase monitoring and limit setting, particularly around drug use and high risk behaviors)
Improving communication and conflict resolution skills
Family Psychoeducation (both youth and their families)
substance use and trauma and the interaction between the two
Adapted from Cohen, Mannarino, Zhitova, & Capone (2003)

24. Essential Components of Integrated Treatment
Random urine drug screenings
Adjunct psychopharmacologic treatments
Case management: working with systems of care
schools
juvenile justice
child welfare
other substance abuse/MH treatment
Possible referral to adolescent self-help/support groups
Adapted from Cohen, Mannarino, Zhitova, & Capone (2003)

25. Trauma/Integrated Treatments for Children and Adolescents
CBITS
SPARCS
I-CARE (integrated)

26. Cognitive Behavioral Intervention for Trauma in Schools (CBITS)
CBITS is a skills-based group intervention aimed at relieving symptoms of PTSD, depression, and anxiety among children exposed to trauma.
Skills are learned through use of drawings and talking in both group and individual sessions.
Skills are reinforced by completing assignments and participating in activities.
There are parent and teacher education sessions as well.

27. CBITS Facts
Population – girls & boys, yrs, exposed to trauma AND suffering moderate symptoms; diverse groups
Sessions – 10 weekly group sessions (5-8 youths), 1-3 individual (exposure), 2 parent, 1 teacher
Setting - school
Components – 6 cognitive behavioral skills
Education on reactions to trauma
Relaxation training
Cognitive therapy
Exposure to trauma reminders
Stress or trauma exposure
Social problem-solving

28. Support for CBITS
Quasi-experiment with control group (Kataoka et al., 2003)
Latino immigrant children exposed to community violence
Children in the CBITS group had significantly greater improvement in PTSD and depressive symptoms compared to those on a wait-list at 3 months.
Randomized controlled trial (Stein, Jaycox, Wong, Tu, Elliott & Fink, 2003)
Largely Latino 6th graders exposed to community violence.
Parents of the children in the CBITS group reported significant improvements in functioning.
Improvements in symptoms and functioning continued to be seen at 6 months.

29. Implementing CBITS
Staff - ideal person has prior training and experience with mental health and CBT.
CBITS manual available from
Jaycox, L. (2003). CBITS: Cognitive-Behavioral Intervention for Trauma in Schools. New York: Sopris West.
Training available – contact Dr. Audra Langley
trainees read background materials and the manual and watch a training video prior to training, attend a 2-day training, receive ongoing supervision from a local clinician with expertise in CBT
More info on CBITS
Contact Sheryl Kataoka

30. Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS)
SPARCS is a skills-based group intervention for chronically traumatized adolescents who may still be living with ongoing stress and are experiencing problems in several areas of functioning:
Emotional and behavioral regulation
Attention/Consciousness
Self-perception
Interpersonal relationships
Somatization and physical health problems
Systems of meaning
·  

31. Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS)
SPARCS’ components are based on three empirically validated interventions.
Dialectical Behavior Therapy for Adolescents (mindfulness and interpersonal skills)
Trauma Adaptive Recovery Group Education and Therapy (TARGET) (problem solving skills)
UCLA Trauma/Grief Program (enhancing social support and planning for future)
Cognitive-behavioral, present-focused, strength-based
Overall goals (the “4 C’s”)
Cultivate awareness
Cope more effectively
Connect with others
Create meaning

32. SPARCS Facts
Population – girls & boys, yrs, who have problems in functioning related to chronic interpersonal trauma
Sessions – 16 weekly 1 hour group sessions (6-10 youths)
Setting – outpatient clinics, schools, group homes, boarding schools, residential treatment, foster care programs
Components (Core Skills)
Mindfulness
Problem Solving
Meaning-making
Relationship building and communication skills
Distress Tolerance
Psychoeducation on stress and trauma

33. Support for SPARCS
Quasi-experiment with comparison group (Lyons et al., in press)
Adolescents in foster care who received were half as likely to run away and a fourth as likely to experience treatment disruptions (e.g., arrests, hospitalization) than those assigned to a standard care intervention.
Pilot study (Habib & Ross, 2006)
Adolescent girls in a 22 session SPARCS group showed significant improvement in overall functioning on level of behavioral dysfunction, interpersonal relationships, and interpersonal coping (support seeking behavior).

34. Implementing SPARCS
Staff – prior training and experience in counseling
SPARCS manual available from treatment developers (Dr. Ruth DeRosa)
DeRosa, R., Habib, M., Pelcovitz, D., Rathus, J., Sonnenklar, J., Ford, J., et al. (2006). Structured Psychotherapy for Adolescents Responding to Chronic Stress. Unpublished manual.
Training available
Initial two day training, later two day training, frequent consultations
Learning Collaborative
More info on SPARCS
Dr. Victor Labruna
Dr. Mandy Habib

35. Integrated Care for Adolescents Struggling with Traumatic Stress and Substance Abuse (I-CARE)
I-CARE is a community-based program for youths who are having difficulties regulating emotions resulting from traumatic experiences and environmental stress and who are also having problems with substance abuse.
Acknowledges the role of the social ecology on youth and family functioning.
The intervention provides a framework for coordinating care.
Following assessment, a multidisciplinary team chooses from a series of interventions based on the youth’s needs.

36. Integrated Care for Adolescents Struggling with Traumatic Stress and Substance Abuse (I-CARE)
I-CARE is based on Trauma Systems Therapy (TST), which is based on several approaches:
Systems-of-Care approach (overall framework)
Multisystemic Therapy (MST) (home-based services)
Dialectical Behavior Therapy (emotional regulation skills training)
Trauma Focused Cognitive Behavioral Therapy (cognitive processing skills training)
Psychopharmacology
I-CARE was previously known as Trauma Systems Therapy – Substance Abuse (TST-SA)

37. I-CARE Facts
Population – girls & boys, yrs, with co-occurring trauma and substance abuse who are having problems with emotional regulation in an environment that cannot contain it.
Sessions – length of treatment is variable, can last from 3 to 9 months depending on severity of youth’s situation; individual and parent/family components
Setting – community-based program - delivered in clinic, at home, in the social environment

38. I-CARE Modules Ready Set Go Stabilization on Site Services Advocacy
Building alliance and enhancing motivation, Psychoeducation, Troubleshooting Practical Barriers, Treatment Planning
Stabilization on Site
Home Based Care, Family Communication, Behavior Management, Community Integration Strategies
Services Advocacy
Connecting the youth and family with needed resources
Psychopharmacology
Coordinated psychiatric evaluation and medication management
Emotion Regulation
Psychoeducation and Skill Building (Affect Management, Competency building, Emotion Identification and Acceptance)
Cognitive Processing
Cognitive Restructuring, Exposure to the Trauma Narrative
Meaning Making
Enacting meaning, future orientation, relapse prevention

39. Support for I-CARE Dissemination: Ulster County Program Evaluation
TST open trial (Saxe, Ellis, Fogler, Hansen, & Sorkin, 2005)
 trauma symptoms,  emotional and behavioral regulation
More stable social environment
Transitioning from more intensive to less intensive phases of treatment
Dissemination: Ulster County Program Evaluation
 trauma symptoms,  family stability
 hospitalization rates and length of hospital stay
 length for need of services
TST controlled trial (preliminary findings)
Reduced drop out rates (10/10 vs. 1/10 retention after 3 months)

40. Implementing I-CARE
Staff – M.A. level counselors; staff with less formal training can deliver components in collaboration with counselors
Materials
I-CARE manual available from treatment developer, Dr. Liza Suárez
Adolescent and parent workbook, assessments
Training available
Two days basic training
Weekly conference call
One day follow-up training at 6 months
More info on I-CARE
Contact Dr. Suárez

41. Trauma/Integrated Treatments for Adults
TREM (integrated)
Seeking Safety (integrated)
ATRIUM (integrated)

42. Trauma Recovery and Empowerment (TREM)
TREM is a comprehensive group intervention for women survivors of physical, sexual, and/or emotional abuse who may use substances and for whom traditional recovery work has been unavailable or ineffective.
Draws on cognitive restructuring, skill-building, and psychoeducational techniques
Teaches techniques for self-soothing, boundary maintenance, and current problem solving
Emphasizes development of coping skills and social support.

43. TREM Facts
Population – women trauma survivors with substance abuse and/or mental health problems; a men’s group and an adolescent girls’ group have been implemented; 18-25, yrs; diverse ethnic groups
Sessions – 24 to 29 to 33 weekly group sessions (6-8 members), 75 minutes per session, over a 9 month period
Setting – substance abuse and mental health programs (residential and non-residential), correctional institutions, welfare-to-work programs, homeless shelters

44. TREM Components Empowerment – learn strategies for… Trauma Education
Self-comfort and accurate self-monitoring
Setting physical and emotional boundaries
Increasing self-esteem
Trauma Education
Explore and reframe the connection between their experiences of abuse and consequences of abuse (other current difficulties), including substance use, mental health symptoms, interpersonal problems
Provided with tools and skills with which they can combat the repercussions of trauma

45. TREM Components Advanced Trauma Recovery
Explore practical coping, problem solving, and skill-building strategies
Topics include communication style, decision-making, managing out-of-control feelings, developing safer relationships
TREM addresses substance abuse throughout the intervention. Skills such as self-awareness, self-soothing, emotional modulation, development of safe and mutual relationships, and consistent problem solving are aimed at active substance abuse treatment and relapse prevention.

46. Support for TREM
Quasi-experimental studies (Amaro et. al., n.d.; Fallot, McHugo, & Harris, 2005; Toussaint, VanDeMark, Bornemann, & Graber, 2007)
Severity of problems related to substance abuse
TREM participants showed significantly greater decreases in drug addiction severity at 6- and 12-month follow-ups than those receiving usual care; significant improvements in alcohol addiction severity
Mean alcohol and drug problem severity scores decreased from baseline to 1-year follow-up, relative to recipients of alternative care
Psychological problems/symptoms
TREM participants showed significantly reduced symptoms of psychological problems 1 year after the intervention
Trauma symptoms
At 12-month follow-up, trauma symptoms were significantly reduced among TREM participants compared with recipients of alternative care.

47. Implementing TREM Female co-leaders (male leaders in men’s group)
TREM manual available from Community Connections or in bookstores
Harris, M. (1998). Trauma Recovery and Empowerment: A Clinician’s Guide for working with women in groups. New York: The Free Press.
Training available from developers, designed for 2 trainers and up to 40 participants
More info on TREM
Rebecca Wolfson Berley, M.S.W.

48. Seeking Safety
Seeking Safety is a present-focused therapy designed to promote safety and recovery for individuals with PTSD and substance abuse as well as those who have trauma histories but who do not meet clinical criteria for PTSD.
Based on 5 key principles:
Safety is the primary goal
Work on PTSD/trauma and substance abuse at the same time
Focus on ideals to counteract the loss of ideals from the experiences of PTSD/trauma and substance abuse
Address cognitive, behavioral, interpersonal, and case management areas of client functioning
Focus on clinician processes (e.g., helping clinicians work with countertransference issues)

49. Seeking Safety Facts
Population – adults and adolescents (male and female) with PTSD/trauma and substance abuse disorders
Sessions – 25 weekly minute sessions (or twice weekly), group or individual formats
Setting – substance abuse treatment (OP, residential), correctional facilities, health and mental health centers

50. Seeking Safety Components
There are 25 components roughly equally divided between cognitive, behavioral, and interpersonal domains. Below is a sample of topics:
Safety
Recovery thinking
Taking back your power
Creating meaning
Grounding
Community resources
When substances control you
Setting boundaries in relationships
Asking for help
Coping with triggers
Self-nurturing
Healing from anger

51. Seeking Safety Components
No exposure
considered later stage of treatment
risk of painful memories triggering substance use in misguided attempt to cope
could trigger others if in group format

52. Support for Seeking Safety
Evidence base of published studies - 6 pilot studies, 4 randomized controlled trials (RCTs), 1 controlled nonrandomized trial, 2 multisite controlled trials, and 1 dissemination study
Populations - men, women, veterans, adolescents, homeless, and criminal justice
All outcome studies evidenced positive outcomes (decreased trauma symptoms, decreased substance abuse, improvements in other areas such as HIV risk, suicidal symptoms, problem solving, social functioning, and sense of meaning).
In the controlled trials, Seeking Safety typically outperformed the comparison condition.

53. Implementing Seeking Safety
Seeking Safety has been implemented by counselors (M.A. level, B.A. level, case managers), social workers, and psychologists
Seeking Safety manual
Najavits, L.M. (2002). Seeking Safety: A Treatment Manual for PTSD and Substance Abuse. New York: Guildford.
Training
Individualized to specific needs of clinic
Via videos, on-site, existing training, telephone consultation
More info on Seek Safety
Contact Lisa Najavits

54. Addiction & Trauma Recovery Integrated Model (ATRIUM)
ATRIUM is a 12-step informed intervention for women survivors of sexual and physical abuse who have substance abuse and other addictive behaviors
Based on the premise that trauma impacts body, mind, and spirit
Integrates cognitive-behavioral and relational treatment while emphasizing mental, physical, and spiritual health
May be used in conjunction with 12-step or other addiction treatment programs, as a supplement to trauma-focused psychotherapy, or as an independent model for healing

55. ATRIUM Facts
Population – women survivors of sexual and physical abuse who have substance abuse and other addictive behaviors; has been used with men too; diverse groups
Sessions – 12 weekly sessions, minutes; individual or group format; single sex groups
Setting – substance abuse or mental health treatment, peer group environments; has been used in local prisons, jail diversion projects, AIDS programs, and drop-in centers for survivors

56. ATRIUM Components
Curriculum is a blend of psycho-educational, process, and expressive activities.
Each session includes a didactic component, a process section, an experiential component, and a homework assignment.
Information on body’s response to addiction and traumatic stress, anxiety, sexuality, self-harm, depression, anger, physical complaints and ailments, sleep difficulties, relationship challenges, spiritual disconnection
Skills-training on self-care, self-soothing, self-expression
Also incorporates meditation, creative expression, spirituality, community action, and peer support

57. Support for ATRIUM
ATRIUM was one of the interventions in SAMHSA’s Women, Co-Occurring Disorders, and Violence Study. Results of the cross-site/cross-intervention study show women in the intervention groups showed greater improvement in trauma and mental health symptoms compared with those in the usual care conditions (Morrissey et al., 2005).
ATRIUM, however, has not been evaluated on it’s own and has yet to be extensively studied with respect to effectiveness.

58. Implementing ATRIUM
Staff – mental health professionals and peer facilitators who understand the impact of trauma and addiction
Manual available from book stores/Amazon
Miller, D., & Guidry, L. (2001). Addictions and trauma recovery: Healing the body, mind and spirit. New York: W. W. Norton & Co.
Training, consultation, and workshops available through Dusty Miller
More info on ATRIUM
Contact Dusty Miller

59. For More Information
National Child Traumatic Stress Network (under SAMHSA’s Center for Mental Health Services)
NCTSN Toolkit
For health care providers, parents, and teenagers.
>Resources >Topics > Adol. Substance Abuse 59

60. For More Information
National Center for Trauma-Informed Care (under SAMHSA’s Center for Mental Health Services)
Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services – 2008 Update

61. Chestnut Health Systems
Contact Information
Janet C. Titus, Ph.D.
Chestnut Health Systems
448 Wylie Drive
Normal, IL
(309)