Presentation on theme: "Janet C. Titus, Ph.D. Chestnut Health Systems"— Presentation transcript:
1Janet 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 DisordersJanet C. Titus, Ph.D.Chestnut Health Systems
2Presentation RoadmapBrief 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?
3Defining Trauma Trauma = Traumatic Event + Stress Reaction Traumatic events (trauma exposure)Experiencing a serious injury or witnessing a serious injury to or death of someone elseFacing actual threats of serious injury or death to yourself or othersLearning about unexpected or violent death, harm, or threat of death/harm to someone closeStress reactionIntense fearHelplessnessHorrorDisorganized or agitated behavior (children)
4Types of Traumatic Events Child abuse (physical, sexual, emotional) and neglectTraumatic loss & griefDomestic violenceCommunity and school violenceComplex traumaMedical traumaRefugee and war zone traumaNatural disastersTerrorism
5Acute vs. Chronic Traumatic Events Occur at a particular time and placeUsually short-livedExamples – school shootings, gang violence, terrorist attacks, natural disasters, serious accidents, sudden or violent loss, physical or sexual assaultChronicOccur repeatedly over long periods of timeA “lifestyle” that leads to intense fear, loss of trust, decreased sense of safety, guilt, shameExamples – some forms of physical abuse, long-standing sexual abuse, domestic violence, wars and political violence
6The 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 attackerFlight – running away from dangerFreeze – going “dead” such as during rapeDissociation (a kind of Flight) – out of body experiencesAdrenalin and cortisol are released to give the body a burst of energy and strength
7Physical Sensations Heart pounding Palpitations Fast pulse Nausea Knot in stomachDry mouth and throatDifficulty swallowingSweatingClammy feelingCold handsPale face and skinBlurred visionLight seems brighterFeeling detached from self or surroundingsFeeling frozen or immobileFeeling spaced out or in another world
8The 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.
9Trauma RemindersThe 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.
10Substance 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).
11Connection Between Trauma and Substance Use Bad coping/Avoidant responseTrigger/Reminder/SignalEmotional/PhysicalReactionSadness, anger,anxiety, guilt, shameCravingSubstance use
12Characteristics of Individuals with Traumatic Stress and Substance Abuse Emotional and behavioral dysregulationCoping deficitsFamily strainEnvironmental stressAcademic & vocational difficultiesHealth problemsInvolvement with multiple service systems (legal system, social services, mental health, substance abuse, special education)
13Setting 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).
14Posttraumatic Stress Disorder A set of characteristic symptoms that can develop when trauma overwhelms the person’s ability to copeRe-Experiencing the traumatic event through intrusive thoughts or dreams of the event, or intense psychological distress when exposed to reminders of the eventAvoidance of thoughts, feelings, images, or locations that remind one of or are associated with the traumatic eventIncreased arousal such as hyper-vigilance, irritability, exaggerated startle response, and sleeping difficulties14
15The 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.
16Co-occurring SUD & PTSD/trauma Integrated TreatmentCo-occurring SUD & PTSD/trauma
17Trauma vs. Trauma-Informed Substance Abuse Treatment Trauma-Informed Substance Abuse TxTrauma TxCBITSSPARCSTrauma Systems Tx (TST)TARGET-ATF-CBTI-CARE (TST-SA)RRFTSeeking SafetyCognitive Processing Therapy (CPT)Prolonged Exposure (PE)EMDRCognitive RestructuringStress InnoculationRelaxationATRIUMARTSTREMConcurrent Tx of PTSD/Cocaine DepTranscendYouthAdults
18Trauma-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
19Trauma-Specific Components Help trauma survivors understand how trauma changes the body and brain's normal stress response into an extreme survival-based alarm responseSkills 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.
20Substance Abuse Components Help identify triggers and manage cravingsRelapse prevention: Acknowledge and prepare for the role of stress and trauma on relapseDrug refusal skillsMotivational interviewing
21Essential Components of Integrated Treatment Therapeutic relationship that is consistent, trusting, and collaborativeMotivational enhancement strategies (Miller & Rollnick) focused on engagement/participation in treatment; safety; reduction of harm/risk, use, truancy, delinquencyStress management skills such as relaxation and positive self-talkEmotion regulation skills such as the identification, expression, and modulation of negative affect
22Essential Components of Integrated Treatment Cognitive restructuring such as recognizing, challenging, and correcting negative cognitionsIncreasing problem-solving, drug refusal, and safety skillsSocial skills trainingGradual exposure to achieve desensitization to trauma remindersAdapted from Cohen, Mannarino, Zhitova, & Capone (2003)
23Essential Components of Integrated Treatment Parental involvement in treatmentParenting skills (behavioral management strategies, increase monitoring and limit setting, particularly around drug use and high risk behaviors)Improving communication and conflict resolution skillsFamily Psychoeducation (both youth and their families)substance use and trauma and the interaction between the twoAdapted from Cohen, Mannarino, Zhitova, & Capone (2003)
24Essential Components of Integrated Treatment Random urine drug screeningsAdjunct psychopharmacologic treatmentsCase management: working with systems of careschoolsjuvenile justicechild welfareother substance abuse/MH treatmentPossible referral to adolescent self-help/support groupsAdapted from Cohen, Mannarino, Zhitova, & Capone (2003)
25Trauma/Integrated Treatments for Children and Adolescents CBITSSPARCSI-CARE (integrated)
26Cognitive 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.
27CBITS FactsPopulation – girls & boys, yrs, exposed to trauma AND suffering moderate symptoms; diverse groupsSessions – 10 weekly group sessions (5-8 youths), 1-3 individual (exposure), 2 parent, 1 teacherSetting - schoolComponents – 6 cognitive behavioral skillsEducation on reactions to traumaRelaxation trainingCognitive therapyExposure to trauma remindersStress or trauma exposureSocial problem-solving
28Support for CBITSQuasi-experiment with control group (Kataoka et al., 2003)Latino immigrant children exposed to community violenceChildren 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.
29Implementing CBITSStaff - ideal person has prior training and experience with mental health and CBT.CBITS manual available fromJaycox, L. (2003). CBITS: Cognitive-Behavioral Intervention for Trauma in Schools. New York: Sopris West.Training available – contact Dr. Audra Langleytrainees 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 CBTMore info on CBITSContact Sheryl Kataoka
30Structured 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 regulationAttention/ConsciousnessSelf-perceptionInterpersonal relationshipsSomatization and physical health problemsSystems of meaning·
31Structured 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-basedOverall goals (the “4 C’s”)Cultivate awarenessCope more effectivelyConnect with othersCreate meaning
32SPARCS FactsPopulation – girls & boys, yrs, who have problems in functioning related to chronic interpersonal traumaSessions – 16 weekly 1 hour group sessions (6-10 youths)Setting – outpatient clinics, schools, group homes, boarding schools, residential treatment, foster care programsComponents (Core Skills)MindfulnessProblem SolvingMeaning-makingRelationship building and communication skillsDistress TolerancePsychoeducation on stress and trauma
33Support for SPARCSQuasi-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).
34Implementing SPARCSStaff – prior training and experience in counselingSPARCS 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 availableInitial two day training, later two day training, frequent consultationsLearning CollaborativeMore info on SPARCSDr. Victor LabrunaDr. Mandy Habib
35Integrated 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.
36Integrated 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)PsychopharmacologyI-CARE was previously known as Trauma Systems Therapy – Substance Abuse (TST-SA)
37I-CARE FactsPopulation – 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 componentsSetting – community-based program - delivered in clinic, at home, in the social environment
38I-CARE Modules Ready Set Go Stabilization on Site Services Advocacy Building alliance and enhancing motivation, Psychoeducation, Troubleshooting Practical Barriers, Treatment PlanningStabilization on SiteHome Based Care, Family Communication, Behavior Management, Community Integration StrategiesServices AdvocacyConnecting the youth and family with needed resourcesPsychopharmacologyCoordinated psychiatric evaluation and medication managementEmotion RegulationPsychoeducation and Skill Building (Affect Management, Competency building, Emotion Identification and Acceptance)Cognitive ProcessingCognitive Restructuring, Exposure to the Trauma NarrativeMeaning MakingEnacting meaning, future orientation, relapse prevention
39Support for I-CARE Dissemination: Ulster County Program Evaluation TST open trial (Saxe, Ellis, Fogler, Hansen, & Sorkin, 2005) trauma symptoms, emotional and behavioral regulationMore stable social environmentTransitioning from more intensive to less intensive phases of treatmentDissemination: Ulster County Program Evaluation trauma symptoms, family stability hospitalization rates and length of hospital stay length for need of servicesTST controlled trial (preliminary findings)Reduced drop out rates (10/10 vs. 1/10 retention after 3 months)
40Implementing I-CAREStaff – M.A. level counselors; staff with less formal training can deliver components in collaboration with counselorsMaterialsI-CARE manual available from treatment developer, Dr. Liza SuárezAdolescent and parent workbook, assessmentsTraining availableTwo days basic trainingWeekly conference callOne day follow-up training at 6 monthsMore info on I-CAREContact Dr. Suárez
41Trauma/Integrated Treatments for Adults TREM (integrated)Seeking Safety (integrated)ATRIUM (integrated)
42Trauma 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 techniquesTeaches techniques for self-soothing, boundary maintenance, and current problem solvingEmphasizes development of coping skills and social support.
43TREM FactsPopulation – 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 groupsSessions – 24 to 29 to 33 weekly group sessions (6-8 members), 75 minutes per session, over a 9 month periodSetting – substance abuse and mental health programs (residential and non-residential), correctional institutions, welfare-to-work programs, homeless shelters
44TREM Components Empowerment – learn strategies for… Trauma Education Self-comfort and accurate self-monitoringSetting physical and emotional boundariesIncreasing self-esteemTrauma EducationExplore and reframe the connection between their experiences of abuse and consequences of abuse (other current difficulties), including substance use, mental health symptoms, interpersonal problemsProvided with tools and skills with which they can combat the repercussions of trauma
45TREM Components Advanced Trauma Recovery Explore practical coping, problem solving, and skill-building strategiesTopics include communication style, decision-making, managing out-of-control feelings, developing safer relationshipsTREM 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.
46Support for TREMQuasi-experimental studies (Amaro et. al., n.d.; Fallot, McHugo, & Harris, 2005; Toussaint, VanDeMark, Bornemann, & Graber, 2007)Severity of problems related to substance abuseTREM 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 severityMean alcohol and drug problem severity scores decreased from baseline to 1-year follow-up, relative to recipients of alternative carePsychological problems/symptomsTREM participants showed significantly reduced symptoms of psychological problems 1 year after the interventionTrauma symptomsAt 12-month follow-up, trauma symptoms were significantly reduced among TREM participants compared with recipients of alternative care.
47Implementing TREM Female co-leaders (male leaders in men’s group) TREM manual available from Community Connections or in bookstoresHarris, 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 participantsMore info on TREMRebecca Wolfson Berley, M.S.W.
48Seeking SafetySeeking 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 goalWork on PTSD/trauma and substance abuse at the same timeFocus on ideals to counteract the loss of ideals from the experiences of PTSD/trauma and substance abuseAddress cognitive, behavioral, interpersonal, and case management areas of client functioningFocus on clinician processes (e.g., helping clinicians work with countertransference issues)
49Seeking Safety FactsPopulation – adults and adolescents (male and female) with PTSD/trauma and substance abuse disordersSessions – 25 weekly minute sessions (or twice weekly), group or individual formatsSetting – substance abuse treatment (OP, residential), correctional facilities, health and mental health centers
50Seeking Safety Components There are 25 components roughly equally divided between cognitive, behavioral, and interpersonal domains. Below is a sample of topics:SafetyRecovery thinkingTaking back your powerCreating meaningGroundingCommunity resourcesWhen substances control youSetting boundaries in relationshipsAsking for helpCoping with triggersSelf-nurturingHealing from anger
51Seeking Safety Components No exposureconsidered later stage of treatmentrisk of painful memories triggering substance use in misguided attempt to copecould trigger others if in group format
52Support 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 studyPopulations - men, women, veterans, adolescents, homeless, and criminal justiceAll 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.
53Implementing Seeking Safety Seeking Safety has been implemented by counselors (M.A. level, B.A. level, case managers), social workers, and psychologistsSeeking Safety manualNajavits, L.M. (2002). Seeking Safety: A Treatment Manual for PTSD and Substance Abuse. New York: Guildford.TrainingIndividualized to specific needs of clinicVia videos, on-site, existing training, telephone consultationMore info on Seek SafetyContact Lisa Najavits
54Addiction & 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 behaviorsBased on the premise that trauma impacts body, mind, and spiritIntegrates cognitive-behavioral and relational treatment while emphasizing mental, physical, and spiritual healthMay 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
55ATRIUM FactsPopulation – women survivors of sexual and physical abuse who have substance abuse and other addictive behaviors; has been used with men too; diverse groupsSessions – 12 weekly sessions, minutes; individual or group format; single sex groupsSetting – 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
56ATRIUM ComponentsCurriculum 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 disconnectionSkills-training on self-care, self-soothing, self-expressionAlso incorporates meditation, creative expression, spirituality, community action, and peer support
57Support for ATRIUMATRIUM 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.
58Implementing ATRIUMStaff – mental health professionals and peer facilitators who understand the impact of trauma and addictionManual available from book stores/AmazonMiller, 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 MillerMore info on ATRIUMContact Dusty Miller
59For More InformationNational Child Traumatic Stress Network (under SAMHSA’s Center for Mental Health Services)NCTSN ToolkitFor health care providers, parents, and teenagers.>Resources >Topics > Adol. Substance Abuse59
60For More InformationNational 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
61Chestnut Health Systems Contact InformationJanet C. Titus, Ph.D.Chestnut Health Systems448 Wylie DriveNormal, IL(309)