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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.

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Presentation on theme: "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."— Presentation transcript:

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) 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 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) 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 Majority are victims of childhood abuse and repeated trauma Present to treatment with high rates of other co-morbid disorders Present to treatment with high rates of other co-morbid disorders Have interpersonal, behavioral and emotion regulation deficits Have interpersonal, behavioral and emotion regulation deficits Abuse the most severe substances Abuse the most severe substances

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

5 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. Pandora

6 Clinical Challenges in the Treatment of Traumatic Stress and Addiction Abstinence may not resolve comorbid trauma-related disorders – for some PTSD may worsen 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 Confrontational approaches typical in addictions settings frequently exacerbate mood and anxiety disorders 12-Step Models often do not acknowledge the need for pharmacologic interventions 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 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) ATRIUM: Addictions and Trauma Recovery Integrated Model (Miller & Guidry, 2001) Concurrent Treatment of PTSD and Cocaine Dependence (Back et al., 2001) Concurrent Treatment of PTSD and Cocaine Dependence (Back et al., 2001) Seeking Safety (Najavits, 1998; Seeking Safety (Najavits, 1998; SDPT: Substance Dependence PTSD Therapy (Triffleman et. al, 1999) SDPT: Substance Dependence PTSD Therapy (Triffleman et. al, 1999) TARGET - Trauma Affect Regulation: Guidelines for Education and Therapy (Ford; ) TARGET - Trauma Affect Regulation: Guidelines for Education and Therapy (Ford; Transcend (Donovan et al., 2001) 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) 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 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 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 Developed as a group treatment for PTSD/SUD women Structured with flexibility Structured with flexibility Educates patients about PTSD and SUD’s and their interaction Educates patients about PTSD and SUD’s and their interaction Based on CBT models of SUDs, PTSD treatment, women’s treatment and educational research Based on CBT models of SUDs, PTSD treatment, women’s treatment and educational research Goals include abstinence and decreased PTSD symptoms Goals include abstinence and decreased PTSD symptoms Focuses on enhancing cognitive and interpersonal coping skills, safety and self-care Focuses on enhancing cognitive and interpersonal coping skills, safety and self-care Therapist is active: teaches, supports and encourages Therapist is active: teaches, supports and encourages Includes case management component Includes case management component Najavits, 2002;

10 Comparison of Existing Trauma and Substance Use Disorder- Focused Treatment Research

11 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 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 Core Treatment Components Outreach and engagement Outreach and engagement Screening and assessment Screening and assessment Treatment activities Treatment activities Parenting skills Parenting skills Resource coordination and advocacy Resource coordination and advocacy Trauma-specific services Trauma-specific services Crisis intervention Crisis intervention Peer-run services Peer-run services

12 Summary CBT, including exposure therapy, shows promise in treating PTSD/SUD 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 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. 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 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 Women’s Health Project Treatment and Research Center ISTSS, November 6, 2006 Hollywood, CA

14 Integrating Trauma Treatment Trauma-Informed Treatment vs. Trauma-Specific Treatment

15 Trauma-specific treatment is not enough.

16 Creating a Trauma-Informed Addiction Treatment System Lessons from the WCDVS* Outreach and Engagement Outreach and Engagement Screening and Assessment Screening and Assessment Substance Abuse and Mental Health Treatment Substance Abuse and Mental Health Treatment Parenting Skills Parenting Skills Resource Coordination and Advocacy Resource Coordination and Advocacy Trauma-specific Services Trauma-specific Services Crisis Intervention Crisis Intervention Peer-Run Services (Consumers / Survivors / In Recovery) Peer-Run Services (Consumers / Survivors / In Recovery) *WCDVS information is drawn from

17 Trauma-Informed Services: Characteristics (WCDVS) Aware of the role of violence and victimization in women’s lives. Aware of the role of violence and victimization in women’s lives. Minimize victimization and re-victimization. Minimize victimization and re-victimization. Hospitable and engaging for survivors. Hospitable and engaging for survivors. Facilitate recovery. Facilitate recovery. Empower. Empower. Respect a woman's choices and control over her recovery. Respect a woman's choices and control over her recovery. Goals are mutual and collaboratively established. Goals are mutual and collaboratively established. Emphasize women’s strengths. Emphasize women’s strengths.

18 Trauma-Informed Services: Principles (WCDVS) Respect trauma as a central concern in a woman’s life. Respect trauma as a central concern in a woman’s life. Symptoms are adaptations to traumatic experiences. Symptoms are adaptations to traumatic experiences. Reframe ‘Adaptive’ behavior as positive coping. Reframe ‘Adaptive’ behavior as positive coping. Violence and trauma have broad impact. Violence and trauma have broad impact. Providers need to meet the woman where she is. Providers need to meet the woman where she is.

19 Introducing Trauma-Specific Treatment Counselor Buy In Counselor Buy In Challenges to Agency and Treatment Philosophies Challenges to Agency and Treatment Philosophies Protocol Training Protocol Training Safety Safety Supervision Supervision Counselor Self-care Counselor Self-care

20 Should I or Shouldn’t I? Why counselors may be hesitant to provide trauma treatment Why counselors may be hesitant to provide trauma treatment Pandora’s box: Fear Pandora’s box: Fear Clients and/or Counselors will become overwhelmed. Clients and/or Counselors will become overwhelmed. Clients will relapse, act out or drop out. Clients will relapse, act out or drop out. Clients will become threatening or destructive to self or others. Clients will become threatening or destructive to self or others.

21 Should I or Shouldn’t I? Why counselors may be hesitant to provide trauma treatment Why counselors may be hesitant to provide trauma treatment Personal history Personal history Addiction history and recovery Addiction history and recovery Survivors of trauma themselves; increased vulnerability Survivors of trauma themselves; increased vulnerability

22 What do Counselors Need to Learn?

23 Try Something New Treatment that differs from the Counselor’s own past treatment. Treatment that differs from the Counselor’s own past treatment. Treatment is not one-size-fits-all. Treatment is not one-size-fits-all. Addiction treatment that pays attention to abuse. Addiction treatment that pays attention to abuse. Treatment that challenges traditional substance abuse treatment models Treatment that challenges traditional substance abuse treatment models Medical (Disease) Model Medical (Disease) Model 12 Step Model 12 Step Model Confrontational Methods Confrontational Methods

24 Difficult 12 Step Concepts for Survivors in Recovery Surrender your power. Surrender your power. Surrender to a higher power. Surrender to a higher power. Get off your pity potty. Get off your pity potty.

25 Philosophical Differences Abstinence vs. Harm Reduction Abstinence vs. Harm Reduction What is the Agency response to lapse/relapse? What is the Agency response to lapse/relapse? Harm reduction can be a path to Abstinence Harm reduction can be a path to Abstinence Compassion and collaboration Compassion and collaboration

26 Why Use Manualized Trauma Treatment? Psychoeducation for survivors Psychoeducation for survivors Structure for Clients and Counselors Structure for Clients and Counselors Less opportunity to go too deep Less opportunity to go too deep Time-limited possibilities Time-limited possibilities

27 Developing a New Stance Identify Counselor skills sets. Identify Counselor skills sets. Collaborate, Don’t Dominate. Collaborate, Don’t Dominate. Validate and support. Validate and support. Notice non-verbal communication. Notice non-verbal communication. In group, keep members safe. In group, keep members safe. Work within the “therapeutic window” (Briere). Work within the “therapeutic window” (Briere). Motivational interviewing strategies are helpful, and not just for substances. Motivational interviewing strategies are helpful, and not just for substances.

28 Client and Counselor Safety Managing an angry and aggressive client Managing an angry and aggressive client “Tool box” not Pandora’s box “Tool box” not Pandora’s box Child welfare involvement Child welfare involvement Intimate partner violence Intimate partner violence

29 The Counselor Should Not Feel Alone Trauma specialists Trauma specialists In Agency In Agency In the Community In the Community Get the client off to a good start Get the client off to a good start Attending to trauma as part of recovery Attending to trauma as part of recovery Stabilize Stabilize Most trauma processing will follow Most trauma processing will follow

30 Potential for Vicarious Traumatization Sensitivity for Counselor survivors Sensitivity for Counselor survivors Conducting trauma treatment should be voluntary Conducting trauma treatment should be voluntary Supportive environments Supportive environments Moderate caseloads Moderate caseloads Regular supervision Regular supervision

31 Supervision is Critical Protocol training is only the beginning. Protocol training is only the beginning. A safe place. A safe place. Individual or group supervision. Individual or group supervision. Should not be on the ‘back burner’. Should not be on the ‘back burner’. Ensure fidelity to the treatment. Ensure fidelity to the treatment. Are audio or video recordings possible? Are audio or video recordings possible?

32 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.” “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

33 Counselor Self-Care Practice what you preach Practice what you preach Rest and exercise Rest and exercise Opportunities for personal renewal Opportunities for personal renewal Personal therapy Personal therapy

34 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

35 Washington Node Residence XII New York Node ARTC Long Island Node Lead Node New England Node LMG Programs South Carolina Node Charleston Center Florida Node The Village Florida Node Gateway Community Ohio Valley Node Maryhaven NIDA Clinical Trials Network Women & Trauma Sites

36 Pre-Post Control Group Design Pre-Treatment Weeks Treatment 6 Weeks Post Treatment Follow-up 46 Weeks 1 Week3 Month6 Month12 Month Pre-screening, Screening, Baseline, Randomization, Individual Counselor Session 12 Twice Weekly Group Sessions

37 Participant Eligibility Criteria Inclusion female, years old female, years old used an illicit substance within the past six months and have a current diagnosis of illicit drug/alcohol abuse or dependence 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 PTSD or Sub-threshold PTSD enrolled at participating community treatment program enrolled at participating community treatment programExclusion advanced stage medical disease (AIDS, TB) advanced stage medical disease (AIDS, TB) impaired mental status (MMSE: less than or equal to 21) impaired mental status (MMSE: less than or equal to 21) significant risk of suicidal/homicidal intent or behavior significant risk of suicidal/homicidal intent or behavior history of schizophrenia-spectrum diagnosis history of schizophrenia-spectrum diagnosis active psychosis (prior 2 months) active psychosis (prior 2 months) involved in PTSD-related litigation involved in PTSD-related litigation refuses to be audio or videotaped refuses to be audio or videotaped

38 Assessment Measures Demographics Demographics Substance Abuse/Dependence Diagnosis (CIDI) Substance Abuse/Dependence Diagnosis (CIDI) Substance Use (past 7, 30 days (ASI, SUI) Substance Use (past 7, 30 days (ASI, SUI) Biological Measures of Substance Use Biological Measures of Substance Use PTSD Diagnosis (CAPS) PTSD Diagnosis (CAPS) PTSD Symptom Severity (PSS-SR) PTSD Symptom Severity (PSS-SR) Psychiatric Symptoms (BSI) Psychiatric Symptoms (BSI) Other Service Utilization (medication) Other Service Utilization (medication) General Health, Social Network General Health, Social Network HIV Risk Behaviors HIV Risk Behaviors Child/Adult Physical/Sexual Violence Child/Adult Physical/Sexual Violence

39 PTSD Assessment Clinician Administered PTSD Scale (CAPS) Clinician Administered PTSD Scale (CAPS) DSM-IV symptom clusters DSM-IV symptom clusters A: Exposure A: Exposure B: Re-experiencing B: Re-experiencing C: Avoidance C: Avoidance D: Arousal D: Arousal Subthreshold PTSD: criteria A, B, C or D, E (duration of at least 1 month) and F (clinically significant impairment). 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 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., The development of a Clinician-Administered PTSD Scale. J Trauma Stress. 8,

40 Enrollment Initial Screen N=1,963 Eligible N=1,212 (62%) Ineligible N=751 Completed Full Screen N=541 No Full Screen N=751 Eligible N=379 (70%) Ineligible N=162 Randomized N=353 (93%) Not Randomized (multiple reasons) N=26

41 Sample Characteristics (N=353)

42 Sample Characteristics (n=353)

43 PTSD Diagnosis and Severity at Baseline (n=353)

44 Substance Use Disorders at Baseline (n=353)

45 Lifetime Trauma Exposure (n=353)

46 Treatment Groups Seeking Safety (SS; Najavits, 1998) Seeking Safety (SS; Najavits, 1998) Short term, manualized treatment Short term, manualized treatment Cognitive Behavioral Cognitive Behavioral Focused on addiction and trauma Focused on addiction and trauma Women’s Health Education (WHE) Women’s Health Education (WHE) Short term, manualized treatment Short term, manualized treatment Pyschoeducational, didactic Pyschoeducational, didactic Focused on understanding women’s health issues and empowerment Focused on understanding women’s health issues and empowerment

47 Seeking Safety Topics Safety Safety PTSD: Taking Back Your Power PTSD: Taking Back Your Power Detaching from Emotional Pain Detaching from Emotional Pain When Substances Control You When Substances Control You Taking Good Care of Yourself Taking Good Care of Yourself Compassion Compassion Red and Green Flags Red and Green Flags Honesty Honesty Integrating the Split Self Integrating the Split Self Creating Meaning Creating Meaning Setting Boundaries in Relationships Setting Boundaries in Relationships Healing from Anger Healing from Anger

48 Women’s Health Education Topics Body Systems Body Systems Female anatomy Female anatomy Breast care Breast care Infections Infections HIV HIV Contraception Contraception Pregnancy Pregnancy STDs STDs Nutrition Nutrition High Blood Pressure High Blood Pressure Diabetes Diabetes Menopause Menopause

49 Who were the clinicians? All female staff All female staff Agreed to randomization, videotaping and research monitoring Agreed to randomization, videotaping and research monitoring Demonstrated ability to conduct manualized, problem-solving session prior to randomization Demonstrated ability to conduct manualized, problem-solving session prior to randomization Had no prior experience with study interventions Had no prior experience with study interventions

50 Counselor and Supervisor Demographics Counselorsn=18Supervisorsn=18 Age: M 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 Years at Program: M Highest Degree: N (%) >Bachelors Degree Bachelors Degree Master ’ s Degree/Doctorate 1 (5.5) 7 (38.9) 10 (55.6) 1 (5.5) 2 (11.1) 15 (83.3) In Recovery: N (%) NoYes Prefer not to answer 13 (72.3) 4 (22.2) 1 (5.5) 15 (83.3) 2 (11.1) 1 (5.5)

51 Intervention-Specific Training Elements 3-day group training 3-day group training Explanation, demonstration and role-play Explanation, demonstration and role-play Post-training certification Post-training certification Counselors and supervisors conducted pilot groups Counselors and supervisors conducted pilot groups Supervisors coded counselors’ sessions and compared ratings with lead experts Supervisors coded counselors’ sessions and compared ratings with lead experts Train-the-trainer model Train-the-trainer model Used for supervisor training Used for supervisor training

52 Research-within-Practice Challenges The Therapeutic Misconception The Therapeutic Misconception Research is not treatment Research is not treatment Protocol adherence is key Protocol adherence is key Avoiding cross-contamination Avoiding cross-contamination Need to keep interventions separate Need to keep interventions separate Can’t share information with other colleagues or clients Can’t 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 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 Calls included discussion of specific issues, review of session tapes and adherence ratings

54 Adherence Monitoring Counselors Counselors Supervisors rated 50% of cases and gave feedback based on ratings Supervisors rated 50% of cases and gave feedback based on ratings Cut-offs for continued participation in trial and guidelines for retraining Cut-offs for continued participation in trial and guidelines for retraining Supervisors Supervisors Lead node experts rated 25% of sessions rated by local supervisors and gave feedback on level of agreement 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 (68.3) 267 (73.8) WHE (94.4) 206 (90.3)

56 Treatment Attendance Treatment Group NMeanSDMedian SS WHE

57 Counselor and Supervisor Benefits Expanded skills in delivering and supervising interventions Expanded skills in delivering and supervising interventions Became more comfortable using treatment manuals and working explicitly with women with co-occurring disorders Became more comfortable using treatment manuals and working explicitly with women with co-occurring disorders Sustainability and interest after conclusion of trial Sustainability and interest after conclusion of trial

58 Counselor and Supervisor Challenges Rolling admission groups and no-shows led to delays in providing interventions Rolling admission groups and no-shows led to delays in providing interventions TTT model led to counselors feeling less involved in the process TTT model led to counselors feeling less involved in the process Adherence monitoring Adherence monitoring Counselor issues Counselor issues Supervisor issues Supervisor issues Participant characteristics Participant characteristics Time commitment Time commitment

59 Summary Training, supervision and implementation require time and commitment from all levels of staff Training, supervision and implementation require time and commitment from all levels of staff Involve counselors and supervisors in ongoing supervision from “lead node” Involve counselors and supervisors in ongoing supervision from “lead node” Ensure adequate training in research process, procedures and special need of patient population 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 levels of multiple trauma exposure with clinically significant PTSD symptoms. High percentage of sexual assaults (range=85%- 100%). High percentage of sexual assaults (range=85%- 100%). Differences across sites: Types of other traumatic experiences reported. Types of other traumatic experiences reported. Types of drugs used and drug diagnosis. Types of drugs used and drug diagnosis. Continued levels of substance use. Continued levels of substance use. Recruitment success linked to type of CTP population and number of available intakes. 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. 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. 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: Participation in this study made possible by: NIDA CTN Long Island Regional Node NIDA CTN Long Island Regional Node NIDA/NIH Grant U10 DA13035 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. We would like to acknowledge the dedication of staff and resilience and strength of the participants who made this study possible.


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