Presentation on theme: "Columbia University School of Social Work"— Presentation transcript:
1 Columbia University School of Social Work Treatment for Co-occurring PTSD and Substance Use Disorders: State of the ScienceLisa R. Cohen, PhDColumbia University School of Social WorkISTSSNovember 6, 2006Hollywood, CA
2 Scope of the ProblemAs many as 80% of women seeking SUD treatment report histories of sexual and physical assault (Brady et al., 1994; Dansky et al., 1995; FuIlilove et al., 1993; Hien & Scheier, 1996; Miller et al. 1993)Among substance abusers, lifetime rates of PTSD range from 14-60% (Triffleman, 2003; Donovan et al., 2001; Najavits et al., 1997; Brady et al., 2001)Among PTSD populations, co-occurring substance use disorders may occur in 60-80% of individuals (Donovan et al., 2001)
3 Clinical Profile: Women with PTSD/SUD Majority are victims of childhood abuse and repeated traumaPresent to treatment with high rates of other co-morbid disordersHave interpersonal, behavioral and emotion regulation deficitsAbuse the most severe substances
5 PandoraThe 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.17
6 Clinical Challenges in the Treatment of Traumatic Stress and Addiction Abstinence may not resolve comorbid trauma-related disorders – for some PTSD may worsenConfrontational approaches typical in addictions settings frequently exacerbate mood and anxiety disorders12-Step Models often do not acknowledge the need for pharmacologic interventionsTreatments for PTSD only —such as Exposure-Based Approaches often may not be advisable to treat women with addictions or may be marked by complications44
7 PTSD/SUD TreatmentsATRIUM: Addictions and Trauma Recovery Integrated Model (Miller & Guidry, 2001)Concurrent Treatment of PTSD and Cocaine Dependence (Back et al., 2001)Seeking Safety (Najavits, 1998;SDPT: Substance Dependence PTSD Therapy (Triffleman et. al, 1999)TARGET - Trauma Affect Regulation: Guidelines for Education and Therapy (Ford;Transcend (Donovan et al., 2001)
8 Treatments for co-morbid PTSD vs. PTSD only treatments Addition of components specifically designed to deal with coping and cognitive restructuring related to substance use (cravings and relapse triggers)Concurrent Model : Additional components may be integrated and delivered concurrentlySequential Model: Initial phase may focus on substance abuse related symptoms in preparation for working on trauma related symptoms later
9 Seeking Safety Developed as a group treatment for PTSD/SUD women Structured with flexibilityEducates patients about PTSD and SUD’s and their interactionBased on CBT models of SUDs, PTSD treatment, women’s treatment and educational researchGoals include abstinence and decreased PTSD symptomsFocuses on enhancing cognitive and interpersonal coping skills, safety and self-careTherapist is active: teaches, supports and encouragesIncludes case management componentNajavits, 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 historiesCore Treatment ComponentsOutreach and engagementScreening and assessmentTreatment activitiesParenting skillsResource coordination and advocacyTrauma-specific servicesCrisis interventionPeer-run services
12 SummaryCBT, including exposure therapy, shows promise in treating PTSD/SUDPTSD treatments did not make patients worse, improved PTSD, substance use and general psychiatric symptomsIntegrated counseling may be one of the key program features that impacts outcomes.More research needed to examine the duration, scope, timing and combination of components to identify optimal model of PTSD/SUD treatment integration
13 Challenges to Implementing Trauma-focused Interventions in Substance Abuse Treatment Programs Lisa Caren Litt, Ph.D.Columbia University College of Physicians and SurgeonsWomen’s Health Project Treatment and Research CenterISTSS, November 6, 2006Hollywood, CA
16 Creating a Trauma-Informed Addiction Treatment System Lessons from the WCDVS* Outreach and EngagementScreening and AssessmentSubstance Abuse and Mental Health TreatmentParenting SkillsResource Coordination and AdvocacyTrauma-specific ServicesCrisis InterventionPeer-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 .Minimize victimization and re-victimization.Hospitable and engaging for survivors.Facilitate recovery.Empower.Respect a woman's choices and control over her recovery.Goals are mutual and collaboratively established.Emphasize women’s strengths.
18 Trauma-Informed Services: Principles (WCDVS) Respect trauma as a central concern in a woman’s life.Symptoms are adaptations to traumatic experiences.Reframe ‘Adaptive’ behavior as positive coping.Violence and trauma have broad impact.Providers need to meet the woman where she is.
19 Introducing Trauma-Specific Treatment Counselor Buy InChallenges to Agency and Treatment PhilosophiesProtocol TrainingSafetySupervisionCounselor Self-care
20 Should I or Shouldn’t I?Why counselors may be hesitant to provide trauma treatmentPandora’s box: FearClients and/or Counselors will become overwhelmed.Clients will relapse, act out or drop out.Clients will become threatening or destructive to self or others.
21 Should I or Shouldn’t I?Why counselors may be hesitant to provide trauma treatmentPersonal historyAddiction history and recoverySurvivors of trauma themselves; increased vulnerability
23 Try Something NewTreatment that differs from the Counselor’s own past treatment.Treatment is not one-size-fits-all.Addiction treatment that pays attention to abuse.Treatment that challenges traditional substance abuse treatment modelsMedical (Disease) Model12 Step ModelConfrontational Methods
24 Difficult 12 Step Concepts for Survivors in Recovery Surrender your power.Surrender to a higher power.Get off your pity potty.
25 Philosophical Differences Abstinence vs. Harm ReductionWhat is the Agency response to lapse/relapse?Harm reduction can be a path to AbstinenceCompassion and collaboration
26 Why Use Manualized Trauma Treatment? Psychoeducation for survivorsStructure for Clients and CounselorsLess opportunity to go too deepTime-limited possibilities
27 Developing a New Stance Identify Counselor skills sets.Collaborate, Don’t Dominate.Validate and support.Notice non-verbal communication.In group, keep members safe.Work within the “therapeutic window” (Briere).Motivational interviewing strategies are helpful, and not just for substances.
28 Client and Counselor Safety Managing an angry and aggressive client“Tool box” not Pandora’s boxChild welfare involvementIntimate partner violence
29 The Counselor Should Not Feel Alone Trauma specialistsIn AgencyIn the CommunityGet the client off to a good startAttending to trauma as part of recoveryStabilizeMost trauma processing will follow
30 Potential for Vicarious Traumatization Sensitivity for Counselor survivorsConducting trauma treatment should be voluntarySupportive environmentsModerate caseloadsRegular supervision
31 Supervision is Critical Protocol training is only the beginning.A safe place.Individual or group supervision.Should not be on the ‘back burner’.Ensure fidelity to the treatment.Are audio or video recordings possible?
32 About Direct Observation “It seems very frightening at 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 Rest and exercise Opportunities for personal renewalPersonal therapy
34 Columbia University School of Social Work NIDA Clinical Trials Network Women’s Treatment for Trauma and Substance Use Disorders: Issues in Training and AssessmentAimee Campbell, MSWColumbia University School of Social WorkISTSS, November 6, 2006Hollywood, CA
35 NIDA Clinical Trials Network Women & Trauma Sites Washington Node Residence XIINew England Node LMG ProgramsNew York Node ARTCOhio Valley Node MaryhavenLong Island Node Lead NodeSouth Carolina Node Charleston CenterFlorida Node Gateway CommunityFlorida Node The Village
36 Pre-Post Control Group Design Pre-screening, Screening, Baseline, Randomization, Individual Counselor SessionPre-Treatment1 - 4 WeeksTreatment6 Weeks12 Twice Weekly Group SessionsPost Treatment Follow-up46 Weeks1 Week3 Month6 Month12 Month
37 Participant Eligibility Criteria Inclusionfemale, years oldused an illicit substance within the past six months and have a current diagnosis of illicit drug/alcohol abuse or dependencePTSD or Sub-threshold PTSDenrolled at participating community treatment programExclusionadvanced stage medical disease (AIDS, TB)impaired mental status (MMSE: less than or equal to 21)significant risk of suicidal/homicidal intent or behaviorhistory of schizophrenia-spectrum diagnosisactive psychosis (prior 2 months)involved in PTSD-related litigationrefuses to be audio or videotaped
38 Assessment Measures Demographics Substance Abuse/Dependence Diagnosis (CIDI)Substance Use (past 7, 30 days (ASI, SUI)Biological Measures of Substance UsePTSD Diagnosis (CAPS)PTSD Symptom Severity (PSS-SR)Psychiatric Symptoms (BSI)Other Service Utilization (medication)General Health, Social NetworkHIV Risk BehaviorsChild/Adult Physical/Sexual Violence
39 PTSD Assessment Clinician Administered PTSD Scale (CAPS) DSM-IV symptom clustersA: ExposureB: Re-experiencingC: AvoidanceD: ArousalSubthreshold 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 supervisorBlake, 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 Ineligible N=751 Eligible No Full ScreenN=751Completed Full ScreenN=541IneligibleN=162EligibleN=379 (70%)Not Randomized(multiple reasons)N=26RandomizedN=353 (93%)
46 Treatment Groups Seeking Safety (SS; Najavits, 1998) Short term, manualized treatmentCognitive BehavioralFocused on addiction and traumaWomen’s Health Education (WHE)Pyschoeducational, didacticFocused on understanding women’s health issues and empowerment
47 Seeking Safety Topics Red and Green Flags Honesty PTSD: Taking Back Your PowerDetaching from Emotional PainWhen Substances Control YouTaking Good Care of YourselfCompassionRed and Green FlagsHonestyIntegrating the Split SelfCreating MeaningSetting Boundaries in RelationshipsHealing from Anger
48 Women’s Health Education Topics Body SystemsFemale anatomyBreast careInfectionsHIVContraceptionPregnancySTDsNutritionHigh Blood PressureDiabetesMenopause
49 Who were the clinicians? All female staffAgreed to randomization, videotaping and research monitoringDemonstrated ability to conduct manualized, problem-solving session prior to randomizationHad no prior experience with study interventions
50 Counselor and Supervisor Demographics Counselorsn=18SupervisorsAge: M38.041.8Race: N (%)WhiteBlack/African AmericanHispanic/Latina9 (50.0)5 (27.8)4 (22.2)12 (66.7)1 (5.5)Yrs in Substance Abuse: M4.89.0Years at Program: M3.9Highest Degree: N (%)>Bachelors DegreeBachelors DegreeMaster’s Degree/Doctorate7 (38.9)10 (55.6)2 (11.1)15 (83.3)In Recovery: N (%)NoYesPrefer not to answer13 (72.3)
51 Intervention-Specific Training Elements 3-day group trainingExplanation, demonstration and role-playPost-training certificationCounselors and supervisors conducted pilot groupsSupervisors coded counselors’ sessions and compared ratings with lead expertsTrain-the-trainer modelUsed for supervisor training
52 Research-within-Practice Challenges The Therapeutic MisconceptionResearch is not treatmentProtocol adherence is keyAvoiding cross-contaminationNeed to keep interventions separateCan’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 interventionCalls included discussion of specific issues, review of session tapes and adherence ratings
54 Adherence Monitoring Counselors Supervisors Supervisors rated 50% of cases and gave feedback based on ratingsCut-offs for continued participation in trial and guidelines for retrainingSupervisorsLead node experts rated 25% of sessions rated by local supervisors and gave feedback on level of agreement
55 Site/Lead Adherence Agreement N (%) Treatment FidelitySite Adherent(%)Lead Adherent (%)Site/Lead Adherence Agreement N (%)Total Adherent at SiteN (%)SS60.078.360 (68.3)267 (73.8)WHE80.371 (94.4)206 (90.3)
56 Treatment Attendance SS WHE Treatment Group N Mean SD Median 170 6.3 4.47WHE1722.214.171.124
57 Counselor and Supervisor Benefits Expanded skills in delivering and supervising interventionsBecame more comfortable using treatment manuals and working explicitly with women with co-occurring disordersSustainability and interest after conclusion of trial
58 Counselor and Supervisor Challenges Rolling admission groups and no-shows led to delays in providing interventionsTTT model led to counselors feeling less involved in the processAdherence monitoringCounselor issuesSupervisor issuesParticipant characteristicsTime commitment
59 SummaryTraining, supervision and implementation require time and commitment from all levels of staffInvolve counselors and supervisors in ongoing supervision from “lead node”Ensure adequate training in research process, procedures and special need of patient population
60 Summary Consistent across sites: High levels of multiple trauma exposure with clinically significant PTSD symptoms.High percentage of sexual assaults (range=85%-100%).Differences across sites:Types of other traumatic experiences reported.Types of drugs used and drug diagnosis.Continued levels of substance use.Recruitment success linked to type of CTP population and number of available intakes.
61 ImplicationsThough all participants met PTSD and SUD diagnoses as per study inclusion criteria, findings show that within this sample population there was substantial variability across sites in terms of types of trauma exposure, types of drugs used and specific drug use diagnoses.Clinicians and researchers need to be aware of the potential for such differences when developing or delivering treatment interventions so as to best meet needs of this heterogeneous group.
62 Support Participation in this study made possible by: NIDA CTN Long Island Regional NodeNIDA/NIH Grant U10 DA13035We would like to acknowledge the dedication of staff and resilience and strength of the participants who made this study possible.