Janet C. Titus, Ph.D. Chestnut Health Systems Community Corrections and Offender Reentry Program Grantee Meeting May 3, 2011 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

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?

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)

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

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

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

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

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.

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.

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).

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

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)

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).

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

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.

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

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

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

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.

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

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

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)

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)

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)

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

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.

CBITS Facts Population – girls & boys, 10-15 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

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.

Implementing CBITS Staff - ideal person has prior training and experience with mental health and CBT. CBITS manual available from http://www.sopriswest.com Jaycox, L. (2003). CBITS: Cognitive-Behavioral Intervention for Trauma in Schools. New York: Sopris West. Training available – contact Dr. Audra Langley (alangley@mednet.ucla.edu) 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 www.cbitsprogram.org. More info on CBITS Contact Sheryl Kataoka (skataoka@ucla.edu)

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 ·  

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

SPARCS Facts Population – girls & boys, 12-19 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

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).

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 http://sparcstraining.com/index.php Initial two day training, later two day training, frequent consultations Learning Collaborative More info on SPARCS Dr. Victor Labruna (vlabruna@nshs.edu) Dr. Mandy Habib (mhabib@nshs.edu)

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.

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)

I-CARE Facts Population – girls & boys, 13-17 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

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

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)

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 (lsuarez@psych.uic.edu) 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

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

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.

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, 26-55 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

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

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.

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.

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. rwolfson@communityconnectionsdc.org www.communityconnectionsdc.org

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)

Seeking Safety Facts Population – adults and adolescents (male and female) with PTSD/trauma and substance abuse disorders Sessions – 25 weekly 50-90 minute sessions (or twice weekly), group or individual formats Setting – substance abuse treatment (OP, residential), correctional facilities, health and mental health centers

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

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

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.

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 (info@seekingsafety.org) http://www.seekingsafety.org

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

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, 60-90 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

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

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.

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 (dustymi@aol.com) More info on ATRIUM Contact Dusty Miller http://www.dustymiller.org

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

For More Information National Center for Trauma-Informed Care (under SAMHSA’s Center for Mental Health Services) http://www.samhsa.gov/nctic/ Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services – 2008 Update http://www.theannainstitute.org/Models%20for%20Developing%20Traums-Report%201-09-09%20_FINAL_.pdf

Chestnut Health Systems Contact Information Janet C. Titus, Ph.D. Chestnut Health Systems 448 Wylie Drive Normal, IL 61761 (309) 451-7851 jtitus@chestnut.org