1. Kevin Koffler, MA, LMFT Clinical Director Sunspire Health Desert Palms
Treating Trauma-Related Symptoms and Substance Disorders with Evidence-Based Practices
Kevin Koffler, MA, LMFT
Clinical Director
Sunspire Health Desert Palms

2. Treating Trauma-Related Symptoms and Substance Disorders with Evidence Based Practices
What are Evidence-Based Practices, and Why Do They Matter?
What is trauma, how do we assess for it, and how does it present itself in our clients?
How does trauma-informed treatment differ from traditional substance abuse treatment?
An introduction to Seeking Safety

3. What Are Evidence Based Practices- And Why Do They Matter?

4. Evidence
Facts, theory, or subject matter that support or refute the claim that a given practice produces a specific clinical outcome. Evidence may include research findings and expert or consensus opinions.
(“COCE,” 2007)

5. Evidence-Based Thinking
A process by which diverse sources of information (research, theory, practice principles, practice Thinking guidelines, and clinical experience) are synthesized by a clinician, expert, or group of experts in order to identify or choose the optimal clinical approach for a given clinical situation.
(“COCE,” 2007)

6. Evidence-Based Practice
A practice which, based on research findings and expert or consensus opinion about available evidence,
Practice is expected to produce a specific clinical outcome (measurable change in client status).
(“COCE,” 2007)

7. The Goal of Evidence Based Practice
The goal of EBP is the integration of: (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client /patient/ caregiver  perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the clients we serve. Conceptually, the trilateral principles forming the bases for EBP can be represented through a simple figure:
(ASHA, 2015)
Figure 1: Trilateral Diagram (ASHA, 2015)

8. Fidelity
Fidelity is the extent to which a treatment approach as actually implemented corresponds to the treatment strategy as designed. Following the initial design with high fidelity is expected to result in greater success in achieving desired client outcomes than deviating from the design (i.e., having low fidelity).
(“COCE,” 2007)

9. E EBP’S at a Treatment Level: At Sunspire Health Desert Palms We Use:
Motivational Interviewing (MI)
Cognitive Behavioral Therapy (CBT)
Dialectical Behavioral Therapy (DBT)
Illness Management and Recovery (IMR)
Matrix Model (For Relapse Prevention)
Eye Movement Desensitization And Reprocessing (EMDR)
Seeking Safety (SS)

10. Trauma

12. Think of a time that was particularly stressful (but not traumatic) in your life. Revisit this period as an observer watching the events unfold and then ask yourself, “What made this time particularly stressful?” It is likely that a part of your answer will include the difficulty of managing one situation before another circumstance came along demanding your time. Stressful times denote being bombarded with many things at one time, perceived or actual, without sufficient time or ability to address them emotionally, cognitively, spiritually, and/or physically. The same goes for trauma—rapid exposure to numerous traumas, one after another, lessens one’s ability to process the event before the next onslaught. This creates a cumulative effect, making it more difficult to heal from any one trauma.

14. What is Trauma?
The term “trauma” refers to experiences that cause intense physical and psychological stress reactions. It can refer to “a single event, multiple events, or a set of circumstances that is experienced by an individual as physically and emotionally harmful or threatening and that has lasting adverse effects on the individual’s physical, social, emotional, or spiritual wellbeing”
(SAMHSA, 2012, p. 2)

15. Fight, Flight or Freeze
When a person experiences a traumatic event, all of the sights, sounds and smells in their environment get instantaneously paired with a surge of adrenaline, stress and fear, leading them to do one of three things –

16. That surge of adrenaline, stress and fear is precipitated by over activity in the amygdala. The region of the brain responsible for assessing threat-related stimuli. 

17. Consequently, when a person is exposed to one of the sights, sounds or smells they experienced during a trauma, their amygdala interprets that as a threat and begins to overcompensate, sending a false signal to the body letting it know it's in danger.

18. As a result of this process, a person may not understand why they suddenly feel anxious, or fearful when they encounter a certain sight, sound or smell and they will likely go to great lengths to avoid feeling that way.

19. How Do We Assess for Trauma
Through doing standard trauma history profile to gather symptoms, problem behaviors and functional impairments utilizing the criteria listed in the DSM-5
Through the use of outcome measure screening tools including the UCLA PTSD INDEX and the PCL-C

20. DSM-5 Diagnostic Criteria for PTSD Criterion A
Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
Directly experiencing the traumatic event.
Witnessing, in person, the event as it occurred to others.
Learning that the traumatic event occurred to a close family member or friend. In cases of actual or threatened death of a family member or friend, the event must have been violent or accidental.
Experiencing repeated or extreme exposure to aversive details of the traumatic event (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).

21. DSM-5 Diagnostic Criteria for PTSD Cluster B
Presence of more than one of the following intrusion symptoms associated w/ the traumatic event(s), beginning after the traumatic event(s) has occurred:
Recurrent, involuntary, & intrusive distressing memories of the event.
Repetitive play w/ trauma themes
Recurrent distressing dreams related to the event.
May have frightening dreams w/o recognizable content
Dissociative reactions (e.g., flashbacks) in which the individual feels/acts as if the event were recurring.
Trauma-specific reenactment may occur in play
Psychological distress at cues resembling event.
Physiological reactions to cues resembling the event

22. DSM-5 Diagnostic Criteria for PTSD Cluster C:
Persistent avoidance of stimuli associated w/ the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by more than one of the following
Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event.
Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event.

23. DSM-5 Diagnostic Criteria for PTSD Cluster D:
Negative alterations in cognitions & mood associated w/ the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by more than two 2 of the following:
Inability to remember an important aspect of the event (not due to head injury or substance use).
Persistent & exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted”).
Persistent, distorted cognitions about the cause or consequences of the event that lead the individual to blame himself/herself or others.
Persistent negative emotional state (e.g., fear, anger, guilt, or shame).
Markedly diminished interest or participation in significant activities.
Feelings of detachment or estrangement from others.
Persistent inability to experience positive emotions

24. DSM-5 Diagnostic Criteria for PTSD Cluster E
Marked alterations in arousal & reactivity associated w/ the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by more than two of the following:
Irritable behavior & angry outbursts (w/ little or no provocation) typically expressed as verbal or physical aggression.
Reckless or self-destructive behavior.
Hypervigilance.
Exaggerated startle response.
Problems w/ concentration.
Sleep disturbance

25. DSM-5 Diagnostic Criteria for PTSD
Duration of the disturbance (Criteria B, C, D, & E) is more than 1 month.
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The disturbance is not attributable to the physiological effects of a substance or other medical condition.

26. Since Clients Entering Treatment Can Be Poor Historians and/or are Avoiding Disclosure Due to Shame or Paranoid Ideations, We Utilize the PCL-C
It’s in the public domain, and doesn’t cost anything to use
Provides standard measurements by having the patient answer a 17 item questionnaire
Allows patients to disclose symptoms without discussing them in an interview
Allows clinicians to measure progress made at reducing trauma-related symptoms more effectively.

27. IMMEDIATE AND DELAYED REACTIONS TO TRAUMA
Sources: Briere & Scott, 2006b; Foa, Stein, & McFarlane, 2006; Pietrzak, Goldstein, Southwick, & Grant, 2011.

28. Immediate Emotional Reactions
Numbness and detachment Anxiety or severe fear
Guilt (including survivor guilt)
Exhilaration as a result of surviving
Anger
Sadness
Helplessness
Feeling unreal; depersonalization (e.g., feeling as if you are watching yourself)
Feeling out of control
Denial about self, discussion of traumatic events or reactions to them
Constriction of feelings

29. Delayed Emotional Reactions
Irritability and/or hostility
Depression
Mood swings, instability
Anxiety (e.g., phobia, generalized anxiety)
Fear of trauma recurrence
Grief reactions
Shame
Feelings of fragility and/or vulnerability
Emotional detachment from anything that requires emotional reactions

30. Immediate Physical Reactions
Nausea and/or gastrointestinal distress
Sweating or shivering
Muscle tremors or uncontrollable shaking
Elevated heartbeat, respiration, and blood pressure
Extreme fatigue or exhaustion levels
Greater startle responses
Depersonalization

31. Delayed Physical Reactions
Sleep disturbances, nightmares
Somatization
Faintness
Appetite and digestive changes
Lowered resistance to colds and infection
Persistent fatigue
Elevated levels of cortisol
Hyper arousal
Long-term health problems

32. Immediate Cognitive Reactions
Difficulty concentrating
Rumination or racing thoughts (e.g., replaying the traumatic event over and over again)
Distortion of time and space (e.g., traumatic event may be perceived as if it was happening in slow motion, or a few seconds can be perceived as minutes)
Memory problems (e.g., not being able to recall important aspects of the trauma)
Strong identification with victims

33. Delayed Cognitive Reactions
Intrusive memories or flashbacks
Reactivation of previous traumatic events
Self-blame
Preoccupation with event
Difficulty making decisions
Magical thinking: belief that certain behaviors, including avoidant behavior, will protect against future trauma
Belief that feelings or memories are dangerous
Generalization of triggers (e.g., a person who experiences a home invasion during the daytime may avoid being alone during the day)
Suicidal thinking

34. Immediate Behavioral Reactions
Startled reaction
Restlessness
Sleep and appetite disturbances
Engagement in high-risk behaviors
Argumentative behavior
Increased use of alcohol, drugs, and tobacco
Withdrawal and apathy

35. Delayed Behavioral Reactions
Avoidance of event reminders
Social relationship disturbances
Decreased activity level
Difficulty expressing oneself
Increased use of alcohol and drugs
Withdrawal

36. Immediate Existential Reactions
Intense use of prayer
Restoration of faith in the goodness of others (e.g., receiving help from others)
Loss of self-efficacy
Despair about humanity, particularly if the event was intentional
Immediate disruption of life assumptions (e.g., fairness, safety, goodness, predictability of life)

37. Delayed Existential Reactions
Delayed Existential Reactions Questioning (e.g., “Why me?”)
Increased cynicism
Disillusionment
Increased self-confidence (e.g., “If I can survive this, I can survive anything”)
Loss of purpose Renewed faith
Hopelessness
Reestablishing priorities
Redefining meaning and importance of life
Reworking life’s assumptions to accommodate the trauma (e.g., taking a self-defense class to reestablish a sense of safety

38. So What Can This Look Like for Someone in Treatment?

39. The following examples reflect some of the types of cognitive or thought-process changes that can occur in response to traumatic stress.

40. Cognitive Errors
Misinterpreting a current situation as dangerous because it resembles, even remotely, a previous trauma (e.g., a client overreacting to an overturned canoe in 8 inches of water, as if she and her paddle companion would drown, due to her previous experience of nearly drowning in a rip current 5 years earlier).

41. Triggers
A trigger is a stimulus that sets off a memory of a trauma or a specific portion of a traumatic experience. Imagine you were trapped briefly in a car after an accident. Then, several years later, you were unable to unlatch a lock after using a restroom stall; you might have begun to feel a surge of panic reminiscent of the accident, even though there were other avenues of escape from the stall.

42. Flashbacks

43. Flashbacks
A flashback is re experiencing a previous traumatic experience as if it were actually happening in that moment. It includes reactions that often resemble the client’s reactions during the trauma. Flashback experiences are very brief and typically last only a few seconds, but the emotional aftereffects linger for hours or longer. Flashbacks are commonly initiated by a trigger, but not necessarily. Sometimes, they occur out of the blue. Other times, specific physical states increase a person’s vulnerability to re experiencing a trauma

44. Excessive or Inappropriate Guilt
Attempting to make sense cognitively and gain control over a traumatic experience by assuming responsibility or possessing survivor’s guilt, because others who experienced the same trauma did not survive.

45. Trauma Induced Hallucinations or Delusions
Experiencing hallucinations and delusions that, although they are biological in origin, contain cognitions that are congruent with trauma content (e.g., a woman believes that a person stepping onto her bus is her father, who had sexually abused her repeatedly as child, because he wore shoes similar to those her father once wore).

46. Intrusive Thoughts or Memories
Experiencing, without warning or desire, thoughts and memories associated with the trauma. These intrusive thoughts and memories can easily trigger strong emotional and behavioral reactions, as if the trauma was recurring in the present. The intrusive thoughts and memories can come rapidly, referred to as flooding, and can be disruptive at the time of their occurrence. If an individual experiences a trigger, he or she may have an increase in intrusive thoughts and memories for a while.

47. Foreshortened Future
Trauma can affect one’s beliefs about the future via loss of hope, limited expectations about life, fear that life will end abruptly or early, or anticipation that normal life events won’t occur (e.g., access to education, ability to have a significant and committed relationship, good opportunities for work).

48. When Assessing Trauma, the Clinician Must Consider:
Was it a single, repeated or sustained trauma?
Was there enough time to process the experience?
How many losses did the trauma cause?
Was the trauma expected or unexpected?
Were the trauma’s effects on the person’s life isolated or pervasive?
Who was responsible for the trauma, and was the act intentional
What has happened since the trauma?

49. Evidence Based Treatment for Trauma Can Include:
Prolonged Exposure (PE)
Cognitive Processing Therapy (CPT)
Eye Movement Desensitization Reprocessing (EMDR)
Seeking Safety (SS)

50. These therapies prove to be effective in the treatment of PTSD due to their ability to reduce the severity of symptoms by retraining the brain to no longer send out false signals

51. Seeking Safety Trauma Video

52. Secondary or Vicarious Trauma
Secondary trauma refers to trauma-related stress reactions and symptoms resulting from exposure to another individual’s traumatic experiences, rather than from exposure directly to a traumatic event. Secondary trauma can occur among behavioral health service providers across all behavioral health settings and among all professionals who provide services to those who have experienced trauma(e.g., healthcare providers, peer counselors, first responders, clergy, intake workers).

53. 15 Minute Break

54. Introduction To Seeking Safety

55. Co-Morbidity of PTSD and SUD is Not Unusual
Women – 51% experience trauma, with 10% developing PTSD
Men – 61% experience trauma, with 5% developing PTSD
Najavits, L. M., (2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse.
New York: Guilford

56. Common Factors of SUD and Trauma-Related Symptoms
Two main themes of both disorders are secrecy and control
Each of the disorders makes the other more likely
Both diagnoses have higher rates of personality disorders
PTSD symptoms widely reported to become worse with initial abstinence
Both situations produce a profound need to be in an altered state
Najavits, L. M., (2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse.

57. What is Seeking Safety?
Seeking Safety is an evidenced based treatment model that treats the co-occurring diagnosis’s of SUD and TRAUMA RELATED SYMPTOMS

58. Delivering Seeking Safety Can Be Highly Flexible
In group or individual treatment
Inpatient and outpatient settings
In long term residential care
For men and women
For Adolescents and TAY
For patients who do not necessarily meet formal criteria for current PTSD and substance abuse
With other ongoing treatment approaches
Najavits, L. M.,(2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse.
New York: Guilford

59. Seeking Safety Treatment Manual

60. Seeking Safety is Based on Five Central Ideas
Safety as the priority for this first stage of treatment
Integrated treatment of PTSD and SUD
A focus on ideals
Four content areas: cognitive, behavioral, interpersonal and case management
Attention to the therapist’s process
Najavits, L. M.,(2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse.
New York: Guilford

61. Najavitis Based Her Model on the Herman’s Three Stage Model of Recovery (1992)
Safety
Mourning
Reconnections
Safety Stage is the initial process of Najavits’ treatment model and is the treatment stage presented in this training.
Mourning and Reconnections are later stages of recovery that are initiated in therapy work separate from the Seeking Safety Skills Group.
Najavits, L. M.,(2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse. New York: Guilford

62. Safety As An Unbrella Term
Discontinue substance use, reduce suicidality, minimize exposure to HIV and HCV, letting go of extreme symptoms, stopping self harming behavior (such as cutting)
Najavits, L. M.,(2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse. New York: Guilford

63. Treatment Focuses on the Here and Now

64. Treatment Focuses on Recovery Interventions that are Common to SUD and Trauma-Related Symptoms

65. Safety Elements Within the Management of PTSD Symptoms Reflect Traditional Safety Elements in Substance Abuse Recovery:
Education
Assessing the impact of condition
Dealing with urges and cravings
Focus on self care
Attention to relapse prevention
Najavits, L. M.,(2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse.
New York: Guilford

66. The Goals of Seeking Safety
Develop commitment to practicing safety
Master coping skills (responses to symptoms)
Utilize safety planning (prevention)
Report unsafe behaviors (asking for help)
Utilize Safety contract (response to urges)
Najavits, L. M.,(2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse.
New York: Guilford

67. 25 Treatment Topics Safety Compassion PTSD: Taking Back Your Power
Detaching from Emotional Pain (Grounding)
When Substances Control You
Asking for Help
Taking Good Care of Yourself
Compassion
Red and Green Flags
Honesty
Recovery Thinking
Integrating the Split Self
Najavits, L. M.,(2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse. New York: Guilford

68. Treatment Topics (Continued)
Commitment
Creating Meaning
Community Resources
Setting Boundaries in Relationships
Discovery
Getting Others to Support Your Recovery
Coping with Triggers
Respecting Your Time
Healthy Relationships
Self-Nurturing
Healing from Anger
The Life Choices Game (Review)
Termination
Najavits, L. M.,(2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse.
New York: Guilford

69. Detail to the Process Between the Counselor/ Therapist and Client
Attention to problematic countertransference reactions.
Avoid harsh confrontation
Voyeurism
Inability to hold patients accountable – misguided sympathy
Allowing patients to be scapegoated
Becoming a victim
Identification with patient’s PTSD which can result in excessive support and overindulgence with patient’s vulnerability
Being afraid of patients
Najavits, L. M.,(2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse.
New York: Guilford

70. Treatment Approach and Intervention Orientation
THE FOCUS IS ON SAFETY AS THE PRIMARY THEME
Najavits’ model emphasizes “safety skills” in the management of PTSD symptoms, feelings of emotional turmoil, and self doubt
Interactions with clients focus on supporting and facilitating safety themes in making behavioral choices, in response to emotions and reactions to situations
In addition to Cognitive/Behavioral approaches, the teaching of grounding skills is used to enable the client to self sooth and disengage from destructive urges, emotional pain, and feelings of being overwhelmed.
Najavits, L. M.,(2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse. New York: Guilford

71. Important for Therapists New to Seeking Safety
Direct process without taking charge
Apply 80/20 rule
Ask provocative questions – “How might this apply to your PTSD and substance use”
Relate material to current and specific problems in patients’ lives
Process barriers and obstacles
Refer to Coping and Commitment Sheets
Najavits, L. M.,(2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse. New York: Guilford

72. How To Facilitate A Seeking Safety Session

73. Check In Since your last session: How are you feeling?
What good coping have you done?
Any substance use or other unsafe behavior?
Did you complete your commitment?
Community Resources Update

74. Quotation

75. Handouts

76. Seeking Safety Grounding Exercise Demonstration

77. Check Out
Name one thing you got out of today’s session (and any problems with the session).
What is your new commitment?
What community resource will you call?

78. Questions And Answers

79. Final Check Out

80. For Further Information on Seeking Safety or Treatment of Trauma and SUD Evidence Based Treatment
Official Seeking Safety Website:
PTSD: National Center for PTSD (Resource for treatment information and access to outcome measures:
SAMSHA National Center for Trauma-Informed Care:
National Child Traumatic Stress Network (For those Working with Adolescents or TAY):
Trauma Informed Care in Behavioral Health Services: Trauma-Informed-Care-in-Behavioral-Health-Services/SMA
Understanding Evidence-Based Practices for Co-Occurring Disorders: Disorders/SMA

81. kkoffler@sunspirehealth.com 760.992.3478
Thank You.
C O N T A C T I N F O R M A T I O N:
Kevin Koffler, MA LMFT Clinical Director