Integrated Treatment for Trauma and Addiction: Seeking Safety

1
Integrated Treatment for Trauma and Addiction
Seeking Safety

• Denise Hien, PhD, LI Node, Columbia University
• Tracy Simpson, PhD, VAPSHCS, University of
  Washington
• NIDA CTN Blending Conference
• Seattle, WA
• October 16, 2006

PLEASE DO NOT CITE CONTENTS OF PRESENTATION
WITHOUT PERMISSION OF THE AUTHOR
2
Scope of the Problem

• 1 in 2 women in the U.S. experience some type of
  traumatic event (Kessler, 1995)
• Approximately 33 of females under age 18
  experience sexual abuse (Finkelhor, 1994 Wyatt,
  1999)
• Prevalence rates of PTSD in community samples
  have ranged from 13 to 36 (Breslau, 1991
  Kilpatrick, 1987 Norris, 1992 Resnick, 1993)
• Studies have documented PTSD rates among
  substance using populations to be between 14-60
  (Brady, 2001 Donovan, 2001 Najavits, 1997
  Triffleman, 2003)

3

• The past isnt dead, it isnt even past.
• -William Faulkner

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DSM-IV Criteria for Posttraumatic Stress
Disorder (PTSD)

• A. Exposure to a traumatic event
• Involved actual or threatened death or serious
  injury, or a threat to the physical integrity of
  self or others
• Response involved intense fear, helplessness, or
  horror
• B. Event is persistently re-experienced
• C. Avoidance of stimuli associated with the
  event, numbing of general responsiveness
• D. Persistent symptoms of increased arousal
• Difficulty falling or staying asleep,
  irritability or outbursts of anger, difficulty
  concentrating, hypervigilance, exaggerated
  startle response

(American Psychiatric Association, 1994)
5
Neurobiological Changes in Response to Traumatic
Stress

• Limbic System -- Hippocampus and Amygdala (Affect
  and Memory, e.g, Ledoux, 2000 van der Kolk,
  1996)
• Neurotransmitters and Peptides (Numbing and
  Depression, e.g., Pitman, 1991, Southwick, 1999)
• Changes in Hormonal System (HPA axis) (Arousal,
  e.g., Yehuda, 2000)

6
Pathways Between Trauma-related Disorders and
Substance Use
PTSD
SUD
TRAUMA
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Pandora

• 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.

8
Clinical Challenges in the Treatment of Traumatic
Stress and Addiction

• Abstinence may not resolve comorbid
  trauma-related disorders for some PTSD may
  worsen
• Women with PTSD abuse the most severe substances
  and are vulnerable to relapse, as well as
  re-traumatization
• Confrontational approaches typical in addictions
  settings frequently exacerbate mood and anxiety
  disorders
• 12-Step Models often do not acknowledge the need
  for pharmacologic interventions

• Treatment programs do not often offer integrated
  treatments for Substance Use and PTSD
• Treatments for only one disordersuch as
  Exposure-Based Approaches are often marked by
  complications
• treatments developed for PTSD alone may not be
  advisable to treat women with addictions

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PTSD Treatment Approaches

• Cognitive Behavioral
• Prolonged Exposure in vivo imaginal
  conditioning theory (Foa Kozak, 1986 Cooper
  Klum, 1989 Keane, 1991 Foa, 1991)
• SIT Stress Inoculation Training (Foa, 1991)
• TREM Trauma Recovery and Empowerment (Harris,
  1998)
• STAIR Skills Training in Affective and
  Interpersonal Regulation (Cloitre, 2002)
• EMDR Eye Movement Desensitization and
  Reprocessing (Shapiro, 1995)

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PTSD/SUD Integrative Treatments

• Seeking Safety (Najavits, 1998)
• ATRIUM Addictions and Trauma Recovery Integrated
  Model (Miller Guidry, 2001)
• Not specifically designed for PTSD
• TARGET - Trauma Affect Regulation Guidelines for
  Education and Therapy (Ford www.ptsdfreedom.org)

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Comparison of Existing Trauma/ SUD- Focused
Treatment Research
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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
• Core Treatment Components
• Outreach and engagement
• Screening and assessment
• Treatment activities
• Parenting skills
• Resource coordination and advocacy
• Trauma-specific services
• Crisis intervention
• Peer-run services

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Spiral of Addiction and Recovery (Covington, 1999)
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Do you think it is easy to change? Alas, it is
very hard to change and be different. It means
passing through the waters of oblivion.-D. H.
Lawrence, Change (1971)
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Motivational Enhancement for Patients with
Comorbid PTSD Substance Use Disorders
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Overview

• What is it like to be ambivalent?
• Why are motivation enhancement strategies
  promising ways to address these issues?
• Basic philosophy and components of MI
• MI example with a PTSD/SUD patient

17
aMbivAlenCe
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Treatment Compliance

• A general study of missed psychiatric
  appointments (Portland VA) found that those with
  PTSD and/or a SUD were most likely to miss
  appointments
• Most studies of SUD treatment compliance have
  found that PTSD/SUD comorbidity is associated
  with poorer compliance

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Why do we see these patterns?
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Effects of Substance Use

• Patients with PTSD/SUD report stronger substance
  use expectancies for tension reduction
• Patients with PTSD/SUD report substance use helps
  to
• facilitate social situations
• get to sleep
• deal with bad dreams and trauma memories
• deal with negative emotions
• enhance positive emotions

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Other Challenges

• Social isolation/alienation/lack of trust in
  others
• Feelings of guilt or unworthiness
• Shrinkage of world
• Profound fear of own emotions and thoughts
• Sleep disturbance/nightmares
• Frightening re-experiencing symptoms
• Foreshortened sense of the future (why bother)
• Cognitive rigidity/poor attention capacities when
  stressed
• Numb and unable to tap into reinforcers
• Anger dyscontrol/irritability
• Trauma anniversaries during first month of
  treatment
• Disability/service connection issues (possibly)

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How might a motivational enhancement approach
help those with PTSD/SUD comorbidity?
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PTSD Treatment ModelStages of Recovery (Herman,
1992)

• 1. SAFETY
• 2. MOURNING
• 3. RECONNECTION

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PTSD Treatment Model MI

• Solidifying motivation to engage in safety work
• Safety and stabilization
• Integration and mourning
• Reclaiming or developing a meaningful life

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MI Enhances TreatmentEngagement Among
OtherDually Diagnosed Individuals

• Several studies have found that MI-oriented
  session(s) ranging from 1 to 9 contacts have
  helped improve
• Aftercare initiation
• Attending more treatment sessions

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Basic MI Principles

• Express empathy to convey understanding/acceptance
  
• Develop discrepancy between current and desired
• Avoid argument to limit resistance
• Roll with resistance and use it for momentum
• Support self-efficacy and belief that can change

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Basic MI Tools OARS

• Open-ended questions used to facilitate patient
  talking (yes/no ?s can bog down)
• Affirmations used judiciously and sincerely to
  convey warmth and appreciation
• Reflections simple, double-sided, amplified,
  unstated emotions used to facilitate further
  exploration
• Summaries used to let patient hear their own
  words again and to convey understanding

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Opening Constructively orBalancing Concerns

• Ascertain patients understanding of session
• Explain role
• Orient to format and time
• Elicit patients central concerns
• Determine whether and how substance use is
  perceived to be a factor in concerns or problems,
  particularly with regard to PTSD symptoms

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Using Feedback

• Orient to feedback
• Provide normative information for comparison
• Use a neutral tone (nonjudgmental)
• Gently reflect back surprise, disbelief, concern
• Check whether information seems accurate
• Avoid argument e.g., let disbelief go
• Include range of relevant information (not just
  drug and alcohol)

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Values Clarification or Developing Discrepancy

• Goal is to help patient articulate what he/she
  holds dear and ascertain how current behaviors
  may or may not be barriers to achieving what
  he/she wants in life
• Can use results of a values card sort to start
  conversation

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Tipping the Balance TowardsChange

• Pros and Cons of NOT changing alcohol or drug use
• Pros and Cons of NOT changing PTSD-related
  behaviors (e.g., avoidance, anger behaviors)

• Pros and Cons of changing alcohol or drug use
• Pros and Cons of changing PTSD-related behaviors

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Importance of making changes?

• How important to client is addressing her PTSD?
• How important is addressing her drinking?
• How important is addressing her marijuana use?

1 2 3 4 5 6 7 8 9 10
Not at
Very all important
important
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Confidence in ability to change?

• How confident is client that she can change her
  PTSD?
• How confident is she that she can change her
  drinking?
• How confident can change her marijuana use?

1 2 3 4 5 6 7 8 9 10
Not at
Very all confident

confident
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Menu of Options

• Once patient has indicated that she/he is willing
  to consider making a change
• Elicit options patient is familiar with
• Ask permission to offer other options
• Provide information regarding other options
• Assist in sorting out viable option(s)
• Elicit statement regarding follow through

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Goals and how to get to them

• Often useful to have written goal sheet that
  includes
• Specific goal (or goals)
• First few steps to achieve goal(s)
• Reasons for making change
• List of who can be helpful and how
• Identify potential obstacles
• Identify ways of dealing with obstacles

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Important Feedback Mechanisms

• Your clients in-session behavior is the central
  way to gauge whether you are dancing or wrestling
• Your own emotional or gut reactions to what is
  happening in the session are also critical for
  staying on track
• Listening to tapes of own sessions with or
  without rating
• Supervision (group or individual) opportunities
  to provide outside feedback and ideas as well as
  to get support for taking this quieter, gentler
  path

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How might Relapse Prevention help those with
PTSD/SUD comorbidity?
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Seeking Safety (SS) vs. Relapse Prevention (RPT)
vs. TAU Outcomes PTSD Symptom Severity by
Treatment Group (N107)
Plt.01
Plt.01
Plt.01
All analyses adjusted for age and baseline PTSD
severity. End-of-Tx F4.71 (2,106), r2.42
3-month Post F4.94 (2,106), r2.28 6-month Post
F5.51 (2,106), r2.22. Findings reported in
Hien, DA, Cohen, LR, Litt, LC, Miele, GM
Capstick, C. (2004), Promising Empirically
Supported Treatments for Women with Comorbid PTSD
and SUD, American Journal of Psychiatry,
1611426-1432. Do not cite without permission of
the authors.
39
Seeking Safety (SS) vs. Relapse Prevention (RPT)
vs. TAU Outcomes Substance Use Severity by
Treatment Group (N107)
P.06
Plt.001
Plt.01
All analyses adjusted for age and baseline
substance use severity. End-of-Tx F6.01 (2,106),
r2.42 3-month Post F4.82(2,106), r2.36
6-month Post F2.87(2,106), r2.35. Findings
reported in Hien, DA, Cohen, LR, Litt, LC, Miele,
GM Capstick, C. (2004), Promising Empirically
Supported Treatments for Women with Comorbid PTSD
and SUD, American Journal of Psychiatry.
1611426-1432. Do not cite without permission of
the authors.
40
Relapse Prevention Treatment Why does it work
with PTSD?

• Symptoms of SUD and PTSD that overlap
• Emotion regulation problems that manifest in
  unstable temperament with expressions of anger,
  irritability, and depression

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Maladaptive emotion focused coping
Affective lability
Biased information processing and problem solving
Emotion Regulation Deficits
Disruptions in attention, memory consciousness
Difficulties with intimacy and trust
Difficulty managing anger
Poor tolerance of negative emotional states
Behavioral Impulsivity
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Complex Trauma and Addictions Underlying
Commonalities

• Complex Trauma (DESNOS) is associated with
  repeated incidents (domestic violence or ongoing
  childhood abuse).
• Broader range of symptoms self-harm, suicide,
  dissociation (losing time) problems with
  relationships, memory, sexuality, health, anger,
  shame, guilt, numbness, loss of faith and trust,
  feeling damaged.

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Self-Perpetuating Cycle
Substance Use
Interpersonal difficulties, no anger management,
? isolation
Complicated Depression
? sleep disturbance irritability
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Relapse Prevention Treatment

• Assumptions of RPT
• Substance abuse is a learned behavior
• A habit that can be changed
• Serves a function in their lives
• Positive consequences
• Negative consequences
• Abstinence or harm reduction is possible
• Difference motivation levels
• A lapse is not relapse

G. A. Marlatt and J. R. Gordon (1985)
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Characteristics of RPT

• Active treatment for both clinician and client
• Focus on current emotional and substance abuse
  issues and their connection
• Identification of high risk situations
• Coping skills
• Triggers
• Cravings
• High risk situations
• Practice skills through homework

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Replace Addictive Behaviors

• Learn new coping skills
• Resisting social pressure
• Increase assertiveness
• Relaxation and stress management
• Communication skills
• Anger management
• Social skills

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Lifestyle Changes

• Increase pleasant activities
• Increase positive addictions and healthy habits
• Short-circuit Seemingly Irrelevant Decisions

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Seemingly Irrelevant Decisions

• Skill Rationale
• The most mundane choice can move you closer to
  using.
• You are not just an innocent bystander in your
  life.
• It just happened.I couldnt help it.
• Promote accountability

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Creating Safety

• Although the world is full of suffering, it is
  full also of the overcoming of it.
• Helen Keller

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Seeking Safety

• Developed as a group treatment for PTSD/SUD women
• Based on CBT models of SUDs, PTSD treatment,
  womens treatment and educational research
• Educates patients about PTSD and SUDs and their
  interaction
• Goals include abstinence and decreased PTSD
  symptoms
• Focuses on enhancing coping skills, safety and
  self-care
• Active, structured treatment - therapist
  teaches, supports and encourages
• Case management

Najavits, 2002 www.seekingsafety.org
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NIDA Clinical Trials Network Women Trauma Sites
Washington Node Residence XII
Ohio Valley Node Maryhaven
New England Node LMG Programs
New York Node ARTC
Long Island Node Lead Node
South Carolina Node Charleston Center
Florida Node Gateway Community
Florida Node The Village
52
Treatment Groups

• Seeking Safety (SS)
• Short term, manualized treatment
• Cognitive Behavioral
• Focused on addiction and trauma
• Womens Health Education (WHE)
• Short term, manualized treatment
• Focused on understanding womens health issues

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Support

• Participation in this study made possible by
• NIDA CTN Long Island Regional Node
• NIDA/NIH Grant U10 DA13035
• We would like to acknowledge all of the staff and
  participants who made this study possible.

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Participating Nodes and CTPs
Node Node PI(s) Protocol PI CTP Site PI Location
Florida Jose Szapocznik Daniel Santisteban Lourdes Suarez-Morales The Village Michael Miller Miami, FL
Florida Jose Szapocznik Daniel Santisteban Lourdes Suarez-Morales Gateway Community Candace Hodgkins Jacksonville, FL
New England Kathleen Carroll Melissa Gordon LMG Programs Samuel Ball Stamford, CT
New York John Rotrosen Marion Schwartz Addiction Research Treatment Corporation Robert Sage Brooklyn, NY
Ohio Valley Gene Somoza Greg Brigham Maryhaven Greg Brigham Columbus, OH
South Carolina Kathleen Brady Therese Killeen Charleston Center Mark Cowell Charleston, SC
Washington Dennis Donovan Betsy Wells Betsy Wells Residence XII Karen Canida Kirkland, WA
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Project Directors/Protocol PIs

• Frankie Kropp
• Agatha Kulaga
• Melissa Gordon
• Chanda Brown
• Silvia Mestre
• Nadja Schreiber

• Mary Hatch-Maillette
• Chris Neuenfeldt
• Cheri Hansen
• Karen Esposito
• Sharon Chambers

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CTN-0015 Research Staff

• Brianne OSullivan
• Ileana Graf
• Melissa Chu
• Nishi Kanukollu
• Treneane Salisbury
• Rebecca Krebs
• Ann Whetzel
• Stella Resko
• Carol Hutchinson
• Chanda Brown
• Janice Ayuda
• Pamela Bernard
• Jessica Ucha
• Nicole Moodie

• Allison Kristman-Valente
• Lynette Wright
• Melanie Spear
• Lisa Johnson
• Catherine Williams
• Calonie Gray
• Michele DiBono
• Rachel Hayon
• Barbara Bettini
• Barbara Thomas
• Lisa Markiewicz
• Elizabeth Cowper
• Rosaline King
• Lara Reichert

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CTN-0015 Clinicians

• Lisa Cohen
• Dawn Baird-Taylor
• Lisa Litt
• Martha Schmitz
• Karen Tozzi
• Darlene Franklin
• Kathleen Estlund
• Molly McHenry-Whalen
• Erin Demirjian
• Anslie Stark
• Karen Bowes
• Metris Batts
• Felisha Lyons
• Kathy McPherson
• Victoria Johnson
• Denese Lewis
• Sharon Anderson-Goss
• Merilee Perrine
• Angela Waldrop

• Leslie Lobel-Juba
• Maria Mercedes Giol
• Lourdes Barrios
• Lisa Mandelman
• Jeanette Suarez
• Danielle Macri
• Maria Hurtado
• Tina Klem
• Nancy Magnetti
• Anne Marie Sales
• Renee Sumpter
• Michelle Melendez
• Ida Landers
• Regina Morrison
• Clare Tyson
• Mary Hodge-Moen
• Sandra Free
• Goldie Galloway
• Karen Canida

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CTN-0015 QA and Data Management

• Jim Robinson
• JP Noonan
• Connie Klein
• Karen Loncto
• Chris Hutz
• Lauren Fine
• Michelle Cordner
• Melissa Gordon
• Maura Weber
• Kristie Smith
• Catherine Dillon
• Donna Bargoil
• Jurine Lewis
• Girish Gurnani

• Inna Logvinsky
• Peggy Somoza
• Sharon Pickrel
• Katie Weaver
• Molly Carney
• Catherine Otto
• Rebecca Defevers
• Emily DeGarmo
• Royce Sampson
• Stephanie Gentilin
• Clare Tyson
• Anthony Floyd
• Nathilee Francois

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