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 ConferenceSeattle, WAOctober 16, 2006

PLEASE DO NOT CITE CONTENTS OF PRESENTATION WITHOUT PERMISSION OF THE AUTHOR

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)

“The past isn’t dead, it isn’t even past.”

-William Faulkner

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)

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)

Pathways Between Trauma-related Disorders and Substance Use

PTSD SUDTRAUMA

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

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 disorder—such as Exposure-Based Approaches are often marked by complications

treatments developed for PTSD alone may not be advisable to treat women with addictions

PTSD Treatment Approaches

Cognitive BehavioralProlonged 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)

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)

Najavits, 1998

Triffleman, 2000

Brady, 2001

Donovan, 2001

Hien, 2004

N N=27 women 17 (>6 sess) No Control

N=19 (53% women) RCT

39 (82% women) 15 (>10 sess) No Control

N=46 men No Control

N=107 women RCT

Length of TX

Group, 24 sessions, 2x/wk, 90-min/group

Individual, 5 months, 2x/wk

Individual, 16 sessions, 90 min sessions

12 weeks, 10 hrs/week partial hosp,

Individual, 3 months

TX

Content Seeking Safety: Cog Behavioral Interpersonal coping skills

SDPT (Coping, CBT, Stress Inoc, In Vivo, RP-2 phase) vs 12 step

Exposure Therapy & CBT

CBT, RP & peer social support (2-phase)

Seeking Safety/CBT vs RPT

Follow Up

3 mo post 1 mo post 6 mo post 6/12 mo post 6/9 mo post

Results Improvement on SU, PTSD, Depression, increase in somatization

Improvement on SU, PTSD, psych, No gender differences

Improvement in SU, PTSD & Depression

Improvement in SU, PTSD

Improvement @ 6 mo, diminished at 9 mo, no diff b/t SS/RPT

Variable SU, PTSD, Psych, Cog

SU, PTSD, psych

SU, PTSD, Depression

SU, PTSD SU, PTSD, Psych

Limits Small N, No Control, Did not follow up Drop-outs

Small N, Short FU period

Small N, No Control, large drop out rate

Small N, No Control, 30 day abstinence required, one site

Non-randomized TAU

Comparison of Existing Trauma/ SUD- Focused Treatment Research

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 ComponentsOutreach and engagementScreening and assessmentTreatment activitiesParenting skillsResource coordination and advocacyTrauma-specific servicesCrisis interventionPeer-run services

Spiral of Addiction and Recovery (Covington, 1999)

“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)

Motivational Enhancementfor Patients with

Comorbid PTSD &Substance Use Disorders

Overview

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

aMbivAlenCe

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

Why do we see these patterns?

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

Other ChallengesSocial isolation/alienation/lack of trust in othersFeelings of guilt or unworthinessShrinkage of worldProfound fear of own emotions and thoughtsSleep disturbance/nightmaresFrightening re-experiencing symptomsForeshortened sense of the future (why bother)Cognitive rigidity/poor attention capacities when stressedNumb and unable to tap into reinforcersAnger dyscontrol/irritabilityTrauma anniversaries during first month of treatmentDisability/service connection issues (possibly)

How might a motivational enhancement approach help those with PTSD/SUD comorbidity?

PTSD Treatment ModelStages of Recovery (Herman, 1992)

1. SAFETY

2. MOURNING

3. RECONNECTION

PTSD Treatment Model + MI

Solidifying motivation to engage in safety work

Safety and stabilization

Integration and mourning

Reclaiming or developing a meaningful life

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

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

Basic MI Tools: OARS

OOpen-ended questions; used to facilitate patient talking (yes/no ?’s can bog down)

AAffirmations; used judiciously and sincerely to convey warmth and appreciation

RReflections; simple, double-sided, amplified, unstated emotions; used to facilitate further exploration

SSummaries; used to let patient hear their own words again and to convey understanding

Opening Constructively orBalancing Concerns

Ascertain patient’s understanding of sessionExplain roleOrient to format and timeElicit patient’s central concernsDetermine whether and how substance use is perceived to be a factor in concerns or problems, particularly with regard to PTSD symptoms

Using Feedback

Orient to feedback Provide normative information for comparisonUse a neutral tone (nonjudgmental)Gently reflect back surprise, disbelief, concernCheck whether information seems accurateAvoid argument; e.g., let disbelief go Include range of relevant information (not just drug and alcohol)

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

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

1 2 3 4 5 6 7 8 9 10Not at Veryall important important

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 10Not at Veryall confident confident

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?

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

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

Important Feedback Mechanisms

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

How might Relapse Prevention help those with PTSD/SUD

comorbidity?

Seeking Safety (SS) vs. Relapse Prevention (RPT) vs. TAU Outcomes: PTSD Symptom Severity by Treatment Group (N=107)

-1

-0.7

-0.4

-0.1

0.2

0.5

Baseline End-of-Tx 3-month Post 6-month Post

SSRPTTAU

**P<.01 **P<.01

All analyses adjusted for age and baseline PTSD severity. End-of-Tx F=4.71 (2,106), r2=.42; 3-month Post F=4.94 (2,106), r2=.28; 6-month Post F=5.51 (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, 161:1426-1432. Do not cite without permission of the authors.

**P<.01

Seeking Safety (SS) vs. Relapse Prevention (RPT) vs. TAU Outcomes: Substance Use Severity by Treatment Group (N=107)

-1

-0.7

-0.4

-0.1

0.2

0.5

Baseline End-of-Tx 3-month Post 6-month Post

SSRPTTAU

***P<.001

End-of-Tx-0.060.31

**P<.01

All analyses adjusted for age and baseline substance use severity. End-of-Tx F=6.01 (2,106), r2=.42; 3-month Post F=4.82(2,106), r2=.36; 6-month Post F=2.87(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. 161:1426-1432. Do not cite without permission of the authors.

P=.06

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

Emotion Regulation Deficits

Maladaptive emotion focused

coping Affective lability

Behavioral Impulsivity

Difficulty managing anger

Poor tolerance of negative emotional

states

Disruptions in attention, memory &

consciousness

Difficulties with intimacy

and trust

Biased information processing and problem solving

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.

Self-Perpetuating Cycle

Substance Use

Complicated Depression

sleep disturbance & irritability

Interpersonal difficulties, no anger

management, isolation

Relapse Prevention Treatment

Assumptions of RPTSubstance abuse is a learned behaviorA habit that can be changedServes a function in their livesPositive consequencesNegative consequencesAbstinence or harm reduction is possibleDifference motivation levelsA lapse is not relapse

G. A. Marlatt and J. R. Gordon (1985)

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 skillsTriggers

Cravings

High risk situations

Practice skills through homework

Replace Addictive Behaviors

Learn new coping skillsResisting social pressure

Increase assertiveness

Relaxation and stress management

Communication skills

Anger management

Social skills

Lifestyle Changes

Increase pleasant activitiesIncrease “positive addictions” and healthy habits

Short-circuit “Seemingly Irrelevant Decisions”

Seemingly Irrelevant Decisions

Skill RationaleThe most mundane choice can move you closer to using.

You are not just an innocent bystander in your life.

“It just happened….I couldn’t help it.”

Promote accountability

Creating Safety

“Although the world is full of suffering, it is full also of

the overcoming of it.”

Helen Keller

Seeking SafetyDeveloped as a group treatment for PTSD/SUD womenBased on CBT models of SUDs, PTSD treatment, women’s treatment and educational researchEducates patients about PTSD and SUD’s and their interactionGoals include abstinence and decreased PTSD symptomsFocuses on enhancing coping skills, safety and self-careActive, structured treatment - therapist teaches, supports and encouragesCase management

Najavits, 2002; www.seekingsafety.org

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

Treatment Groups

Seeking Safety (SS)Short term, manualized treatmentCognitive BehavioralFocused on addiction and trauma

Women’s Health Education (WHE)Short term, manualized treatmentFocused on understanding women’s health issues

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.

Participating Nodes and CTPsNode Node PI(s) Protocol PI CTP Site PI Location

Florida

Jose Szapocznik & Daniel Santisteban

Lourdes Suarez-Morales

The VillageMichael Miller

Miami, FL

Gateway Community

Candace Hodgkins

Jacksonville, FL

New England

Kathleen Carroll

Melissa Gordon

LMG Programs

Samuel Ball

Stamford, CT

New YorkJohn Rotrosen

Marion Schwartz

Addiction Research & Treatment Corporation

Robert Sage

Brooklyn, NY

Ohio ValleyGene Somoza

Greg Brigham

MaryhavenGreg Brigham

Columbus, OH

South Carolina

Kathleen Brady

Therese Killeen

Charleston Center

Mark Cowell

Charleston, SC

Washington

Dennis Donovan & Betsy Wells

Betsy Wells Residence XIIKaren Canida

Kirkland, WA

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

CTN-0015 Research StaffBrianne O’SullivanIleana GrafMelissa ChuNishi KanukolluTreneane SalisburyRebecca KrebsAnn WhetzelStella ReskoCarol HutchinsonChanda BrownJanice AyudaPamela BernardJessica UchaNicole Moodie

Allison Kristman-ValenteLynette WrightMelanie SpearLisa JohnsonCatherine WilliamsCalonie GrayMichele DiBonoRachel HayonBarbara BettiniBarbara ThomasLisa MarkiewiczElizabeth CowperRosaline KingLara Reichert

CTN-0015 CliniciansLisa CohenDawn Baird-TaylorLisa LittMartha SchmitzKaren TozziDarlene FranklinKathleen EstlundMolly McHenry-WhalenErin DemirjianAnslie StarkKaren BowesMetris BattsFelisha LyonsKathy McPhersonVictoria JohnsonDenese LewisSharon Anderson-GossMerilee PerrineAngela Waldrop

Leslie Lobel-JubaMaria Mercedes GiolLourdes BarriosLisa MandelmanJeanette SuarezDanielle MacriMaria HurtadoTina KlemNancy MagnettiAnne Marie SalesRenee SumpterMichelle MelendezIda LandersRegina MorrisonClare TysonMary Hodge-MoenSandra FreeGoldie GallowayKaren CanidaKatie Revenaugh

CTN-0015 QA and Data Management

Jim RobinsonJP NoonanConnie KleinKaren LonctoChris HutzLauren FineMichelle CordnerMelissa GordonMaura WeberKristie SmithCatherine DillonDonna BargoilJurine LewisGirish Gurnani

Inna LogvinskyPeggy SomozaSharon PickrelKatie WeaverMolly CarneyCatherine OttoRebecca DefeversEmily DeGarmoRoyce SampsonStephanie GentilinClare TysonAnthony FloydNathilee Francois