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Treatment for Cooccurring PTSD and Substance Use Disorders: State of the Science


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Title: Treatment for Cooccurring PTSD and Substance Use Disorders: State of the Science

Treatment for Co-occurring PTSD and Substance Use
Disorders State of the Science
  • Lisa R. Cohen, PhD
  • Columbia University School of Social Work
  • November 6, 2006
  • Hollywood, CA

Scope of the Problem
  • As 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.,
  • Among PTSD populations, co-occurring substance
    use disorders may occur in 60-80 of individuals
    (Donovan et al., 2001)

Clinical Profile Women with PTSD/SUD
  • Majority are victims of childhood abuse and
    repeated trauma
  • Present to treatment with high rates of other
    co-morbid disorders
  • Have interpersonal, behavioral and emotion
    regulation deficits
  • Abuse the most severe substances

Self-Perpetuating Cycle
Substance Use
Interpersonal difficulties, no anger management,
increased isolation
Complicated Depression
Increased sleep disturbance irritability
  • 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
  • As the gods had anticipated, Pandora opened the
    box, allowing the evils to escape.

Clinical Challenges in the Treatment of Traumatic
Stress and Addiction
  • Abstinence may not resolve comorbid
    trauma-related disorders for some PTSD may
  • Confrontational approaches typical in addictions
    settings frequently exacerbate mood and anxiety
  • 12-Step Models often do not acknowledge the need
    for pharmacologic interventions
  • Treatments for PTSD only such as Exposure-Based
    Approaches often may not be advisable to treat
    women with addictions or may be marked by

PTSD/SUD Treatments
  • ATRIUM 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)

Treatments for co-morbid PTSD vs. PTSD only
  • Addition of components specifically designed to
    deal with coping and cognitive restructuring
    related to substance use (cravings and relapse
  • Concurrent Model Additional components may be
    integrated and delivered concurrently
  • Sequential Model Initial phase may focus on
    substance abuse related symptoms in preparation
    for working on trauma related symptoms later

Seeking Safety
  • Developed as a group treatment for PTSD/SUD women
  • Structured with flexibility
  • Educates patients about PTSD and SUDs and their
  • Based on CBT models of SUDs, PTSD treatment,
    womens treatment and educational research
  • Goals include abstinence and decreased PTSD
  • Focuses on enhancing cognitive and interpersonal
    coping skills, safety and self-care
  • Therapist is active teaches, supports and
  • Includes case management component

Najavits, 2002
Comparison of Existing Trauma and Substance Use
Disorder- Focused Treatment Research
Women, Co-occurring Disorders Violence Study
  • 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

  • CBT, including exposure therapy, shows promise in
    treating PTSD/SUD
  • PTSD treatments did not make patients worse,
    improved PTSD, substance use and general
    psychiatric symptoms
  • Integrated 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

Challenges to Implementing Trauma-focused
Interventions in Substance Abuse Treatment
  • Lisa Caren Litt, Ph.D.
  • Columbia University College of Physicians and
  • Womens Health Project Treatment and Research
  • ISTSS, November 6, 2006
  • Hollywood, CA

Integrating Trauma Treatment
  • Trauma-Informed Treatmentvs.
  • Trauma-Specific Treatment

  • Trauma-specific treatment
  • is not enough.

Creating a Trauma-Informed Addiction Treatment
System Lessons from the WCDVS
  • Outreach and Engagement
  • Screening and Assessment
  • Substance Abuse and Mental Health Treatment
  • Parenting Skills
  • Resource Coordination and Advocacy
  • Trauma-specific Services
  • Crisis Intervention
  • Peer-Run Services (Consumers / Survivors / In

WCDVS information is drawn from
Trauma-Informed Services Characteristics (WCDVS)
  • Aware of the role of violence and victimization
    in womens lives .
  • Minimize victimization and re-victimization.
  • Hospitable and engaging for survivors.
  • Facilitate recovery.
  • Empower.
  • Respect a woman's choices and control over her
  • Goals are mutual and collaboratively established.
  • Emphasize womens strengths.

Trauma-Informed Services Principles (WCDVS)
  • Respect trauma as a central concern in a womans
  • Symptoms are adaptations to traumatic
  • Reframe Adaptive behavior as positive coping.
  • Violence and trauma have broad impact.
  • Providers need to meet the woman where she is.

Introducing Trauma-Specific Treatment
  • Counselor Buy In
  • Challenges to Agency and Treatment Philosophies
  • Protocol Training
  • Safety
  • Supervision
  • Counselor Self-care

Should I or Shouldnt I?
  • Why counselors may be hesitant to provide trauma
  • Pandoras box Fear
  • Clients and/or Counselors will become
  • Clients will relapse, act out or drop out.
  • Clients will become threatening or destructive to
    self or others.

Should I or Shouldnt I?
  • Why counselors may be hesitant to provide trauma
  • Personal history
  • Addiction history and recovery
  • Survivors of trauma themselves increased

  • What do Counselors
  • Need to Learn?

Try Something New
  • Treatment that differs from the Counselors own
    past treatment.
  • Treatment is not one-size-fits-all.
  • Addiction treatment that pays attention to abuse.
  • Treatment that challenges traditional substance
    abuse treatment models
  • Medical (Disease) Model
  • 12 Step Model
  • Confrontational Methods

Difficult 12 Step Concepts for Survivors in
  • Surrender your power.
  • Surrender to a higher power.
  • Get off your pity potty.

Philosophical Differences
  • Abstinence vs. Harm Reduction
  • What is the Agency response to lapse/relapse?
  • Harm reduction can be a path to Abstinence
  • Compassion and collaboration

Why Use ManualizedTrauma Treatment?
  • Psychoeducation for survivors
  • Structure for Clients and Counselors
  • Less opportunity to go too deep
  • Time-limited possibilities

Developing a New Stance
  • Identify Counselor skills sets.
  • Collaborate, Dont 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.

Client and Counselor Safety
  • Managing an angry and aggressive client
  • Tool box not Pandoras box
  • Child welfare involvement
  • Intimate partner violence

The Counselor Should Not Feel Alone
  • Trauma specialists
  • In Agency
  • In the Community
  • Get the client off to a good start
  • Attending to trauma as part of recovery
  • Stabilize
  • Most trauma processing will follow

Potential for Vicarious Traumatization
  • Sensitivity for Counselor survivors
  • Conducting trauma treatment should be voluntary
  • Supportive environments
  • Moderate caseloads
  • Regular supervision

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?

About Direct Observation
  • It seems very frightening at firstyou risk
    being naked in front of your peersbut, if the
    people watching you are generous and supportive,
    it is actually a great relief. You discover that
    you dont 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

David Treadway, quoted in Wylie Markowitz,
1992, p.29
Counselor Self-Care
  • Practice what you preach
  • Rest and exercise
  • Opportunities for personal renewal
  • Personal therapy

NIDA Clinical Trials Network Womens Treatment
for Trauma and Substance Use Disorders Issues in
Training and Assessment
  • Aimee Campbell, MSW
  • Columbia University School of Social Work
  • ISTSS, November 6, 2006
  • Hollywood, CA

NIDA Clinical Trials Network Women Trauma Sites
Washington Node Residence XII
New England Node LMG Programs
New York Node ARTC
Ohio Valley Node Maryhaven
Long Island Node Lead Node
South Carolina Node Charleston Center
Florida Node Gateway Community
Florida Node The Village
Pre-Post Control Group Design
Pre-screening, Screening, Baseline,
Randomization, Individual Counselor Session
Pre-Treatment 1 - 4 Weeks
Treatment 6 Weeks
12 Twice Weekly Group Sessions
Post Treatment Follow-up 46 Weeks
1 Week
3 Month
6 Month
12 Month
Participant Eligibility Criteria
  • Inclusion
  • female, 18 - 65 years old
  • used an illicit substance within the past six
    months and have a current diagnosis of illicit
    drug/alcohol abuse or dependence
  • PTSD or Sub-threshold PTSD
  • enrolled at participating community treatment
  • Exclusion
  • advanced stage medical disease (AIDS, TB)
  • impaired mental status (MMSE less than or equal
    to 21)
  • significant risk of suicidal/homicidal intent or
  • history of schizophrenia-spectrum diagnosis
  • active psychosis (prior 2 months)
  • involved in PTSD-related litigation
  • refuses to be audio or videotaped

Assessment Measures
  • Demographics
  • Substance Abuse/Dependence Diagnosis (CIDI)
  • Substance Use (past 7, 30 days (ASI, SUI)
  • Biological Measures of Substance Use
  • PTSD Diagnosis (CAPS)
  • PTSD Symptom Severity (PSS-SR)
  • Psychiatric Symptoms (BSI)
  • Other Service Utilization (medication)
  • General Health, Social Network
  • HIV Risk Behaviors
  • Child/Adult Physical/Sexual Violence

PTSD Assessment
  • Clinician Administered PTSD Scale (CAPS)
  • DSM-IV symptom clusters
  • A Exposure
  • B Re-experiencing
  • C Avoidance
  • D Arousal
  • Subthreshold 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

Blake, D.B., Weathers, F.W., Nagy, L.M.,
Kaloupek, D.G., Gusman, F.D., Charney, D.S.,
Keane, T.M., 1995. The development of a
Clinician-Administered PTSD Scale. J Trauma
Stress. 8, 75-90.
Initial Screen N1,963
Ineligible N751
Eligible N1,212 (62)
No Full Screen N751
Completed Full Screen N541
Ineligible N162
Eligible N379 (70)
Not Randomized (multiple reasons) N26
Randomized N353 (93)
Sample Characteristics (N353)
Sample Characteristics (n353)
PTSD Diagnosis and Severity at Baseline (n353)
Substance Use Disorders at Baseline (n353)
Lifetime Trauma Exposure (n353)
Treatment Groups
  • Seeking Safety (SS Najavits, 1998)
  • Short term, manualized treatment
  • Cognitive Behavioral
  • Focused on addiction and trauma
  • Womens Health Education (WHE)
  • Short term, manualized treatment
  • Pyschoeducational, didactic
  • Focused on understanding womens health issues
    and empowerment

Seeking Safety Topics
  • Safety
  • PTSD Taking Back Your Power
  • Detaching from Emotional Pain
  • When Substances Control You
  • Taking Good Care of Yourself
  • Compassion
  • Red and Green Flags
  • Honesty
  • Integrating the Split Self
  • Creating Meaning
  • Setting Boundaries in Relationships
  • Healing from Anger

Womens Health Education Topics
  • Body Systems
  • Female anatomy
  • Breast care
  • Infections
  • HIV
  • Contraception
  • Pregnancy
  • STDs
  • Nutrition
  • High Blood Pressure
  • Diabetes
  • Menopause

Who were the clinicians?
  • All female staff
  • Agreed to randomization, videotaping and research
  • Demonstrated ability to conduct manualized,
    problem-solving session prior to randomization
  • Had no prior experience with study interventions

Counselor and Supervisor Demographics
Intervention-SpecificTraining Elements
  • 3-day group training
  • Explanation, demonstration and role-play
  • Post-training certification
  • Counselors and supervisors conducted pilot groups
  • Supervisors coded counselors sessions and
    compared ratings with lead experts
  • Train-the-trainer model
  • Used for supervisor training

Research-within-Practice Challenges
  • The Therapeutic Misconception
  • Research is not treatment
  • Protocol adherence is key
  • Avoiding cross-contamination
  • Need to keep interventions separate
  • Cant share information with other colleagues or

Ongoing Supervision and Monitoring
  • Supervisors attended weekly supervision
    teleconferences with Lead Node experts in the
    respective intervention
  • Calls included discussion of specific issues,
    review of session tapes and adherence ratings

Adherence Monitoring
  • Counselors
  • Supervisors rated 50 of cases and gave feedback
    based on ratings
  • Cut-offs for continued participation in trial and
    guidelines for retraining
  • Supervisors
  • Lead node experts rated 25 of sessions rated by
    local supervisors and gave feedback on level of

Treatment Fidelity
Treatment Attendance
Counselor and SupervisorBenefits
  • Expanded skills in delivering and supervising
  • Became more comfortable using treatment manuals
    and working explicitly with women with
    co-occurring disorders
  • Sustainability and interest after conclusion of

Counselor and SupervisorChallenges
  • Rolling admission groups and no-shows led to
    delays in providing interventions
  • TTT model led to counselors feeling less involved
    in the process
  • Adherence monitoring
  • Counselor issues
  • Supervisor issues
  • Participant characteristics
  • Time commitment

  • Training, supervision and implementation require
    time and commitment from all levels of staff
  • Involve counselors and supervisors in ongoing
    supervision from lead node
  • Ensure adequate training in research process,
    procedures and special need of patient population

  • Consistent across sites
  • High levels of multiple trauma exposure with
    clinically significant PTSD symptoms.
  • High percentage of sexual assaults
  • 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.

  • Though 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

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