Integrated Treatment for Trauma and Addiction: Seeking Safety

About This Presentation

Title:

Integrated Treatment for Trauma and Addiction: Seeking Safety

Description:

Title: PowerPoint Presentation Author: Tracy Lynn Simpson Last modified by: Meg Brunner Created Date: 6/18/2002 10:34:20 PM Document presentation format – PowerPoint PPT presentation

Number of Views:935

Avg rating:3.0/5.0

Slides: 60

Provided by: TracyLyn4

Learn more at: https://ctnlibrary.org

Category:

more less

Transcript and Presenter's Notes

Title: 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PLEASE DO NOT CITE CONTENTS OF PRESENTATION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)

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

4
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
7
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

9
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)

10
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)

11
Comparison of Existing Trauma/ SUD- Focused
Treatment Research
12
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

13
Spiral of Addiction and Recovery (Covington, 1999)
14
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)
15
Motivational Enhancement for Patients with
Comorbid PTSD Substance Use Disorders
16
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
18
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

19
Why do we see these patterns?
20
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

21
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)

22
How might a motivational enhancement approach
help those with PTSD/SUD comorbidity?
23
PTSD Treatment ModelStages of Recovery (Herman,
1992)

1. SAFETY
2. MOURNING
3. RECONNECTION

24
PTSD Treatment Model MI

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

25
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

26
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

27
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

28
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

29
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)

30
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

31
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

32
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
33
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
34
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

35
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

36
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

37
How might Relapse Prevention help those with
PTSD/SUD comorbidity?
38
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

41
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
42
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.

43
Self-Perpetuating Cycle
Substance Use
Interpersonal difficulties, no anger management,
? isolation
Complicated Depression
? sleep disturbance irritability
44
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)
45
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

46
Replace Addictive Behaviors

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

47
Lifestyle Changes

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

48
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

49
Creating Safety

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

50
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
51
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

53
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.

54
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
55
Project Directors/Protocol PIs