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Tracy Simpson, PhD, VAPSHCS, University of Washington NIDA CTN Blending Conference Seattle, WA October 16, 2006 PLEASE DO NOT CITE CONTENTS OF PRESENTATION WITHOUT PERMISSION OF THE AUTHOR

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.

B.

C.

D.

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 Event is persistently re-experienced Avoidance of stimuli associated with the event, numbing of general responsiveness 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 TRAUMA SUD

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.

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 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)

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)

Comparison of Existing Trauma/ SUD Focused Treatment Research N Najavits, 1998

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

Triffleman, 2000

N=19 (53% women) RCT

Brady, 2001

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

Donovan, 2001

N=46 men No Control

Length of TX TX Content

Group, 24 sessions, 2x/wk, 90 min/group Seeking Safety: Cog Behavioral Interpersonal coping skills

Follow Up Results

3 mo post Improvement on SU, PTSD, Depression, increase in somatization Variable SU, PTSD, Psych, Cog

Limits

Small N, No Control, Did not follow up Drop-outs Individual, 5 months, 2x/wk SDPT (Coping, CBT, Stress Inoc, In Vivo, RP-2 phase) vs 12 step 1 mo post Improvement on SU, PTSD, psych, No gender differences SU, PTSD, psych Small N, Short FU period Individual, 16 sessions, 90 min sessions Exposure Therapy & CBT 6 mo post Improvement in SU, PTSD & Depression SU, PTSD, Depression Small N, No Control, large drop out rate 12 weeks, 10 hrs/week partial hosp, CBT, RP & peer social support (2 phase) 6/12 mo post Improvement in SU, PTSD SU, PTSD Small N, No Control, 30 day abstinence required, one site

Hien, 2004

N=107 women RCT Individual, 3 months Seeking Safety/CBT vs RPT 6/9 mo post Improvement @ 6 mo, diminished at 9 mo, no diff b/t SS/RPT SU, PTSD, Psych Non randomized TAU

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

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 Enhancement for 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 MI MI 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 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)

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

PTSD Treatment Model Stages 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 Treatment Engagement Among Other Dually 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

O

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

A

ffirmations; used judiciously and sincerely to convey warmth and appreciation

R

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

S

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

Opening Constructively or Balancing Concerns

Ascertain patient’s understanding of session Explain role Orient to format and time Elicit patient’s central concerns Determine 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 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)

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 Towards Change

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

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

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

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 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

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) 0.5

0.2

-0.1

-0.4

-0.7

**P<.01

**P<.01

**P<.01

SS RPT TAU -1 Baseline End-of-Tx 3-month Post 6-month Post

All analyses adjusted for age and baseline PTSD severity. End-of-Tx F=4.71 (2,106), r 2 =.42; 3-month Post F=4.94 (2,106), r 2 =.28; 6-month Post F=5.51 (2,106), r 2 =.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.

Seeking Safety (SS) vs. Relapse Prevention (RPT) vs. TAU Outcomes: Substance Use Severity by Treatment Group (N=107) 0.5

0.2

-0.1

-0.4

-0.7

***P<.00

1 E n d - o f - T x - 0 . 0 6 0 . 3 1 **P<.01

P=.06

SS RPT TAU -1 Baseline End-of-Tx 3-month Post 6-month Post

All analyses adjusted for age and baseline substance use severity. End-of-Tx F=6.01 (2,106), r 2 =.42; 3-month Post F=4.82(2,106), r 2 =.36; 6-month Post F=2.87(2,106), r 2 =.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.

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

Biased information processing and problem solving Maladaptive emotion focused coping Affective lability Difficulties with intimacy and trust

Emotion Regulation Deficits

Disruptions in attention, memory & consciousness Difficulty managing anger Behavioral Impulsivity Poor tolerance of negative emotional states

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 Interpersonal difficulties, no anger management,



isolation Complicated Depression



sleep disturbance & irritability

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)

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

Replace Addictive Behaviors

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

Lifestyle Changes

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

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 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 Safety

Developed as a group treatment for PTSD/SUD women Based on CBT models of SUDs, PTSD treatment, women’s treatment and educational research Educates patients about PTSD and SUD’s 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

NIDA Clinical Trials Network Women & Trauma Sites Washington Node Residence XII Ohio Valley Node Maryhaven New England Node New York LMG Programs Node ARTC Long Island Node Lead Node South Carolina Node Charleston Center Florida Node Gateway Community Florida Node The Village

Treatment Groups

Seeking Safety (SS) Short term, manualized treatment Cognitive Behavioral Focused on addiction and trauma Women’s Health Education (WHE) Short term, manualized treatment Focused 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 CTPs Node Node PI(s) Protocol PI CTP Site PI Location

Florida New England New York Jose Szapocznik & Daniel Santisteban Lourdes Suarez Morales Kathleen Carroll Melissa Gordon John Rotrosen Marion Schwartz Ohio Valley South Carolina Washington Gene Somoza Kathleen Brady Greg Brigham Therese Killeen Dennis Donovan & Betsy Wells Betsy Wells The Village Gateway Community LMG Programs Addiction Research & Treatment Corporation Maryhaven Charleston Center Michael Miller Candace Hodgkins Samuel Ball Robert Sage Greg Brigham Mark Cowell Residence XII Karen Canida Miami, FL Jacksonville, FL Stamford, CT Brooklyn, NY Columbus, OH Charleston, SC 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 Staff

Brianne O’Sullivan Ileana Graf Allison Kristman Valente Melissa Chu Lynette Wright Nishi Kanukollu Melanie Spear Treneane Salisbury Lisa Johnson Rebecca Krebs Catherine Williams Ann Whetzel Calonie Gray Stella Resko Michele DiBono Carol Hutchinson Rachel Hayon Chanda Brown Barbara Bettini Janice Ayuda Barbara Thomas Pamela Bernard Lisa Markiewicz Jessica Ucha Elizabeth Cowper Nicole Moodie Rosaline King Lara Reichert

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 Katie Revenaugh

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