Transcript Seeking Safety in Methadone Maintenance Treatment: A Model

Seeking Safety in Methadone
Maintenance Treatment:
A Model for Treating Trauma and
Opioid Dependence
Marshall Rosier, MS
Connecticut Counseling Centers, Inc.
Alan Lee Nolan, LCSW
Connecticut Counseling Centers, Inc.
Lisa Najavits, Ph.D.
Department of Psychiatry
Harvard Medical School, McLean Hospital
Diane Heyward, MS
Connecticut Counseling Centers, Inc.
Michael Freeman, MS, LADC
Connecticut Counseling Centers, Inc.
2004 COPYRIGHT M. Rosier, MS
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Goals of Presentation
 Introduce the Connecticut Trauma Initiative
 Discuss psychological trauma and PTSD
 Outline several features of Seeking Safety
 Discuss the technology transfer process
 Share lessons learned
2004 COPYRIGHT M. Rosier, MS
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Celebrating 20 years of
Treatment Excellence
1984 -2004
JCAHO Accredited
• Middlebury – Executive Offices
– Executive Director, Richard Bilangi, MS
203.577.5320 e-mail:[email protected]
• Waterbury Clinic
– Program Director, Michael Freeman, MS, LADC
• Norwalk Clinic
– Program Director, Robert Lambert, MA, LADC
• Danbury Clinic (Opening February 2005)
2004 COPYRIGHT M. Rosier, MS
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Celebrating 20 years of
Treatment Excellence
1984 -2004
JCAHO Accredited
Mission Statement:
CCC, Inc. is a not-for-profit corporation that
provides a full range of licensed outpatient
substance abuse and mental health
prevention, education and treatment
services to assist adults in becoming
productive members of society.
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Waterbury Clinic
JCAHO Accredited
Patient Demographics:
 825 Methadone Maintenance Patients
 46% Women
 54% Men
 56% Caucasian
 28% Hispanic
 12% African American
 4% Other
2004 COPYRIGHT M. Rosier, MS
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Behavioral Health
Care Services
JCAHO Accredited
– Opiate Withdrawal Programs
– Methadone Maintenance Treatment
Programs
– Intensive Outpatient Program
– Partial Hospitalization Program
– Dual Diagnosis Treatment and Services
– Non-Chemically Supported Outpatient
Treatment Program
– Mental Health Treatment and Services
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Behavioral Health
Care Services
JCAHO Accredited
– Pregnant Addict Care Programs
– Women Centered Treatment Services
– Patient Transportation
– HIV, TB, HEP A, B, and C
• Screening, Education & Counseling
– Research Department
• NIDA Clinical Trails Network
NEW ENGLAND Node / Yale University
– Suboxone - Bupenorphine Clinical Trial
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Connecticut Trauma Initiative:
Department of Mental Health and Addiction Services
Source: http://www.dmhas.state.ct.us/trauma/overview.htm
Goals of the Initiative
 Promote co-occurring PTSD competency
 Link resources to system-wide care in public sector
 Develop partnerships
Criteria for Treatment Models
 Representative target population
 Cultural diversity
 Evidence-based
 Gender-sensitive
 Skills-based rather than exposure-based
 Empowering to survivors
 Compatible with treatment needs and clinicians
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Posttraumatic Stress Disorder (PTSD)
DSM-IV-TR (2000) American Psychiatric Association
Exposure to a traumatic event
– Experienced, witnessed or was
confronted with traumatic event or
events that involved
• Actual or threatened death or serious injury
• Threat to the physical integrity of self or others
– Response involved
• Intense fear, helplessness, or horror
Intrusion
Avoidance
Arousal
2004 COPYRIGHT M. Rosier, MS
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Posttraumatic Stress Disorder (PTSD)
DSM-IV-TR (2000) American Psychiatric Association
Intrusion
Event is persistently reexperienced
– Distressing recollections such as images,
thoughts, or perceptions
– Recurrent dreams
– Acting or feeling as if event were recurring
– Distress or reactivity to exposure of internal or
external cues that symbolize an aspect of the
trauma
2004 COPYRIGHT M. Rosier, MS
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Posttraumatic Stress Disorder (PTSD)
DSM-IV-TR (2000) American Psychiatric Association
Avoidance
Persistent avoidance of stimuli associated with the
trauma and numbing of general responsiveness
– Efforts to avoid thoughts, feelings or conversations
associated with trauma
– Efforts to avoid activities, places or people that arouse
recollection of trauma
– Inability to recall important aspects of trauma
– Markedly diminished interest or participation in significant
activities
– Feelings of detachment or estrangement from others
– Restricted range of affect
– Sense of foreshortened
future
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Posttraumatic Stress Disorder (PTSD)
DSM-IV-TR (2000) American Psychiatric Association
Arousal
Persistent symptoms of increased arousal
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Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle response
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Co-Occurring Psychiatric
& Substance Use Disorders
Getting Better: A Study of Addiction Services in Connecticut. DMAHS & UCONN
Men and Women Entering Addiction Treatment in Connecticut
60
50
40
53.2
37
37.8
26
30
21.9
20
13.3
19.4
12.2
10
0
Any Disorder Depression
Men
Anxiety
Women
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PTSD
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Seeking Safety:
A Psychotherapy for Trauma/PTSD
and Substance Use Disorders
 Seeking Safety is a present-focused
therapy to help people attain safety
from both PTSD and substance abuse.
 The treatment was designed for
flexible use. It has been conducted in
group and individual format; for
women, men, and mixed-gender;
using all topics or fewer topics; in a
variety of settings (e.g., outpatient,
inpatient, residential); and for both
substance abuse and dependence. It
has also been used with people who
have a trauma history, but do not
meet criteria for PTSD.
www.seekingsafety.org
2004 COPYRIGHT M. Rosier, MS
Lisa Najavits, Ph.D.
Picture courtesy of NIDA
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Principles of Seeking Safety:
Safety is the fundamental treatment goal
“When a person has both active substance abuse
and PTSD, the most urgent clinical need is to
establish safety.”
Najavits, 2002
“Seeking safety refers to helping patients free
themselves from such negative behaviors and,
in so doing, to move toward freeing themselves
from trauma at a deep emotional level.”
Najavits, 2002
Seeking Safety:
A Treatment Manual for PTSD and Substance Abuse
Najavits (2002) The Guilford Press, New York
www.guilford.com
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Principles of Seeking Safety:
Five Central Ideas
 Safety is the priority of first-stage treatment
 Integrated treatment for trauma and substance
use disorders
 A focus on ideals
 Four content areas: cognitive, behavioral,
interpersonal and case management
 Various therapist processes emphasized such as
building therapeutic alliances, using coping
skills, giving patients control, modeling positive
behavior and asking for patient feedback
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Principles of Seeking Safety:
Safety is the fundamental treatment goal
Safety is an umbrella term that signifies various
elements:
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Discontinuing substance use
Reducing suicidality
Minimizing exposure to HIV risk
Letting go of dangerous relationships
Gaining control over extreme symptoms
Stopping self-harm behaviors
Najavits, 2002
2004 COPYRIGHT M. Rosier, MS
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Principles of Seeking Safety:
Additional Features of Treatment
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Focus on potential rather than pathology
Attention to language
Emphasis on practical solutions
Relating the material to patient’s live
Making the treatment interesting to patients
Substance abuse as a priority
Patients do not necessarily need to meet formal
criteria for PTSD
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Principles of Seeking Safety:
Recommended Session Format
 Check-in
 Quotation
 Session Topic
 Check-Out
 End of Session Questionnaire
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Principles of Seeking Safety:
Recommended Session Format
 Check-in
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How are you feeling?
What good coping have you done?
Any substance use or unsafe behavior?
Did you complete your commitment?
Community resource update?
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Principles of Seeking Safety:
Recommended Session Format
 Quotation
 The purpose of the quotation
 Engage patient emotionally
 Provide inspiration
 Offer treatment reference for future
good coping
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Principles of Seeking Safety:
Sample Quotation
“Let your heart guide you.
It whispers, so listen closely”
-Molly Goode
(20th-century American writer)
Taken from Seeking Safety – Setting Boundaries in Relationships
(page 271)
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Principles of Seeking Safety:
Recommended Session Format
 Session Topic
 Ask patients to review written materials
 Relate material to current and specific
issues
 Ask patients what they find to be most
relevant
 Identify patient issues to process
 Mention PTSD and Substance Abuse
 Encourage patients to generate options
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Principles of Seeking Safety:
Recommended Session Format
 Check-Out
 Name one thing that you got out of today’s
session?
 Any problems with the session?
 What is your new commitment?
 Encourages the patient to keep moving forward
 Viable and realistic
 Patient oriented
 What community resource will you contact?
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Principles of Seeking Safety:
Recommended Session Format
 End of Session Questionnaire
 Ask patients to complete feedback
questionnaire
 Benefits of anonymous feedback
 Patients are empowered
 Patients feel valued
 Helpful in planning future sessions
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Seeking Safety:
Sample Treatment Topics
Essential first steps…
 Introduction to Treatment/Case Management
 Safety
 PTSD: Taking Back Your Power
 Detaching
from
Emotional Pain
(Grounding)
 Taking Care of Yourself
 Asking
for Help
 Setting Boundaries in
Relationships
 Coping with Triggers
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Technology Transfer Process:
Research to Practice
Technology Transfer
“Involves creating a mechanism by which a desired
change is accepted, incorporated and reinforced
at all levels of an organization or system.”
The Change Book: A Blueprint for Technology Transfer (2000)
See www.nattc.org/resPubs/changeBook.html
Goal of Technology Transfer
To integrate technology, research and innovation not
only into the practices and policies, but into the
culture, of the organization
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Technology Transfer Process:
Research to Practice
Other Issues for Consideration
Institutional Supports
Barriers to Change
Readiness for Change
Climate for Change
Resources
Quality Improvement Process and Assessment
Dwayne Simpson (2002)
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Seeking Safety:
Research to Practice
Fall 2002: Seeking Safety two-day training
Dr. Lisa Najavits
The Women’s Consortium New Haven, CT
 Discussed trauma and Posttraumatic Stress Disorder
 Reviewed history of trauma treatment
 Discussed current theories and treatment
 Introduced the Seeking Safety model
 Integrated case studies, research findings and clinical
techniques in providing Seeking Safety treatment
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Seeking Safety:
Research to Practice
• One year consultation with Lisa Najavits,
Ph.D. and Martha Schmitz, Ph.D.
• Weekly phone and once a month on-site
consultations with clinical team
• Referrals to Seeking Safety sessions
reviewed by clinical team
• Seeking Safety sessions scheduled in both
the AM and PM clinics
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Seeking Safety:
Research to Practice
Clinical Practice Challenges
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Systemic
Environmental
Economic
Program Policies and Procedures
Clinical Staff Recruitment
Clinical Orientation
Patient Education
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Seeking Safety:
Women’s Group
Nearly 1 in 4 women from the MMTP
participated in Seeking Safety groups
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7 groups with female clinical co-facilitation
Groups served between 5 – 12 women
Most groups 26 weeks or more in duration
Weekly group meetings
Sessions lasted between 1 and 1 ½ hours
Relationship issues, boundaries and anger
management
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Seeking Safety:
IOP/PHP Group
Seeking Safety has been integrated into
the IOP/PHP program for all women
 2 groups with female clinical co-facilitation
 Twice weekly group meetings
 Sessions last 1 hour with extended application
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through out IOP/PHP program
Greater emphasis on skills application into life
experiences due to increased exposure
Beneficial cohort effects = Increased comfort
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Seeking Safety:
HIV Positive Group
Safety and Case Management have
been the central themes
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1 Women’s group and 1 Men’s group
Co-facilitated by female clinicians
Bi-weekly for 1 ½ hours
Safe coping and skills building focused
Commitments tended to focus on medical
issues, healthy behaviors and lifestyle
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Seeking Safety:
Men’s Group
Men’s Group remained active
for over 2 years
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2 groups with male clinician co-facilitation
Groups served 12 men – 8 consistently
Weekly group meetings
Sessions lasted 1 ½ hours
Termination was particularly challenging
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Seeking Safety:
Implementation Issues
 Length of Session
 Length of Treatment
60 vs. 90 minutes
 Group Composition
Mixed vs. Same Gender
 Clinician Representation
 Topic Selection
Female vs. Male
1 vs. 2
Choice vs. Assigned
 Session Format
Structured vs. Fluid
 Level of Care
Entry vs. Maintenance
Open vs. Closed
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Seeking Safety:
Implementation Issues
 Expert Consultation
 On site and electronic/phone
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Structured Weekly Peer Supervision
Ongoing Training and development
Top-Down Administrative Support
Utilization of Consumer Feedback
Data Collection
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Seeking Safety:
Benefits of Treatment
Patients’ Self-Reported Improvements
 Reduced Substance Use
 Fewer Psychiatric Symptoms
 Less Hopelessness and Depression
 Improved Psychological Functioning
 Higher Quality Interpersonal Relationships
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Seeking Safety:
Benefits of Treatment
Observed Benefits of Treatment
 Flexible Treatment Model
 Increased Treatment Satisfaction
 Improved Problem Solving and Help
Seeking
 Increased Ownership and Empowerment
of Recovery
2004 COPYRIGHT M. Rosier, MS
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Seeking Safety:
Future Directions
 Treatment Outcome Research
 Expanded Treatment
 Inter-Agency Collaboration
 Evolution of the CT State Trauma Initiative
 Community Education and Awareness
 Continuity of Care
 Community Resources Database
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Summary
 People entering treatment for substance use
disorders are very likely to have a trauma history
 Evidence-based practices now exist to effectively
treat co-occurring psychological trauma/PTSD
and substance use disorders
 Seeking Safety is a flexible, highly acceptable and
feasible treatment for people with Opioid Use
Disorders
 Seeking Safety can be implemented into the
existing clinical practices of MMTPs to provide
beneficial treatment that improve patient
outcomes and satisfaction
2004 COPYRIGHT M. Rosier, MS
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Presenter’s Contact Information
Marshall Rosier, MS
[email protected]
(203) 755-8874
Alan Lee Nolan, LCSW
[email protected]
Lisa Najavits, Ph.D.
www.seekingsafety.org
Diane Heyward, MS
[email protected]
Michael Freeman, MS, LADC
[email protected]
2004 COPYRIGHT M. Rosier, MS
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