Treating Trauma and Addiction: The CTN Women and Trauma Study

1. Treating Trauma and Addiction: The CTN Women and Trauma Study Denise Hien, Ph.D. Research Scholar, Columbia University School of Social Work Executive Director, Women’s Health Project Treatment and Research Center, Dept of Psychiatry, St. Luke’s\ Roosevelt Hospital Center Gloria Miele, Ph.D. Training Director, New York State Psychiatric Institue, Columbia University Greg Brigham, Ph.D. Chief Research Officer, Maryhaven National Conference on Women, Addiction and Recovery: News You Can Use Anaheim, CA, July 14, 2006

2. Overall Presentation Objectives • Participants will gain an overview of specific treatment approaches for women with trauma and substance use disorders based upon our collective work with CTN’s Women and Trauma Study. • Participants will learn important descriptive characteristics of women with trauma who attend outpatient substance abuse treatment. • Participants will gain knowledge about training and supervision required when using empirical approaches to treating women with trauma. • Participants will learn the benefits and challenges to implementing empirical approaches to treating women with trauma in community treatment programs.

3. Historical Context for the Study of Trauma and Addiction • Women’s Movement and Grassroots Advocacy for Battered Women in 1970’s. • Crack/ Cocaine epidemic; DSM-IIIR broadens criteria for PTSD; PTSD studies in Vets and Non Substance Abusers; Fullilove’s Snowball Sample, Miller’s work with criminal justice population in mid-late 1980’s. • Surgeon General Koop declares Violence a Public Health Epidemic in 1991. • Judith Herman’s book Trauma and Recovery published in 1992.

4. Historical Context for the Study of Trauma and Addiction (cont’d.) • Epidemiology from cross-disciplinary research over the late 80’s and 90’s establishes high rates—surpassing normal population estimates—for childhood abuse, domestic violence, crime victimization and PTSD—especially for women. • Chilcoat and Breslau identify support for self-medication model in 1998; Kendler and colleagues publish first co-twin study demonstrating causal link between childhood abuse and substance use disorders in 2000. • National consciousness of PTSD and addiction links following September 11, 2001.

5. DSM-IV Criteria for Posttraumatic Stress Disorder (PTSD) • The person has been exposed to a traumatic event • Event involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others • The person’s response involved intense fear, helplessness, or horror • The traumatic event is persistently re-experienced • Avoidance of stimuli associated with the trauma and numbing of general responsiveness • Persistent symptoms of increased arousal, including difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, exaggerated startle response (American Psychiatric Association, 1994)

6. PTSD vs. Complex Trauma • PTSD typically develops from one incident, usually experienced as an adult. • 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.

7. Pathways Between Trauma-related Disorders and Substance Use SUD PTSD TRAUMA

8. Abstinence may not resolve comorbid trauma-related disorders for many patients the PTSD worsens Women with PTSD abuse the most severe substances and are vulnerable to relapse for both conditions, as well as repeated trauma 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 often do not 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 Clinical Challenges in the Treatment of Traumatic Stress and Addiction

9. 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.

10. Spiral of Addiction and Recovery (Covington, 1999)

11. Other Relevant Treatment Models • Linehan – Dialectical Behavioral Therapy (DBT) • Cloitre – Skills Training in Affective and Interpersonal Regulation(STAIR/STAIR-PE) • TREM

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

13. NIDA Clinical Trials Network Women & Trauma Sites Washington Node Residence XII Ohio Valley NodeMaryhaven New England NodeLMG Programs New York NodeARTC Long Island NodeLead Node South Carolina NodeCharleston Center Florida NodeGateway Community Florida NodeThe Village

14. CTN Long Island Node Team Denise Hien, Lead Investigator Edward Nunes, Node PI Gloria Miele, Training Director Lisa Cohen, Protocol Manager Aimee Campbell, Project Director Jennifer Lima, Node Coordinator Eva Petkova, Lead Statistician David Liu, NIDA Liaison

15. Participating Nodes and CTPs

16. Seeking Safety is in the Community • In the CSAT study on Women and Violence, nine sites were offered a choice of three treatment models for PTSD/SUD; more chose SS than any other treatment model. • The Veterans Affairs 10-site project on homeless women veterans selected SS as the sole treatment to be compared to “treatment-as-usual”. • The State of Connecticut trauma initiative selected SS as one of three trauma treatments. Seven agencies chose SS for this year-long project.

17. Study Aims • To assess the effectiveness of adding Seeking Safety (SS) to standard substance abuse treatment (TAU). • To evaluate the transportability of a 12- session group version of SS in community drug/alcohol treatment settings.

18. 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

19. Stages of Healing 1.SAFETY: This is the phase you are in now. The goals are to free yourself from substance abuse, stay alive, build healthy relationships, gain control over your feelings, learn to cope with day-to-day problems, protect yourself from destructive people and situations, not hurt yourself or others, increase your functioning, and attain stability. 2. MOURNING: Once you are more safe, you may need to grieve about the past, about what your trauma and substance abuse did to you. You may need to cry deeply to get over the losses and pain you experienced: loss of innocence, loss of trust, loss of time. 3. RECONNECTION: After letting yourself experience mourning, you will find yourself more willing and able to reconnect with the world in joyful ways: thriving, enjoying life, able to work and relate well to others. You will get to this stage if you can establish safety now. Adapted from Herman, Trauma and Recovery, 1992

20. 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

21. Key Treatment Concepts • Safety first • From substances and harmful situations • “Safe Coping Skills” • Anticipating dangerous situations • “Red Flags/Green Flags” • Setting boundaries • Anger management • Affect regulation skills

22. Women’s Health Education • Empowerment • Information is empowering • Self-care • Substance abuse and trauma interfere with ability to care for oneself • Exposure to traumatic stress can affect people on many different levels of functioning including: • emotional • behavioral • cognitive • characterological • somatic • There is significant overlap of PTSD and physical symptoms • In the national comorbidity survey, use of medical care services was highest in PTSD and panic disorder patients

23. CTP Criteria for Study Inclusion • Outpatient Program • Length of program stay at least 10 weeks • Average 2-3 new female intakes per week • At least 4 interested counselors/therapists • Ability to accommodate 2 groups conducting twice weekly sessions over 1 year

24. 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

25. 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 CTP Exclusion • advanced stage medical disease (AIDS, TB) • impaired mental status (MMSE: less than or equal to 21) • significant risk of suicidal/homicidal intent or behavior • history of schizophrenia-spectrum diagnosis • active psychosis (prior 2 months) • involved in PTSD-related litigation • refuses to be audio or videotaped

26. Assessment Measures • Demographics • Substance Abuse/Dependence Diagnosis • Substance Use (past 7, past 30 days/biological) • PTSD Symptoms (CAPS, PSS-SR) • Psychiatric Symptoms (BSI) • Other Service Utilization (medication) • Health Related Questions • HIV Risk Behaviors • Child/Adult Physical/Sexual Violence

27. Primary Outcomes(baseline, 1week post, 3-, 6-, 12-month follow-up) • PTSD Symptoms (CAPS) • Biologically Confirmed Substance Abstinence • Substance Use Inventory (SUI) • Urine Drug Screen (UDS) • Saliva Alcohol Screen (ST)

28. Secondary Analyses • Site characteristics • Frequency and length of TAU • Group sizes • Type of treatment and modality • Proportion of patients on medication • Gender/Trauma specific interventions • Individual baseline characteristics • Severity, type, duration of substance use/PTSD • Psychotropic medication use • Drug use and PTSD symptoms over time

29. Enrollment Initial Screen • 1,963 Completed • 1,212 (62%) Eligible Screening Interviews • 541 Completed • 379 (70%) Eligible • 353 (93%) Eligible Pts. Randomized

30. Eligibility of Screened Sample (N=541)*

31. Randomization (N=353)

32. Sample Characteristics (N=353)

33. ASI Alcohol & Drug Composite Scores (N=353)

34. Partner Violence 261 (73.9) Partner Sexual Violence 117 (33.1) Childhood Physical Abuse 205 (58.1) Childhood Sexual Abuse 244 (69.1) Traumatic Events* Physical Assault 91.8% Sexual Assault 89.2% Other Unwanted Sexual Experience 81.9% Sudden Unexpected Death 79.0% Transportation Accident 72.5% Assault with Weapon 71.7% Trauma Characteristics (N=353) *Taken from the Life Events Checklist

35. Trauma Exposure (N=353)*

36. PTSD Diagnosis – Full vs Subthreshold (N=353)*

37. PTSD Symptom Severity (CAPS Subscales) (N=353)*

38. Summary Consistent across sites: • High levels of multiple trauma exposure with clinically significant PTSD symptoms. • High percentage of sexual assaults (range=85%-100%). • High rates of service utilization (i.e. 12 step, medical and mental health visits). • Low overall depression levels, but with clinically significant subgroup with higher depression scores. Differences across sites: • Types of other traumatic experiences reported. • Types of drugs used and drug diagnosis. • Recruitment success linked to type of CTP population and number of available intakes.

39. Implications • 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 group.

40. Implementation Issues • Intervention Delivery • Weeks in treatment • Number and type of sessions received • Number of participants in each group session • Session length • Therapist • Characteristics • Adherence Levels • Race/Ethnicity • Alliance • Treatment as Usual • Gender/Trauma services

41. Additional Challenges • Training and re-training replacements • Varied levels of experience and education • Slow start up • Slow recruitment • Adherence levels (Seeking Safety) • Multi-site communication

42. Overview of Stage of Science • Treatment outcome research which examines longer-term interventions is urgently needed. • Improving retention remains a clinical challenge. • Studies are needed which test effects of elements such as: • timing of sessions in the context of substance abuse treatment, • optimal dose, • combination psychopharmacology and behavioral interventions, • mechanisms/mediators of treatment outcomes (i.e., emotion regulation) • how and when to add other behavioral approaches such as exposure therapy.

43. 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.