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Tracy Simpson, PhD, VAPSHCS, University of Washington NIDA CTN Blending Conference Seattle, WA October 16, 2006 PLEASE DO NOT CITE CONTENTS OF PRESENTATION WITHOUT PERMISSION OF THE AUTHOR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

3. “The past isn’t dead, it isn’t 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. 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 Clinical Challenges in the Treatment of Traumatic Stress and Addiction

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 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

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. 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 Tipping the Balance TowardsChange

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 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

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 (N=107) **P<.01 **P<.01 **P<.01 All analyses adjusted for age and baseline PTSD severity. End-of-Tx F=4.71 (2,106), r2=.42; 3-month Post F=4.94 (2,106), r2=.28; 6-month Post F=5.51 (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, 161:1426-1432. 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 (N=107) P=.06 ***P<.001 **P<.01 All analyses adjusted for age and baseline substance use severity. End-of-Tx F=6.01 (2,106), r2=.42; 3-month Post F=4.82(2,106), r2=.36; 6-month Post F=2.87(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. 161:1426-1432. 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 Difficulties with intimacy and trust Disruptions in attention, memory & consciousness 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 couldn’t 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, 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