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Treatment for Co-occurring PTSD and Substance Use Disorders: State of the Science. Lisa R. Cohen, PhD Columbia University School of Social Work ISTSS November 6, 2006 Hollywood, CA. Scope of the Problem.

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treatment for co occurring ptsd and substance use disorders state of the science

Treatment for Co-occurring PTSD and Substance Use Disorders: State of the Science

Lisa R. Cohen, PhD

Columbia University School of Social Work


November 6, 2006

Hollywood, CA

scope of the problem
Scope of the Problem
  • As many as 80% of women seeking SUD treatment report histories of sexual and physical assault(Brady et al., 1994; Dansky et al., 1995; FuIlilove et al., 1993; Hien & Scheier, 1996; Miller et al. 1993)
  • Among substance abusers, lifetime rates of PTSD range from 14-60%(Triffleman, 2003; Donovan et al., 2001; Najavits et al., 1997; Brady et al., 2001)
  • Among PTSD populations, co-occurring substance use disorders may occur in 60-80% of individuals (Donovan et al., 2001)
clinical profile women with ptsd sud
Clinical Profile: Women with PTSD/SUD
  • Majority are victims of childhood abuse and repeated trauma
  • Present to treatment with high rates of other co-morbid disorders
  • Have interpersonal, behavioral and emotion regulation deficits
  • Abuse the most severe substances
self perpetuating cycle
Self-Perpetuating Cycle

Substance Use

Interpersonal difficulties, no anger management, increased isolation

Complicated Depression

Increased sleep disturbance & irritability



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

Confrontational approaches typical in addictions settings frequently exacerbate mood and anxiety disorders

12-Step Models often do not acknowledge the need for pharmacologic interventions

Treatments for PTSD only —such as Exposure-Based Approaches often may not be advisable to treat women with addictions or may be marked by complications

Clinical Challenges in the Treatment of Traumatic Stress and Addiction
ptsd sud treatments
PTSD/SUD Treatments
  • ATRIUM: Addictions and Trauma Recovery Integrated Model(Miller & Guidry, 2001)
  • Concurrent Treatment of PTSD and Cocaine Dependence(Back et al., 2001)
  • Seeking Safety(Najavits, 1998;
  • SDPT: Substance Dependence PTSD Therapy(Triffleman et. al, 1999)
  • TARGET - Trauma Affect Regulation: Guidelines for Education and Therapy(Ford;
  • Transcend(Donovan et al., 2001)
treatments for co morbid ptsd vs ptsd only treatments
Treatments for co-morbid PTSD vs. PTSD only treatments
  • Addition of components specifically designed to deal with coping and cognitive restructuring related to substance use (cravings and relapse triggers)
    • Concurrent Model :Additional components may be integrated and delivered concurrently
    • Sequential Model:Initial phase may focus on substance abuse related symptoms in preparation for working on trauma related symptoms later
seeking safety
Seeking Safety
  • Developed as a group treatment for PTSD/SUD women
  • Structured with flexibility
  • Educates patients about PTSD and SUD’s and their interaction
  • Based on CBT models of SUDs, PTSD treatment, women’s treatment and educational research
  • Goals include abstinence and decreased PTSD symptoms
  • Focuses on enhancing cognitive and interpersonal coping skills, safety and self-care
  • Therapist is active: teaches, supports and encourages
  • Includes case management component

Najavits, 2002;

women co occurring disorders violence study samhsa
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
  • CBT, including exposure therapy, shows promise in treating PTSD/SUD
  • PTSD treatments did not make patients worse, improved PTSD, substance use and general psychiatric symptoms
  • Integrated counseling may be one of the key program features that impacts outcomes.
  • More research needed to examine the duration, scope, timing and combination of components to identify optimal model of PTSD/SUD treatment integration
challenges to implementing trauma focused interventions in substance abuse treatment programs

Challenges to Implementing Trauma-focused Interventions in Substance Abuse Treatment Programs

Lisa Caren Litt, Ph.D.

Columbia University College of Physicians and Surgeons

Women’s Health Project Treatment and Research Center

ISTSS, November 6, 2006

Hollywood, CA

integrating trauma treatment
Integrating Trauma Treatment

Trauma-Informed Treatmentvs.

Trauma-Specific Treatment

creating a trauma informed addiction treatment system lessons from the wcdvs
Outreach and Engagement

Screening and Assessment

Substance Abuse and Mental Health Treatment

Parenting Skills

Resource Coordination and Advocacy

Trauma-specific Services

Crisis Intervention

Peer-Run Services (Consumers / Survivors / In Recovery)

Creating a Trauma-Informed Addiction Treatment SystemLessons from the WCDVS*

*WCDVS information is drawn from

trauma informed services characteristics wcdvs
Trauma-Informed Services:Characteristics (WCDVS)
  • Aware of the role of violence and victimization in women’s lives .
  • Minimize victimization and re-victimization.
  • Hospitable and engaging for survivors.
  • Facilitate recovery.
  • Empower.
  • Respect a woman's choices and control over her recovery.
  • Goals are mutual and collaboratively established.
  • Emphasize women’s strengths.
trauma informed services principles wcdvs
Trauma-Informed Services:Principles (WCDVS)
  • Respect trauma as a central concern in a woman’s life.
  • Symptoms are adaptations to traumatic experiences.
  • Reframe ‘Adaptive’ behavior as positive coping.
  • Violence and trauma have broad impact.
  • Providers need to meet the woman where she is.
introducing trauma specific treatment
Introducing Trauma-Specific Treatment
  • Counselor Buy In
  • Challenges to Agency and Treatment Philosophies
  • Protocol Training
  • Safety
  • Supervision
  • Counselor Self-care
should i or shouldn t i
Should I or Shouldn’t I?
  • Why counselors may be hesitant to provide trauma treatment
    • Pandora’s box: Fear
      • Clients and/or Counselors will become overwhelmed.
      • Clients will relapse, act out or drop out.
      • Clients will become threatening or destructive to self or others.
should i or shouldn t i21
Should I or Shouldn’t I?
  • Why counselors may be hesitant to provide trauma treatment
    • Personal history
      • Addiction history and recovery
      • Survivors of trauma themselves; increased vulnerability
What do Counselors

Need to Learn?

try something new
Try Something New
  • Treatment that differs from the Counselor’s own past treatment.
    • Treatment is not one-size-fits-all.
  • Addiction treatment that pays attention to abuse.
  • Treatment that challenges traditional substance abuse treatment models
    • Medical (Disease) Model
    • 12 Step Model
    • Confrontational Methods
difficult 12 step concepts for survivors in recovery
Difficult 12 Step Concepts for Survivors in Recovery
  • Surrender your power.
  • Surrender to a higher power.
  • Get off your pity potty.
philosophical differences
Philosophical Differences
  • Abstinence vs. Harm Reduction
    • What is the Agency response to lapse/relapse?
    • Harm reduction can be a path to Abstinence
    • Compassion and collaboration
why use manualized trauma treatment
Why Use ManualizedTrauma Treatment?
  • Psychoeducation for survivors
  • Structure for Clients and Counselors
  • Less opportunity to go too deep
  • Time-limited possibilities
developing a new stance
Developing a New Stance
  • Identify Counselor skills sets.
  • Collaborate, Don’t Dominate.
  • Validate and support.
  • Notice non-verbal communication.
  • In group, keep members safe.
  • Work within the “therapeutic window” (Briere).
  • Motivational interviewing strategies are helpful, and not just for substances.
client and counselor safety
Client and Counselor Safety
  • Managing an angry and aggressive client
    • “Tool box” not Pandora’s box
  • Child welfare involvement
  • Intimate partner violence
the counselor should not feel alone
The Counselor Should Not Feel Alone
  • Trauma specialists
    • In Agency
    • In the Community
  • Get the client off to a good start
    • Attending to trauma as part of recovery
    • Stabilize
    • Most trauma processing will follow
potential for vicarious traumatization
Potential for Vicarious Traumatization
  • Sensitivity for Counselor survivors
  • Conducting trauma treatment should be voluntary
  • Supportive environments
    • Moderate caseloads
    • Regular supervision
supervision is critical
Supervision is Critical
  • Protocol training is only the beginning.
  • A safe place.
  • Individual or group supervision.
  • Should not be on the ‘back burner’.
  • Ensure fidelity to the treatment.
    • Are audio or video recordings possible?
about direct observation
About Direct Observation
  • “It seems very frightening at first—you risk being naked in front of your peers—but, if the people watching you are generous and supportive, it is actually a great relief. You discover that you don’t really have to hide anything; your work has been seen and validated, which is something you can carry with you for the rest of your life.”

David Treadway, quoted in Wylie & Markowitz, 1992, p.29

counselor self care
Counselor Self-Care
  • Practice what you preach
  • Rest and exercise
  • Opportunities for personal renewal
  • Personal therapy

NIDA Clinical Trials Network Women’s Treatment for Trauma and Substance Use Disorders: Issues in Training and Assessment

Aimee Campbell, MSW

Columbia University School of Social Work

ISTSS, November 6, 2006

Hollywood, CA

nida clinical trials network women trauma sites
NIDA Clinical Trials Network Women & Trauma Sites

Washington Node Residence XII

New England NodeLMG Programs

New York NodeARTC

Ohio Valley NodeMaryhaven

Long Island NodeLead Node

South Carolina NodeCharleston Center

Florida NodeGateway Community

Florida NodeThe Village

pre post control group design

Pre-screening, Screening, Baseline, Randomization, Individual Counselor Session


1 - 4 Weeks

Pre-Post Control Group Design


6 Weeks

12 Twice Weekly Group Sessions

Post Treatment Follow-up

46 Weeks

1 Week

3 Month

6 Month

12 Month

participant eligibility criteria
Participant Eligibility Criteria


  • 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 community treatment program


  • 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
assessment measures
Assessment Measures
  • Demographics
  • Substance Abuse/Dependence Diagnosis (CIDI)
  • Substance Use (past 7, 30 days (ASI, SUI)
  • Biological Measures of Substance Use
  • PTSD Diagnosis (CAPS)
  • PTSD Symptom Severity (PSS-SR)
  • Psychiatric Symptoms (BSI)
  • Other Service Utilization (medication)
  • General Health, Social Network
  • HIV Risk Behaviors
  • Child/Adult Physical/Sexual Violence
ptsd assessment
PTSD Assessment
  • Clinician Administered PTSD Scale (CAPS)
    • DSM-IV symptom clusters
      • A: Exposure
      • B: Re-experiencing
      • C: Avoidance
      • D: Arousal
    • Subthreshold PTSD: criteria A, B, C or D, E (duration of at least 1 month) and F (clinically significant impairment).
    • Independent assessor training and ongoing supervision and adherence monitoring by expert supervisor

Blake, D.B., Weathers, F.W., Nagy, L.M., Kaloupek, D.G., Gusman, F.D., Charney, D.S., Keane, T.M., 1995. The development of a Clinician-Administered PTSD Scale. J Trauma Stress. 8, 75-90.


Initial Screen





N=1,212 (62%)

No Full Screen


Completed Full Screen





N=379 (70%)

Not Randomized

(multiple reasons)



N=353 (93%)

treatment groups
Treatment Groups
  • Seeking Safety (SS; Najavits, 1998)
    • Short term, manualized treatment
    • Cognitive Behavioral
    • Focused on addiction and trauma
  • Women’s Health Education (WHE)
    • Short term, manualized treatment
    • Pyschoeducational, didactic
    • Focused on understanding women’s health issues and empowerment
seeking safety topics

PTSD: Taking Back Your Power

Detaching from Emotional Pain

When Substances Control You

Taking Good Care of Yourself


Red and Green Flags


Integrating the Split Self

Creating Meaning

Setting Boundaries in Relationships

Healing from Anger

Seeking Safety Topics
women s health education topics
Body Systems

Female anatomy

Breast care







High Blood Pressure



Women’s Health Education Topics
who were the clinicians
Who were the clinicians?
  • All female staff
  • Agreed to randomization, videotaping and research monitoring
  • Demonstrated ability to conduct manualized, problem-solving session prior to randomization
  • Had no prior experience with study interventions
intervention specific training elements
Intervention-SpecificTraining Elements
  • 3-day group training
  • Explanation, demonstration and role-play
  • Post-training certification
    • Counselors and supervisors conducted pilot groups
    • Supervisors coded counselors’ sessions and compared ratings with lead experts
  • Train-the-trainer model
    • Used for supervisor training
research within practice challenges
Research-within-Practice Challenges
  • The Therapeutic Misconception
    • Research is not treatment
    • Protocol adherence is key
  • Avoiding cross-contamination
    • Need to keep interventions separate
    • Can’t share information with other colleagues or clients
ongoing supervision and monitoring
Ongoing Supervision and Monitoring
  • Supervisors attended weekly supervision teleconferences with Lead Node experts in the respective intervention
  • Calls included discussion of specific issues, review of session tapes and adherence ratings
adherence monitoring
Adherence Monitoring
  • Counselors
    • Supervisors rated 50% of cases and gave feedback based on ratings
    • Cut-offs for continued participation in trial and guidelines for retraining
  • Supervisors
    • Lead node experts rated 25% of sessions rated by local supervisors and gave feedback on level of agreement
counselor and supervisor benefits
Counselor and SupervisorBenefits
  • Expanded skills in delivering and supervising interventions
  • Became more comfortable using treatment manuals and working explicitly with women with co-occurring disorders
  • Sustainability and interest after conclusion of trial
counselor and supervisor challenges
Counselor and SupervisorChallenges
  • Rolling admission groups and no-shows led to delays in providing interventions
  • TTT model led to counselors feeling less involved in the process
  • Adherence monitoring
    • Counselor issues
    • Supervisor issues
  • Participant characteristics
  • Time commitment
  • Training, supervision and implementation require time and commitment from all levels of staff
  • Involve counselors and supervisors in ongoing supervision from “lead node”
  • Ensure adequate training in research process, procedures and special need of patient population

Consistent across sites:

  • High levels of multiple trauma exposure with clinically significant PTSD symptoms.
  • High percentage of sexual assaults (range=85%-100%).

Differences across sites:

  • Types of other traumatic experiences reported.
  • Types of drugs used and drug diagnosis.
  • Continued levels of substance use.
  • Recruitment success linked to type of CTP population and number of available intakes.
  • 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.
  • Participation in this study made possible by:
    • NIDA CTN Long Island Regional Node
    • NIDA/NIH Grant U10 DA13035
  • We would like to acknowledge the dedication of staff and resilience and strength of the participants who made this study possible.