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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.

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Integrated treatment for trauma and addiction seeking safety l.jpg

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PLEASE DO NOT CITE CONTENTS OF PRESENTATION WITHOUT PERMISSION OF THE AUTHOR


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Scope of the Problem Safety

  • 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)



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DSM-IV Criteria for SafetyPosttraumatic 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)


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Neurobiological Changes in Response to Traumatic Stress Safety

  • 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)



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Pandora Safety

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.


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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


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PTSD Treatment Approaches – for some PTSD may worsen

  • 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)


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PTSD/SUD Integrative Treatments – for some PTSD may worsen

  • 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)



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Women, Co-occurring Disorders & Violence Study (SAMHSA) Research

  • 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


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Spiral of Addiction and Recovery Research(Covington, 1999)


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“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)


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Motivational Enhancement to change and be different. It means passing through the waters of oblivion.”

for Patients with

Comorbid PTSD &

Substance Use Disorders


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Overview to change and be different. It means passing through the waters of oblivion.”

  • 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


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aMbivAlenCe to change and be different. It means passing through the waters of oblivion.”


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Treatment Compliance to change and be different. It means passing through the waters of oblivion.”

  • 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


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Why do we see these patterns? to change and be different. It means passing through the waters of oblivion.”


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Effects of Substance Use to change and be different. It means passing through the waters of oblivion.”

  • 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


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Other Challenges to change and be different. It means passing through the waters of oblivion.”

  • 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)


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How might a motivational to change and be different. It means passing through the waters of oblivion.”

enhancement approach help those with PTSD/SUD comorbidity?


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PTSD Treatment Model to change and be different. It means passing through the waters of oblivion.”Stages of Recovery (Herman, 1992)

1. SAFETY

2. MOURNING

3. RECONNECTION


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PTSD Treatment Model + MI to change and be different. It means passing through the waters of oblivion.”

  • Solidifying motivation to engage in safety work

  • Safety and stabilization

  • Integration and mourning

  • Reclaiming or developing a meaningful life


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MI Enhances Treatment to change and be different. It means passing through the waters of oblivion.”Engagement 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


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Basic MI Principles to change and be different. It means passing through the waters of oblivion.”

  • 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


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Basic MI Tools: OARS to change and be different. It means passing through the waters of oblivion.”

  • 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


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Opening Constructively or to change and be different. It means passing through the waters of oblivion.”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


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Using Feedback to change and be different. It means passing through the waters of oblivion.”

  • 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)


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Values Clarification or Developing Discrepancy to change and be different. It means passing through the waters of oblivion.”

  • 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


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Pros and Cons of NOT changing alcohol or drug use to change and be different. It means passing through the waters of oblivion.”

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


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Importance of making changes? to change and be different. It means passing through the waters of oblivion.”

  • 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


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Confidence in ability to change? to change and be different. It means passing through the waters of oblivion.”

  • 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


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Menu of Options to change and be different. It means passing through the waters of oblivion.”

  • 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


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Goals and how to get to them… to change and be different. It means passing through the waters of oblivion.”

  • 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


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Important Feedback Mechanisms to change and be different. It means passing through the waters of oblivion.”

  • 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



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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.


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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.


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Relapse Prevention Treatment: Why does it work with PTSD? Outcomes: Substance Use Severity by Treatment Group (N=107)

  • Symptoms of SUD and PTSD that overlap

    • Emotion regulation problems that manifest in unstable temperament with expressions of anger, irritability, and depression


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Maladaptive emotion focused coping Outcomes: Substance Use Severity by Treatment Group (N=107)

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


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Complex Trauma and Addictions: Underlying Commonalities Outcomes: Substance Use Severity by Treatment Group (N=107)

  • 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.


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Self-Perpetuating Cycle Outcomes: Substance Use Severity by Treatment Group (N=107)

Substance Use

Interpersonal difficulties, no anger management,  isolation

Complicated Depression

 sleep disturbance & irritability


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Relapse Prevention Treatment Outcomes: Substance Use Severity by Treatment Group (N=107)

  • 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)


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Characteristics of RPT Outcomes: Substance Use Severity by Treatment Group (N=107)

  • 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


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Replace Addictive Behaviors Outcomes: Substance Use Severity by Treatment Group (N=107)

  • Learn new coping skills

    • Resisting social pressure

    • Increase assertiveness

    • Relaxation and stress management

    • Communication skills

    • Anger management

    • Social skills


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Lifestyle Changes Outcomes: Substance Use Severity by Treatment Group (N=107)

  • Increase pleasant activities

    • Increase “positive addictions” and healthy habits

  • Short-circuit “Seemingly Irrelevant Decisions”


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Seemingly Irrelevant Decisions Outcomes: Substance Use Severity by Treatment Group (N=107)

  • 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


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Creating Safety Outcomes: Substance Use Severity by Treatment Group (N=107)

“Although the world is full of suffering, it is full also of the overcoming of it.”

Helen Keller


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Seeking Safety Outcomes: Substance Use Severity by Treatment Group (N=107)

  • 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


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NIDA Clinical Trials Network Outcomes: Substance Use Severity by Treatment Group (N=107)Women & Trauma Sites

Washington Node Residence XII

Ohio Valley Node Maryhaven

New England Node LMG Programs

New York Node ARTC

Long Island Node Lead Node

South Carolina Node Charleston Center

Florida Node Gateway Community

Florida Node The Village


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Treatment Groups Outcomes: Substance Use Severity by Treatment Group (N=107)

  • 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


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Support Outcomes: Substance Use Severity by Treatment Group (N=107)

  • 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.


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Participating Nodes and CTPs Outcomes: Substance Use Severity by Treatment Group (N=107)


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Frankie Kropp Outcomes: Substance Use Severity by Treatment Group (N=107)

Agatha Kulaga

Melissa Gordon

Chanda Brown

Silvia Mestre

Nadja Schreiber

Mary Hatch-Maillette

Chris Neuenfeldt

Cheri Hansen

Karen Esposito

Sharon Chambers

Project Directors/Protocol PIs


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Brianne O’Sullivan Outcomes: Substance Use Severity by Treatment Group (N=107)

Ileana Graf

Melissa Chu

Nishi Kanukollu

Treneane Salisbury

Rebecca Krebs

Ann Whetzel

Stella Resko

Carol Hutchinson

Chanda Brown

Janice Ayuda

Pamela Bernard

Jessica Ucha

Nicole Moodie

Allison Kristman-Valente

Lynette Wright

Melanie Spear

Lisa Johnson

Catherine Williams

Calonie Gray

Michele DiBono

Rachel Hayon

Barbara Bettini

Barbara Thomas

Lisa Markiewicz

Elizabeth Cowper

Rosaline King

Lara Reichert

CTN-0015 Research Staff


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Lisa Cohen Outcomes: Substance Use Severity by Treatment Group (N=107)

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 Clinicians


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Jim Robinson Outcomes: Substance Use Severity by Treatment Group (N=107)

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

CTN-0015 QA and Data Management