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PLEASE DO NOT CITE CONTENTS OF PRESENTATION WITHOUT PERMISSION OF THE AUTHOR
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)
“The past isn’t dead,
it isn’t even past.”
-William Faulkner
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.
C.
Event is persistently re-experienced
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)
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)
Pathways Between Trauma-related
Disorders and Substance Use
PTSD
TRAUMA
SUD
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.
Clinical Challenges in the Treatment
of Traumatic Stress and Addiction
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
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)
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)
Comparison of Existing Trauma/ SUDFocused Treatment Research
N
Length
of TX
TX
Content
Follow
Up
Results
Variable
Limits
Najavits,
1998
Triffleman,
2000
Brady,
2001
N=27 women
17 (>6 sess)
N=19
(53% women)
39
(82% women)
15 (>10 sess)
N=46 men
No Control
RCT
No Control
No Control
Group,
24 sessions,
2x/wk, 90min/group
Seeking
Safety: Cog
Behavioral
Interpersonal
coping skills
Individual,
5 months,
2x/wk
Individual,
16 sessions,
90 min
sessions
Exposure
Therapy &
CBT
12 weeks,
10 hrs/week
partial hosp,
CBT, RP &
peer social
support (2phase)
Seeking
Safety/CBT
vs RPT
6 mo post
6/12 mo post
6/9 mo post
Improvement
in SU, PTSD
& Depression
Improvement
in SU, PTSD
SU, PTSD,
Depression
Small N, No
Control, large
drop out rate
SU, PTSD
Improvement
@ 6 mo,
diminished at
9 mo, no diff
b/t SS/RPT
SU, PTSD,
Psych
Nonrandomized
TAU
3 mo post
Improvement
on SU, PTSD,
Depression,
increase in
somatization
SU, PTSD,
Psych, Cog
Small N, No
Control, Did
not follow up
Drop-outs
SDPT
(Coping,
CBT, Stress
Inoc, In Vivo,
RP-2 phase)
vs 12 step
1 mo post
Improvement
on SU, PTSD,
psych, No
gender
differences
SU, PTSD,
psych
Small N,
Short FU
period
Donovan,
2001
Small N, No
Control, 30
day
abstinence
required, one
site
Hien,
2004
N=107
women
RCT
Individual,
3 months
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
Spiral of Addiction and
Recovery (Covington, 1999)
“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)
Motivational Enhancement
for Patients with
Comorbid PTSD &
Substance Use Disorders
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
aMbivAlenCe
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
Why do we see these
patterns?
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
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)
How might a motivational
enhancement approach
help those with PTSD/SUD
comorbidity?
PTSD Treatment Model
Stages of Recovery (Herman, 1992)
1. SAFETY
2. MOURNING
3. RECONNECTION
PTSD Treatment Model + MI
Solidifying motivation to engage in
safety work
Safety and stabilization
Integration and mourning
Reclaiming or developing a
meaningful life
MI Enhances Treatment
Engagement Among Other
Dually Diagnosed Individuals
Several studies have found that MIoriented session(s) ranging from 1 to
9 contacts have helped improve:
Aftercare initiation
Attending more treatment sessions
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
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
Opening Constructively or
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
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)
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
Tipping the Balance Towards
Change
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 PTSDrelated behaviors
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
Not at
all important
4
5 6 7 8 9
10
Very
important
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
Not at
all confident
4
5 6 7 8 9
10
Very
confident
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
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
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
How might Relapse Prevention
help those with PTSD/SUD
comorbidity?
Seeking Safety (SS) vs. Relapse Prevention
(RPT) vs. TAU Outcomes: PTSD Symptom
Severity by Treatment Group (N=107)
0.5
0.2
-0.1
SS
RPT
TAU
-0.4
**P<.01
**P<.01
End-of-Tx
3-month Post
**P<.01
-0.7
-1
Baseline
6-month Post
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.
Seeking Safety (SS) vs. Relapse Prevention
(RPT) vs. TAU Outcomes: Substance Use
Severity by Treatment Group (N=107)
0.5
0.2
-0.1
SS
RPT
TAU
En d -o f-T x
-0 . 0 6
0 .3 1
-0.4
-0.7
***P<.00
1
**P<.01
End-of-Tx
3-month Post
P=.06
-1
Baseline
6-month Post
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.
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
Biased information
processing and
problem solving
Difficulties
with intimacy
and trust
Maladaptive
emotion focused
coping
Emotion Regulation
Deficits
Difficulty
managing anger
Behavioral
Impulsivity
Affective
lability
Disruptions in
attention,
memory &
consciousness
Poor tolerance
of negative
emotional
states
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.
Self-Perpetuating Cycle
Substance Use
Interpersonal
difficulties, no anger
management, 
isolation
Complicated
Depression
 sleep disturbance
& irritability
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)
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
Replace Addictive Behaviors
Learn new coping skills
Resisting social pressure
Increase assertiveness
Relaxation and stress management
Communication skills
Anger management
Social skills
Lifestyle Changes
Increase pleasant activities
Increase “positive addictions” and
healthy habits
Short-circuit “Seemingly Irrelevant
Decisions”
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
Creating Safety
“Although the world is full of
suffering, it is full also of
the overcoming of it.”
Helen Keller
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
NIDA Clinical Trials Network
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
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
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.
Participating Nodes and CTPs
Node
Node PI(s)
Protocol PI
CTP
Site PI
Location
The Village
Michael
Miller
Miami, FL
Gateway
Community
Candace
Hodgkins
Jacksonville,
FL
Melissa
Gordon
LMG
Programs
Samuel
Ball
Stamford, CT
Robert
Sage
Brooklyn, NY
Florida
Jose
Szapocznik
& Daniel
Santisteban
Lourdes
SuarezMorales
New
England
Kathleen
Carroll
New York
John
Rotrosen
Marion
Schwartz
Addiction
Research &
Treatment
Corporation
Ohio Valley
Gene
Somoza
Greg
Brigham
Maryhaven
Greg
Brigham
Columbus,
OH
South
Carolina
Kathleen
Brady
Therese
Killeen
Charleston
Center
Mark
Cowell
Charleston,
SC
Washington
Dennis
Donovan &
Betsy Wells
Betsy
Wells
Residence XII
Karen
Canida
Kirkland, WA
Project Directors/Protocol PIs
Frankie Kropp
Agatha Kulaga
Melissa Gordon
Chanda Brown
Silvia Mestre
Nadja Schreiber
Mary HatchMaillette
Chris Neuenfeldt
Cheri Hansen
Karen Esposito
Sharon Chambers
CTN-0015 Research Staff
Brianne O’Sullivan
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 KristmanValente
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 Clinicians
Lisa Cohen
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 QA and Data
Management
Jim Robinson
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