Shari A. McKee, Ph.D., C.Psych. Olivia Forrest, AC Georgianwood Concurrent Disorders Program...
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Assessing and Treating Trauma in Clients with Concurrent Disorders Shari A. McKee, Ph.D., C.Psych. Olivia Forrest, AC Georgianwood Concurrent Disorders Program Penetanguishene, ON
Shari A. McKee, Ph.D., C.Psych. Olivia Forrest, AC Georgianwood Concurrent Disorders Program Penetanguishene, ON
Shari A. McKee, Ph.D., C.Psych. Olivia Forrest, AC Georgianwood
Concurrent Disorders Program Penetanguishene, ON
Slide 2
Georgianwood Concurrent Disorders Program Located at the
Waypoint Centre (formerly the Mental Health Centre Penetanguishene)
Revamped in 2007 became 3-month residential program offering fully
integrated substance use and mental illness treatment for adults
12bed program was based on best-practice recommendations for CDs
Groups include CBT, Seeking Safety, skills training, self-help
facilitation, psychoeducation, family education, anger management,
leisure education, discharge planning & aftercare
Slide 3
Prevalence of PTSD in CD Populations Rates of PTSD among
clients in treatment for substance abuse range from 25-42 % (E.g.,
Brady et al., 2004; Langeland & Hartgers, 1998) Studies that
focused only on women find higher rates: 30-59% (E.g., Najavits et
al., 1997; Stewart et al., 1999) Masters thesis data collected at
Georgianwood found that 60% of our clients met DSM-IV criteria for
PTSD
Slide 4
What Does the Research Say? Becoming abstinent from substances
does not resolve PTSD; but successfully treating PTSD does lead to
decreases in substance abuse (Brady et al., 1994; Hien et al, 2010)
Treatment outcomes for clients with PTSD and substance abuse are
worse than for other clients with concurrent disorders and for
those solely with substance abuse ( Ouimette et al., 2003) When
PTSD symptoms worsen, substance misuse symptoms worsen and vice
versa (Henslee & Coffey, 2010)
Slide 5
What are the Recommendations? (Henslee & Coffey, 2010)
Assess trauma symptoms in all clients. Provide trauma-focused
treatment to addicted clients with PTSD. Manuals have been created
which offer combined PTSD & substance abuse treatment (e.g.,
Seeking Safety; Concurrent Treatment of PTSD and Cocaine
Dependence; Substance Dependence PTSD Treatment) Despite the
difficulties in administration, prolonged exposure therapy is the
gold standard in PTSD treatment.
Slide 6
Screening for PTSD All clients should be routinely screened for
PTSD. There are many screening/assessment tools available. National
Center for PTSD lists many available free screeners and assessment
tools on their website. We use the PTSD Checklist ( PCL-S;
Weathers, Litz, Huska, & Keane, 1994) & the Brief Trauma
Questionnaire ( Schnurr, Vielhauer, Weathers & Findler,
1999).
Slide 7
PTSD Screeners First determine whether the client experienced
at least 1 traumatic event meeting DSM-IV criteria: (1) person
experienced, witnessed, or was confronted with an event or events
that involved actual or threatened death or serious injury, or a
threat to the physical integrity of self or others; (2) the
person's response involved intense fear, helplessness, or
horror.
Slide 8
PTSD Screeners contd Then determine whether they have
experienced PTSD symptoms for at least 1 month: 1. Reexperiencing
(1)(e.g., dreams, flashbacks) 2. Avoidance & Numbing (3)(e.g.,
avoid thoughts, people, objects that are reminders of the trauma;
diminished interest; detachment) 3. Increased arousal (2) (e.g.,
sleep problems, startle, hypervigilance, irritability)
Slide 9
Suggestions for Effective Screening We do trauma screening
within 2 days of admission. Assign the task to one person who
should use a gentle, empathic approach. Give a rationale for the
screening: we are asking this so any PTSD symptoms can be
addressed. Ask briefly for past traumas but do not elicit so much
detail that it is re-traumatizing for the client.
Slide 10
Suggestions for Effective Screening contd Score the tool ASAP
so can give feedback to the client. If they screen positive for
PTSD, invite them to attend Seeking Safety and give information
about the group. Instill hope we can work with you to help you with
these PTSD symptoms.
Slide 11
Seeking Safety (2002) Developed by Lisa Najavits at Harvard. Is
considered first stage treatment for concurrent PTSD &
substance abuse (which involves safety). Safety from substance
abuse, self-harm, violent relationships etc. Many clients will
require further treatment. Fully-integrated curriculum addresses
substance use & PTSD in every session.
Slide 12
Seeking Safety contd Teaches healthy coping skills in 25
sessions (hard to cover that many sessions) Groups are
psychoeducational but manual offers ideas on how to make it more
skills-focused. The group involves NO trauma details.
Slide 13
Seeking Safety Training Five Georgianwood staff attended a
2-day Najavits workshop in Toronto. Had to decide on which sessions
we would offer in our 12-week program. Currently have a weekly
2-hour group that is co-led by an addiction counselor and an RN
mixed gender group.
Slide 14
Seeking Safety Topics Include: 1. * Grounding 2. *Asking for
help 3. Safety 4. *Compassion 5. *Setting boundaries 6. Healing
from anger 7. *Self-nurturing 8. Coping with triggers 9. Recovery
thinking 10. Healthy relationships 11. *Integrating the split self
12. Community resources 13. *Honesty 14. *Taking good care of
yourself 15. Getting others to support your recovery 16. *Taking
back your power 17. *Red & green flags 18. Commitment 19.
Creating meaning 20. When substances control you 21. Discovery 22.
Respecting your time
Slide 15
Core Concepts of Seeking Safety Stay safe Respect yourself Use
coping not substances- to escape the pain Make the present and
future better than the past Learn to trust Take good care of your
body Get help from safe people If one method doesnt work, try
something else Never, never, never, never, never give up !
Slide 16
Seeking Safety Session Format Check-in Quotation Handouts on
the topic discussion, practice skills Commitment (homework)
Check-out / feedback
Slide 17
Check-in (5 mins/client) 5 minutes per client max Ask clients
to reflect on how they are feeling and how things have gone over
the past week: 4 questions: How are you feeling? Did you practice
any safe coping this week? Any substance use or other unsafe
behaviour this week? Did you complete your commitment?
Slide 18
Quotation (5 minutes) Helps to engage the clients emotionally
in the session. E.g., for Safety session: Although the world is
full of suffering, it is full also of the overcoming of it. Helen
Keller Ask What is the main point of the quotation?
Slide 19
Handouts on the Topic & Discussion/Practice (50 minutes)
Handouts copied from manual 2-5 handouts per topic May take up to 4
sessions to get through all handouts on a topic Clients encouraged
to read handouts out loud Each main point is discussed by group
& topic is related to each clients life Many topics have
suggestions for behavioural skills practice (i.e., role plays)
Slide 20
Example: Grounding Topic Gives definition of grounding: a
distraction technique used to detach from emotional pain. Explains
rationale for grounding: to gain control over your feelings and
stay safe (from substance use or self-harm). Guidelines for
grounding: Can use it anywhere, any time Use it to deal with
cravings, anger, dissociation, pain Keep eyes open Focus on the
present
Slide 21
3 Types of Grounding clients practice each type of grounding as
a group 1. Mental Grounding: describe your environment; categories
game (cities that start w/ A, B, etc); read 2. Physical Grounding:
cool water on hands; grip chair; dig heels into floor; touch
grounding object 3. Soothing Grounding: say kind statements; think
of favourites (foods, TV shows); photos of loved ones
Slide 22
Commitment (1min/client) Similar to homework in CBT. Is
optional but encouraged. Clients can choose a commitment idea from
a list or make up one of their own. Idea is to put into practice
some of the safe coping skills.
Slide 23
Example of Commitments Safe coping sheet contrast old ways of
coping versus new, safe ways. Find a small grounding object, such
as a stone, to carry with them. Writing a letter or a story (e.g.,
a letter giving themselves permission to nurture themselves).
Practice grounding for 10 minutes. Practice self-nurturing (e.g.,
take a long bath)
Slide 24
Check-out (10 mins) To reinforce the clients progress and give
therapist feedback. How was the session today? What did you like?
What didnt you like? What is your new commitment?
Slide 25
Outcome Research: Seeking Safety Seeking Safety is the only
model of concurrent PTSD and substance abuse that meets Chambless
& Hollon (1998) criteria as an effective treatment. The
evidence comes from 6 pilot studies, 4 RCTs, 1 controlled
nonrandomized trial, 2 multisite controlled trials and 1
dissemination study. All outcomes studies showed positive outcomes
all studies showed reduction in PTSD symptoms and all but 1 found
reductions in substance use (that study did not use all Seeking
Safety sessions).
Slide 26
Outcome Research: Seeking Safety contd In 4 out of 5 controlled
trials, Seeking Safety outperformed the comparison condition
(treatment as usual). Seeking Safety was also found to have several
advantages over other treatments: greater therapeutic alliance more
rapid PTSD improvement greater HIV risk reduction greater
sustaining of gains during follow-up greater impact on clients who
were heavy substance users.
Slide 27
Outcome Research: Seeking Safety contd Treatment satisfaction
was high in all studies. More research is needed: What are the key
components to treatment effectiveness? How many sessions are needed
for optimal response? Does clinician training impact outcomes? How
does Seeking Safety do compared to other manualized
treatments?
Slide 28
Fidelity & Knowledge Acquisition It is recommended that
regular fidelity checks are done to assess whether the therapists
are sticking to the manual. All of our sessions are audiotaped and
the psychologist listens to random tapes and assesses fidelity to
the Seeking Safety model (Seeking Safety Adherence Scale). Also
created a pre/post quiz to measure knowledge acquisition of key
Seeking Safety skills and concepts. Screen for PTSD pre and post
program have their symptoms decreased as a result of the program
?
Slide 29
Preliminary Data: Georgianwood N = 57 all screening positive
for PTSD on admission. On discharge, 41 (72%) no longer screened
positive for PTSD. Improvements likely due to a combination of
factors: 3 months of sobriety, a supportive environment, CBT and
Seeking Safety.
Slide 30
Example: Compassion Quotation: You yourself, as much as anybody
in the entire universe, deserve your love and affection.
Buddha
Slide 31
Exposure Therapy Exposure therapy is an evidence-based
intervention & is considered the gold-standard of trauma
treatment. Exposure therapy was the only psychosocial treatment
deemed effective for PTSD by the Institute of Medicine (2008). Edna
Foa - named one of Time Magazines 100 Most Influential People in
the World in 2010, to acknowledge how effective exposure therapy
has been in treating PTSD.
Slide 32
Exposure Therapy contd Involves clients being exposed to
memories or to objects/situations that remind them of a trauma. It
is thought to work by allowing the client to see that although the
traumatic event wasnt safe, the memories and reminders of the event
are safe. It also involves clients repeatedly exposing themselves
to the feared objects/memories, allowing for habituation of the
fear. It also allows the client to fully process what happened to
them (which avoidance does not permit).
Slide 33
Prolonged Exposure Typically involves 2 types of exposure work:
1. In Vivo client is exposed to objects (e.g., dogs) or situations
(e.g., going to a grocery store) that are associated with a trauma
and that cause fear and avoidance. 2. Imaginal client is exposed to
memories of the traumatic event.
Slide 34
Prolonged Exposure contd Work with the client to create 2
hierarchies one for in vivo and one for imaginal. Want a range of
objects/memories from mild anxiety to severe anxiety. Slowly work
up the hierarchy as they experience success with the less
anxiety-provoking items, they develop confidence to tackle the more
difficult items.
Slide 35
Prolonged Exposure: Warnings Not easy is difficult for the
client and the therapist. Need extensive background in CBT first.
Need to fully understand the rationale for PE. Need to follow
closely to an effective manual. Should get supervision/
consultation when first doing this work. For CSA and BPD, the
combination of PE with DBT is recommended. In the short-run can
increase nightmares/flashbacks and should continuously assess for
suicidal ideation.
Slide 36
Summary The majority of CD clients have experienced significant
trauma and many have PTSD. Treating their substance abuse without
addressing the trauma leads to poorer outcomes. Screen all
concurrent disorders clients for PTSD. When identified, either
refer or treat in-house. There are a number of CD/PTSD manualized
treatments available (e.g., Seeking Safety).
Slide 37
Summary contd Identify staff who may have the interest and
background to get training and supervision in exposure therapy.
Considering training in DBT to increase the effectiveness of your
trauma interventions. Reassess PTSD symptoms after treatment to see
whether it was effective. Very good substance use outcomes can be
achieved when trauma is treated concurrently!
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Chambless, D.L. & Hollon, S.D. (1998). Defining empirically
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Slide 40
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Slide 41
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Slide 42
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Slide 43
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