Treating Co-Occurring PTSD and Substance Abuse in Community Settings: Focus on Seeking Safety

Transcription

1 Treating Co-Occurring PTSD and Substance Abuse in Community Settings: Focus on Seeking Safety Holly Hills, PhD July 1, 2014 Partners in Crisis Annual Conference Orlando, FL

2 Overview: Focus on Trauma in the DSM-5 Trauma Informed Care Seeking Safety Implementation of Innovation Holly Hills, Ph.D.,

3 PTSD: Changes in DSM-5 PTSD is what happens when the brain's alarm system doesn't automatically or rapidly re-set itself. When the brain's alarm continues to signal danger even though safety has been restored, the brain's overall functioning remains in an altered state that is the chronic stress response..(quote by Julian Ford, Ph.D. ( Holly Hills, Ph.D.,

4 PTSD: Changes in DSM-5 Survival trumps self-regulation in this case: staying alert and ready to react in fightflight mode to the next assault or betrayal takes precedence over sorting out our emotions and thoughts, taking care of our body's health, considering our core values and who we aspire to be.. (quote by Julian Ford, Ph.D. ( Holly Hills, Ph.D.,

5 PTSD: Diagnostic Criteria (DSM-5) A. Exposure to actual or threatened death, serious injury, or sexual violence in various ways B. Presence of intrusion symptoms associated with the traumatic event, beginning after the event C. Persistent avoidance of stimuli associated with the traumatic event, beginning after event D. Negative alternation in cognitions and mood E. Marked alterations in arousal and reactivity F. Duration of disturbance is more than one month G. Causes clinical significant distress or impairment H. Not attributable to the physiological effects of a substance or medical condition Holly Hills, Ph.D., hills@fmhi.usf.edu

6 PTSD: Diagnostic Criteria (DSM- 5) continued Specifiers With dissociative symptoms With delayed expression Holly Hills, Ph.D.,

7 PTSD: Changes in DSM-5 Classification Changes PTSD (as well as Acute Stress Disorder) Moved from the class of anxiety disorders into a new class of "trauma and stressor-related disorders." Requires exposure to a traumatic or stressful event as a diagnostic criterion Rationale: Clinical recognition of variable expressions of distress as a result of traumatic experience. Holly Hills, Ph.D., hills@fmhi.usf.edu

8 PTSD: Changes in DSM-5 The necessary criteria of exposure to trauma links the conditions included in this class the homogeneous expression of anxiety or fear-based symptoms anhedonic and dysphoric symptoms, externalizing anger or aggressive symptoms, dissociative symptoms, or some combination of those listed differentiates the diagnoses within the class (NCPTSD) Holly Hills, Ph.D.,

9 Symptoms of Trauma and PTSD Disorders of Thought Guilt, negativity, memory difficulties, intrusive/obsessive thoughts Disorders of Emotion Wide range of affective/anxiety symptoms Disorders of Behavior Self-injury, rage, promiscuity Disorders of Personality Unstable interpersonal relationships, suicidal gestures, emptiness, paranoia Holly Hills, Ph.D.,

10 Symptoms of Posttraumatic Stress Depression Grief and Loss Isolation Interpersonal Distancing Mistrust Anxiety Over-stimulation Sleep disturbances Rejection and Betrayal Anger, Irritability, Rage Low Self-Esteem Alienation, Avoidance Guilt, Shame Psychosis Substance Abuse Holly Hills, Ph.D.,

11 Core Assumptions Regarding the Impact of Trauma and PTSD The impact of abuse is experienced throughout life The impact of abuse is felt in areas of functioning seemingly unrelated to the abuse itself Current problematic behaviors or symptoms may have originated as attempts to cope with, process, and defend against trauma Holly Hills, Ph.D.,

12 PTSD, Violence and Incarceration PTSD does not correlate with increased episodes of severe violence PTSD does not appear to correlate with increased incidence of psychiatric hospitalization PTSD may correlate with increased episodes of jail incarceration Holly Hills, Ph.D.,

13 Prevalence of PTSD Lifetime prevalence for PTSD in the United States is 8.7% of the adult population Women are at twice the risk for PTSD For at-risk populations (e.g. survivors of rape, combat and captivity, ethnically or politically motivated internment, torture or genocide), the prevalence rate is between 33% and 50% of those individuals assessed for PTSD 33-59% of women in substance abuse treatment are diagnosed with PTSD (Najavits, 2002) Holly Hills, Ph.D.,

14 Prevalence of PTSD Within most clinical and court settings, PTSD remains a diagnosis that is often considered as an afterthought, if at all Other diagnoses are utilized to explain symptoms presented PTSD may not be recognized and treated as such, and symptoms masked as a result of other, less appropriate interventions Holly Hills, Ph.D., hills@fmhi.usf.edu

15 A Framework for Working with Traumatized Individuals Trauma as a starting point for understanding presenting much of the familiar symptomology: The expectation rather than the exception Beginning with PTSD as a rule-out diagnosis Other diagnoses (including substance use disorder) may be relevant as well Holly Hills, Ph.D., hills@fmhi.usf.edu

16 Clinical Treatment with Traumatized Individuals Client Assessment Inventory of symptomology Examination of social contexts for roots of trauma and abuse: Family Community Geography Political Climate Holly Hills, Ph.D.,

17 Clinical Treatment with Traumatized Individuals Identification of Client-Specific Key Issues: Individual client experiences Family history of traumatic experiences Community history of trauma Contextual/environmental trauma Population-specific experiences of trauma Holly Hills, Ph.D.,

18 Key Elements of Successful, Trauma- Informed Services Education on the nature and extent of violence Finding relationship of other problems and disorders to the violence Creation of safe and supportive space to explore these issues Holly Hills, Ph.D.,

19 Key Elements Continued Learning specific skills to promote recovery Skill development to identify thoughts, feelings, behaviors Effective problem solving techniques Relaxation, grounding, stress reduction, etc. Holly Hills, Ph.D.,

20 Key Elements Continued Strengthening of interpersonal skills, e.g., assertiveness training, boundary setting, interpersonal support, etc. Relapse prevention Alternatives to substance abuse and other destructive behaviors Development of short-term and longterm safety plans to protect self and children in the community Holly Hills, Ph.D.,

21 Examination of Formal and Informal Policies and Procedures Trauma-informed services incorporate an awareness of trauma and abuse into all aspects of the program procedures Gender-specific services take into account the roles and elements of personal history that are unique to women This awareness can also be used to modify procedures for working with women to create alternative, trauma-sensitive procedures Trauma treatment is best accomplished in as trauma-free an environment as possible Holly Hills, Ph.D.,

22 Examining Formal and Informal Policies and Procedures (cont.) At a minimum, environments and therapeutic techniques should be evaluated for their potential to be re-traumatizing Administrators should strongly consider providing training on cultural competence and on gender and trauma issues to program staff Holly Hills, Ph.D., hills@fmhi.usf.edu

23 Trauma and Retraumatization Many routine procedures, court-ordered and voluntary MH and SA services contain coercive elements that can be perceived as dangerous and threatening Responses to these perceived threats might be to: withdraw fight back have a strong emotional outburst display worsening psychiatric symptoms experience physical health problems Holly Hills, Ph.D., hills@fmhi.usf.edu

24 Key Areas of Modification: Screening and Assessment Screening and assessment should examine the presence of: Mental and substance use disorders Histories of trauma and abuse Whether a woman has children and, if so, related needs (e.g. custody issues) Health risks (such as HIV/AIDS, STD s, Hepatitis, and other chronic medical problems) Methods should include validated structured interview or self-report methods that have been derived from and used with relevant samples Holly Hills, Ph.D., hills@fmhi.usf.edu

25 Key Areas of Modification: Screening and Assessment Screening for Trauma / PTSD All persons entering court-related / other programs should be screened for trauma Any staff member can screen for symptoms of trauma Many simple, non-proprietary screening instruments are available Positive screens should be referred for a comprehensive assessment Holly Hills, Ph.D., hills@fmhi.usf.edu

26 Key Areas of Modification: Screening and Assessment Screening for Trauma Provide safe, private environment, free from startling noises, provide adequate interpersonal distance Identify trauma-related symptoms Gather information on mental health treatment, substance abuse patterns, psychiatric medication use, etc. Holly Hills, Ph.D.,

27 Developing a Trauma-Informed Treatment Programs Administrative commitment to change Appropriate trauma screening Trauma training and education Hiring practices Review of formal policies Review of formal and informal service procedures Holly Hills, Ph.D., hills@fmhi.usf.edu

28 Incorporating Trauma-Sensitive Services into Existing Programs Prioritize awareness of trauma and abuse in all aspects of treatment and treatment environment Modify procedures for working with women and men in full range of service settings Create alternative, trauma-sensitive procedures less likely to exacerbate symptoms and more likely to promote effective behavioral management and client change Holly Hills, Ph.D.,

29 Trauma and Treatment Engagement and Outcomes Impacts interaction with figures of authority Impacts sleep patterns Can lead to self injurious behavior Impacts how rage and anger are experienced Holly Hills, Ph.D.,

30 Building on a Foundation Provide Integrated Treatment Work on Engagement and Motivation Work from a position of optimism Educate about Trauma and COD Treat at multiple levels.more treatment leads to better results, incorporate elements in all interactions Encourage accountability, expect more effort not less Focus on creating a strong therapeutic bond or alliance Holly Hills, Ph.D., hills@fmhi.usf.edu

31 Addressing Trauma in MH and SA Treatment Provide Integrated Treatment Work on Engagement and Motivation Work from a position of optimism Educate about Trauma and COD

32 Addressing Trauma in MH and SA Treatment Treat at multiple levels.more treatment leads to better results, incorporate elements in all interactions Encourage accountability, expect more effort not less Focus on creating a strong therapeutic bond or alliance

33 Stage Conceptualizations Stage One: Focuses on stress management, symptom reduction, education, building trust, improving communication, teaching coping skills, stabilization and reduction of symptoms and safety Stage Two: Exploration of memories, integration, remembrance and mourning (facing the past by exploring the impact of trauma and SA)

34 Stage Conceptualizations Stage Three: characterized by integration of self, personality, trauma experiences, long term coping and reconnection (attaining a healthy engagement with the world through work and relationships (Najavits, 2003; Herman, 1992).

35 Gender/Trauma Informed Programming Some examples of trauma-recovery models: Seeking Safety (Najavits, 2001) Trauma Recovery & Empowerment (TREM, Harris, 1998) Holly Hills, Ph.D.,

36 Seeking Safety (Lisa Najavits, 2001) Structured interventions in manual format Organized around 25 traumarelated topics Integrates trauma & substance abuse For more information: Seeking Safety: A Treatment Manual for PTSD and Substance Abuse (Guilford Press, 2002) Holly Hills, Ph.D., hills@fmhi.usf.edu

37 Seeking Safety (Najavits, 2002) Structured interventions in manual format Organized around 25 traumarelated topics

38 Seeking Safety (Najavits, 2002) Integrates trauma & substance abuse Derived primarily from Cognitive Behavioral Therapy With a focus on structured activities Problem solving in the present Education Is time-limited

39 Seeking Safety Primary Strategies In the Stage Model: Seeking Safety is considered to be a Stage One Model: Effort is focused on Stress management Symptom reduction / stabilization Education Building trust Improving communication Teaching coping skills, and Safety

40 Therapist Selection

41 Considerations in Selecting Staff No specific degree requirements per LN What has been their previous work history with regard to running group interventions? How do they respond to supervision / feedback? Are they comfortable with other colleagues observing their group?

42 Considerations in Selecting Staff What would colleagues / peers say about their ability to form therapeutic alliances? Are they on-board with following a manual? What is their opinion re adoption of innovation / application of EBPs? Consider a group try-out to determine fit

43 Key Program Elements in Early Treatment Finding relationship of other problems and disorders to the violence Creation of safe and supportive space to explore these issues Learning specific skills to promote recovery Skill development to identify thoughts, feelings, behaviors Effective problem solving techniques Relaxation, grounding, stress reduction, etc.

44 Key Program Elements Continued Strengthening of interpersonal skills, e.g., assertiveness training, boundary setting, interpersonal support, etc. Relapse prevention Alternatives to substance abuse and other destructive behaviors Development of short-term and long-term safety plans to protect self and children in the community

45 Designed for flexible use: Can be conducted in group or individual format; for women, men, or mixed-gender; using all topics or fewer topics; in a variety of settings.

46 The model also pays attention to therapist processes: The balance of praise and accountability Evaluation of countertransference (sadism, scapegoating, victimization, giving up on patients) Self-care

47 Range of Clinical Topics Covered

48 Four content areas: Cognitive Behavioral Interpersonal Case management

49 Interpersonal topics: Honesty Asking for Help Setting Boundaries in Relationships Getting Others to Support Your Recovery Healthy Relationships Community Resources

50 Cognitive topics: PTSD Taking Back Your Power Compassion When Substances Control You Creating Meaning Discovery Integrating the Split Self Recovery Thinking

51 Behavioral topics: Taking Good Care of Yourself Commitment Respecting Your Time Coping with Triggers Self-Nurturing Red and Green Flags Detaching from Emotional Pain (Grounding)

52 Case Management: Introduction Case Management Safety Life Choices Termination

53 Combination Safety Life Choices Game Termination

54 Format of Clinical Sessions

55 Session Format: Check-In: Describe coping, unsafe behaviors Quotation: Engages emotionally in content Handouts and Discussion: Relate the topic to their life (30-40min) Check-out: identify impact of session, formulate commitment

56 A report of unsafe behaviors at Check-In Focusing on Safety: Through creating a list of safe coping skills Use of a Safe Coping Sheet to review recent unsafe incidents A Safety Plan to identify stages of danger, and how to address

57 Client Selection

58 Client Selection has been applied to diverse populations was designed for men and women be inclusive as possible encourage application of coping skills very broadly use CM to engage in additional treatment

59 Client Selection Instruct to ignore terms of they don t apply Allow a try-out of treatment Allow participation at any stage of recovery Can be applied from the start of treatment

60 Measurement of Fidelity Using the Adherence Scale In training Ongoing assessment

61 Overview of the Research Evidence Continuously updated at

62 Overview of the Research Evidence (Najavits, 2010) All outcome studies evidenced positive outcomes* In the controlled trials, Seeking Safety typically outperformed the comparison condition Treatment satisfaction was high in all studies More research is needed

63 Issues in Implementation and Sustainability: Global and Specific

64 NIRN: The Implementation Problem What is known is not what is adopted to help children, families, and adults Clear pathways to implementation are not well known / understood EBPs are often not implemented with fidelity There is drift over time and with staff turnover NIRN, 2005

65 NIRN: Global Considerations There are two separate sets of issues and considerations: One involves the interventions specified by the evidence-based program or practice The other involves the implementation processes and strategies to put the intervention in place NIRN, 2005

66 Work of Implementation Changing the behavior of adult human service professionals Changing organizational structures, cultures, and climates Changing the thinking of system directors and policy makers Successful and sustainable implementation of evidence-based practices and programs always requires organizational change. NIRN, 2005

67 Implementation Facilitators Effective strategies to change adult behavior (e.g., line staff, supervisors) Effective strategies to change program operations (e.g. HR, scheduling) Reduction of systems and policy barriers Right resources at the right time Fidelity and Outcome Measures NIRN, 2005

68 Implementation Drivers STAFF EVALUATION CONSULTATION & COACHING DECISION SUPPORT DATA SYSTEMS PRESERVICE TRAINING INTEGRATED & COMPENSATORY FACILITATIVE ADMINISTRATIVE SUPPORTS RECRUITMENT AND SELECTION SYSTEMS INTERVENTIONS NIRN, 2005

69 Implementing New Knowledge Excellent experimental evidence for what does not work Dissemination of information by itself does not lead to successful implementation (research literature, mailings, promulgation of practice guidelines) Training alone, no matter how well done, does not lead to successful implementation NIRN, 2005

70 Stages of Implementation Implementation occurs in stages: Exploration Installation Initial Implementation Full Implementation Innovation Sustainability NIRN, 2005

71 Stages of Implementation Exploration Awareness, preplanning, initiation (stakeholders, leaders, champions) Community-Purveyor information exchange, mutual assessment Perceived risk, ability to manage risk Installation Structural and instrumental changes (hire/redeploy staff, cell phones, HR policies, funding and referrals, space) Resources consumed but no consumers seen (start up may add 10-20% to first year costs) NIRN, 2005

72 Stages of Implementation Initial Implementation Change practices, provide services Put components in place, change organizational structures & culture, manage change process, overcome fear & inertia Full Implementation Components integrated, fully functioning New implementation site ready to be evaluated re: consumer outcomes NIRN, 2005

73 Stages of Implementation Innovation First do it right (high fidelity) Then do it differently (evaluate changes, improvement/drift) Sustainability Starts during exploration, never stops Information and trust, good outcomes, expanding support base during all stages Ability to retain function while changing form given turnover, changing needs and context NIRN, 2005

74 Implementation and Adaptation: Seeking Safety Methods for Teaching Coping Skills Walk Through In-session exercise Role-play Identify role models Say aloud Consider obstacles Replay scenes Make a Tape

75 Implementation and Adaptation: Seeking Safety Tying content to Trauma Experience Headlines, not Details Returning Again to the Concept of Safety Controlling the flow of the group Redirecting: How do you do this? Addressing Issues of Power Respecting the Past, Addressing the Present

76 Implementation and Adaptation: Seeking Safety Suggestions for Specific Audiences Adolescents Gender issues Military / Veterans Racial / Ethnic Diversity What do you think you might do differently based on who is in the group?

77 Implementation and Adaptation: Seeking Safety Considerations in Selecting Staff No specific degree requirements per LN Must be able to recognize their limits Interested in using the manual / following the format Other helpful characteristics

78 Use of Quotations What are the words you do not yet have? What do you need to say?.there are so many silences to be broken.. Not to laugh, not to lament, not to judge, but to understand You are not responsible for being down, but you are responsible for getting up

79 Addressing Challenging Statements I can t talk to myself compassionately, I hate myself too much Substances help me deal with my PTSD These are good skills, but I will never remember to do them I don t deserve to take better care of myself I want to set a boundary with you.stop telling me to stop using I am not ready

80 For More Information Further information on Seeking Safety Manual and Model at:

81 Seeking Safety: A Treatment Manual for PTSD and Substance Abuse (Najavits, 2002) can be ordered from Guilford Press ( ) or online at

82 Web Resources National Registry of Evidence based Programs and Practices Co-occurring Center of Excellence Holly Hills, Ph.D.,

83 For More Information Trauma and Recovery by Judith Herman, MD (1992). Trauma and Substance Abuse: Causes, Consequences, and Treatment of Comorbid Disorders. Edited by Paige Ouimette and Pamela Brown (2003). Narrative approaches to working with Adult Male Survivors of Child Sexual Abuse by Kim Etherington (2000). The Post-Traumatic Stress Disorder Sourcebook by Glenn R. Schiraldi (2000). Effective Treatments for PTSD by Foa, Keane, and Friedman (2000).