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
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
 12–bed 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
Prevalence of PTSD in CD
 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)
 Master’s thesis data collected at Georgianwood
found that 60% of our clients met DSM-IV criteria
for PTSD
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)
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.
Screening for PTSD
 All clients should be routinely screened for PTSD.
 There are many screening/assessment tools
 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).
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.”
PTSD Screeners cont’d
 Then determine whether they have
experienced PTSD symptoms for at least 1
 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)
Suggestions for Effective Screening
 We do trauma screening within 2 days of
 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
Suggestions for Effective Screening
 Score the tool ASAP so can give feedback to the
 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.
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.
Seeking Safety cont’d
 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.
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.
Seeking Safety Topics Include:
*Asking for help
*Setting boundaries
Healing from anger
Coping with triggers
Recovery thinking
Healthy relationships
*Integrating the split self
Community resources
13. *Honesty
14. *Taking good care of yourself
15. Getting others to support your
*Taking back your power
*Red & green flags
Creating meaning
When substances control you
Respecting your time
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 doesn’t work, try something else
 Never, never, never, never, never give up!
Seeking Safety Session Format
Handouts on the topic– discussion, practice skills
Commitment (homework)
Check-out / feedback
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?
Quotation (5 minutes)
 Helps to engage the clients emotionally in the
 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?”
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 client’s life
 Many topics have suggestions for behavioural skills
practice (i.e., role plays)
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
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
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
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)
Check-out (10 mins)
 To reinforce the clients’ progress and give therapist
 How was the session today?
 What did you like?
 What didn’t you like?
 What is your new commitment?
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).
Outcome Research: Seeking Safety
 In 4 out of 5 controlled trials, Seeking Safety
outperformed the comparison condition (treatment as
 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.
Outcome Research: Seeking Safety
 Treatment satisfaction was high in all studies.
 More research is needed:
 What are the key components to treatment
 How many sessions are needed for optimal
 Does clinician training impact outcomes?
 How does Seeking Safety do compared to other
manualized treatments?
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
 Screen for PTSD pre and post program – have their
symptoms decreased as a result of the program?
Preliminary Data: Georgianwood
 N = 57 all screening positive for PTSD on
 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.
Example: “Compassion”
 Quotation:
“You yourself, as much as anybody in the
entire universe, deserve your love and
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 Magazine’s 100
Most Influential People in the World in 2010, to
acknowledge how effective exposure therapy has
been in treating PTSD.
Exposure Therapy cont’d
 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 wasn’t 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).
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
 2. Imaginal – client is exposed to memories of the
traumatic event.
Prolonged Exposure cont’d
 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
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
 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).
Summary cont’d
 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!
Thank you!
[email protected][email protected]
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