Thursday, February 21, 2008
Dual Diagnosis PTSD and Substance Abuse Treatments and Issues
Najavits et al (1997), identify treatment as crucial, "not only because of the prevalence and severity of co-occurring PTSD and substance abuse, but also because treatments that are typically used for PTSD or substance abuse alone may be insufficient for their combination". Problems of using treatments suited to one or other of the disorders with patients that have dial diagnosis are numerous. One problem is that specific treatments for PTSD or substance abuse issues may have negative effects on patients who have both disorders; two researchers (Abueg and Fairbank, 1991; Solomon, Gerrity, and Muff, 1992) suggested that "behavioral exposure and flooding models, which are quite successful for PTSD-alone, are…ill-advised for patients with substance abuse because their emotional intensity might too easily trigger a substance abuse relapse" (Najavits et al, 1997). Other issues with established treatment methods are discussed: Alcoholics Anonymous (AA) and other twelve-step self-help groups are identified as potentially problematic for dual-diagnosis patients because of elements such as "the presence of males at most meetings, the philosophy of not focusing on the past, and [the idea of surrendering to a higher power as part of the AA philosophy]" (Najavits et al, 1997); substance abuse treatments that are heavily confrontational in approach may re-evoke traumatic experiences (Najavits et al, 1997; Nace, Davis, and Gaspari, 1991). Issues with clients I have observed with my own clients include an inability to sit in meetings due to high activation, relational and trust problems with other group members and their sponsor, lack of understanding within the fellowship regarding PTSD, some who are on medications are shamed for this because they are "not really clean", although that seems to be shifting some. As a result of some of these conflicts, the client may feel further shame and may then turn to substances to cope.
No empirically validated standard of care exists for PTSD-alone although Curtois, Chu, and Briere have each developed models for treatment. In her own review of treatment practices, Curtois (1999) also attempts to establish the history of PTSD treatment and current standards in Chapter Nine of her treatment principles and guidelines for dealing with PTSD sufferers who were also victims of sexual assault.
The model of integrated treatment, methods for treating both the PTSD and substance abuse together in dual-diagnosis patients has much evidence to support its efficiency and, at the very least, it appears valid that dual diagnosis PTSD and substance abuse is not the same as either PTSD-alone or substance abuse-alone. As to what constitutes the most effective treatment for women with PTSD and substance abuse, only one study (Najavits et al, 1997) has addressed the issue with any real effort and only one publication (Najavits, 2002) covers the subject in any depth. In one journal, Najavits specifically explores the issue of counselor training. The effort, however, was in a very limited context. The article "Training Clinicians in the Seeking Safety Treatment Protocol for Traumatic Stress Disorder and Substance Abuse" (Najavits, 2000), clearly focuses on the specific treatment procedures outlined by Najavits in her own publication. She indicates that research on substance abuse treatment over the past decade has confirmed that clinicians differing widely in their impact on outcomes. The differences in outcomes are identified as severe; studies such as Christensen and Jacobson (1994), Najavits and Weiss (1994), Najavits, Crits-Christoph, and Dierberger (2000) all identify the best-case role of the clinician as "life-saving" versus the worst case scenario being a "damaging" role (Najavits, 2000, p. 3)
The findings of these two research efforts revealed a significant reduction in PTSD and substance abuse symptoms after a 24-session cognitive-behavioral group therapy specifically designed for a population of women with dual-diagnosis PTSD and substance abuse issues (Najavits et al, 1997).
Najavits (1997) and other studies such as Gatz et al (2005) paved the way for many in terms of grants and funding to implement programs in substance abuse treatment centers with a PTSD focus. However, there is not an immediate or large shift in treatment for substance abuse treatment centers.
No empirically validated standard of care exists for PTSD-alone although Curtois, Chu, and Briere have each developed models for treatment. In her own review of treatment practices, Curtois (1999) also attempts to establish the history of PTSD treatment and current standards in Chapter Nine of her treatment principles and guidelines for dealing with PTSD sufferers who were also victims of sexual assault.
The model of integrated treatment, methods for treating both the PTSD and substance abuse together in dual-diagnosis patients has much evidence to support its efficiency and, at the very least, it appears valid that dual diagnosis PTSD and substance abuse is not the same as either PTSD-alone or substance abuse-alone. As to what constitutes the most effective treatment for women with PTSD and substance abuse, only one study (Najavits et al, 1997) has addressed the issue with any real effort and only one publication (Najavits, 2002) covers the subject in any depth. In one journal, Najavits specifically explores the issue of counselor training. The effort, however, was in a very limited context. The article "Training Clinicians in the Seeking Safety Treatment Protocol for Traumatic Stress Disorder and Substance Abuse" (Najavits, 2000), clearly focuses on the specific treatment procedures outlined by Najavits in her own publication. She indicates that research on substance abuse treatment over the past decade has confirmed that clinicians differing widely in their impact on outcomes. The differences in outcomes are identified as severe; studies such as Christensen and Jacobson (1994), Najavits and Weiss (1994), Najavits, Crits-Christoph, and Dierberger (2000) all identify the best-case role of the clinician as "life-saving" versus the worst case scenario being a "damaging" role (Najavits, 2000, p. 3)
The findings of these two research efforts revealed a significant reduction in PTSD and substance abuse symptoms after a 24-session cognitive-behavioral group therapy specifically designed for a population of women with dual-diagnosis PTSD and substance abuse issues (Najavits et al, 1997).
Najavits (1997) and other studies such as Gatz et al (2005) paved the way for many in terms of grants and funding to implement programs in substance abuse treatment centers with a PTSD focus. However, there is not an immediate or large shift in treatment for substance abuse treatment centers.
Labels: Dual-Diagnosis-Treatment, Post-Traumatic-Stress-Disorder, Substance-Abuse
