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For substance abuse patients, and therapy in general, the effectiveness of treatment is determined as much by the therapist as by any theoretical orientation or patient characteristics. With this dual-diagnosis population, it is often difficult to provide effective therapy. Therapist processes emphasized in Seeking Safety include compassion for patients' experiences; using coping skills; giving patients control whenever possible to counteract the loss of control inherent in trauma and substance abuse; promoting honesty in contrast to the secrecy, denial and lying that may occur in trauma and substance abuse; meeting patients more than halfway doing whatever is possible within professional bounds to help patients get better; and obtaining feedback about how patients view the treatment. The more severe the patient, the more likely that negative processes may impede the treatment. This includes harsh confrontation, sadism, difficulty holding patients accountable due to misguided sympathy, becoming victim to the patient's abusiveness, power struggles, and in group treatment, allowing a patient to be made a scapegoat.

What the evidence does suggest, however, is that it is first necessary for clinicians and researchers in the field to begin to address the severity and unique profile presented by dual-diagnosis PTSD and substance abuse victims, particularly women.

Labels: Dual-Diagnosis-Treatment, Post-Traumatic-Stress-Disorder, Substance-Abuse

A third study of a hundred inner-city outpatient women compared Seeking Safety with relapse prevention treatment (RPT), both in individual format, with a treatment-as-usual (TAU) control condition in a randomized controlled trial (Hien, Cohen, Litt, Miele and Capstick). At the end of treatment, patients in both Seeking Safety and RPT had significant reductions in substance use frequency and intensity, PTSD symptoms, and psychiatric symptom severity, whereas subjects in the TAU comparison group did not show any significant changes. Improvements in PTSD severity were sustained at the six-month follow-up point but not at nine months, for participants in Seeking Safety and RPT. Although statistically significant improvements in substance use and psychiatric severity were not maintained for Seeking Safety or RPT at the six-month follow-up, trends in the direction of lower substance use and psychiatric severity were found.
Finally, a fourth study evaluated a combination of Seeking Safety and exposure therapy for PTSD in a sample of five men (Najavits, Weiss, Shaw, and Muenz). Significant improvements were found in drug use, family and social functioning, trauma symptoms, anxiety, dissociation, sexuality, hostility, overall functioning, meaningfulness, and feelings and thoughts related to safety. Treatment attendance, satisfaction and alliance were very high.

Najavits (2000) contends that Seeking Safety is designed to treat PTSD and substance abuse at the same time. An integrated model is recommended by experts as more likely to succeed, more sensitive to patient needs and more cost-effective than sequential treatment of the disorders. It also is preferred by patients. Yet, many treatment systems for substance abuse and mental health remain separate, leaving patients to integrate treatment themselves. In correctional settings, adding Seeking Safety treatment to existing programming appeared to work well.

It is important to note that integration in Seeking Safety means attention to both disorders in the present. It does not mean asking patients to discuss their pasts in detail. Despite the known efficacy of trauma processing for PTSD, such work may not be safe for substance abusers until they have achieved a period of stable abstinence and functionality. Correctional settings, in particular, may be unsafe, as inmates may be destabilized by such treatment. In Seeking Safety, integrated treatment means helping patients understand the two disorders and why they so frequently co-occur; teaching safe coping skills that apply to both; exploring the relationship between the two disorders in the present, such as using a substance to cope with flashbacks; and helping patients understand that healing from each disorder requires attention to both.

For example, the topic "honesty" combats denial, lying and the "false self." "Commitment" is the opposite of irresponsibility and impulsivity. "Taking good care of yourself" is a solution for the bodily self-neglect of PTSD and substance abuse. The language throughout emphasizes values such as respect, care, integration and healing. By aiming for what can be, the hope is that patients can summon the motivation for the hard work of recovery from both disorders. (Najavits, 2000)

While originally designed as a cognitive-behavioral intervention, the treatment was expanded to include equally strong attention to interpersonal and case management issues. Interpersonal topics now comprise one-third of the sessions, and case management begins in the first session and is addressed at every subsequent session throughout treatment. The interpersonal domain is an area of special need because PTSD most commonly arises from traumas inflicted by others, both for women and men. Interpersonal issues include when to trust others and how to avoid re-enactments of abusive power, both as victims and perpetrators. Similarly, substance abuse often is initiated and encouraged in negative relationships. The case management component of the treatment helps patients obtain help with problems such as housing, job counseling, HIV testing, domestic violence and child care.

Labels: Dual-Diagnosis-Treatment, Post-Traumatic-Stress-Disorder, Substance-Abuse

Stephanie Covington has created a trauma specific model for women as well in 2003. In the introduction to her program, Covington (2003) discusses the integrated treatment approach focusing on women. "The connection between addiction and trauma for women is intricate and not easily disentangled" (p. 16). She goes on to discuss that the treatment provider cannot assume, when reviewing a patient with both addiction and trauma, that one is a primary problem and the other a secondary one. "Nor is it always beneficial to delay working on trauma symptoms until the client as been abstinent for a minimum time" (Covington, 2003, p. 16).

Women exposed to trauma and addicted to alcohol or another drug are considered to be at higher risk of mental disorder (Covington, 2003, p. 16). Studies, including those by Najavits, Weiss, and Shaw (1997) that indicate that comorbid mental disorders, medical problems, psychological problems, inpatient admissions, interpersonal problems; lower levels of functioning, compliance with aftercare, and motivation for treatment; and other significant life problems are more common among those with PTSD and substance abuse compared to among those that have one or other of the problems.

Co-occurring disorders are complex and the historical division in the fields of mental health and substance abuse typically result in contradictory treatments (Covington, 2003, p. 16).

Her model calls for a self-guided, quasi-self-help approach to healing dual-diagnosis PTSD and substance abuse. For example, the outline for one session focuses around asking the client to think of "recent incidents" (p. 191) of trauma, "substance use, self-harm, or other recent acting out behaviors". The purpose of the exercise is to put the patient in touch with their "red-flags", the triggers of their self-harm behavior.

Long-term reviews of treatment courses have yet to be conducted and a great deal more information must be assembled before it is possible to draw sustained conclusions about the methods of treatment that have a high degree of success for dual-diagnosis patients. There are a number of reviews of Seeking Safety, however. To date, four studies have evaluated Seeking Safety, the treatment program developed by Lisa Najavits; one of the four studies was conducted in a correctional setting. In all the studies, the patients had PTSD and substance use disorder. The first two studies evaluated groups that met twice a week for three months. The first study was a pilot, with the treatment in group format (Najavits, L.M. et al. 1998). Of twenty-seven outpatient women enrolled, seventeen (63%) completed the minimum six sessions. Results for these seventeen women showed an average attendance rate of 67% of sessions, as well as significant improvements in substance use, trauma-related symptoms, suicidal thoughts and risk, social adjustment, family functioning, problem-solving, depression, cognitions about substance use and didactic knowledge related to treatment.

The second study evaluated Seeking Safety in a correctional setting (Zlotnick, Najavits, and Rohsenow). Seventeen women participated in the trial, which used a group version of the treatment. The attendance rate was 83% of sessions and measures of client satisfaction were high. Of the seventeen women, nine (53%) no longer met criteria for PTSD by the end of the three-month treatment period; at a follow-up three months later, 46% still no longer met criteria for PTSD. Substance use could not be assessed while the women were in the prison's controlled environment, but a follow-up six weeks after release from prison indicated that 70% did not meet criteria for substance use disorder. The recidivism rate was 39% at a three-month follow-up, which is typical of this population. A study is under way to evaluate whether providing additional Seeking Safety sessions after release from prison might be beneficial.

Labels: Dual-Diagnosis-Treatment, Post-Traumatic-Stress-Disorder, Substance-Abuse

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.

Labels: Dual-Diagnosis-Treatment, Post-Traumatic-Stress-Disorder, Substance-Abuse

Although early research on PTSD and substance abuse focused almost exclusively on male combat veterans whose substance abuse was connected to war trauma (Keane and Wolfe, 1990), research has expanded its focus to now include review of the clinical profile of women with PTSD and substance abuse issues (Najavits et al, 1997). Evidence indicates that women typically have different profiles from men (Najavits et al, 1997).

The combination of PTSD and substance abuse is more common among women than it is among men (Najavits et al, 1997). Two studies are cited by Najavits et al (1997) for having compared women and men with dual diagnosis PTSD and substance abuse. The findings indicated that women have more than two to nearly four times the rate of PTSD, with 43% of women versus 12% of men (Brown, Recupero, and Stout, 1995), and 30% of women versus 15% of men (Najavits et al, 1995) reported by the two studies respectively.

Other interesting findings presented by Najavits et al (1997) that warrant review here, were the range of life problems associated with women with dual diagnosis PTSD and substance abuse. Findings from several studies found that dual diagnosis PTSD and substance abuse victims have higher rates of a whole range of issues, including mood and anxiety disorders (Najavits et al, 1995; Brady et al, 1994; Kofoed et al, 1993), medical problems (Najavits et al, 1995), psychological symptoms (Najavits et al, 1995), inpatient admissions (Brown et al, 1995), and interpersonal problems (Najavits et al, 1995). They also demonstrated lower global level of functioning (Najavits et al, 1995), compliance with aftercare (Brady et al, 1994), and motivation for treatment (Najavits et al, 1995). Additionally, women with PTSD and substance abuse issues also report a range of co-occurring life problems such as homelessness (Smith, North, and Spitznagel, 1993; Paone, Chavkin, Willets, et al, 1992), loss of child custody (Fullilove, Kinscherff, and Fenton, 1992), maltreatment of their children (Famularo et al , 1992), and instance of battered woman syndrome (Levit, 1991).

According to the National Institute for Drug Abuse [NIDA] (2000), while men are more likely to have the opportunity to use drugs, men and women are equally likely to develop an addiction. Women and men do, however, differ in their vulnerability. While men are more likely to abuse marijuana and alcohol, women are more likely to become addicted or dependent on depressants and sedatives. Men and women are equally likely to become addicted to or dependent on cocaine, heroin, hallucinogens, tobacco, and inhalants. Women are more likely to look to depress sleeplessness and anxiety with sedatives.

Of course, women are also more likely to be exposed to certain kinds of trauma (NIDA, 2000) and are at greater risk of revictimization in the context of substance abuse combined with PTSD.

Labels: Dual-Diagnosis-Treatment, Post-Traumatic-Stress-Disorder

Najavits, Weiss, and Shaw (1997) specifically discuss the relationship between PTSD and substance abuse, identifying that "the syndromes appear to be strongly linked. For example, the presence of either disorder alone can increase the risk of developing the other disorder." Najavits et al (1997) also supports the findings that he disorders consistently co-occur across various types of traumas and substances (Keane and Wolfe, 1990; Kofeod, Friedman, and Peck, 1993).

Najavits (2002) also discusses many of the key features of dual-diagnosis PTSD and substance abuse. Most people with PTSD and substance abuse are vulnerable to repeat trauma (Fullilove et al, 1993; Herman, 1992). The risk is found to be greater with dual-diagnosis patients than with those who only have substance abuse issues (Dansky, Brady, and Saladin, 1998). PTSD and substance abuse have also consistently been found to co-occur, regardless of the nature of the trauma or the type of substance use (Keane and Wolfe, 1990; Kofoed et al, 1993).

In Najavits et al (1998), the severity of addiction is compared to trauma and PTSD. The findings of this study demonstrated that a high rate of co-occurring PTSD in patients with substance use disorder (SUD). One study found that 59% of inner-city female drug users had a history of PTSD (Fullilove et al, 1993). Fifty-eight percent of male substance abuse inpatient veterans (Triffleman, 1993), 25% of inpatients in substance abuse treatment (Brown et al, 1995), and 20.5% of cocaine-dependent outpatients (Najavits et a, 1995; Rounsaville et al, 1982; Yandow, 1989). The conclusion drawn by Najavits et al (1998) and these other studies is that the association between PTSD and SUD is definitely clinically significant, "not just because of its frequency but because of the increased treatment difficulties presented by [dual-diagnosis patients]" (p. 3).

Evidence supports that women are increasingly susceptible to PTSD. A study of the link between substance abuse and post traumatic stress disorder undertaken by Najavits et al (1997) also revealed the particularly high rates of dual diagnosis PTSD and substance abuse in women; rates were reported to be between 30% and 59%. It is important to note that none of these articles take complex PTSD into account, thus, if those suffering multiple traumas presenting with the Complex PTSD were included, it is estimated that the statistics would be much higher for women.

The study also found strong links between PTSD diagnosis and histories of repetitive childhood physical or sexual assault among the women featured in the study (Najavits et al, 1997). Instances of dual diagnosis PTSD and substance abuse are two to three times lower among men.

Among women with substance abuse, studies have found frequent histories of childhood physical and sexual assault; the rates range from 32% to 66%: sexual assault, 66% (Miller, Downs, and Testa, 1993); sexual assault and physical assault (Fullilove, Fullilove, Smith, et al, 1993); sexual assault (Grice, Brady, Dustan, et al, 1995); physical or sexual assault (Brady, Killeen, Saladin, et al, 1994); sexual assault and physical assault (Najavits, Gastfriend, Barber, et al, 1995).

Labels: Dual-Diagnosis-Treatment, Post-Traumatic-Stress-Disorder

Dual-diagnosis PTSD and substance abuse has a complex history and position within the field of psychiatry and the context of treatments for mental disorders.

One of perhaps the most relevant studies on dual-diagnosis published by Najavits and Weiss (1999), assessing the clinical characteristics of twenty-eight women with dual diagnosis PTSD and substance abuse compared to the characteristics of twenty-nine women who had only PTSD. The findings demonstrated that the twenty-eight women with dual diagnosis PTSD and substance abuse consistently had "a more severe clinical profile, including worse life conditions (e.g. physical appearance, opportunities in life) both as children and as adults; greater criminal behavior; a higher number of lifetime suicide attempts; a greater number having a sibling with a drug problem; and fewer outpatient psychiatric treatments" (Najavits and Weiss, 1999). The two groups did not differ in the number or type of lifetime traumas, PTSD onset or severity, family history of substance use; coping styles, functioning level, psychiatric symptoms, or sociodemographic characteristics (Najavits and Weiss, 1999).

The findings of this study and a number of other similar studies strongly suggest that severe PTSD leads to substance abuse, PTSD-sufferers with "severe clinical profiles" are at high risk for substance abuse issues, likely brought on as a means of coping with symptoms and issues related to PTSD (Najavits and Weiss, 1999; Back, Sonne, Killeen, Danksy, and Brady, 2003; Mills, Lynskey, Teesson Ross, and Darke, 2005). Najavits et al. (1997) also points out that substance abuse itself, can put a client in situations that are high risk for trauma experiences. Therefore, the substance abuse can facilitate later trauma and PTSD. An example of this may be a woman who has a substance abuse problem, who is then raped after a night of drinking in a bar.

Mills et al (2005), explored the links between post-traumatic stress disorder among people with heroin dependence, documenting the "high rates of psychiatric comorbidity among [heroine addicts], most commonly mood disorders, anxiety disorder, and anti-social personality disorder." Links between these psychiatric conditions and substance abuse have also been identified by other researchers (see Brooner et al, 1997; Darke and Ross, 1997; Darke et al, 1994; Krausz et al, 1998) but only a few studies are identified as having explored the link between PTSD and heroine dependency (Clark et al, 2001; Hien et al, 2000; Milby et al, 1996; Villagomez et al, 1995).

The study undertaken by Mills et al (2005) demonstrated trauma exposure affecting 92% of the study participants, with lifetime PTSD affecting 41% of the study participants. The study also found that PTSD was more common among those in treatment, affecting 52% of those in residential rehabilitation, 42% in maintenance therapies, and 37% detoxification. The study also found that although men and women are both affected by trauma (93% of men and 89% of women reported exposure to traumatic events) women were more likely to develop longtime PTSD. Interestingly, approximately 72% of individuals in methadone maintenance treatment have been exposed to trauma (Clark et al, 2001). Between 14% and 29% have been diagnosed with lifetime PTSD, and 19% and 31% have been diagnosed with current PTSD (Clark et al, 2001; Hien et al, 2000; Milby et al, 1996; Villagomez et al, 1995), although the results of these studies offer only a limited view of the link between heroin use and PTSD outside of methadone maintenance treatment programs in the US (Mills et al, 2005).

Labels: Dual-Diagnosis-Treatment, Post-Traumatic-Stress-Disorder, Substance-Abuse