From: Chapter 16, Treating Problem Substance Use and Posttraumatic Stress Disorder Concurrently, in Highs & Lows: Canadian Perspectives on Women and Substance Use (© CAMH 2007)
Several newer treatment models have been developed, each with a distinct approach to addressing the combination of PTSD and problem substance use. This section describes five such models that illustrate the current approach to integrating PTSD and substance use treatment. These models are currently used, either in their full form or somewhat modified, by various substance use and violence services in locations across Canada.
Seeking Safety is a model for the treatment of concurrent trauma and substance-related problems developed by Lisa Najavits at Harvard Medical School. Its goal is to teach clients to understand and “own” both substance use and PTSD and their interrelationship, and to decrease the frequency with which each problem triggers the other. Seeking Safety combines psychoeducation, cognitive-behavioural therapy, interpersonal therapy and case management. The treatment is practical, solution focused and structured, and includes client handouts and therapist guidelines on 25 topics. The core concepts include:
- staying safe
- respecting oneself
- using coping skills
- making the present and future better than the past
- learning trust
- getting help.
The treatment also stresses providing continuing encouragement to clients to never give up.
The program has been studied for its impact on women in prison (Zlotnick et al., 2003), women in urban settings with low incomes (Hien et al., 2004), women receiving outpatient care (Najavits et al., 1998), adolescent girls (Najavits et al., 2006) and both men and women veterans (Cook et al., 2006).
Dialectical Behaviour Therapy
Dialectical behaviour therapy (DBT) was developed by Marsha Linehan in 1987 to treat borderline personality disorder, and then expanded to include specific strategies to address the needs of people with concurrent substance use and eating disorders, suicidal adolescents, people incarcerated in correctional settings, older people with depression and adults with attention-deficit/hyperactivity disorders (for a review, see Robins & Chapman, 2004). Borderline personality overlaps considerably with experience of trauma (Hermann et al., 1989; Zanarini et al., 1989), to the extent that some experts have proposed that borderline personality disorder may be a trauma-based disorder stemming from early childhood abuse (Gunderson, 1993; McLean & Gallop, 2003).
The DBT model involves four primary sets of skill-based modules, which emphasize dialectically both the need for a person to accept his or her current difficulties and the need to change. The modules are taught in a group setting and reinforced by individual therapy. The tools include:
- the concept of mindfulness (drawn from Zen traditions)
- interpersonal skills
- distress-tolerance skills
- emotion-regulation skills. DBT is a client-centred approach: the client is consulted on his or her goals and has the freedom to choose within the therapy.
More recently, Marsha Linehan and Amy Wagner have specifically focused on the treatment of trauma through dialectical behaviour therapy for “those individuals who have achieved behavioral control yet continue to exhibit significant problems with emotion regulation and experiencing,” and who, in particular, experience significant self-invalidation. In this intervention they propose the targeting of intrusive symptoms, avoidance of emotions, avoidance of situation and experiences, emotion dysregulation and self-invalidation (Linehan & Wagner, 2006).
The Triad Model
Specific models featuring integrated approaches to support for trauma, substance use and mental health problems were developed under the auspices of the Women with Co-occurring Disorders and Violence Study of the U.S. Government’s Substance Abuse and Mental Health Services Administration (SAMHSA). One of the study’s nine study sites, the Triad Women’s Project in rural Florida, developed a manualized approach to integrated treatment, including a case management team, a peer support group and group therapy offered over 16 weeks, all designed to promote survival, recovery and empowerment (Clark et al., 2004). The Triad model is built on four phases of learning:
- Phase I explores the connections between healing the effects of trauma and recovering mental health.
- Phase II addresses interpersonal effectiveness and skills.
- Phase III focuses on emotional regulation, specifically self-soothing and dealing with cravings and urges.
- Phase IV addresses distress tolerance—the skills of dealing with mental health issues and the traumatic effects of violence.
There is a focus on continuity of care (peer group support continues after the formal group work is completed) and on integrated parenting interventions (most women in the study cohort had children). The Triad model is yet to be rigorously studied following the initial SAMHSA study, but it shows promise in its tailoring of treatment to the specific needs of women, particularly those facing domestic violence.
The Trauma Recovery and Empowerment Model
The Trauma Recovery and Empowerment Model (TREM) was developed by Maxine Harris, Roger Fallot and their colleagues at Community Connections in the Washington, DC, area (Harris & Fallot, 2002; 2004; Harris, 1998), and is part of the multi-site SAMHSA study. It is a peer-informed model that emphasizes the key principles of empowerment and of validating women’s experiences with a multicultural perspective (Harris & Fallot, 2004).
The TREM approach to trauma recovery is based on four core assumptions:
- that some current dysfunctional behaviours and/or symptoms may have originated as legitimate coping responses to trauma
- that women who experienced repeated trauma in childhood were deprived of the opportunity to develop certain skills necessary for adult coping
- that traumatic events, specifically sexual and physical abuse, sever core connections to family, community and ultimately the self (including disrupting awareness of one’s own feelings, thoughts and behaviours)
- that women who have been abused repeatedly feel powerless and unable to advocate for themselves (Harris & Fallott, 2002).
TREM employs cognitive restructuring, skills training, psychoeducation and peer support. It has a three-part focus—on empowerment, trauma education and skills building—and includes 33 recovery topics, including the interconnection of trauma with substance use problems, which are covered over nine months in weekly 75-minute meetings. trem groups typically consist of eight to 10 women with two to three coleaders. The model emphasizes skill development in the areas of:
- emotional modulation
- relational mutuality (healthy relationships)
- accurate labelling of self and others
- sense of agency and initiative-taking.
There are also components on consistent problem solving, reliable parenting, developing a sense of purpose and meaning, and improving judgment and decision making. TREM is gender-specific, asserting that gender roles and expectations significantly affect both the experience and the attributions, or meaning, of the trauma. Like the Triad model, the TREM model has not been extensively studied beyond the SAMHSA Women with Co-occurring Disorders and Violence Study.
The Addictions and Trauma Recovery Integration Model
The Addictions and Trauma Recovery Integration Model (ATRIUM) was developed by Dusty Miller and Laurie Guidry and used with women in rural areas of Massachusetts, again in the context of the SAMHSA Women with Co-occurring Disorders and Violence Study (Miller, 2002). It is designed to assess and intervene in the somatic, spiritual and cognitive aspects of experience of trauma, using a cognitive-behavioural and relational approach.
The four basic principles of recovery in the ATRIUM model are:
- recognizing and reinforcing resilience
- achieving abstinence from addiction
- recognizing and healing the wounds of non-protection
- creating a sacred connection to the world coupled with a sense of social purpose.
The model is organized into 12 sessions, each including a didactic component, a process section, an experiential component and a homework assignment. The ATRIUM protocol is organized into sections representing a graded exposure to the painful layering of the participant’s trauma experience. It includes information on anxiety, sexuality, self-harm, depression, anger, physical health problems, sleep difficulties and spiritual disconnection. Unlike the other approaches discussed here, ATRIUM is informed by the 12-step model. It, too, has yet to be extensively studied with respect to effectiveness.
In Treating Problem Substance Use and Posttraumatic Stress Disorder Concurrently