TREATING OFFENDERS WITH SUBSTANCE ABUSE AND POSTTRAUMATIC STRESS DISORDER Douglas L. Delahanty Alec Boros Kent State University Oriana House

Treating offenders with substance Abuse and posttraumatic stress

disorder

Douglas L. Delahanty Alec Boros

Kent State University Oriana House

Overview

Introduction to PTSD Comorbidity of PTSD/SUD Intervention: Prolonged Exposure Using PE with SUD Clients The KSU-Oriana House Studies on

PTSD Challenges of treating offenders in

community corrections Alternatives for treatment in

Community Corrections

Introduction to PTSD

DSM-IV Diagnostic Criteria for PTSD

Exposure to a traumatic event in which the person: experienced, witnessed, or was confronted by death or serious

injury to self or others AND responded with intense fear, helplessness, or horror

Symptoms appear in 3 symptom clusters: re-experiencing,

avoidance/numbing, hyperarousal last for > 1 month cause clinically significant distress or impairment in functioning

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. 1994.


Reexperiencing Persistent re-experiencing of 1 of the following:

recurrent distressing recollections of event recurrent distressing dreams of event acting or feeling event was recurring psychological distress at cues resembling event physiological reactivity to cues resembling event



Avoidance and Numbing Avoidance of stimuli and numbing of general

responsiveness indicated by 3 of the following: avoid thoughts, feelings, or conversations avoid activities, places, or people inability to recall part of trauma interest in activities estrangement from others restricted range of affect sense of foreshortened future



Hyperarousal Persistent symptoms of increased arousal 2:

difficulty sleeping irritability or outbursts of anger difficulty concentrating hypervigilance exaggerated startle response


DSM 5 PTSD Criteria

As of May 2013, the DSM 5 has contained slightly different PTSD diagnostic criteria

Symptoms are mostly the same The 3 clusters of DSM-IV symptoms will be divided into 4

clusters in DSM-5: intrusion symptoms, avoidance symptoms, arousal/reactivity symptoms and negative mood and cognitions.

Criterion A2 (requiring fear, helplessness or horror happen right after the trauma) will be removed.

Based on the proposed DSM-5 criteria, the prevalence of PTSD will be similar to what it is currently in DSM-IV.

Incidence of PTSD

69% of civilians report experiencing a traumatic event (Norris, 1992; Resnick et al., 1993)

Affects more than 10 million American children or adults (National Center for PTSD, 2001)

Lifetime prevalence in the U.S. is 6.8%, making it the third most common anxiety disorder (Kessler et al., 2005)

Females are at approximately 2x greater risk than males

Kessler R et al. J Clin Psychiatry. 2000;61(Suppl 5):4-14. Kessler R et al. Arch Gen Psychiatry. 1995;52:1048-1060.

Prevalence of Trauma and Probability of PTSD

Probability of PTSD

010203040506070

Witness Accident Threat w/Weapon

PhysicalAttack

Molestation Combat Rape

%

Prevalence of Trauma

0

10

20

30

40

%

MaleFemale

Witness Accident Threat w/Weapon

PhysicalAttack

Molestation Combat Rape

Consequences of PTSD

Negative impact on affect regulation, attention, cognition, interpersonal relationships and neuroendocrinology (Hart et al.,1995; Maughan & Cicchetti, 2002; Putnam et al., 1997)

Increased risk for: Physical health problems (Pacella, Hruska, &

Delahanty, 2013)

Unemployment (Smith, Schnurr, Rosenheck, 2005)

Relationship problems (Riggs, Byrne, Weathers, & Litz, 1998)

Suicide (Marshall et al., 2001)

Psychiatric Comorbidity in PTSD

Psychiatric Comorbidity in PTSD (Pietrzak, Goldstein, Southwick, & Grant, 2011)

Agoraphobia

0

10

20

30

40

50

60 Males

Females

Co

mo

rbid

ity

(%)

Psychiatric Comorbidity in PTSD

Major Depressive

Episode

GAD Panic Disorder

Social Anxiety Disorder

AlcoholAbuse/

Dependence

DrugAbuse/

Dependence

Kessler R et al. Arch Gen Psychiatry. 1995; 52:1048-1060.

46.4% of people with PTSD meet criteria for one or more SUDs (Pietrzak, Goldstein, Southwick, & Grant, 2011)

Comorbidity rates of substance abuse/dependence in PTSD are high (up to 43%) (Breslau, Davis, & Schultz, 2003; Deering, Glover, Ready, Edelman, & Alarcon, 1996; Friedman, 1991; Friedman & Yehuda, 1995; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995).

PTSD rates range from 30-50% in substance abusers (Dansky, Roitzsch, Brady, & Saladin, 1997; Mills, Lynskey, Teesson, Ross, & Darke, 2005)

253 Australian detox inpatients (Dore et al., 2012) 80% experienced > 1 trauma 45% screened for PTSD

SUD-PTSD Comorbidity

PTSD-SUD is associated with significant impairment

More severe alcohol problems (McFall, MacKay, & Donovan, 1992)

Greater utilization of addiction treatment services (Brown, Stout, & Mueller, 1999) Higher relapse rates, poorer treatment outcomes (Jacobsen et al., 2001; Read et al.,

2004)

More severe PTSD symptoms (Hien, Campbell, Ruglass, Hu, & Killeen, 2011; Saladin, Brady, Dansky, & Kilpatrick, 1995)

PTSD-SUD is associated with significant impairment, cont’d

Less successful PTSD treatment (Perconte & Giger, 1991)

Greater medical, social and employment costs than either disorder alone (Neuman et al., 2012; Brady et al., 2004; Brown et al., 1994)

Psychiatric comorbidity in SUD patients can serve as a barrier to successful SUD engagement and treatment at every stage of the process

Theories of Comorbidity: SUD and PTSD

The self-medication hypothesisThe high risk hypothesisThe susceptibility hypothesisThe substance-induced anxiety

enhancement hypothesis

The shared vulnerability hypothesis

Stewart & Conrod, 2008; Hruska and Delahanty, in press

Comorbidity Theory: Self-Medication Hypothesis

PTSD temporally precedes SUD and leads to the development of substance use problems as the individual attempts to self-medicate the negative affect associated with their trauma symptoms.

Comorbidity Theory: High Risk Hypothesis

Substance use puts one at risk for exposure to traumatic events and subsequently, PTSD. Substance use precedes PTSD.

Comorbidity Theory: Susceptibility Hypothesis

The use of substances increases the likelihood of developing PTSD following a traumatic event. Substance use precedes PTSD.

Comorbidity Theory: Substance-induced anxiety

enhancement hypothesisSUD leads to the development of PTSD

symptoms following trauma because SUDs affect the functioning of the body’s stress response system

Comorbidity Theory: Shared vulnerability hypothesis

PTSD and SUD onset occur near the same time due to a shared vulnerability (genetic/physiological/ underlying risk factors) common to the development of both disorders

Tension Reduction Model

Neuroendocrine, neuroanatomical, and genetic research support the tension reduction model (Hruska & Delahanty, in press)

Trauma or PTSD diagnosis precedes the onset of alcohol or substance abuse (Bremner et al., 1996; Clark & Jacob, 1992; Davidson et al., 1985, 1990)

Having PTSD increased the risk of developing a subsequent SUD, but presence of drug abuse or dependence did not substantially increase risk for developing PTSD (Chilcoat and Breslau, 1998)

PTSD symptoms mediate the relationship between prior trauma and alcohol use in adult women (Epstein, Saunders, Kilpatrick, & Resnick, 1998).

As trauma victims with PTSD may self-medicate with substances to decrease the intensity of PTSD symptoms, decreasing PTSD symptoms through empirically supported therapies may be associated with a decrease in substance use/abuse.

Failure to address underlying PTSD symptoms results in greater SUD relapse rates, further reinforcing the importance of addressing psychopathological barriers to SUD treatment success (Brown et al., 1999)

Tension Reduction Model

Intervention: Prolonged Exposure

Prolonged exposure therapy (PE) PE therapy has been found to be effective

in the treatment of PTSD and comorbid symptoms across several controlled studies

Most appropriate form of treatment for PTSD (Ballenger et al., 2000)

PE aims to reduce the fear or anxiety associated with the trauma by encouraging patients to repeatedly confront fear-evoking stimuli (Foa et al., 2007)

PE: Mechanisms

Repeated imaginal exposure facilitates habituation and reduction of anxiety associated with the traumatic memory

By imagining and discussing the traumatic event with a supportive therapist, the patient begins to realize that thinking about the trauma is not dangerous

PE: Mechanisms

Through imaginal exposure to the trauma memory and in vivo exposure to external cues, the patient begins to differentiate the traumatic event from other situations, decreasing generalization of fear responses

Following repeated exposure, the patient achieves a sense of mastery that contradicts the typical view of symptoms reflecting weakness

Prolonged Exposure

Equally efficacious in African-Americans and Whites

Effective in treating victims from a wide range of traumas including war experiences, rape, assault, crime, and samples including victims of a variety of different traumas

Effective in treating individuals who have been multiply traumatized and patients who suffer from complex PTSD

PE compared to other approaches

PE is more effective and efficient than: relaxation training eye movement desensitization and

reprocessing (EMDR) counseling stress inoculation training (SIT) combination therapy involving both PE and

SIT, especially at longer-term follow-up assessments

Prolonged Exposure

10 sessions conducted twice per week for 5 weeks.

Each session lasts between 90-120 minutes. Include education about common reactions

to trauma, breathing retraining, prolonged (repeated) imaginal exposure to trauma memories, repeated in vivo exposure to situations the client is avoiding due to trauma-related fear, and discussion of thoughts and feelings related to exposure exercises.

Session 1

Begins with an overview of the treatment program and a general rationale for exposure. The therapist gathers information focusing on the client’s symptoms, details of the trauma, history of previous trauma, and social and occupational functioning. Breathing retraining is introduced and the client practices breathing techniques. Homework consists of daily breathing exercises, listening to the tape of the session, and reviewing the "Rationale for Treatment" handout.

Session 2

Focuses on education, treatment planning, and development of the in vivo exposure hierarchy. The therapist provides an explanation of PTSD, discusses common reactions to trauma, discusses a rationale for the treatment, and provides a description of each treatment component. The use of Subjective Units of Distress (SU) ratings is explained. A list of avoided situations is compiled and an exposure hierarchy is developed.

Session 3

Reviews the rationale for PE and introduces prolonged imaginal exposure. The client is guided through 60 minutes of imaginal reliving of the focal trauma. The client is instructed to relive the trauma as vividly as possible, and to recount it aloud in the present tense. This procedure is repeated until the exposure period is expended. SU ratings are obtained every 5 minutes and vividness ratings are taken every 10 minutes.

Sessions 4-9

Focus on imaginal exposure for 45-60 minutes, followed by discussion of any thoughts and feelings provoked by the reliving. During imaginal exposure, the therapist asks specific questions to clarify the client's thoughts, feelings, and physical reactions while reliving the trauma to facilitate confrontation with fear-evoking cues. The parts of the scenario that are the most anxiety-producing for the client are identified and emphasized in repeated exposure.

Session 10 (Termination)

Imaginal exposure lasts 30 minutes. The therapist and client review treatment progress and discuss applications of treatment principles to daily life. This discussion will address the potential for temporary increases in PTSD symptoms, and how these can be managed. At this time, the therapist and client will evaluate progress and determine whether additional sessions or referral may be worthwhile.

Using Prolonged Exposure for individuals with PTSD and

Substance Abuse

PE in SUD populations

Initial concern was risk for substance use relapse six male veterans undergoing imaginal flooding

therapy for PTSD, 3 out of 4 of the patients with current or past histories of alcoholism relapsed to alcohol abuse (Pitman et al., 1991)

More recent examinations of the efficacy of PE have not found consistent relationships between substance use and treatment outcome or dropout

PE in SUD populations (Cont,d)

Interventions developed to treat comorbid SUD and PTSD have incorporated imaginal exposure

Exposure therapies have demonstrated efficacy in reducing PTSD severity in SUD-PTSD patients

Patients who have received PE reported fewer cravings than those who did not

We have also demonstrated the efficacy of PE in a study of HIV+ individuals, 60% of whom reported substance use at the start of the protocol

PEACH Study (Pacella et al., 2012)

Examine the efficacy of PE at: Reducing HIV related and non- HIV

related PTSD symptoms in PLWH Reducing depressive symptoms Increasing adherence

Participants

43 participants Age (M = 46.39) 29 Males; 14 Females 49% African American; 45.1% Caucasian; 5.9% Hispanic Years living with HIV (M = 13.1; range: 1-27 years) Income: 84% Under $20,000

Pre-Screen (N = 99)

Eligible (N = 65) Ineligible (N = 34)

Intervention

Weekly monitoring control group

Baseline (N = 34) Baseline (N = 25)

Post-intervention (N = 24)

3-month Follow-up (N = 19)

Post-intervention (N = 23)

3-month Follow-up (N = 24)

Treatment Conditions

Prolonged Exposure: Focused on the most traumatic event they’ve

experienced 10 sessions; 5 weeks

Weekly Monitoring/Wait-list group

HIV related PTSS

0

5

10

15

20

25

30

Baseline Post-intervention 3-month follow-up

HIV

rela

ted

PT

SS

Control

Experimental

Non-HIV related PTSS

0

5

10

15

20

25

30

35


No

n-H

IV r

ela

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PT

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Control

Experimental

Depression

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Dep

ressio

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Control

Experimental

Peach Study (Pacella et al., 2012): Conclusions

Overall, PE was readily accepted by PLWH and was efficacious in reducing symptoms of:

PTSS for HIV and non-HIV related trauma Depressive symptoms

PE was not associated with exacerbation of self-reported substance use (SU). The control group went from an average of 7 instances of SU in the last week at baseline to 2 at post-intervention to 7 at 3-month follow-up, while the PE group went from 3 at baseline to 2 at post-intervention to 4.5 at 3-month follow-up.

PE and control participants did not significantly differ on adherence variables

The KSU-Oriana House Studies on PTSD

The KSU-Oriana House Studies

Detox patient studies: The KSU- Summit County ADM Crisis Center Study

(Hruska et al., in press) The Life Experiences and Drug Dependence Study

(Ongoing) Prolonged Exposure and Motivational Interviewing

Study (PE-MI)

Residential Community Based Correctional Facility (Just started)

Non Residential Summit County Felony Drug Court (grant funded,

started in 2013)

KSU-Oriana House Studies on Detox Populations

%

Prevalence of Trauma in Detox studies

Studies on Detox Populations

For the first two detox studies… 42.2% (195/462) meet criteria for PTSD

The incidence of trauma is significantly greater in detox than in the general population

On the average, a detox clients experiences seven different types of trauma

Studies on Detox Populations

Those with PTSD experience greater impairment in a variety of

domains

Detox Clients with PTSD

Detox Clients w/o PTSD

Experience more traumatic events 9.5 5.6

More likely to have depression 56.6 28.2

Report worse alcohol withdrawal symptoms 14.6 10.4

Report worse opiate withdrawal symptoms 28.5 23.5

Report more severe negative consequences due to their addiction

120.9 92.8

Using a greater number of addictive substances 39.8 32.4

Prolonged Exposure and Motivational Interviewing Study

(PE-MI) at Detox• Where: ADM Crisis Center Detox facility

• Purpose: To implement intervention to clients during wait period for substance use treatment

• Intervention: Conduct 9-10 PE sessions with two MI sessions before entering SUD treatment

Detox PE-MI Study, cont’d

Difficult to implement 19 total participants recruited

1 did not meet PTSD criteria 5 excluded for bipolar disorder, suicidality

and/or current DV relationship 5 completed first or second session only 5 never showed for first appt. 2 completed more than 5 sessions

Detox PE-MI Study, cont’d

• Challenges to PE-MI study• Transportation• Chaotic lifestyles• Lack of means to communicate (cell phone, email, etc.)• Lack of case management

– Needed help obtaining housing, food, clothing etc.– Majority of clients were homeless and didn’t have any

support– Difficult to implement intervention when basic needs aren’t

being met

Prolonged Exposure Treatment Engagement study (PETE)

• Where: Male and female CBCF facilities in Akron, OH

• Purpose: Remove trauma-related psychological barriers to engagement in substance use treatment

• Intervention: Implement 10 sessions of PE to clients prior to beginning their SUD treatment within the facility

PETE study, cont’d

Why is a correctional setting better? Removal of basic barriers to

treatment(i.e. shelter, food, clothing) No need for transportation Have social support within facility Limited access to the outside, allowing

for focus of developing skills to manage stress

Limited wait period to begin substance use treatment

The Summit County Felony Drug Court Program (SCFDC)

Summit County Felony Drug Court (SCFDC) started in 2002 931 participants as of 2012

Caucasian = 77% Male= 65% Unemployed= 58% Average age= 33

SCFDC, cont’d

Enhancement Grant from BJA and SAMHSA in 2013 Three Enhancements

Opiate Specific Track Suboxone program for those opiate users that are

interested PTSD Track

SCFDC: Screening Assessment Process

All Drug Court ClientsN=110

Continued Observation

n=40

Screened as indicating PTSD

n=23

No further follow-up

n=47

CAPS Assessment

Refused further assessment or

not yet assessed

n= 11

Met less strict criteria for PTSD

n= 6

Met strict criteria for PTSD

n= 5

Not meeting PTSD criteria

n= 1

17 85PCL

Assessment 44

Individual Counseling

n= 14

SCFDC: PTSD Screening and Gender

Femalesn=44

Malesn= 56

Females: no intervention

neededn=14 (31.8%)

Females:Screened positive

for PTSD n=12 (27.3%)

Males: no intervention

neededn=23 (41.1%)

Males:Monitored based on clinical judgment for

PTSDn=22 (39.3%)

Females:Monitored based on clinical judgment for

PTSDn=18 (40.9%)

Males:Screened positive

for PTSD n=11 (19.6%)

Challenges of treating offenders in a community

corrections

Challenges, cont’d

Therapist Gender Issues

Addressing Comorbidities in a correctional population Issue: Alcohol and Drugs Issue: Bipolar Disorder

Cost of Therapist

Inability to sanction clients for not attending PE sessions

Private Space for homework

Challenges, cont’d

Time Factor Issue: Other demands on time

Cognitive skills (criminal thinking errors) Substance abuse Employment (restitution, court costs, child

support) Other day-to-day issues

Issue: When should the screening tool and assessments be given Upon entrance to Drug Court may not be the

best timeEffects of recent drug use

Issue: When should Prolonged Exposure be placed in the pecking order of other treatment and correctional demands?

Challenges of treating offenders in a community

corrections

Alternatives for treatment in Community Corrections

Recent Adjustments to Accommodate Felony Drug Offenders

Transitioning clients that would benefit from PE Currently use individual counseling sessions and

active review and check-up with patients to discuss substance abuse and PTSD issues

Potential Adjustments to Accommodate Felony Drug Offenders

Requiring clients who are diagnosed with PTSD to attend at least the first two sessions of PE

Clinical judgment and patient must agree to attend further sessions

If not, other PTSD treatments may be offered such as Seeking Safety


Potential Adjustments: Seeking Safety curriculum help transition clients into PET Developed in early 1990’s

Addresses both trauma/PTSD and substance abuse

25 topics usually given over 12-weeks


Advantages of using Seeking Safety: Group and individual Either gender, adults/adolescents Substance abuse/ substance dependence Can be used for clients with trauma history but

meeting PTSD criteria Can be conducted as an open group Lessons can be given in any order

Has QA/CQI tools to be used to measure clinicians adherence to programMore information at www.seekingsafety.org

Douglas L. DelahantyDepartment of

PsychologyKent State UniversityP.O. Box 5190Kent, OH 44242

[email protected]

Questions?

Alec P. BorosResearch ManagerOriana House, Inc.

P.O. Box 1501Akron, OH 44309

[email protected]

Documents

TREATING OFFENDERS WITH SUBSTANCE ABUSE AND POSTTRAUMATIC STRESS DISORDER Douglas L. Delahanty Alec Boros Kent State University Oriana House