Effectiveness of Seeking Safety for Co-Occurring Posttraumatic Stress Disorder and Substance Use

Seeking Safety for women in incarceration: a systematic review

PURPOSE

Seeking Safety is an evidence-based treatment for individuals with comorbid posttraumatic stress disorder and substance use disorder. This treatment shows promise to address the unique, unmet needs of women in prison. The current systematic literature review aims to highlight several critical gaps in research on Seeking Safety in forensic settings that need to be filled before Seeking Safety can be implemented in a widespread manner.

METHODS

PsycINFO, PubMed and Google scholar databases were used to identify studies that were published in English, included women in forensic settings, and incorporated Seeking Safety treatment. A total of seven studies met review criteria. The quality of studies was assessed with the mixed methods appraisal tool.

RESULTS

High risk of contamination, inclusion of small, predominantly White samples, high attrition rates, need for dose-response testing, and lack of follow-up data currently limit the ability to assess the efficacy of Seeking Safety in forensic settings. In addition, there is a lack of research on Seeking Safety's ability to reduce symptoms of substance use disorder for incarcerated women and further cultural adaptation may be needed.

CONCLUSION

Seeking Safety has the potential to address the underlying causes of incarceration for justice-involved women, but additional research addressing these identified gaps is needed to facilitate more widespread implementation.

A combined intervention strategy to increase linkage to and retention in substance use treatment for individuals accessing hospital-based services: study protocol

Background

In 2020, New Mexico had the highest alcohol related death and the 11th highest drug overdose rate in the U.S. Towards the long-term goal of addressing this public health problem, we are implementing and evaluating an multi-level intervention designed to identify adults at risk of substance use disorder (SUD) and encourage linkage to and retention in treatment. The first level includes equipping the ED and medical inpatient units of a safety-net hospital with a method to screen individuals at risk of a SUD. The second level includes Seeking Safety (SS), a trauma-specific treatment for PTSD and SUD; and pharmacotherapy for SUD. Motivational Interviewing (MI) is used throughout both levels. Using the SPIRIT guidelines and checklist, this study protocol describes the multi-level intervention and the methodology we are using to assess feasibility and effectiveness.

Methods

We are using a Type 1 hybrid implementation design with a non-randomized approach (ISRCTN registration # ISRCTN33100750). We aim to enroll 110 adults ( ≧ 18 ) who screen positive for unhealthy use of alcohol, prescription medications (used nonmedically) and/or illicit drugs. Peer support workers are responsible for screening, using MI to increase engagement in screening and treatment and delivery of SS. Pharmacotherapy is provided by addiction clinical specialists. Treatment is provided post hospital discharge via telehealth to increase access to care. Participants are identified through (1) review of electronic health records for individuals with a chief or secondary complaint or mental health condition relating to alcohol and/or other drug use, (2) referrals from clinical staff and (3) screening in the ED and medical inpatient units. Feasibility is being measured through process data. Effectiveness will be determined by changes in two primary outcomes: (i) PTSD symptom severity; and (ii) substance use.

Discussion

Our study will expand on research related to the implementation of treatment strategies for patients presenting at EDs and admitted to medical inpatients units wherein there is a significant window of opportunity to link patients with follow-up behavioral and clinical services for alcohol and/or drug misuse. The challenges associated with implementation and strategies that have been helpful to address these challenges will further inform the field.

A Seeking Safety Mobile App for Recovery from PTSD and Substance Use Disorder: Results of a Randomized Controlled Trial

BACKGROUND

Posttraumatic stress disorder (PTSD) and substance use disorder (SUD) co-occur frequently and have deleterious impact. Seeking Safety (SS) - an evidence-based, present-focused, coping skills model - lends itself to mobile app delivery.

OBJECTIVES

A novel SS mobile app is compared to a control app that lacks the interactivity, social engagement, and feature-richness of the SS app. We hypothesized that the SS app would outperform the control on primary outcome variables (substance use, trauma symptoms) and at least two secondary variables.

METHODS

Outpatients with current PTSD and SUD (n = 116) were randomized to the apps; assessed were pre, post (12 weeks), and 3-month follow-up in this online study.

RESULTS

The SS app outperformed the control on the primary outcomes, but not on secondary outcomes. Also both conditions evidenced significant change over time from pre to post, with gains sustained at follow-up. External medication and supports during the trial did not differ by condition.

CONCLUSION

This first RCT on a SS mobile app had positive results for reduction in substance use and trauma symptoms compared to a control app. This is noteworthy as mental health mobile apps, in general, evidence few positive outcomes. Our substance use finding is also notable as psychosocial interventions in PTSD/SUD populations find it harder to achieve reduction in SUD than trauma symptoms. Our control app may have represented too strong a comparison and weakened our ability to find results on secondary outcomes by condition.

Behavioral and neurocognitive factors distinguishing post-traumatic stress comorbidity in substance use disorders

Significant trauma histories and post-traumatic stress disorder (PTSD) are common in persons with substance use disorders (SUD) and often associate with increased SUD severity and poorer response to SUD treatment. As such, this sub-population has been associated with unique risk factors and treatment needs. Understanding the distinct etiological profile of persons with co-occurring SUD and PTSD is therefore crucial for advancing our knowledge of underlying mechanisms and the development of precision treatments. To this end, we employed supervised machine learning algorithms to interrogate the responses of 160 participants with SUD on the multidimensional NIDA Phenotyping Assessment Battery. Significant PTSD symptomatology was correctly predicted in 75% of participants (sensitivity: 80%; specificity: 72.22%) using a classification-based model based on anxiety and depressive symptoms, perseverative thinking styles, and interoceptive awareness. A regression-based machine learning model also utilized similar predictors, but failed to accurately predict severity of PTSD symptoms. These data indicate that even in a population already characterized by elevated negative affect (individuals with SUD), especially severe negative affect was predictive of PTSD symptomatology. In a follow-up analysis of a subset of 102 participants who also completed neurocognitive tasks, comorbidity status was correctly predicted in 86.67% of participants (sensitivity: 91.67%; specificity: 66.67%) based on depressive symptoms and fear-related attentional bias. However, a regression-based analysis did not identify fear-related attentional bias as a splitting factor, but instead split and categorized the sample based on indices of aggression, metacognition, distress tolerance, and interoceptive awareness. These data indicate that within a population of individuals with SUD, aberrations in tolerating and regulating aversive internal experiences may also characterize those with significant trauma histories, akin to findings in persons with anxiety without SUD. The results also highlight the need for further research on PTSD-SUD comorbidity that includes additional comparison groups (i.e., persons with only PTSD), captures additional comorbid diagnoses that may influence the PTSD-SUD relationship, examines additional types of SUDs (e.g., alcohol use disorder), and differentiates between subtypes of PTSD.

Project Harmony: A Meta-Analysis With Individual Patient Data on Behavioral and Pharmacologic Trials for Comorbid Posttraumatic Stress and Alcohol or Other Drug Use Disorders

OBJECTIVE

Treatment efficacy for co-occurring posttraumatic stress disorder (PTSD) and substance use disorders is well established, yet direct evidence for comparative effectiveness across treatments is lacking. The present study compared the effectiveness of several behavioral and pharmacological therapies for adults with co-occurring PTSD and alcohol or other drug use disorders.

METHODS

A systematic search of PsycINFO, MEDLINE, and ClinicalTrials.gov was conducted through December 2020 for trials targeting PTSD, alcohol or other drug use disorders, or both disorders (36 studies, N=4,046). Primary outcomes were severity scores for PTSD, alcohol use, and drug use, estimated via moderated nonlinear factor analysis. Propensity score weight-adjusted multilevel models were used. Model-predicted effect sizes were estimated for each treatment, and comparative effect sizes for each active arm against treatment as usual, at end of treatment and at 12-month follow-up.

RESULTS

Compared with treatment as usual, combining trauma-focused therapy and pharmacotherapy for substance use disorders showed the largest comparative effect sizes for PTSD severity (d=-0.92, 95% CI=-1.57, -0.30) and alcohol use severity (d=-1.10, 95% CI=-1.54, -0.68) at end of treatment. Other treatments with large comparative effect sizes included pharmacotherapies for alcohol or other drug use disorders, trauma-focused integrated therapies, and trauma-focused nonintegrated therapies. Reductions in outcomes for PTSD symptoms and alcohol use were observed for nearly all treatments.

CONCLUSIONS

The findings provide support for treating comorbid PTSD and substance use disorders using a variety of approaches, with alcohol-targeted pharmacotherapies and trauma-focused behavioral therapies as a combination of treatments that lead to early and sustained improvements in PTSD and alcohol use severity. Further treatment development is indicated for combining behavioral and pharmacological treatments for synergized impact and understanding the mechanisms of action and conditions under which each treatment type is optimized.

Trauma-Integrated Mindfulness-Based Relapse Prevention for Women with Comorbid Post-Traumatic Stress Disorder and Substance Use Disorder: A Cluster Randomized Controlled Feasibility and Acceptability Trial

Background: Comorbid post-traumatic stress disorder and substance use disorder (PTSD-SUD) among women receiving substance use treatment are common. Few evidence-based interventions target PTSD-SUD, however, fewer are gender responsive. Mindfulness-based relapse prevention (MBRP) has shown effectiveness for women with SUD, although it does not explicitly target PTSD. Integration of trauma-focused and gender-responsive treatments into MBRP may address the limited availability of PTSD-SUD interventions for women. This study assessed feasibility and acceptability of trauma-integrated MBRP (TI-MBRP). Methods: A single-blind computer-generated cluster-randomized design was employed in which women with PTSD-SUD (N = 83) received either TI-MBRP (k = 5) or MBRP (k = 5). Measures of PTSD symptom severity and craving were administered at pre-, post-, 1-, 3-, 6-, 9-, and 12-month follow-up and assessed at the individual level. Results: TI-MBRP demonstrated acceptability among participants; however, attrition was high (64%) at 12-month follow-up. Reductions in PTSD were greater in the MBRP than in the TI-MBRP group at postcourse and 1-month follow-up, and there were significant reductions in PTSD severity and craving over the 12-month period in both conditions. Conclusions: Integrating trauma- and gender-focused interventions into MBRP was feasible and acceptable. MBRP alone may be effective in reducing both PTSD and SUD symptoms in women with PTSD-SUD; however, confirmatory studies are warranted. Clinical Trial Registration Number: NCT03505749.

Group therapy in primary care settings for the treatment of posttraumatic stress disorder: A systematic literature review

OBJECTIVE

This systematic review aims to summarize existing literature on group therapy for the treatment of post-traumatic stress disorder (PTSD) in primary care.

METHOD

A PRISMA systematic literature review was performed through February 26, 2022 identifying existing studies of group trauma therapy in primary care. Articles were included if they discussed group trauma therapy for primary care patients. Bias was assessed based on sample sizes and presence of control groups. Results are presented as a weighted average of the engagement rate and a qualitative description of overlapping study traits.

RESULTS

Four studies of group PTSD treatment within primary care were identified with 70 total patients completing group treatment. The weighted treatment engagement rate was 65%. Each utilized distinct group trauma treatment models and reported significant patient improvements in PTSD symptoms on standardized trauma symptom scales.

DISCUSSION

Group trauma therapy models are available and can be disseminated within primary care settings. Limitations include both the small number of studies and participants.

CONCLUSION

There have been few studies of group therapy for PTSD in primary care, but these could represent a promising and scalable approach to meet the high need for trauma treatment. Further research is needed regarding implementation feasibility and impact.

Interpersonal Violence, PTSD, and Substance Use Types among Women Receiving Substance Use Treatment

Objective: Many women receiving substance use treatment report histories of interpersonal violence (IV) victimization, including physical and sexual assault. IV is a risk factor for mental and behavioral health difficulties such as posttraumatic stress disorder (PTSD) and substance use disorder (SUD). Consistent with the self-medication hypothesis, PTSD may explain elevated SUD among IV survivors. Yet, few studies have investigated whether PTSD may have differential mediating effects for different substances, which has significant treatment implications. Methods: In 124 women (M age = 35.37, SD = 11.90) in substance use treatment, we examined PTSD symptoms as a mediator between IV and severity of different types of substance use, including alcohol, cannabis, cocaine, and opioid use. Participants completed self-report measures including the ASSIST, PCL-5, and LEC-5. Data were analyzed using path analysis in Mplus 8.3. Both dichotomous and continuous outcomes of problematic substance use outcomes were examined. Results: Most women (53.3%) reported problematic substance use with at least one substance, including opioids (39.7%), cocaine (13.0%), alcohol (9.6%), and cannabis (5.6%). Most (83.2%) of the sample reported at least one IV incident. On average, women reported clinically significant PTSD symptom severity. When problematic substance use was examined dichotomously, findings revealed significant indirect effects from IV exposure to opioid (β = 0.10, p = .010) and cocaine use (β = 0.07, p = .039) via elevated PTSD symptoms. There were no significant indirect effects for problematic alcohol (β = 0.03, p = .260) or cannabis use (β = 0.02, p = .562). When substance use was examined continuously, results revealed significant indirect effects from IV exposure to opioid (β = 0.09, p = .017), cocaine use (β = 0.09, p = .015), and alcohol use (β = 0.08, p = .020) via elevated PTSD symptoms. Indirect effects for cannabis use remained nonsignificant (β = 0.05, p = .100). Conclusions: IV survivors may be particularly at risk for opioid and cocaine misuse because of elevated PTSD symptoms. Treatments that integrate PTSD and SUD are needed to simultaneously target traumatic stress and substance use. Women with opioid and cocaine misuse may particularly benefit from trauma-focused exposure-based psychotherapy to reduce symptoms of PTSD, and thus, decrease opioid and cocaine misuse.

What's in a name? A data-driven method to identify optimal psychotherapy classifications to advance treatment research on co-occurring PTSD and substance use disorders

Background/Objective

The present study leveraged the expertise of an international group of posttraumatic stress and substance use disorder (PTSD+SUD) intervention researchers to identify which methods of categorizing interventions which target SUD, PTSD, or PTSD+SUD for populations with both PTSD+SUD may be optimal for advancing future systematic reviews, meta-analyses, and comparative effectiveness studies which strive to compare effects across a broad variety of psychotherapy types.

Method

A two-step process was used to evaluate the categorization terminology. First, we searched the literature for pre-existing categories of PTSD+SUD interventions from PTSD+SUD clinical trials, systematic and literature reviews. Then, we surveyed international trauma and substance use subject matter experts about their opinions on pre-existing intervention categorization and ideal categorization nomenclature.

Results

Mixed method analyses revealed that a proliferation of PTSD+SUD treatment research over the last twenty years brought with it an abundance of ways to characterize the treatments that have been evaluated. Results from our survey of experts (N = 27) revealed that interventions for PTSD+SUD can be classified in many ways that appear to overlap highly with one another. Many experts (11/27; 41%) selected the categories of 'trauma-focused and non-trauma focused' as an optimal way to distinguish treatment types. Although several experts reinforced this point during the subsequent meeting, it became clear that no method of categorizing treatments is without flaws.

Conclusion

One possible categorization (trauma-focused/non-trauma focused) was identified. Revised language and nomenclature for classification of PTSD+SUD treatments are needed in order to accommodate the needs of this advancing field.

Investigating the experience of individuals with comorbid posttraumatic stress disorder and substance misuse attending a Seeking Safety group

Purpose

There is no specific recommended treatment for the co-morbid presentation of post-traumatic stress disorder (PTSD) and substance use disorder in the United Kingdom (UK). Seeking Safety (SS), a group-based treatment that targets symptoms of both disorder, has emerging evidence in the USA but lacks evidence from UK-based samples. The purpose of this study was to explore UK service users’ experience of attending SS and evaluate its impact on mental health symptomology and substance misuse.

Design/methodology/approach

A mixed method approach was used to evaluate the acceptability of SS for a small sample (n = 7) of adult users of a substance misuse service in the UK. Thematic analysis was used to explore their experiences, derived from individual semi-structured interviews. The authors also calculated the number of participants who achieved reliable and/or clinically significant change in mental health symptomology and substance misuse from data routinely collected by the service.

Findings

Seven overarching themes emerged: strengthening the foundations of the self, the evocation and management of emotions, safety and validation provided relationally, readiness and commitment, content and delivery, Seeking Safety is Not an Island and ending. Most participants with data available both before and after the group made reliable (three out of four) and clinically significant (two out of three) change for depression and anxiety symptomology; however, this was less evident for PTSD symptomology with two out of three making reliable change and one out of three making clinically significant change.

Originality/value

To the best of the authors’ knowledge, this was the first study exploring the experiences of UK attendees of a SS group as an approach to treating comorbid PTSD and substance misuse.

Developing Signs of Safety: A Deaf-accessible counselling toolkit for trauma and addiction

The U.S. Deaf community-more than half a million Americans who communicate using American Sign Language (ASL)-experiences higher rates of trauma exposure and substance use disorder (SUD) than the general population. Yet there are no evidence-based treatments for any behavioural health condition that have been evaluated for use with Deaf people. The driving aim of our work, therefore, has been to develop and formally evaluate a Deaf-accessible trauma/SUD counselling approach. Here we describe our initial intervention development work and a single-arm pilot that evaluated the feasibility, acceptability, and preliminary clinical efficacy of Signs of Safety-a Deaf-accessible toolkit to be used with an existing, widely adopted protocol for trauma and addiction (Seeking Safety). Preliminary efficacy results indicated clinically significant reductions in PTSD symptoms and frequency of alcohol use for the Seeking Safety/Signs of Safety model. Frequency of drug use did not change significantly-likely attributable to the mid-study legalization of recreational marijuana in our state. Next steps include the redesign and refilming of Signs of Safety based on pilot participant feedback, again using a Deaf-engaged development and production process. This new toolkit will be tested via a pilot randomized controlled trial designed based on present methodological lessons learned.

Evaluating treatments for posttraumatic stress disorder, alcohol and other drug use disorders using meta-analysis of individual patient data: Design and methodology of a virtual clinical trial

This paper describes Project Harmony, a Virtual Clinical Trial (VCT) funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to harmonize and analyze data from over 40 independent psychological, pharmacologic and/or combined pharmacological treatment studies for posttraumatic stress disorder and comorbid alcohol and other drug use disorders (PTSD/AOD). The study attends to three distinct analysis challenges: (1) variation in measurement of PTSD/AOD across studies, time, populations and reporters, (2) cross-study variation in treatment effect sizes and (3) non-randomized, cross-study variation in the classification of treatments (despite within-study randomization of treatment arms). To address these challenges, the study combines meta-analysis of individual patient data (MIPD), integrative data analysis (IDA) and propensity score weighting (PSW) to integrate raw data from these clinical trials. This protocol shows how this VCT analytic framework was used to (1) develop commensurate scale scores of PTSD and AOD severity when measures vary across studies, (2) compare the efficacy of evidence-based treatment models for PTSD/AOD, (3) test for potential mediators of treatment effects on AOD and PTSD across treatment models, and (4) explore individual- and study-level moderators to inform for whom each of the treatment models works best. The advantages of the general VCT approach are juxtaposed against the limitations of single randomized controlled trials and conventional meta-analysis.

PTSD / substance use disorder comorbidity: Treatment options and public health needs

Purpose of Review

Posttraumatic stress disorder (PTSD) commonly co-occurs with substance use disorder (SUD) and is challenging to treat. We review all behavioral therapy models with at least one randomized controlled trial in a current PTSD/SUD population. We identify factors in selecting a model for clinical use, emphasizing a public health framework that balances the need for evidence with the need for feasibility in frontline settings.

Recent Findings

Seven published models and 6 unpublished models are reviewed. Public health considerations for choosing a model include: whether it's been studied across a broad range of SUDs and in complex SUD patients; whether it can be conducted in group modality; its appeal to patients and providers; its cost; workforce requirements; and its ability to reduce substance use in addition to PTSD.

Summary

There are two broad types of models: those that originated in the PTSD field versus the SUD field. Overall, the latter are stronger on public health factors and more feasible in SUD settings. Published models in this category include Relapse Prevention, BRENDA, and Seeking Safety. PTSD/SUD research is at an early stage and there is a need for methodology that quantifies "level of burden" (patients' socioeconomic disadvantages) across trials.

Post-traumatic stress disorder and substance use disorder in individuals with mild intellectual disability or borderline intellectual functioning: A review of treatment studies

Individuals with mild intellectual disability or borderline intellectual functioning (MID-BIF; IQ 50-85) are at high risk for developing post-traumatic stress disorder (PTSD) and substance use disorders (SUD). In individuals without MID-BIF, Seeking Safety (SeSa) is found to be effective in treating PTSD and SUD simultaneously. However, little is known about integrated treatment of PTSD and SUD in individuals with MID-BIF. This review aims to provide an overview of studies about this type of triple psychopathology, as well as PTSD or SUD in individuals with MID-BIF (i.e. dual diagnosis). No studies were found on integrated treatment of PTSD and SUD in individuals with MID-BIF. Thirty-two studies were found on treatment of either PTSD (mostly Eye Movement Desensitization and Reprocessing and cognitive behavior therapy) or SUD (mostly cognitive behavior therapy and mindfulness) in individuals with MID-BIF. Only 9.4 % of these studies mentioned the co-morbidity of PTSD and SUD. Suggestions for adapting treatment to individuals with MID-BIF were provided on communication, structure, non-verbal elements, network, coping skills, therapeutic relationship and use of suitable and reliable instruments to measure treatment progress. More research is needed on the effectivity of EMDR or Imaginary Exposure (IE) combined with SUD treatment (CBT and mindfulness), and on the adaption of SeSa tot individuals with MID-BIF, as well as on this type of triple psychopathology in general.

Healing transgender women of color in Los Angeles: A transgender-centric delivery of Seeking Safety

Background: Transgender women of Color experience disproportionate rates of HIV, depression, and anxiety, and high rates of substance use, attempted suicide, and interpersonal verbal, physical, and sexual violence and assault. However, there are few interventions targeting transgender women of Color that address overlapping health and mental health challenges. Aims: There are two aims/research questions: (1) what are the elements of a transgender-centric model for delivering evidence based interventions and practices?, and (2) does Seeking Safety improve substance use and mental health outcomes for transgender women of Color? Methods: We present a case study of the delivery process of Seeking Safety by Special Service for Groups/Asian Pacific AIDS Intervention Team (SSG/APAIT), and analyze baseline and three month post program participant data (n = 81). Results: The transgender-centric model of intervention delivery consisted of multiple steps, also integrating the structural disadvantages experienced by transgender women of Color. Comparing baseline and three months after completion showed significant decrease in reported alcohol use, depression, and severe anxiety. Discussion: Transgender-centric approaches may lead to programs that significantly improve co-occurring substance use and mental health for transgender women of Color. We recommend that organizations aiming to existing programs include feedback from members of the communities that the adapted programs aim to help, and in addition, train community members to deliver the programs. The statistical results indicate that Seeking Safety, a trauma-based program with a short program delivery timeline, may show longer term effects on substance use and mental health. We recommend that programs targeting substance use and mental health for transgender women of Color should be combined with services that address disadvantage (i.e., lack of access to housing, income/employment, health care).

Comparing Exposure- and Coping Skills-Based Treatments on Trauma-Related Guilt in Veterans With Co-Occurring Alcohol Use and Posttraumatic Stress Disorders

Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) commonly co-occur, and this comorbidity (PTSD-SUD) is associated with more severe symptoms and functional impairment than either disorder alone. Growing evidence indicates that trauma-related guilt, typically concerning negative appraisals of one's actions or inaction during a traumatic event, is associated with PTSD, depression, suicidality, and, possibly, substance use. The present study examined whether integrated treatment for PTSD-SUD was effective in reducing trauma-related guilt as measured by the Trauma-Related Guilt Inventory. Data were drawn from a randomized clinical trial comparing the effectiveness of two integrated therapies on treatment outcomes in a sample of U.S. veterans (N = 119) with comorbid PTSD and SUD. Participants were randomized to receive either Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE; n = 63) or Seeking Safety (SS; n = 56). The results indicated that global guilt decreased over time for the whole sample. However, there was a significant Treatment × Time interaction, such that participants in the COPE condition reported lower rates of global guilt, d = 0.940, over time compared to those in the SS condition, d = .498. To our knowledge, this was the first study to examine the effects of integrated PTSD-SUD treatment on trauma-related guilt. The findings highlight that exposure-based, trauma-focused treatment for comorbid PTSD-SUD can be more effective in decreasing trauma-related guilt, with potentially longer-lasting effects, than non-exposure-based treatment, adding evidence that patients with PTSD-SUD should be offered such treatment.

Trauma-informed Drug Screens for Veterans with Co-occurring Disorders: A Case Series

Objective: This case series describes and illustrates the effective use of a trauma-informed approach, GLAPE, to provide drug screens for individuals in substance use treatment programs. The GLAPE approach recognizes that individuals who have experienced traumatic events and are recovering from substance use difficulties may also face unique challenges when engaging in mental health treatment. The nature of drug screening procedures in practice may feel invasive and triggering for clients with trauma histories. Finding ways to decrease barriers to treatment and increase engagement and retention are important components of effective substance use treatment. Methods: This case series involved three veteran cisgender men with posttraumatic stress disorder (PTSD) and co-occurring substance use conditions in an outpatient addiction recovery program in a Veterans' hospital. The cases illustrate how recovery can be aided by trauma-informed approaches for urine drug screens. The treatment team evaluated various monitoring modalities and collaborated with each client to form a treatment plan that implemented the GLAPE approach to bolster their recovery. The GLAPE approach includes five components: Giving detailed instructions prior to the urine screen procedure, listening to and eliciting questions and concerns of the client, articulating options and exhibiting flexibility in the procedure to accommodate the needs of the individual client, giving permission to the client to voice concerns at any point during the procedure, and evaluating the process in collaboration with the client, including what could be improved for next time. Results: Use of the GLAPE approach effectively helped to engage and retain military veterans with co-occurring PTSD and substance use disorder within a trauma informed outpatient program. Preliminary evidence from three cases provides that this approach may be useful for use in substance use treatment with clients who have trauma histories. Conclusions: Given widespread use of observed urine drug screens in substance use treatment programs, and prominent co-occurrence of substance use disorder and PTSD, it is essential that staff approach this procedure in a trauma-informed way. This case series illustrates an approach that can improve client experience, aid clients in treatment engagement, and assist staff in the provision of effective care.

Service providers' perceptions of barriers to the implementation of trauma-focused substance use services for women in Cape Town, South Africa

BACKGROUND

A substantial number of South African women with substance use disorders also report psychological trauma related to experiences of physical and sexual abuse. Trauma-focused substance use programmes may support recovery from co-occurring substance use disorders and psychological trauma, yet integrated programmes are not widely available in South Africa. As part of the process of developing a trauma-focused substance use programme for South African women, we explored service providers' views of the feasibility of implementing trauma-focused substance use interventions within usual care settings in Cape Town, including potential barriers that need to be considered when planning for implementation.

METHODS

We conducted 16 in-depth interviews with key informants responsible for planning or delivering substance use, psychological trauma or gender-based violence services to women in Cape Town. Guided by Extended Normalisation Process Theory, interviews explored participants' perceptions of the potential value of trauma-focused substance use programmes, the feasibility of their implementation, and factors that may facilitate or hinder the implementation of trauma-focused substance use programmes. Qualitative data were analysed using the framework approach.

RESULTS

Three themes emerged: (1) Potential for the implementation of trauma-focused substance use programmes, describing participants' views of the acceptability of these programmes; (2) Capacity for intersectoral collaboration, which participants considered necessary for limiting barriers to implementation; and (3) Co-operation with community structures to enhance capability for implementation.

CONCLUSION

Findings show potential for implementing trauma-focused substance use interventions in South Africa, however context-specific capacity and capability barriers need to be considered and addressed for implementation to be successful.

Unique versus shared associations between self-reported behavioral addictions and substance use disorders and mental health problems: A commonality analysis in a large sample of young Swiss men

BACKGROUND AND AIMS

Behavioral addictions (BAs) and substance use disorders (SUDs) tend to co-occur; both are associated with mental health problems (MHPs). This study aimed to estimate the proportion of variance in the severity of MHPs explained by BAs and SUDs, individually and shared between addictions.

METHODS

A sample of 5,516 young Swiss men (mean = 25.47 years old; SD = 1.26) completed a self-reporting questionnaire assessing alcohol, cannabis, and tobacco use disorders, illicit drug use other than cannabis, six BAs (Internet, gaming, smartphone, Internet sex, gambling, and work) and four MHPs (major depression, attention-deficit hyperactivity disorder, social anxiety disorder, and borderline personality disorder). Commonality analysis was used to decompose the variance in the severity of MHPs explained (R²) by BAs and SUDs into independent commonality coefficients. These were calculated for unique BA and SUD contributions and for all types of shared contributions.

RESULTS

BAs and SUDs explained between a fifth and a quarter of the variance in severity of MHPs, but individual addictions explained only about half of this explained variance uniquely; the other half was shared between addictions. A greater proportion of variance was explained uniquely or shared within BAs compared to SUDs, especially for social anxiety disorder.

CONCLUSIONS

The interactions of a broad range of addictions should be considered when investigating their associations with MHPs. BAs explain a larger part of the variance in MHPs than do SUDs and therefore play an important role in their interaction with MHPs.

Profiles of mothers who seek treatment for substance use disorders in a clinical centre

Purpose

The purpose of this paper is to explore the prevalence and profile of mothers among women who sought treatment for drug addiction, as well as the therapeutic progression of these patients.

Design/methodology/approach

A sample of 180 Spanish women with addiction problems was assessed. Information was collected on the patients’ socio-demographic characteristics, consumption variables and psychological symptoms.

Findings

Of the total sample, 22.2 per cent (n= 40) of the women seeking treatment for substance use disorder were mothers. Compared with women without children, mothers scored significantly higher on several EuropASI and psychological variables. Specifically, mothers presented with more medical problems, worse employment/financial situations, and more severity in alcohol use. Moreover, having a history of lifetime physical and/or sexual abuse was related to belonging to the group of mothers. Regarding therapeutic progression, no statistically significant differences in the retention rate were found between mothers and non-mothers.

Originality/value

The results of this study show that mothers generally have more severe problems than non-mothers. Therefore, comprehensive, continuum-based, and client-centred care for mothers is paramount for effective treatment in mothers. The implications of these results for further research and clinical practice are discussed.

Do screening and a randomized brief intervention at a Level 1 trauma center impact acute stress reactions to prevent later development of posttraumatic stress disorder?

BACKGROUND

Approximately 20% to 40% of trauma survivors experience posttraumatic stress disorder (PTSD). The American College of Surgeons Committee on Trauma reports that early screening and referral has the potential to improve outcomes and that further study of screening and intervention for PTSD would be beneficial. This prospective randomized study screened hospitalized patients for traumatic stress reactions and assessed the effect of a brief intervention in reducing later development of PTSD.

METHODS

The Primary Care PTSD (PC-PTSD) screen was administered to admitted patients. Patients with symptoms were randomized to an intervention or control group. The brief intervention focused on symptom education and normalization, coping strategies, and utilizing supports. The control group received a 3-minute educational brochure review. Both groups completed in-hospital interviews, then 45- and 90-day telephone interviews. Follow-up collected the PTSD checklist-civilian (PCL-C) assessment and qualitative data on treatment-seeking barriers.

RESULTS

The PC-PTSD screen was successful in predicting later PTSD symptoms at both 45 days (β = 0.43, p < 0.001) and 90 days (β = 0.37, p < 0.001) even after accounting for depression. Correlations of the intervention with the PCL-C scores and factor score estimates did not reach statistical significance at either time point (p = 0.827; p = 0.838), indicating that the brief intervention did not decrease PTSD symptoms over time. Of those at or above the PCL-C cutoff at follow-ups, a minority had sought treatment for their symptoms (43.2%). Primary barriers included focusing on their injury or ongoing rehabilitation, financial concerns, or location of residence.

CONCLUSION

The PC-PTSD screen identified patients who later assess positive for PTSD using the PCL-C. The brief intervention did not reduce 45- and 90-day PTSD development. Follow-up interviews revealed lack of treatment infrastructure in the community. It will be important for trauma centers to align with community resources to address the treatment needs of at-risk patients.

LEVEL OF EVIDENCE

Prospective randomized controlled trial, level II.

Enhancing the Seeking Safety group intervention with trauma-sensitive yoga practice: A program evaluation

BACKGROUND AND PURPOSE

The purpose of this article is to report the results of a qualitative Utilization Focused Program Evaluation on the integration of the Seeking Safety manualized group counseling intervention with Trauma-Sensitive (TS) yoga practice at a community mental health agency. To date, there has been no evaluation of Seeking Safety and TS yoga as complementary therapies.

METHOD AND MATERIALS

Qualitative data were generated from key informant interviews and focus groups, then coded and analyzed for theme and content.

RESULTS

Analysis of data indicate that, in this specific setting, the combination of Seeking Safety and TS Yoga was perceived by clients and clinicians as an effective complementary intervention strategy.

CONCLUSION

The results of this qualitative evaluation are specific to the agency utilizing the interventions. By integrating Seeking Safety with TS yoga many of the inherent weaknesses of the two individual approaches were moderated.

A multisite randomized controlled trial of Seeking Safety vs. Relapse Prevention Training for women with co-occurring posttraumatic stress disorder and substance use disorders

Background: Co-occurring posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are associated with a more severe course and worse outcome than either disorder alone. In Europe, few treatments have been evaluated for PTSD and SUD. Seeking Safety, a manualized, integrated, cognitive-behavioural treatment, has been shown to be effective in studies in the USA. Objective: To test the efficacy of Seeking Safety plus treatment as usual (TAU) in female outpatients with PTSD and SUD compared to Relapse Prevention Training (RPT) plus TAU and TAU alone. Method: In five German study centres a total of N = 343 women were randomized into one of the three study conditions. PTSD severity (primary outcome), substance use, depression and emotion dysregulation (secondary outcomes) were assessed at baseline, post-treatment, as well as at three months and six months post-treatment. Results: Treatment participants attended M = 6.6 sessions (Seeking Safety) and M = 6.1 sessions (RPT). In an intent-to-treat analysis, Seeking Safety plus TAU, RPT plus TAU and TAU alone showed comparable decreases in PTSD severity over the course of the study. Seeking Safety plus TAU showed superior efficacy to TAU alone on depression and emotion regulation and RPT plus TAU was more effective than TAU alone on number of substance-free days and alcohol severity. Minimum-dose analyses suggest additional effects of both programmes among participants who attended at least eight group sessions. Conclusions: With respect to PTSD symptoms, a brief dose of Seeking Safety and RPT in addition to TAU was not superior to TAU alone in women with PTSD and SUD. However, Seeking Safety and RPT showed greater reductions than TAU alone in other domains of psychopathology and substance use outcomes respectively. Future studies should investigate further variables, such as what aspects of each treatment appeal to particular patients and how best to disseminate them.

A Randomized Controlled Trial for Veterans with PTSD and Substance Use Disorder: Creating Change versus Seeking Safety

BACKGROUND

Posttraumatic stress disorder (PTSD) and substance use disorder (SUD) co-occur in military veterans and other populations.

OBJECTIVE

To conduct a randomized controlled trial to compare a new past-focused treatment (Creating Change; CC), to a well-established, evidence-based present-focused treatment for PTSD/SUD (Seeking Safety; SS), on symptoms of both disorders. CC guides patients to process the past through exploration of PTSD/SUD life themes and memories whereas SS focuses on coping skills in the present.

METHODS

Fifty-two male and female veterans with current PTSD/SUD were randomized (n = 26 per treatment) and assessed at baseline, end-of-treatment and 3-month follow-up. They received 17 individual one-hour sessions.

RESULTS

Intent-to-treat analyses indicated that both conditions improved over time, with no difference between conditions, on PTSD, alcohol use, and drug use (our primary outcomes) as well as mental health symptoms, quality of life, self-efficacy, and SUD cognitions. Effect sizes were medium except for alcohol use, which was large. Change over time reflected improvement from baseline to end-of-treatment, with gains sustained at follow-up, although alcohol use showed continued improvement from end-of-treatment to follow-up. Both treatments evidenced a strong safety profile; and attendance, alliance, and treatment satisfaction were also very strong. Conclusions/importance: CC has promise as a PTSD/SUD therapy with strong public health relevance and the potential to fill important gaps in the field. We used minimal exclusionary criteria to obtain a real-world sample, which was severe-predominantly substance-dependent with chronic PTSD and additional psychiatric diagnoses. Future research is warranted, especially on nonveteran samples and treatment mechanisms of action.

Postassault Substance Use and Coping: A Qualitative Study of Sexual Assault Survivors and Informal Support Providers

This qualitative interview study examined 45 informal support dyads where a sexual assault was disclosed. Data from matched pairs of survivors and their primary informal support provider (e.g., friend, family, significant other), were used to explore the survivor-support provider (SP) perspectives of coping with assault-related distress via substance use and the effects of survivor substance use on the survivor-SP relationship. Results revealed that survivors' use of drinking and/or drugs to cope had both positive and negative effects on survivor-SP relationships. Findings also showed that SPs play various roles in providing support to survivors who cope via substance use, including engaging in substance use with the survivor and efforts to help get help in their recovery from the assault and substance abuse. Suggestions are made for how safe spaces can be provided where survivors and supporters can get information and treatment, whether formal or informal, that addresses sexual assault, PTSD and substance abuse issues in an integrated way.