Therapy for Trauma and Substance Abuse

Article excerpt

Author's Note: An earlier version of this article appeared in the Five Borough AIDS Mental Health Alliance Newsletter.

The Sept. 11th terrorist attacks have brought trauma to the forefront of national awareness. After experiencing a trauma, such as a fire, assault, rape, child abuse, a hurricane, a car accident or military combat, most people heal naturally over time. But about one-third of people develop post-traumatic stress disorder (PTSD). (1) PTSD means being "stuck" in the trauma, unable to successfully face the emotional pain, cope with it and go on with normal life. People with PTSD suffer a range of emotional problems that are described in detail in the Diagnostic and Statistical Manual of Mental Disorders IV, (2) including intrusion (images of the trauma keep coming to mind), avoidance (not wanting to discuss the event) and arousal (intense negative feelings when reminded of the event).

Of particular importance is the strong connection between PTSD and substance use disorders. Most women and many men in substance abuse treatment have histories of trauma, and rates of current PTSD range from 12 percent to 59 percent. (3) Aside from numbers, the suffering associated with this dual diagnosis is extraordinary, with multiple life problems (such as domestic violence and homelessness), vulnerability to further trauma, other mental health and physical disorders, and difficulties in treatment. In correctional settings, it is far more the norm than the exception for inmates to have serious histories of substance abuse, trauma or both. (4)

A New Therapy

Beginning in 1993, a new therapy was developed specifically to address the dual diagnosis of substance use disorder and PTSD. The treatment, called Seeking Safety, (5) evolved through trial and error with many patients, as well as scientific testing. The treatment has been published in the book Seeking Safely: A Treatment Manual for PTSD and Substance Abuse. The treatment has been evaluated in four studies thus far, focusing on women in prison, (6) outpatient women, (7) innercity women (8) and men. (9) All four studies have evidenced significant positive outcomes and other studies are under way. The treatment has also been implemented clinically in a variety of settings, including a Connecticut state prison. In addition, the treatment will be implemented in the Federal Bureau of Prisons system for women who suffer from substance abuse and trauma.

Seeking Safety offers 25 treatment topics (see Table 1), each including a therapist guide and patient handouts. Patients and/or therapists select the order of topics, as well as which handouts to read, to provide a flexible treatment. The treatment has been conducted in different formats, including group and individual sessions; open and closed group; 50- and 90-minute sessions; singly and co-led; weekly and twice-weekly sessions:; and in outpatient, inpatient and residential settings. In one study focusing on treatment in a correctional setting, (10) group sessions were 90 minutes long twice weekly for three months.

Principles of Seeking Safety

Seeking Safety is based on five principles:

Safely as the Priority of Treatments. The title Seeking Safety expresses its basic philosophy: When a person suffers from both substance abuse and PTSD, the most urgent clinical need is to establish safety. Safety is an umbrella term that includes discontinuing substance use; reducing suicidal and self-harm behaviors, such as cutting; minimizing HIV exposure; ending dangerous relationships, such as with abusive partners and drug-using friends; and gaining control over extreme symptoms such as dissociation, or "spacing out." Many such self-destructive behaviors re-enact trauma, particularly for childhood abuse victims, who represent a large segment of people with this dual diagnosis." (11) The concept of first-stage treatment as stabilization and safety has been consistently recommended separately in both the PTSD (12) and substance abuse literature. …