Treating Co-Occurring Posttraumatic Stress Disorder and Substance Use Disorders in an Outpatient Setting in New Zealand
Benton, David M., Deering, Daryle E. A., Adamson, Simon J., New Zealand Journal of Psychology
The incidence of anxiety disorders including post traumatic stress disorder (PTSD) is very high among women who abuse alcohol and/or other drugs (Briere & Runtz, 1987; Najavits, Weiss, & Shaw, 1997; Paone, Chavkin, Wiliets, Friedman, & Jarlais, 1992), and data from the US National Comorbidity Survey (Kessler, Berglund, Demler, Jin, Merikangas, & Walters, 1995), an Australian epidemiological study (Mills, Teesson, Ross, & Peters, 2006) and a New Zealand study of alcohol and drug treatment patients found one third were diagnosed with current PTSD (Adamson, Todd, Sellman, Huriwai, & Porter, 2006).
The co-existing disorders of PTSD and SUDS have deleterious effects on the social, psychological and physical wellbeing of sufferers, predict poorer treatment outcomes (Brown, Stout, Mueller 1999; Najavits, Weiss, Shaw, Muenz, 1998; Rosen, Ouimette, Sheikh, Gregg, & Moos, 2002), and tend to persist over many years (Bartels, Drake, & Wallach, 1995). The presence of PTSD is consistently associated with poorer addiction treatment outcomes, and is related to distinct barriers to treatment such as failure to assess PTSD, failure to address or refer to treatment for PTSD issues, and on the part of the patient, emotional pain, shame, and self blame (Ouimette, Brown & Najavits, 1998). Study findings consistently reveal a very vulnerable population with extensive histories of abuse, substantial physical and mental health service needs, and women who often use numbers of different services in an attempt to find help and/or relief (Becker, Noether, Larson, Gatz, Brown, Heckman, & Giard, 2005).
Compared to experiencing either disorder alone therefore, the combination of PTSD and SUDS is marked by a more severe clinical profile and significantly greater impairment on a wide range of variables, including interpersonal and medical problems as well as motivation for treatment and treatment adherence (Brady, Killeen, Saladin, Dansky, & Becker, 1994; Brown, Stout, Mueller, 1999; Najavits, Weiss, & Shaw, 1999). As therapy patients, those with co-occurring PTSD and SUD are anecdotally reported to be very difficult, have fragile treatment alliances and evoke negative emotional responses by therapists (Cramer, 2002). Moreover, PTSD, unlike many other disorders, is widely reported to worsen in early abstinence, making treatment of the SUD particularly challenging (Brady et al., 1994; Freidman and Yehuda, 1995). This may in part be due to the symptoms of substance withdrawal being similar to the arousal symptoms of PTSD (Jacobsen, Southwick, Kosten, 2001), i.e. difficulty sleeping, agitation, anxiety, autonomic hyperactivity or restlessness, tremors, and nausea.
Although consensus is lacking regarding best practices a number of integrated psychosocial treatments (e.g., Seeking Safety, Substance-Dependence PTSD Therapy, Concurrent Treatment of PTSD and Cocaine Dependence) have shown empirically supported promise in reducing symptoms of both disorders (Back, 2006). Evidence regarding integrated treatment for those with co-existing disorders is consistent and positive (Kofoed, Friedman, & Peck, 1993; Brady et al., 1994; Brown, Recupero, & Stout, 1995). However, while there are recently published guidelines on the assessment and management of people with coexisting mental health and substance use problems (Todd, 2010), there is to date no published New Zealand studies that have investigated the provision of integrated treatment, despite the same levels of acuity.
The aim of the present study was to evaluate outcomes of a manualised psychotherapy programme, Seeking Safety which was designed for women who present with concurrent PTSD and SUDS (Brown, Recupero, & Stout, 2002; Najavits Drake, & Wallach, 2002), and eleven published outcome studies establishes its efficacy as a treatment of co-existing PTSD and SUDS (e.g. Hien, Cohen, Miele, Litt, Capstick, 2004; Morrissey, Jackson, Ellis, Amaro, Brown, Najavits, 2005; Desai & Rosenbeck, 2006; Najavits, 2007). …