Two types of cognitive-behavioral therapy (CBT) for drug abuse, "relapse prevention" and "seeking safety," have shown promise in the treatment of women who abuse drugs and also have posttraumatic stress disorder (PTSD). Women participating in either therapy for 3 months showed decreases not only in substance abuse, but also in PTSD symptoms.
The result surprised NIDA-funded investigators, who expected seeking safety, but not relapse prevention therapy, to improve PTSD symptoms. "The patients seemed to apply the skills developed during CBT therapy—identifying and coping with emotional triggers without abusing drugs—to dealing with trauma-related problems," says Dr. Denise Hien, the study's lead investigator and director of the Women's Health Project at St. Luke's/Roosevelt Hospital Center in New York City.
The study participants—107 urban women, aged 18 to 55, with low incomes—faced many barriers to recovery, including difficulties with employment and parenting, and medical conditions. Most abused alcohol, marijuana, or cocaine, and experienced moderate depression-related problems at the beginning of treatment. All had PTSD symptoms, most with the full spectrum and a minority with fewer signs of the condition. Although some had developed PTSD as the result of experiencing or witnessing a single traumatic episode (e.g., an accident or natural disaster), 82 percent had experienced chronic recurring sexual or physical abuse. PTSD severity was not related to substance abuse levels. One in three patients in substance abuse treatment also experience PTSD.
During the study, 75 of the women participated in twice-weekly, 1-hour individual sessions of either seeking safety or relapse prevention CBT for 12 weeks. Compared with the other 32 study participants, who received a variety of standard treatments within the community, patients receiving CBT reduced their substance abuse and experienced fewer and less severe PTSD symptoms after 3 months of treatment. CBT patients maintained these gains 6 months after therapy, whereas those receiving community care experienced worse substance abuse and PTSD symptoms over time.
About half of the 75 women received a form of CBT called relapse prevention, which focuses on managing cravings, strengthening motivation to stop abuse, and enhancing personal relationships and networks to support recovery. They identified situations that might provoke them to relapse and developed specific strategies for avoiding and coping with these. Through role-playing and other activities, the women practiced drug refusal and general decision-making and problem solving skills. The remaining CBT patients, the seeking safety group, addressed PTSD and substance abuse as interrelated problems. Rather than delving into the trauma, these participants identified its effects on their current lives, including substance abuse. They practiced techniques to ease emotional pain, stop blaming themselves for the trauma, and cope with difficult interpersonal and potential relapse situations.
During the final 4 weeks of treatment, the CBT patients on average abused substances less frequently, consumed smaller amounts, spent less money on alcohol and drugs, and experienced fewer alcohol- and drug-related problems than patients in standard care. Before treatment, the CBT and community care patients showed the same Addiction Severity Index (ASI) alcohol scores, which averaged 0.4. The average score fell to 0.31 for the CBT patients after treatment, but did not change for those receiving community care. ASI drug scores also tended to decline for the CBT patients, but not for the comparison group.
The CBT patients, but not those in standard care, reported that their initial strong desires to use drugs eased over the course of the study, becoming mild-to-moderate urges that were easier to resist. The CBT patients also experienced less frequent and intense PTSD symptoms and reported fewer intrusive thoughts and avoidance symptoms compared with those receiving standard care. On the Clinician Administered PTSD Scale (CAPS), patients with a score above 65 are usually diagnosed as having PTSD. Before treatment, both the CBT and community care patients were above this clinical threshold, with average scores of 71.4 and 73.9, respectively. After therapy, only CBT patients showed significant improvement, with the average score falling to 54.5, whereas community care participants still showed signs of PTSD and an average CAPS score of 68. These gains had a significant impact on their lives; for example, they reduced the level of interference with occupational functioning, whereas those in standard care reported more interference problems. Only women who participated in CBT demonstrated improvement in depression-related problems, which changed from moderate to mild on average, according to clinician ratings.
People who have survived trauma often feel that life is meaningless and out of control. In CBT, whether relapse prevention or trauma-focused, the therapist helps the patient break the link between negative feelings, thoughts, and unhealthy behaviors and prepare to react differently in the future. "Cognitive-behavioral therapies offer patients a set of problem solving skills and strategies that help bring life back under their control," says Dr. Cecilia McNamara of NIDA's Division of Clinical Neuroscience, Development and Behavioral Treatment. With practice, their skills improve, which probably explains why the benefits of CBT endure and, according to one study, even increase at later followup points.
Relapse prevention is a well-established treatment for substance abuse, but Dr. Hien's study suggests that the therapy conveys general coping skills that patients can apply to PTSD. Several small studies have suggested seeking safety's promise in improving both PTSD symptoms and drug abuse, but clinicians remain concerned that addressing trauma in therapy might trigger relapse and impede addiction treatment. "Our findings suggest that seeking safety—rather than 'opening Pandora's box,' as some clinicians have thought—did not seem to worsen patients' problems and actually improved substance abuse and PTSD symptoms," says Dr. Hien. Women who participated in seeking safety attended, on average, as many therapy sessions and stayed in treatment as long as those in relapse prevention, suggesting that the seeking safety treatment does not reopen the trauma, and adding to the evidence that the therapy is not harmful. Although this preliminary study doesn't provide a conclusive answer for trauma- and addiction-treatment practitioners, it suggests that both seeking safety and relapse prevention may help people who experience both problems. Dr. Hien says it is a good first step toward evidence-based guidance on managing these commonly co-occurring conditions. Other researchers are studying seeking safety therapy in diverse patient populations, including men and adolescents.
Additional studies are needed to find out whether seeking safety therapy is feasible for community providers. Dr. Hien's study offered patients 24 individualized sessions with clinical psychologists trained in seeking safety and relapse prevention CBT, a level of therapy that may not be available to most people. Dr. Hien is working with NIDA's Clinical Trials Network to conduct a study in which community drug abuse counselors will offer a modified form of seeking safety in typical patient populations and treatment settings.
Source
- Hien, D.A., et al. Promising treatments for women with comorbid PTSD and substance use disorders. American Journal of Psychiatry 161(8):1426-1432, 2004. [Abstract]