2004 COPYRIGHT M. Rosier, MS 1 Seeking Safety in Methadone Maintenance Treatment: A Model for Treating Trauma and Opioid Dependence Marshall Rosier, MS

2004 COPYRIGHT M. Rosier, MS 2004 COPYRIGHT M. Rosier, MS 11

Seeking Safety in Methadone Maintenance

Treatment: A Model for Treating Trauma and

Opioid Dependence

Marshall Rosier, MS Alan Lee Nolan, Marshall Rosier, MS Alan Lee Nolan, LCSWLCSW Connecticut Counseling Centers, Inc. Connecticut Counseling Centers, Connecticut Counseling Centers, Inc. Connecticut Counseling Centers, Inc.Inc.

Lisa Najavits, Ph.D.Lisa Najavits, Ph.D. Department of PsychiatryDepartment of Psychiatry Harvard Medical School, McLean HospitalHarvard Medical School, McLean Hospital

Diane Heyward, MS Michael Freeman, MS, Diane Heyward, MS Michael Freeman, MS, LADCLADC

Connecticut Counseling Centers, Inc. Connecticut Counseling Centers, Connecticut Counseling Centers, Inc. Connecticut Counseling Centers, Inc.Inc.


Goals of Presentation

Introduce the Connecticut Trauma Introduce the Connecticut Trauma Initiative Initiative

Discuss psychological trauma and PTSDDiscuss psychological trauma and PTSD

Outline several features of Outline several features of Seeking Seeking SafetySafety

Discuss the technology transfer processDiscuss the technology transfer process

Share lessons learnedShare lessons learned


• Middlebury – Executive OfficesMiddlebury – Executive Offices– Executive Director, Richard Bilangi, MSExecutive Director, Richard Bilangi, MS

203.577.5320 e-203.577.5320 e-mail:[email protected]:[email protected]

• Waterbury ClinicWaterbury Clinic– Program Director, Michael Freeman, MS, LADCProgram Director, Michael Freeman, MS, LADC

• Norwalk ClinicNorwalk Clinic– Program Director, Robert Lambert, MA, LADCProgram Director, Robert Lambert, MA, LADC

• Danbury ClinicDanbury Clinic (Opening February 2005) (Opening February 2005)

Celebrating 20 years of Celebrating 20 years of Treatment Excellence Treatment Excellence

1984 -20041984 -2004JCAHO Accredited


Mission Statement:Mission Statement: CCC, Inc. is a not-for-profit corporation CCC, Inc. is a not-for-profit corporation

that provides a full range of licensed that provides a full range of licensed outpatient substance abuse and outpatient substance abuse and

mental health prevention, education mental health prevention, education and treatment services to assist adults and treatment services to assist adults

in becoming productive members of in becoming productive members of society.society.

Celebrating 20 years of Celebrating 20 years of Treatment Excellence Treatment Excellence

1984 -20041984 -2004JCAHO Accredited


Waterbury Clinic

Patient Demographics:Patient Demographics: 825 Methadone Maintenance 825 Methadone Maintenance

PatientsPatients 46% Women46% Women 54% Men54% Men 56% Caucasian56% Caucasian 28% Hispanic28% Hispanic 12% African American12% African American 4% Other4% Other

JCAHO Accredited


– Opiate Withdrawal Programs Opiate Withdrawal Programs – Methadone Maintenance Treatment Methadone Maintenance Treatment

ProgramsPrograms– Intensive Outpatient ProgramIntensive Outpatient Program– Partial Hospitalization ProgramPartial Hospitalization Program– Dual Diagnosis Treatment and ServicesDual Diagnosis Treatment and Services– Non-Chemically Supported Outpatient Non-Chemically Supported Outpatient

Treatment ProgramTreatment Program– Mental Health Treatment and ServicesMental Health Treatment and Services

Behavioral Health Care

ServicesJCAHO Accredited


– Pregnant Addict Care ProgramsPregnant Addict Care Programs– Women Centered Treatment ServicesWomen Centered Treatment Services– Patient TransportationPatient Transportation– HIV, TB, HEP A, B, and CHIV, TB, HEP A, B, and C

•Screening, Education & CounselingScreening, Education & Counseling

– Research DepartmentResearch Department•NIDA Clinical Trails NetworkNIDA Clinical Trails Network

NEW ENGLAND Node / Yale UniversityNEW ENGLAND Node / Yale University– Suboxone - Bupenorphine Clinical TrialSuboxone - Bupenorphine Clinical Trial

Behavioral Health Care

ServicesJCAHO Accredited


Connecticut Trauma Initiative:Department of Mental Health and Addiction

Services

Goals of the InitiativeGoals of the Initiative Promote co-occurring PTSD competencyPromote co-occurring PTSD competency Link resources to system-wide care in public Link resources to system-wide care in public

sectorsector Develop partnershipsDevelop partnerships

Criteria for Treatment ModelsCriteria for Treatment Models Representative target populationRepresentative target population Cultural diversityCultural diversity Evidence-basedEvidence-based Gender-sensitiveGender-sensitive Skills-based rather than exposure-basedSkills-based rather than exposure-based Empowering to survivorsEmpowering to survivors Compatible with treatment needs and cliniciansCompatible with treatment needs and clinicians

Source: http://www.dmhas.state.ct.us/trauma/overview.htm


Posttraumatic Stress Disorder (PTSD)

Exposure to a traumatic event Exposure to a traumatic event – Experienced, witnessed or was Experienced, witnessed or was

confronted with traumatic event or confronted with traumatic event or events that involvedevents that involved• Actual or threatened death or serious injuryActual or threatened death or serious injury• Threat to the physical integrity of self or Threat to the physical integrity of self or

othersothers

– Response involved Response involved • Intense fear, helplessness, or horrorIntense fear, helplessness, or horror

IntrusionIntrusionAvoidanceAvoidanceArousalArousal

DSM-IV-TR (2000) American Psychiatric Association



IntrusionIntrusionEvent is persistently reexperiencedEvent is persistently reexperienced– Distressing recollections such as images, Distressing recollections such as images,

thoughts, or perceptionsthoughts, or perceptions– Recurrent dreamsRecurrent dreams– Acting or feeling as if event were recurringActing or feeling as if event were recurring– Distress or reactivity to exposure of Distress or reactivity to exposure of

internal or external cues that symbolize an internal or external cues that symbolize an aspect of the traumaaspect of the trauma




AvoidanceAvoidancePersistent avoidance of stimuli associated with Persistent avoidance of stimuli associated with the trauma and numbing of general the trauma and numbing of general responsivenessresponsiveness– Efforts to avoid thoughts, feelings or conversations Efforts to avoid thoughts, feelings or conversations

associated with traumaassociated with trauma– Efforts to avoid activities, places or people that Efforts to avoid activities, places or people that

arouse recollection of traumaarouse recollection of trauma– Inability to recall important aspects of traumaInability to recall important aspects of trauma– Markedly diminished interest or participation in Markedly diminished interest or participation in

significant activitiessignificant activities– Feelings of detachment or estrangement from othersFeelings of detachment or estrangement from others– Restricted range of affectRestricted range of affect– Sense of foreshortened futureSense of foreshortened future




ArousalArousalPersistent symptoms of increased Persistent symptoms of increased arousalarousal– Difficulty falling or staying asleepDifficulty falling or staying asleep– Irritability or outbursts of angerIrritability or outbursts of anger– Difficulty concentratingDifficulty concentrating– HypervigilanceHypervigilance– Exaggerated startle responseExaggerated startle response



Co-Occurring Psychiatric & Substance Use Disorders

Men and Women Entering Addiction Treatment in Connecticut

37

53.2

26

37.8

13.3

21.9

12.2

19.4

0

10

20

30

40

50

60

Any Disorder Depression Anxiety PTSD

Men Women

Getting Better: A Study of Addiction Services in Connecticut. DMAHS & UCONN


Seeking Safety:A Psychotherapy for Trauma/PTSD

and Substance Use Disorders

Seeking Safety Seeking Safety is a present-focused is a present-focused therapy to help people attain safety therapy to help people attain safety from both PTSD and substance from both PTSD and substance abuse. abuse.

The treatment was designed for The treatment was designed for flexible use. It has been conducted flexible use. It has been conducted in group and individual format; for in group and individual format; for women, men, and mixed-gender; women, men, and mixed-gender; using all topics or fewer topics; in a using all topics or fewer topics; in a variety of settings (e.g., outpatient, variety of settings (e.g., outpatient, inpatient, residential); and for both inpatient, residential); and for both substance abuse and dependence. substance abuse and dependence. It has also been used with people It has also been used with people who have a trauma history, but do who have a trauma history, but do not meet criteria for PTSD. not meet criteria for PTSD.

Lisa Najavits, Ph.D.Picture courtesy of NIDA

www.seekingsafety.org


Principles of Seeking Safety:Safety is the fundamental treatment

goal

““When a person has both active substance When a person has both active substance abuse and PTSD, the most urgent clinical abuse and PTSD, the most urgent clinical

need is to establish safetyneed is to establish safety.”.” Najavits, 2002Najavits, 2002

““Seeking safety refers to helping patients Seeking safety refers to helping patients free themselves from such negative free themselves from such negative behaviors and, in so doing, to move behaviors and, in so doing, to move

toward freeing themselves from trauma at toward freeing themselves from trauma at a deep emotional levela deep emotional level.”.”

Najavits, 2002Najavits, 2002

Seeking Safety: A Treatment Manual for PTSD and Substance Abuse

Najavits (2002) The Guilford Press, New Yorkwww.guilford.com


Principles of Seeking Safety:Five Central Ideas

Safety is the priority of first-stage treatment Safety is the priority of first-stage treatment

Integrated treatment for trauma and Integrated treatment for trauma and substance use disorders substance use disorders

A focus on idealsA focus on ideals

Four content areas: cognitive, behavioral, Four content areas: cognitive, behavioral, interpersonal and case managementinterpersonal and case management

Various therapist processes emphasized Various therapist processes emphasized such as building therapeutic alliances, using such as building therapeutic alliances, using coping skills, giving patients control, coping skills, giving patients control, modeling positive behavior and asking for modeling positive behavior and asking for patient feedbackpatient feedback


Principles of Seeking Safety:Safety is the fundamental treatment

goal

SafetySafety is an umbrella term that signifies is an umbrella term that signifies various elements: various elements:

Discontinuing substance useDiscontinuing substance use Reducing suicidalityReducing suicidality Minimizing exposure to HIV riskMinimizing exposure to HIV risk Letting go of dangerous relationships Letting go of dangerous relationships Gaining control over extreme symptoms Gaining control over extreme symptoms

Stopping self-harm behaviorsStopping self-harm behaviors

Najavits, 2002Najavits, 2002


Principles of Seeking Safety:Additional Features of Treatment

Focus on potential rather than pathologyFocus on potential rather than pathology

Attention to languageAttention to language

Emphasis on practical solutionsEmphasis on practical solutions

Relating the material to patient’s liveRelating the material to patient’s live

Making the treatment interesting to Making the treatment interesting to patientspatients

Substance abuse as a prioritySubstance abuse as a priority

Patients do not necessarily need to meet Patients do not necessarily need to meet formal formal

criteria for PTSDcriteria for PTSD


Principles of Seeking Safety:Recommended Session Format

Check-in Check-in

QuotationQuotation

Session TopicSession Topic

Check-OutCheck-Out

End of Session QuestionnaireEnd of Session Questionnaire



Check-inCheck-in

How are you feeling?How are you feeling? What good coping have you done?What good coping have you done? Any substance use or unsafe Any substance use or unsafe

behavior?behavior? Did you complete your Did you complete your

commitment?commitment? Community resource update?Community resource update?



QuotationQuotation The purpose of the quotationThe purpose of the quotation

Engage patient emotionallyEngage patient emotionally Provide inspirationProvide inspiration Offer treatment reference for Offer treatment reference for

future good copingfuture good coping


Principles of Seeking Safety:Sample Quotation

““Let your heart guide you. Let your heart guide you. It whispers, so listen closely”It whispers, so listen closely”

-Molly Goode-Molly Goode(20th-century American writer)(20th-century American writer)

Taken from Taken from Seeking SafetySeeking Safety – Setting Boundaries in – Setting Boundaries in Relationships (page 271)Relationships (page 271)



Session TopicSession Topic Ask patients to review written materialsAsk patients to review written materials Relate material to current and specific Relate material to current and specific

issuesissues Ask patients what they find to be most Ask patients what they find to be most

relevant relevant Identify patient issues to processIdentify patient issues to process Mention PTSD and Substance AbuseMention PTSD and Substance Abuse Encourage patients to generate optionsEncourage patients to generate options



Check-OutCheck-Out Name one thing that you got out of Name one thing that you got out of

today’s session?today’s session? Any problems with the session?Any problems with the session?

What is your new commitment?What is your new commitment? Encourages the patient to keep moving Encourages the patient to keep moving

forwardforward Viable and realisticViable and realistic Patient oriented Patient oriented

What community resource will you What community resource will you contact?contact?



End of Session QuestionnaireEnd of Session Questionnaire Ask patients to complete feedback Ask patients to complete feedback

questionnairequestionnaire

Benefits of anonymous Benefits of anonymous feedbackfeedback Patients are empoweredPatients are empowered Patients feel valuedPatients feel valued Helpful in planning future sessionsHelpful in planning future sessions


Seeking Safety:Sample Treatment Topics

Detaching from Detaching from Emotional Pain Emotional Pain (Grounding)(Grounding)

Taking Care of Taking Care of YourselfYourself

Asking for HelpAsking for Help Setting Boundaries Setting Boundaries

in Relationshipsin Relationships Coping with TriggersCoping with Triggers

Essential first steps…Essential first steps…

Introduction to Treatment/Case Introduction to Treatment/Case ManagementManagement

SafetySafety

PTSD: Taking Back Your PowerPTSD: Taking Back Your Power


Technology Transfer Process: Research to Practice

Technology TransferTechnology Transfer ““Involves creating a mechanism by which a Involves creating a mechanism by which a desired change is accepted, incorporated and desired change is accepted, incorporated and reinforced at all levels of an organization or reinforced at all levels of an organization or

system.”system.”The Change Book: A Blueprint for Technology Transfer (2000)The Change Book: A Blueprint for Technology Transfer (2000)

See www.nattc.org/resPubs/changeBook.htmlSee www.nattc.org/resPubs/changeBook.html

Goal of Technology TransferGoal of Technology Transfer

To integrate technology, research and innovation To integrate technology, research and innovation not only into the practices and policies, but not only into the practices and policies, but

into the into the culture,culture, of the organization of the organization


Technology Transfer Process: Research to Practice

Other Issues for ConsiderationOther Issues for Consideration

Institutional Supports Institutional Supports Barriers to ChangeBarriers to Change

Readiness for ChangeReadiness for ChangeClimate for ChangeClimate for Change

ResourcesResourcesQuality Improvement Process and Quality Improvement Process and

AssessmentAssessmentDwayne Simpson (2002)Dwayne Simpson (2002)


Seeking Safety:Research to Practice

Fall 2002: Fall 2002: Seeking SafetySeeking Safety two-day training two-day training

Dr. Lisa Najavits Dr. Lisa Najavits

The Women’s Consortium New Haven, CTThe Women’s Consortium New Haven, CT

Discussed trauma and Posttraumatic Stress Discussed trauma and Posttraumatic Stress DisorderDisorder

Reviewed history of trauma treatmentReviewed history of trauma treatment Discussed current theories and treatmentDiscussed current theories and treatment Introduced the Seeking Safety modelIntroduced the Seeking Safety model Integrated case studies, research findings and Integrated case studies, research findings and

clinical techniques in providing Seeking Safety clinical techniques in providing Seeking Safety treatmenttreatment


• One year consultation with Lisa One year consultation with Lisa Najavits, Ph.D. and Martha Schmitz, Najavits, Ph.D. and Martha Schmitz, Ph.D.Ph.D.

• Weekly phone and once a month on-Weekly phone and once a month on-site consultations with clinical teamsite consultations with clinical team

• Referrals to Seeking Safety sessions Referrals to Seeking Safety sessions reviewed by clinical teamreviewed by clinical team

• Seeking Safety sessions scheduled in Seeking Safety sessions scheduled in both the AM and PM clinicsboth the AM and PM clinics



Clinical Practice Challenges Clinical Practice Challenges SystemicSystemic Environmental Environmental EconomicEconomic Program Policies and ProceduresProgram Policies and Procedures Clinical Staff RecruitmentClinical Staff Recruitment Clinical OrientationClinical Orientation Patient EducationPatient Education



Seeking Safety:Women’s Group

Nearly 1 in 4 women from the MMTP Nearly 1 in 4 women from the MMTP participated in Seeking Safety participated in Seeking Safety

groupsgroups

7 groups with female clinical co-facilitation7 groups with female clinical co-facilitation Groups served between 5 – 12 womenGroups served between 5 – 12 women Most groups 26 weeks or more in durationMost groups 26 weeks or more in duration Weekly group meetingsWeekly group meetings Sessions lasted between 1 and 1 ½ hoursSessions lasted between 1 and 1 ½ hours Relationship issues, boundaries and anger Relationship issues, boundaries and anger

managementmanagement


Seeking Safety:IOP/PHP Group

Seeking Safety has been integrated Seeking Safety has been integrated into the IOP/PHP program for all into the IOP/PHP program for all

womenwomen

2 groups with female clinical co-facilitation2 groups with female clinical co-facilitation Twice weekly group meetingsTwice weekly group meetings Sessions last 1 hour with extended Sessions last 1 hour with extended

application application through out IOP/PHP through out IOP/PHP programprogram

Greater emphasis on skills application into Greater emphasis on skills application into life life experiences due to increased exposureexperiences due to increased exposure

Beneficial cohort effects = Increased Beneficial cohort effects = Increased comfortcomfort


Seeking Safety:HIV Positive Group

SafetySafety and Case Management and Case Management have been the central themeshave been the central themes

1 Women’s group and 1 Men’s group1 Women’s group and 1 Men’s group Co-facilitated by female cliniciansCo-facilitated by female clinicians Bi-weekly for 1 ½ hoursBi-weekly for 1 ½ hours Safe coping and skills building focusedSafe coping and skills building focused Commitments tended to focus on Commitments tended to focus on

medical medical issues, healthy behaviors and issues, healthy behaviors and lifestylelifestyle


Seeking Safety:Men’s Group

Men’s Group remained active Men’s Group remained active

for over 2 yearsfor over 2 years

2 groups with male clinician co-facilitation2 groups with male clinician co-facilitation Groups served 12 men – 8 consistentlyGroups served 12 men – 8 consistently Weekly group meetingsWeekly group meetings Sessions lasted 1 ½ hoursSessions lasted 1 ½ hours Termination was particularly challengingTermination was particularly challenging


Length of SessionLength of Session

Seeking Safety:Implementation Issues

Length of TreatmentLength of Treatment

Group CompositionGroup Composition

Topic SelectionTopic Selection

Clinician Clinician RepresentationRepresentation

Session FormatSession Format

Level of Care Level of Care

60 vs. 90 minutes60 vs. 90 minutes

Mixed vs. Same GenderMixed vs. Same Gender

Female vs. MaleFemale vs. Male1 vs. 21 vs. 2

Open vs. ClosedOpen vs. Closed

Choice vs. AssignedChoice vs. Assigned Structured vs. FluidStructured vs. Fluid

Entry vs. MaintenanceEntry vs. Maintenance


Expert ConsultationExpert Consultation On site and electronic/phone On site and electronic/phone

Structured Weekly Peer Structured Weekly Peer SupervisionSupervision

Ongoing Training and developmentOngoing Training and development Top-Down Administrative SupportTop-Down Administrative Support Utilization of Consumer FeedbackUtilization of Consumer Feedback Data Collection Data Collection

Seeking Safety:Implementation Issues


Seeking Safety:Benefits of Treatment

Patients’ Self-Reported Patients’ Self-Reported ImprovementsImprovements

Reduced Substance UseReduced Substance Use

Fewer Psychiatric SymptomsFewer Psychiatric Symptoms

Less Hopelessness and DepressionLess Hopelessness and Depression

Improved Psychological FunctioningImproved Psychological Functioning

Higher Quality Interpersonal Higher Quality Interpersonal RelationshipsRelationships


Seeking Safety:Benefits of Treatment

Observed Benefits of TreatmentObserved Benefits of Treatment

Flexible Treatment ModelFlexible Treatment Model

Increased Treatment SatisfactionIncreased Treatment Satisfaction

Improved Problem Solving and Help Improved Problem Solving and Help SeekingSeeking

Increased Ownership and Increased Ownership and Empowerment Empowerment of Recoveryof Recovery


Treatment Outcome ResearchTreatment Outcome Research Expanded TreatmentExpanded Treatment Inter-Agency CollaborationInter-Agency Collaboration Evolution of the CT State Trauma Evolution of the CT State Trauma

InitiativeInitiative Community Education and AwarenessCommunity Education and Awareness Continuity of CareContinuity of Care Community Resources DatabaseCommunity Resources Database

Seeking Safety:Future Directions


SummaryPeople entering treatment for substance use People entering treatment for substance use

disorders are very likely to have a trauma disorders are very likely to have a trauma historyhistory

Evidence-based practices now exist to Evidence-based practices now exist to effectively treat co-occurring psychological effectively treat co-occurring psychological trauma/PTSD and substance use disorderstrauma/PTSD and substance use disorders

Seeking SafetySeeking Safety is a flexible, highly is a flexible, highly acceptable and feasible treatment for people acceptable and feasible treatment for people with Opioid Use Disorders with Opioid Use Disorders

Seeking SafetySeeking Safety can be implemented into the can be implemented into the existing clinical practices of MMTPs to existing clinical practices of MMTPs to provide beneficial treatment that improve provide beneficial treatment that improve patient outcomes and satisfactionpatient outcomes and satisfaction


Presenter’s Contact Information

Marshall Rosier, [email protected]

(203) 755-8874

Alan Lee Nolan, [email protected]

Lisa Najavits, Ph.D. www.seekingsafety.org

Diane Heyward, [email protected]

Michael Freeman, MS, [email protected]

Documents

2004 COPYRIGHT M. Rosier, MS 1 Seeking Safety in Methadone Maintenance Treatment: A Model for Treating Trauma and Opioid Dependence Marshall Rosier, MS