1. 2004 COPYRIGHT M. Rosier, MS 1 Seeking Safety in Methadone Maintenance Treatment: A Model for Treating Trauma and Opioid Dependence Marshall Rosier, MS Alan Lee Nolan, LCSW Marshall Rosier, MS Alan Lee Nolan, LCSW Connecticut Counseling Centers, Inc. Connecticut Counseling Centers, Inc. Connecticut Counseling Centers, Inc. Connecticut Counseling Centers, Inc. Lisa Najavits, Ph.D. Lisa Najavits, Ph.D. Department of Psychiatry Department of Psychiatry Harvard Medical School, McLean Hospital Harvard Medical School, McLean Hospital Diane Heyward, MS Michael Freeman, MS, LADC Diane Heyward, MS Michael Freeman, MS, LADC Connecticut Counseling Centers, Inc. Connecticut Counseling Centers, Inc. Connecticut Counseling Centers, Inc. Connecticut Counseling Centers, Inc.

2. 2004 COPYRIGHT M. Rosier, MS2 Goals of Presentation  Introduce the Connecticut Trauma Initiative  Discuss psychological trauma and PTSD  Outline several features of Seeking Safety  Discuss the technology transfer process  Share lessons learned

3. 2004 COPYRIGHT M. Rosier, MS3 Middlebury – Executive OfficesMiddlebury – Executive Offices –Executive Director, Richard Bilangi, MS 203.577.5320 e-mail:rbilangi@ctcounseling.org Waterbury Clinic Waterbury Clinic –Program Director, Michael Freeman, MS, LADC Norwalk ClinicNorwalk Clinic –Program Director, Robert Lambert, MA, LADC Danbury Clinic (Opening February 2005)Danbury Clinic (Opening February 2005) Celebrating 20 years of Treatment Excellence 1984 -2004 JCAHO Accredited

4. 2004 COPYRIGHT M. Rosier, MS4 Mission Statement: CCC, Inc. is a not-for-profit corporation that provides a full range of licensed outpatient substance abuse and mental health prevention, education and treatment services to assist adults in becoming productive members of society. CCC, Inc. is a not-for-profit corporation that provides a full range of licensed outpatient substance abuse and mental health prevention, education and treatment services to assist adults in becoming productive members of society. Celebrating 20 years of Treatment Excellence 1984 -2004 JCAHO Accredited

5. 2004 COPYRIGHT M. Rosier, MS5 Waterbury Clinic Patient Demographics:  825 Methadone Maintenance Patients  46% Women  54% Men  56% Caucasian  28% Hispanic  12% African American  4% Other JCAHO Accredited

6. 2004 COPYRIGHT M. Rosier, MS6 –Opiate Withdrawal Programs –Methadone Maintenance Treatment Programs –Intensive Outpatient Program –Partial Hospitalization Program –Dual Diagnosis Treatment and Services –Non-Chemically Supported Outpatient Treatment Program –Mental Health Treatment and Services Behavioral Health Care Services JCAHO Accredited

7. 2004 COPYRIGHT M. Rosier, MS7 –Pregnant Addict Care Programs –Women Centered Treatment Services –Patient Transportation –HIV, TB, HEP A, B, and C Screening, Education & Counseling Screening, Education & Counseling –Research Department NIDA Clinical Trails NetworkNIDA Clinical Trails Network NEW ENGLAND Node / Yale University –Suboxone - Bupenorphine Clinical Trial Behavioral Health Care Services JCAHO Accredited

8. 2004 COPYRIGHT M. Rosier, MS8 Connecticut Trauma Initiative: Department of Mental Health and Addiction Services Goals of the Initiative  Promote co-occurring PTSD competency  Link resources to system-wide care in public sector  Develop partnerships Criteria for Treatment Models  Representative target population  Cultural diversity  Evidence-based  Gender-sensitive  Skills-based rather than exposure-based  Empowering to survivors  Compatible with treatment needs and clinicians Source: http://www.dmhas.state.ct.us/trauma/overview.htm

9. 2004 COPYRIGHT M. Rosier, MS9 Posttraumatic Stress Disorder (PTSD) Exposure to a traumatic event –Experienced, witnessed or was confronted with traumatic event or events that involved Actual or threatened death or serious injury Threat to the physical integrity of self or others –Response involved Intense fear, helplessness, or horror Intrusion Avoidance Arousal DSM-IV-TR (2000) American Psychiatric Association

10. 2004 COPYRIGHT M. Rosier, MS10 Posttraumatic Stress Disorder (PTSD) Intrusion Event is persistently reexperienced –Distressing recollections such as images, thoughts, or perceptions –Recurrent dreams –Acting or feeling as if event were recurring –Distress or reactivity to exposure of internal or external cues that symbolize an aspect of the trauma DSM-IV-TR (2000) American Psychiatric Association

11. 2004 COPYRIGHT M. Rosier, MS11 Posttraumatic Stress Disorder (PTSD) Avoidance Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness –Efforts to avoid thoughts, feelings or conversations associated with trauma –Efforts to avoid activities, places or people that arouse recollection of trauma –Inability to recall important aspects of trauma –Markedly diminished interest or participation in significant activities –Feelings of detachment or estrangement from others –Restricted range of affect –Sense of foreshortened future DSM-IV-TR (2000) American Psychiatric Association

12. 2004 COPYRIGHT M. Rosier, MS12 Posttraumatic Stress Disorder (PTSD) Arousal Persistent symptoms of increased arousal –Difficulty falling or staying asleep –Irritability or outbursts of anger –Difficulty concentrating –Hypervigilance –Exaggerated startle response DSM-IV-TR (2000) American Psychiatric Association

13. 2004 COPYRIGHT M. Rosier, MS13 Co-Occurring Psychiatric & Substance Use Disorders Men and Women Entering Addiction Treatment in Connecticut Getting Better: A Study of Addiction Services in Connecticut. DMAHS & UCONN

14. 2004 COPYRIGHT M. Rosier, MS14 Seeking Safety: A Psychotherapy for Trauma/PTSD and Substance Use Disorders  Seeking Safety is a present-focused therapy to help people attain safety from both PTSD and substance abuse.  Seeking Safety is a present-focused therapy to help people attain safety from both PTSD and substance abuse.  The treatment was designed for flexible use. It has been conducted in group and individual format; for women, men, and mixed-gender; using all topics or fewer topics; in a variety of settings (e.g., outpatient, inpatient, residential); and for both substance abuse and dependence. It has also been used with people who have a trauma history, but do not meet criteria for PTSD.  The treatment was designed for flexible use. It has been conducted in group and individual format; for women, men, and mixed-gender; using all topics or fewer topics; in a variety of settings (e.g., outpatient, inpatient, residential); and for both substance abuse and dependence. It has also been used with people who have a trauma history, but do not meet criteria for PTSD. Lisa Najavits, Ph.D. Picture courtesy of NIDA www.seekingsafety.org

15. 2004 COPYRIGHT M. Rosier, MS15 Principles of Seeking Safety: Safety is the fundamental treatment goal “ When a person has both active substance abuse and PTSD, the most urgent clinical need is to establish safety.” Najavits, 2002 “ Seeking safety refers to helping patients free themselves from such negative behaviors and, in so doing, to move toward freeing themselves from trauma at a deep emotional level.” Najavits, 2002 Seeking Safety: A Treatment Manual for PTSD and Substance Abuse Najavits (2002) The Guilford Press, New York www.guilford.com

16. 2004 COPYRIGHT M. Rosier, MS16 Principles of Seeking Safety: Five Central Ideas  Safety is the priority of first-stage treatment  Integrated treatment for trauma and substance use disorders  A focus on ideals  Four content areas: cognitive, behavioral, interpersonal and case management  Various therapist processes emphasized such as building therapeutic alliances, using coping skills, giving patients control, modeling positive behavior and asking for patient feedback

17. 2004 COPYRIGHT M. Rosier, MS17 Principles of Seeking Safety: Safety is the fundamental treatment goal Safety is an umbrella term that signifies various elements:  Discontinuing substance use  Reducing suicidality  Minimizing exposure to HIV risk  Letting go of dangerous relationships  Gaining control over extreme symptoms  Stopping self-harm behaviors Najavits, 2002

18. 2004 COPYRIGHT M. Rosier, MS18 Principles of Seeking Safety: Additional Features of Treatment  Focus on potential rather than pathology  Attention to language  Emphasis on practical solutions  Relating the material to patient’s live  Making the treatment interesting to patients  Substance abuse as a priority  Patients do not necessarily need to meet formal criteria for PTSD criteria for PTSD

19. 2004 COPYRIGHT M. Rosier, MS19 Principles of Seeking Safety: Recommended Session Format  Check-in  Quotation  Session Topic  Check-Out  End of Session Questionnaire

20. 2004 COPYRIGHT M. Rosier, MS20 Principles of Seeking Safety: Recommended Session Format  Check-in  How are you feeling?  What good coping have you done?  Any substance use or unsafe behavior?  Did you complete your commitment?  Community resource update?

21. 2004 COPYRIGHT M. Rosier, MS21 Principles of Seeking Safety: Recommended Session Format  Quotation  The purpose of the quotation  Engage patient emotionally  Provide inspiration  Offer treatment reference for future good coping

22. 2004 COPYRIGHT M. Rosier, MS22 Principles of Seeking Safety: Sample Quotation “Let your heart guide you. It whispers, so listen closely” -Molly Goode (20th-century American writer) Taken from Seeking Safety – Setting Boundaries in Relationships (page 271)

23. 2004 COPYRIGHT M. Rosier, MS23 Principles of Seeking Safety: Recommended Session Format  Session Topic  Ask patients to review written materials  Relate material to current and specific issues  Ask patients what they find to be most relevant  Identify patient issues to process  Mention PTSD and Substance Abuse  Encourage patients to generate options

24. 2004 COPYRIGHT M. Rosier, MS24 Principles of Seeking Safety: Recommended Session Format  Check-Out  Name one thing that you got out of today’s session?  Any problems with the session?  What is your new commitment?  Encourages the patient to keep moving forward  Viable and realistic  Patient oriented  What community resource will you contact?

25. 2004 COPYRIGHT M. Rosier, MS25 Principles of Seeking Safety: Recommended Session Format  End of Session Questionnaire  Ask patients to complete feedback questionnaire  Benefits of anonymous feedback  Patients are empowered  Patients feel valued  Helpful in planning future sessions

26. 2004 COPYRIGHT M. Rosier, MS26 Seeking Safety: Sample Treatment Topics  Detaching from Emotional Pain (Grounding)  Taking Care of Yourself  Asking for Help  Setting Boundaries in Relationships  Coping with Triggers Essential first steps…  Introduction to Treatment/Case Management  Safety  PTSD: Taking Back Your Power

27. 2004 COPYRIGHT M. Rosier, MS27 Technology Transfer Process: Research to Practice Technology Transfer “Involves creating a mechanism by which a desired change is accepted, incorporated and reinforced at all levels of an organization or system.” The Change Book: A Blueprint for Technology Transfer (2000) See www.nattc.org/resPubs/changeBook.html Goal of Technology Transfer To integrate technology, research and innovation not only into the practices and policies, but into the culture, of the organization

28. 2004 COPYRIGHT M. Rosier, MS28 Technology Transfer Process: Research to Practice Other Issues for Consideration Institutional Supports Barriers to Change Readiness for Change Climate for Change Resources Quality Improvement Process and Assessment Dwayne Simpson (2002)

29. 2004 COPYRIGHT M. Rosier, MS29 Seeking Safety: Research to Practice Fall 2002: Seeking Safety two-day training Dr. Lisa Najavits The Women’s Consortium New Haven, CT  Discussed trauma and Posttraumatic Stress Disorder  Reviewed history of trauma treatment  Discussed current theories and treatment  Introduced the Seeking Safety model  Integrated case studies, research findings and clinical techniques in providing Seeking Safety treatment

30. 2004 COPYRIGHT M. Rosier, MS30 One year consultation with Lisa Najavits, Ph.D. and Martha Schmitz, Ph.D. One year consultation with Lisa Najavits, Ph.D. and Martha Schmitz, Ph.D. Weekly phone and once a month on-site consultations with clinical team Weekly phone and once a month on-site consultations with clinical team Referrals to Seeking Safety sessions reviewed by clinical team Referrals to Seeking Safety sessions reviewed by clinical team Seeking Safety sessions scheduled in both the AM and PM clinics Seeking Safety sessions scheduled in both the AM and PM clinics Seeking Safety: Research to Practice

31. 2004 COPYRIGHT M. Rosier, MS31 Clinical Practice Challenges  Systemic  Environmental  Economic  Program Policies and Procedures  Clinical Staff Recruitment  Clinical Orientation  Patient Education Seeking Safety: Research to Practice

32. 2004 COPYRIGHT M. Rosier, MS32 Seeking Safety: Women’s Group Nearly 1 in 4 women from the MMTP participated in Seeking Safety groups  7 groups with female clinical co-facilitation  Groups served between 5 – 12 women  Most groups 26 weeks or more in duration  Weekly group meetings  Sessions lasted between 1 and 1 ½ hours  Relationship issues, boundaries and anger management

33. 2004 COPYRIGHT M. Rosier, MS33 Seeking Safety: IOP/PHP Group Seeking Safety has been integrated into the IOP/PHP program for all women  2 groups with female clinical co-facilitation  Twice weekly group meetings  Sessions last 1 hour with extended application through out IOP/PHP program  Greater emphasis on skills application into life experiences due to increased exposure  Beneficial cohort effects = Increased comfort

34. 2004 COPYRIGHT M. Rosier, MS34 Seeking Safety: HIV Positive Group Safety and Case Management have been the central themes  1 Women’s group and 1 Men’s group  Co-facilitated by female clinicians  Bi-weekly for 1 ½ hours  Safe coping and skills building focused  Commitments tended to focus on medical issues, healthy behaviors and lifestyle

35. 2004 COPYRIGHT M. Rosier, MS35 Seeking Safety: Men’s Group Men’s Group remained active Men’s Group remained active for over 2 years  2 groups with male clinician co-facilitation  Groups served 12 men – 8 consistently  Weekly group meetings  Sessions lasted 1 ½ hours  Termination was particularly challenging

36. 2004 COPYRIGHT M. Rosier, MS36  Length of Session Seeking Safety: Implementation Issues  Length of Treatment  Group Composition  Topic Selection  Clinician Representation  Session Format  Level of Care 60 vs. 90 minutes Mixed vs. Same Gender Mixed vs. Same Gender Female vs. Male 1 vs. 2 Open vs. Closed Open vs. Closed Choice vs. Assigned Structured vs. Fluid Structured vs. Fluid Entry vs. Maintenance Entry vs. Maintenance

37. 2004 COPYRIGHT M. Rosier, MS37  Expert Consultation  On site and electronic/phone  Structured Weekly Peer Supervision  Ongoing Training and development  Top-Down Administrative Support  Utilization of Consumer Feedback  Data Collection Seeking Safety: Implementation Issues

38. 2004 COPYRIGHT M. Rosier, MS38 Seeking Safety: Benefits of Treatment Patients’ Self-Reported Improvements  Reduced Substance Use  Fewer Psychiatric Symptoms  Less Hopelessness and Depression  Improved Psychological Functioning  Higher Quality Interpersonal Relationships

39. 2004 COPYRIGHT M. Rosier, MS39 Seeking Safety: Benefits of Treatment Observed Benefits of Treatment  Flexible Treatment Model  Increased Treatment Satisfaction  Improved Problem Solving and Help Seeking  Increased Ownership and Empowerment of Recovery

40. 2004 COPYRIGHT M. Rosier, MS40  Treatment Outcome Research  Expanded Treatment  Inter-Agency Collaboration  Evolution of the CT State Trauma Initiative  Community Education and Awareness  Continuity of Care  Community Resources Database Seeking Safety: Future Directions

41. 2004 COPYRIGHT M. Rosier, MS41 Summary  People entering treatment for substance use disorders are very likely to have a trauma history  Evidence-based practices now exist to effectively treat co-occurring psychological trauma/PTSD and substance use disorders  Seeking Safety is a flexible, highly acceptable and feasible treatment for people with Opioid Use Disorders  Seeking Safety can be implemented into the existing clinical practices of MMTPs to provide beneficial treatment that improve patient outcomes and satisfaction

42. 2004 COPYRIGHT M. Rosier, MS42 Presenter’s Contact Information Marshall Rosier, MS mrosier@ctcounseling.org (203) 755-8874 Alan Lee Nolan, LCSW anolan@ctcounseling.org Lisa Najavits, Ph.D. www.seekingsafety.org Diane Heyward, MS dheyward@ctcounseling.org Michael Freeman, MS, LADC mfreeman@ctcounseling.org