PAC 240 Module 5 Co-Occurring Disorders Example

Sober First or Safe First? Integrated Treatment for a Woman With Posttraumatic Stress and Alcohol Use Disorder

Student Name

Psychology and Addiction Studies Program, Aspen University

PAC 240: Helping Skills

Instructor Name

Month Day, Year

Sober First or Safe First? Integrated Treatment for a Woman With Posttraumatic Stress and Alcohol Use Disorder

Jenna is twenty-nine and works as a dental assistant. A year ago she left a partner who had abused her for three years. Since then she has had nightmares most nights, startles at sudden noises, avoids the neighborhood where they lived and feels constantly on guard. She drinks most nights, usually four or five drinks, to fall asleep, and on bad nights more. When she sought help at a community mental health clinic, she was told she needed to stop drinking before trauma therapy could begin. When she went to an addiction program, she was told her drinking was a symptom of trauma that should be treated first. She arrived at Riverside Recovery Services, the composite program in these papers, saying she felt like a problem nobody wanted. Jenna is invented and Riverside is fictional; the research is real.

How Common Co-Occurring Disorders Are

Regier et al. (1990) reported findings from the Epidemiologic Catchment Area study, a survey of more than twenty thousand adults in five American communities. Mental disorders and substance use disorders frequently occurred together. Among people with a drug use disorder at some point in their lives, more than half also had a mental disorder, and among those with an alcohol use disorder, more than a third did. People with severe mental illnesses, such as schizophrenia and bipolar disorder, had very high rates of substance use disorders. The authors concluded that co-occurrence was the rule rather than the exception in some populations and called for services that could address both.

Kessler et al. (1996) examined co-occurring disorders in the National Comorbidity Survey, a national sample of Americans. About half of the people with a lifetime addictive disorder also had at least one lifetime mental disorder. In most cases, the mental disorder began earlier than the addictive disorder, suggesting that early mental disorders may be a risk factor for later substance problems and a target for prevention. Among people with co-occurring disorders in the past year, only a minority had received any treatment, and fewer still had received treatment for both.

Three Ways to Organize Care

Integrated Treatment

Drake et al. (2001) described the components of integrated dual diagnosis treatment, developed mainly for people with severe mental illness and substance use disorders. In integrated treatment, the same clinicians or team treat both disorders, so the client receives one consistent approach. The model includes stage-wise interventions matched to the client's readiness, from engagement through active treatment and relapse prevention, along with motivational interventions, counseling to build skills, social support, attention to housing and other needs, assertive outreach when needed and a long-term perspective, since recovery from both disorders takes time. The authors noted that integrated programs were supported by research but rarely available, and they described the organizational changes needed to implement them.

Seeking Safety

Najavits et al. (1998) developed and tested Seeking Safety, a cognitive-behavioral treatment designed specifically for people with both posttraumatic stress disorder and substance use disorder. Rather than asking clients to retell traumatic memories, which can increase distress and substance use early in recovery, Seeking Safety focuses on the present and on safety: safe coping skills, healthy relationships, taking care of oneself and recognizing the links between trauma symptoms and substance use. In a pilot study with women in outpatient treatment, participants who completed the program showed improvements in substance use, trauma-related symptoms, suicidality and several other areas. The study was small and uncontrolled, and later controlled trials produced more mixed results, but the approach has become widely used because it addresses both disorders together and is safe to begin immediately.

Jenna's Diagnoses

Jenna meets criteria for posttraumatic stress disorder, with intrusive memories and nightmares, avoidance, negative changes in mood and beliefs and heightened arousal for more than a month after the trauma. She also meets criteria for a moderate alcohol use disorder, including drinking more than intended, failed attempts to cut down, continued use despite sleep and mood problems and tolerance. Neither diagnosis explains away the other; both need treatment.

Why Drinking Helps, and Why It Stops Helping

Jenna's drinking makes sense in light of her symptoms. Alcohol quiets the arousal that keeps her awake and dulls the nightmares for a few hours, which is why she reaches for it each night. But it also fragments sleep later in the night, worsens anxiety the next day and keeps her from learning that she can tolerate her feelings without it. Over time, each disorder feeds the other. Explaining this cycle to Jenna, without blame, is part of treatment: it gives her a reason to work on both at once and shows her that her drinking was an understandable attempt to cope.

An Integrated Plan

Jenna's plan treats both disorders together, on one team. She will join a Seeking Safety group twice weekly, with individual sessions that apply its skills to her nights. A psychiatric prescriber on the team will review her sleep and drinking and consider medications that address posttraumatic stress symptoms and alcohol use, coordinated so that sedating medications are avoided while she drinks. Because her former partner still lives in the city, her counselor will complete a safety plan with her, including contacts at a domestic violence program, and with her consent coordinate with an advocate there. Once her drinking and sleep have stabilized and she feels ready, the team will consider trauma-focused therapy that addresses memories directly. Her progress on both disorders will be reviewed together every month.

Conclusion

Jenna was turned away twice, by services that each insisted the other disorder be treated first. Regier and colleagues and Kessler and colleagues show that co-occurring disorders are common, that mental disorders often come first and that few people receive treatment for both. Drake and colleagues describe how integrated treatment brings care for both under one team, and Najavits and colleagues offer a present-focused approach that can start immediately. An integrated plan lets Jenna begin recovery from both disorders without being told to finish one first.

References

Drake, R. E., Essock, S. M., Shaner, A., Carey, K. B., Minkoff, K., Kola, L., Lynde, D., Osher, F. C., Clark, R. E., & Rickards, L. (2001). Implementing dual diagnosis services for clients with severe mental illness. Psychiatric Services, 52(4), 469-476. https://doi.org/10.1176/appi.ps.52.4.469

Kessler, R. C., Nelson, C. B., McGonagle, K. A., Edlund, M. J., Frank, R. G., & Leaf, P. J. (1996). The epidemiology of co-occurring addictive and mental disorders: Implications for prevention and service utilization. American Journal of Orthopsychiatry, 66(1), 17-31. https://doi.org/10.1037/h0080151

Najavits, L. M., Weiss, R. D., Shaw, S. R., & Muenz, L. R. (1998). "Seeking safety": Outcome of a new cognitive-behavioral psychotherapy for women with posttraumatic stress disorder and substance dependence. Journal of Traumatic Stress, 11(3), 437-456. https://doi.org/10.1023/A:1024496427434

Regier, D. A., Farmer, M. E., Rae, D. S., Locke, B. Z., Keith, S. J., Judd, L. L., & Goodwin, F. K. (1990). Comorbidity of mental disorders with alcohol and other drug abuse: Results from the Epidemiologic Catchment Area (ECA) Study. JAMA, 264(19), 2511-2518. https://doi.org/10.1001/jama.1990.03450190043026