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West Quality Improvement Award Winner: Integrating trauma care into substance use treatment

May 1, 2008
by Sharon Chambers, LICSW, CDP and Allison Kristman-Valente, BS, MSW
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Residence XII created a program that helps women with these often co-occurring problems

JAMES W. WEST, MD, QUALITY IMPROVEMENT AWARD WINNER

Residence XII in Kirkland, Washington, provides gender-specific substance use treatment for women. To address the high rate of women with substance use issues and co-occurring traumatic life experiences, Residence XII began its Trauma Integration Project in February 2007.

Our primary objectives included integrating a trauma assessment into the intake form for our intensive outpatient program (IOP), incorporating a new trauma-related curriculum into the IOP, monitoring trauma symptoms of women engaged in the specialized curriculum, monitoring symptoms of reported substance use, and comparing discharge rates of patients pre- and postimplementation.

Curriculum

We chose to integrate Lisa Najavits' Seeking Safety curriculum (http://www.seekingsafety.org) into our IOP. Seeking Safety uses a manualized cognitive-behavioral approach. Each session addresses both trauma issues and substance use issues, and sessions focus on goals such as safety being a priority, how the two issues are related, and coping and other behavioral skills relevant to both trauma and substance use. The highly structured sessions can be conducted in a group or individual format (We use the 12-session group format because it fits well with our IOP). We felt this curriculum was a good fits for our IOP for the following reasons.

Consumer need. Among Residence XII's clients 51.2% report a history of physical abuse and 41.5% report a history of sexual abuse. These figures are consistent with the literature. This is a primary clinical issue impacting women in early recovery.

Seeking Safety provides women with tools to address both their trauma and substance use simultaneously. Research has found that Seeking Safety is well-liked by women participants, demonstrated by high attendance rates.

Staff familiarity with the Seeking Safety curriculum. Between 2002 and 2007 Residence XII participated in the CTN 0015 Women's Treatment for Trauma and Substance Use Disorders clinical trial led by Columbia University's Denise Hien, PhD, and sponsored by the National Institute on Drug Abuse. During this protocol clinicians and supervisors were trained in the Seeking Safety methodology.

Alignment of clinical philosophies. Seeking Safety uses cognitive-behavioral techniques that align well with Residence XII's clinical philosophy, which focuses on cognitive-behavioral treatment and motivational interviewing.

Community need. Few programs in the Seattle metro area offer services addressing both chemical dependency and trauma issues. In King County, Washington State's most densely populated county, only the Veteran's Administration offered groups specifically targeting these issues. Other co-occurring treatment facilities addressed both substance use and trauma but did not have a specialized curriculum or clinical track.

In the past Residence XII's standard practice was to refer patients with trauma symptoms to facilities in Arizona (The Meadows and Sierra Tucson), the closest “specialty” centers that incorporated a trauma curriculum within chemical dependency treatment. To our knowledge, at the time we implemented our program no other facility in Washington State offered gender-specific treatment for co-occurring trauma and chemical dependency.

Results

In February 2007 we implemented the Seeking Safety curriculum in our morning IOP group. We integrated a brief screening for traumatic life events into the preexisting intake questionnaire to identify clients who would benefit from the voluntary Seeking Safety breakout group.

Between February 2007 and February 2008 we collected data on women entering the morning IOP group. The women were organized into two categories: those who attended the trauma curriculum (T) and those in standard education (SE). We used a modified Post Traumatic Stress Self Report and Interview and a modified Substance Use Inventory questionnaire to collect data. We sampled 39 women receiving SE and 42 in the T curriculum.

We found a decrease in the frequency and severity of trauma symptoms for women in the T group. The differences in initial mean score, for both severity and frequency of trauma symptoms, compared to the ending mean score were found to be significant using a paired t-test of means (table). In addition, substance use inventories revealed a decline in the number of patients reporting substance use between the initial and exit assessments in both the SE (12% to 0% of respondents) and T groups (22% to 5% of respondents).


Table. Results of t-tests

Initial Assessment

Exit Assessment

Mean—frequency of trauma symptoms

36.87879

30.93939

Mean—severity of trauma symptoms

41.42424

33.78787879


Patient retention was reviewed to determine if there was a difference between the groups. Discharges in the categories of against staff advice, medical discharge, at staff request, and transferring to a higher level of care were not significantly different between the groups.

Conclusion

We consider the project a success because we accomplished the integration we sought and because of its low overhead cost, positive impact on client services, and potential for sustainability. Residence XII is now the only gender-specific treatment facility in the state of Washington to offer an integrated co-occurring trauma and substance abuse track.

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