Behavioral Treatment for Women with Co-Occurring Posttraumatic Stress and Substance Use Disorders: The NIDA CTN Women & Trauma Study

Background and Purpose: The “Women & Trauma Study” was proposed in response to the overwhelming need expressed by providers for an appropriate intervention for trauma-related problems commonly experienced by clients seeking addiction treatment. Women with co-occurring mental health and substance use disorders are now seen as a substantial subgroup of treatment-seeking patients in substance abuse programs, but community-based treatment research in this area remains limited. Seeking Safety (SS; Najavits, 2002) was selected as a promising study treatment because it was specific to co-occurring substance use and posttraumatic stress disorders (PTSD) and had the most empirical support (Rubin & Springer, 2009). Moreover, SS already had seen acceptability on the part of clinicians and adoption within some community treatment programs. The National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) offered an ideal platform to further test SS in a large, multi-site, rigorous community-based evaluation.

Methods: The Women & Trauma Study enrolled 353 women from seven community-based intensive outpatient substance abuse treatment programs located throughout the US. Eligible participants had at least one lifetime traumatic event and met DSM-IV criteria for either full or sub-threshold PTSD. Women were randomized to 12 sessions of either Seeking Safety (SS) or Women's Health Education (WHE), in addition to receiving treatment-as-usual in their community treatment programs. Participants were assessed at baseline, weekly during the 6-week treatment phase, and 1-week, 3-, 6-, and 12-months post treatment.

Results: Results from the primary analysis showed that PTSD symptoms decreased significantly during the treatment phase for both SS and WHE; symptoms continued to decrease over follow-up but at a slower rate. No treatment effects were observed on substance use outcomes. In a series of secondary analyses, findings revealed: 1) no differences in safety events between SS and WHE; 2) significantly lower PTSD symptoms among alcohol misusers in SS compared to WHE during treatment and follow-up; 3) SS was more effective in achieving substance use improvement compared to WHE among those who were heavy substance users at baseline and had achieved significant PTSD reductions; and 4) participants in SS who were at higher sexual risk (i.e., at least 12 unprotected sexual occasions per month) significantly reduced the number of unprotected occasions over 12-month follow up compared to WHE. Participating treatment programs continued to implement SS and WHE to varying degrees based on perceptions of “evidence-based”, in addition to practical issues such as staff turnover.

Conclusions & Implications: This study demonstrated that community clinicians could provide a comprehensive treatment for trauma and substance abuse safely and with fidelity. Secondary analyses revealed that SS was more effective among subgroups of women, including alcohol misusers, heavier substance users who improve on PTSD symptoms, and women at higher risk for HIV/AIDS. Social work advocacy around appropriate assessment and treatment provision among women dependent on drugs and alcohol is essential to improving care. Adoption and implementation decisions regarding evidence-based practice are complicated and research investigators and providers must balance clinical trial outcomes with clinical relevance and cost effectiveness concerns.