An integrative approach to treating substance use problems and PTSD among maltreated youth. Carla Kmett Danielson PhD Medical University of South Caolina

1. Risk Reduction through Family
Therapy (RRFT): An Integrative
Approach to Treating Substance
Use Problems and PTSD Among
Maltreated Youth
Carla Kmett Danielson, Ph.D.
Medical University of South Carolina
April 13, 2015

2. Objectives
• 1) Understand the relation between high-risk
behaviors and child victimization
• 2) Become familiar with the clinical and empirical
rationale for taking an integrated and risk reduction
approach to treatment with maltreated adolescent
populations
• 3) Learn the fundamental components in
administering RRFT

3. Relation Between
High-Risk Behaviors and
Child Victimization

4. Outcomes of CSA
0
5
10
15
20
25
30
35
40
45
Past 6-12 months Lifetime
PTSD
MDE
Delinquent Behavior
Drinking to Intx
Non-exp Drug Use
*Danielson et al., 2010
Prevalence of problems
among CSA victims
(n=269*)

5. Trauma and Substance Abuse
• CSA: Over 2 times more likely to develop
alcohol or hard drug abuse
• CPA: Over 1.5 times more likely to develop
alcohol or marijuana abuse; over 3 times more
likely to develop hard drug abuse
• WV: Over 2.5 times more likely to report alcohol
abuse and over 4 times more likely to report
marijuana or hard drug abuse
• PTSD: Over 2 times more likely to report
marijuana or hard drug abuse

6. CSA and Risky Sexual Bx
• Among adolescent girls:
– CSA significantly increased the odds of experiencing
an adolescent pregnancy by 2.21-fold (up to 13 times
more likely);
– 2. 5 times more likely to have 3 or more partners;
• Among adolescent boys:
– Sexually abused boys were significantly more likely
than nonabused boys to report unprotected
intercourse (1.91), multiple sexual partners (2.91),
and pregnancy involvement (4.81).

7. Rationale for an Integrated
Approach to Treatment

8. What drives risky behavior among
trauma-exposed teens?
Community
School
Peer
Family
Individual

9. What drives risky behavior among
trauma-exposed teens?
Community
School
Peer
Family
Individual
Being an adolescent
(Neurology)
Coping skills
Other traumatic event
exposure

10. Allstate Ad, 2007

11. WHY?
• Traumatic Event Exposure?
– Reenactment
– Coping
– G X E

12. Link between trauma and substance abuse:
Negative Reinforcement Model
• Negative reinforcement models
– “Self-Medication Hypothesis”
– The motivational basis of behavior is the
reduction or avoidance of aversive internal
states.

13. Link between trauma and substance
abuse: Negative Reinforcement Model
Trauma
Significant
stressors
produce
strong
negative
affect
• Biased
attentional
&
response
selection
processes
• Escaping
negative
affective
state
becomes
primary
motivation
al concern
Hot
Information
Processing
Biases the
individual
toward the
response
options
that have
most
efficiently
ameliorate
d negative
affect in
the past
Other
response
options less
tightly
linked with
the
reduction of
negative
affect are
devalued

14. Example: Substance Abuse is
Increased by Removing Aversive Affect
Adolescent is
sexually
assaulted;
strong negative
affect response
Adolescent
attends to this
negative affect;
primary motivation
for behavior
becomes avoiding
this negative
affect
Adolescent who
“successfully”
escapes the
negative affect by
using substances is
likely to engage in
this behavior again

15. What drives risky behavior among
trauma-exposed teens?
Community
School
Peer
Family
Individual
Family History
Limited monitoring of
adolescent behavior
Family activity level
Being an adolescent
(Neurology)
Coping skills
Traumatic event
exposure

16. What drives risky behavior among CSA teens?
Community
School
Peer
Family
Individual
Using vs.
non-using
peers
Family History
Limited monitoring of
adolescent behavior
Family activity level
Being an adolescent
(Neurology)
Coping skills
Other traumatic event
exposure

17. What drives risky behavior among CSA
teens?
Community
School
Peer
Family
Individual
Truancy
Support
person in
school
environment
Using vs.
non-using
peers
Family History
Limited monitoring of
adolescent behavior
Family activity level
Being an adolescent
(Neurology)
Coping skills
Other traumatic event
exposure

18. What drives risky behavior among CSA
teens?
Community
School
Peer
Family
Individual
Drug community
Activities in the
community
Truancy
Support
person in
school
environment
Using vs.
non-using
peers
Family History
Limited monitoring of
adolescent behavior
Family activity level
Being an adolescent
(Neurology)
Coping skills
Other traumatic event
exposure

19. Risk Factors: Community
• Drug community?
• Rural?
• Structured activities?

20. State of the Science for Integrated
Approaches for Adolescents
• Progress in Adult Trauma/Substance Abuse Field
– Some data that integrated approaches are safe (exposure),
efficacious, and preferred by consumer (Back et al., 2006; Brady
et al., 2001; Cocozza et al., 2005; Mills et al., 2012)
• Seeking Safety (Najavits, Gallop, & Weiss, 2006)
– 1 Pilot RCT (n=33; vs. TAU)
– No treatment effects for PTSD
• No Exposure

21. State of the Science for Integrated
Approaches for Adolescents
• Three RRFT studies to date
– Completed open pilot trial (N=10) (Danielson et al., 2010b )
– Completed pilot RCT vs. Usual Care (N=30) (Danielson et
al., 2012)
– CSA; 70% reported other types of traumatic events
– Assessments:
• Interviews, urine drug screens, parent-report, youth-
report, chart
• Pre, Post, 3-month and 6-month follow-ups
– Ongoing RCT vs. TAU (n=80 to date)
• Through 18 month follow-up

22. RRFT Overview

23. Identifying RRFT Clients
• ‘Who’ is an RRFT case?

24. RRFT Overview
• Clinical Pathways Approach
– Use assessment to guide clinical decisions regarding
risk reduction vs. intensive treatment and order
• Seven primary OVERLAPPING components:
– Psychoeducation & Engagement
– Family Communication
– Substance Abuse
– Coping Skills
– PTSD
– Healthy Dating and Sexual Decision Making
– Revictimization Risk Reduction

25. RRFT Overview
• Principle 1: Finding the Fit
• Principle 2: Positive and Strength
Focused
• Principle 3: Increasing
Responsibility
• Principle 4: Present-Focused,
Action-Oriented and Well-Defined
• Principle 5: Targeting Sequences
• Principle 6: Developmentally
Appropriate
• Principle 7: Continuous Effort
• Principle 8: Evaluation and
Accountability
• Principle 9: Generalization
• P sychoeducation and
parenting skills
• R elaxation
• A ffective expression and
regulation
• C ognitive coping
• T rauma narrative development
& processing
• I n vivo gradual exposure
• C onjoint parent child sessions
• E nhancing safety and future
development

26. RRFT Fundamentals
• Confident
• Authentic
• Put it to paper
• Tangible progress
• Agenda
• Integrity
• Novelty

27. RRFT Fundamentals
• Confident

28. RRFT Fundamentals
• Authentic
• “What made the difference?”
• Hearing what is important to the teen, the
caregiver, the family….

29. RRFT Fundamentals
• Put it to paper
• What should get written down?

30. RRFT Fundamentals
• Tangible progress
• What is the value of this?
• How does efficacy get built?
• Real example

32. RRFT Fundamentals
• Agenda
• What does this mean?
• What is the value of this?

33. RRFT Fundamentals
• Integrity
• Ecologically valid sessions
• Ways to do this?

34. RRFT Fundamentals
• Novelty
• Always change things up

35. RRFT Format
• Individual and Family Sessions
• Office or community
• Phone Check Ins are critical
• Homework

36. RRFT Case Conceptualization
• Initial case conceptualization after completion
of RRFT Intake
• Ecological Functioning Handout
– Targets of intervention
• Maslow’s Hierarchy of
Needs Always in Play

37. Risk Factors: Ecological Model
Community
School
Peer
Family
Individual
Drug community
Truancy
Using vs.
Non-using
Peers
Family Hx of
Substance Abuse
Poor monitoring of
adolescent behavior
Family Activity Level
Being an Adolescent
(Neurology)
Traumatic event hx
Coping Skills

39. Psychoeducation &
Engagement (P & E)

40. Goals of P & E
 Provide information about traumatic events as relevant
 Provide information about psychological and physiological
reactions to stress
 Normalize teen’s and caregiver’s reactions to severe stress
 Emphasis on substance use and other risk behavior
 Instill hope for teen and family recovery
 Engage and Educate family about the benefits and need
for sticking with treatment
 Barrier assessment
 Safety planning
 SET TREATMENT GOALS!!! ( ‘carrot’)
 Enhance motivation for cutting down on substance use and
reducing other risky behavior as relevant
 Youth and caregiver

41. Family Communication

42. Goals of Family Communication
• Improve healthy communication between teen and
caregivers
• Increase family cohesion
• Decrease family conflict
• Increase parenting skills to manage high risk
behaviors
– Build caregiver’s efficacy via successful experiences
• Establish caregiver as the person the teen turns to for
help in times of trouble
• For youth without a participating caregiver:
– Identify other champions for the youth
– Process thoughts and feelings about not having participating
caregiver

43. SUBSTANCE ABUSE

44. Goals of Substance Abuse
• To reduce substance use
• To enhance motivation and efficacy in reducing use
• To identify drivers of substance use problems and implement
evidence-based interventions to address the drivers
– To help teen better understand link between their trauma history
and their substance abuse
• To bolster protective factors against substance abuse
• To teach realistic refusal skills
• To replace needs met by substance use with more adaptive
strategies
– Activating the reward system in other ways!
• To monitor use with random screening (ideally by caregiver)
• To monitor use in the context of trauma treatment
– Weekly assessments

45. • Disclosure to caregiver right away
when possible
• Harm reduction right away when
possible
• Drug/breath screening right away
when possible, even when youth is
denying use
• Ecological Validity (create the ‘mood’)
Substance Abuse:
Emphasized Key Components

46. Substance Abuse
• Fit Circle
• Substance abuse goes in the middle
• What are behaviorally specific drivers?
– Some common drivers:
– Poor monitoring
– Negative peers
– Lack of positive activities
– Low social support of family
– Truancy

47. Fit Circle
SUBSTANCE
ABUSE
Good
friends
use dugs
Use as
avoidance of
memories of
Sexual assault
Truancy
Parental
monitoring

48. Substance Abuse
• Include teen and caregiver in this process (in
session)
• Begin by choosing one or two primary “drivers”
• Then do a fit circle around each one of these to
determine your interventions
– Strength-focused
– Target sequence of events
– Behaviorally specific

49. Fit Circle
Good friends
use drugs
Unsure of
how to
approach/
socialize
with non-
using
peers
Is afraid friends
will think he/she
is uncool
Has fun
when
using
with
friends
Lack of
opportunities
to meet non-
using peers
Social
Skills
training
Refusal
skills
Identify
positive
activities
that will
be fun

50. Fit Circle Role Play

51. Drug Testing Protocol
Objective:
1. Provide a reliable and valid measure of substance use
so that contingencies can be applied appropriately and
quickly.
Drug screening is key!
• Teaching caregivers
• Therapist testing in absence of caregiver
• What to do with alcohol, less urine screen-able
drugs

52. • “7 C’s of Leverage” (Dr. Wes Boyd)
1.Cash
2.Computer
3.Curfew
4.Cell phone
5.Car
6.Credit
7. Cards
Substance Use:
Contingency Management

53. SUBSTANCE MONITORING CONTRACT
If [teen]’s urine drug screen is negative (no drugs detected or reported) and there were no
positive or refused alcohol breath tests since the last drug screen, I will:
1) Praise their progress!
2) Ask how I can help them keep up the good work.
3) Celebrate their progress by: (a) _____ (b) ______ (c) ______
If [teen]’s urine drug screen is positive (drugs detected or reported) and/or there were
positive or refused alcohol breath tests since the last drug screen, I will:
1) Remain calm!
2) Not give a lecture.
3) Ask how I can help them.
4) Express confidence that they can do better next time.
5) Use the following consequence: __________
Parent signature _______ Date _______ Teen signature _______ Date ______
Substance Use:
Contingency Management
Stanger & Budney, 2010, Child Adolesc Psychiatr Clin N Am.

54. Substance Abuse
• Progress is progress (harm reduction)

55. COPING

56. Goals of Coping Component
• Understand concept of positive and negative coping
• Feelings identification and expression
– Feeling safe
– SUDS scale
• To be able to differentiate and understand the link
between thoughts, feelings, and behaviors
• Increase positive coping techniques
– Relaxation
– Guided Imagery and PMR
– Cognitive processing
• To increase distress tolerance skills
– Mindfulness

57. PTSD

58. Goals of PTSD Component
• Psychoeducation-PTSD symptoms
• More intensive trauma exposure work (memories,
emotions, cues): Trauma Narrative and In Vivo
• Identification of Inaccurate or Unhelpful Core
– Beliefs that have been developed or reinforced as a
function of trauma exposure
• Processing of such beliefs to become more
helpful and/or accurate
• “Make Meaning”

59. Healthy Dating & Sexual
Decision Making

60. Healthy Dating & Sexual
Decision Making: Goals
• Redefine meaning of sex, intimacy
• Differentiate healthy vs unhealthy romantic relationships
– Healthy relationship with self
• Discuss factors in making decisions related to dating and
intimacy and how current decision making either coincides
or flies in the face of client’s goals
• Provide psychoeducation related to sexuality (STDs,
pregnancy)
• Develop skills for consistent and proper condom use
• When feasible and appropriate, establish caregiver as the
person the client will speak with in future regarding dating
and sex.

61. Revictimization Risk Reduction

62. Revictimization Risk Reduction:
Goals
• Primary goal of this component is
enhancement of safety
– Listening to ‘inner voice’: Recognizing cues, signs, etc
for potentially unsafe people, places, and situations
– For CSEC or gang, will be to reduce risk of their being
sexually exploited again, or going back to the streets.
• Other goals include:
– Reduce risk of other forms of victimization (e.g., on-
line, witnessing community violence)
– Relapse prevention of symptoms that have improved

64. Considerations for Child
Welfare
• How do these youth get identified?
• How do they get labeled?
• What types of referrals are (or can be)
made?

66. Contact information:
Carla Kmett Danielson, Ph.D.
Office: 843-792-2945
Email: danielso@musc.edu