Integrating Treatment of Posttraumatic Stress Disorder and Substance Use Disorder

Historically, administrators and clinicians have been hesitant to address posttraumatic stress disorder (PTSD) in the treatment of substance use disorders (SUDs). However, research shows that SUD treatment recruitment and outcomes may be adversely affected if co‐occurring PTSD is left untreated. The authors provide guidelines for screening and assessment, treatment services, and workforce and organizational development that are designed to facilitate integrated PTSD–SUD treatment. Case examples illustrate the necessary precautions related to and the potential benefits of integrating treatment of PTSD and SUD.     

Substance Abuse Treatment Outcomes: Treatment Practice and Policy Implications

Treatment professionals, whether clinicians, scientists, or policy makers, are interested in developing methods to improve behavioral health treatment outcomes. Clinicians are interested in knowing what treatment practices to incorporate into the services they offer clients. Policymakers request guidance regarding which decisions are most likely to lead to effective treatment approaches and structures. Scientists are eager to contribute knowledge pertinent to building and evaluating effective treatment practices and policies. The papers in this special series provide information on substance abuse treatment practices andpresent findings relevant to clinical practice, policy decisions, and scientific inquiry. This paper provides a brief overview of the National Treatment Improvement Evaluation Study (NTIES) and briefly summarizes the other research papers included in this issue, all of which exemplify practice and policy issues in the substance abuse treatment field and bolster approaches applied to address these issues.     

Wellness,Emotion Regulation,and Relapse During Substance Use Disorder Treatment

Using a cross-sectional study design, the authors investigated the impact of wellness and emotion regulation on relapse in 179 individuals currently enrolled in substance use disorder treatment. An integration of the indivisible self model of wellness (Myers & Sweeney, 2004) and the covert antecedents model of relapse (Marlatt, 1985) informed the study hypothesis that emotion regulation mediates the wellness-relapse relationship. Binomial logistic regressions revealed that Creative Self wellness (odds ratio [OR] = 1.09, p = .002), reappraisal (OR = 1.08, p = .008), difficulties in emotion regulation (OR = 1.03, p = .007), and Physical Self wellness (OR = 0.95, p < .001) were associated with the odds of relapse on any given day during treatment. Sobel tests indicated 2 occurrences of full mediation, including that difficulties in emotion regulation mediated the relationship between Coping Self wellness and relapse (OR = 0.97, p = .015).     

Behavioral Family Interventions for Improving Child-rearing: A Review of the Literature for Clinicians and Policy Makers

This paper reviews evidence that behavioral family interventions are effective at improving child-rearing in distressed families and families with children exhibiting disruptive behavior. Essential therapeutic strategies offered within a collaborative therapeutic process are identified. Exemplary materials for parents and clinicians are identified. Differences between behavioral family interventions and two popular press parenting approaches are highlighted, including the lack of empirical support for these widely used programs and the advice they offer which runs counter to behavioral approaches. Recommendations are offered for combining behavioral family interventions with other empirically supported approaches, promoting more widespread use of empirically supported treatments, such as behavioral family interventions, and the need for a public health perspective on family functioning, involving collaboration among clinicians, policy makers, and researchers.     

Childhood Emotional Abuse and Maladaptive Coping in Adults Seeking Treatment for Substance Use Disorder

Little is understood about distinct traumatic exposures and their relationship to later coping strategies. Adults receiving treatment for substance use were assessed for experiential avoidance and a range of traumatic exposures. Only childhood emotional abuse significantly predicted experiential avoidance.     

Behavioral Couples Treatment for Substance Use Disorder: Secondary Effects on the Reduction of Youth Internalizing Symptoms

This study examined the secondary effects of Behavioral Couples Treatment (BCT) for parents with substance use disorder on youth reports of internalizing symptoms (i.e., depressive and anxiety symptoms). Participants were 59 triads (father, mothers, and youth; 32 girls, 27 boys) in which one or both parents met criteria for drug or alcohol use disorder (or both). Mothers, fathers, and youth completed pretreatment, post-intervention, and 6-month post-intervention follow-up assessments. Two piecewise latent growth models examined whether number of sessions attended was associated with parents’ relationship satisfaction or its growth over time, and in turn if parents’ relationship satisfaction was uniquely associated with youth depressive/anxiety symptoms or their growth over time. A significant indirect effect at post-intervention revealed the number of sessions attended contributed to decreases in youth depressive symptoms via increases in mothers’ and fathers’ relationship satisfaction. Mothers’ relationship satisfaction uniquely mediated the relationship between number of sessions attended and youth depressive symptoms at post-intervention. With regards to fathers, there was a non-significant trend such that increases in sessions attended was associated with decreases in youth depressive symptoms post- intervention via increasing relationship satisfaction among fathers. Findings suggest that BCT may have protective secondary effects in reducing youth reports of depressive symptoms among couples in which one or both parents have substance use disorder.     

The Links Between Social Anxiety Disorder,Insomnia Symptoms,and Alcohol Use Disorders: Findings From a Large Sample of Adolescents in the United States

Social anxiety disorder (SAD) is associated with increased risk of developing an alcohol use disorder (AUD). Most of the current literature has focused on the role of acute stress responding in this relation; however, both SAD and AUDs also are linked to insomnia symptoms (i.e., difficulty falling or staying asleep). As adolescence is a sensitive period for the onset of these disorders, the present study examined if insomnia symptoms might partially account for the SAD-AUD link in a large sample of adolescents. Data from the National Comorbidity Survey–Adolescent Supplement were examined. Participants (N = 10,140) completed interviews to assess past 12-month SAD and AUD diagnostic status as well as insomnia symptoms. Analyses tested whether insomnia symptoms accounted for a significant proportion of the SAD-AUD relation. Results indicated that insomnia symptoms were positively related to both SAD and AUD status, and the relation between SAD and AUD status was significantly reduced when insomnia symptoms were included in the model. Findings remained significant after controlling for the effects of age, gender, posttraumatic stress disorder, major depressive disorder, and other drug dependence status. Experimental examination and intensive longitudinal assessment of these relationships are needed before strong conclusions can be inferred about causality and temporal relationships. The current findings do indicate insomnia may be an important indirect and stigma-free treatment target to address in prevention and treatment efforts for SAD, AUDs, and their co-occurrence.     

From Resistance to Buy-In: Experiences of Clinicians in Training Using Feedback-Informed Treatment

In this qualitative research study, the authors use grounded theory analysis to examine the experiences of clinicians in training and use client feedback to inform treatment. Twenty-six marriage and family therapy graduate students in their first or second semester of clinical practicum participated in this study. Participants were trained in eliciting and responding to client feedback at the end of every therapy session. At the end of the semester, participants reflected on their learning experience. Participant experiences reflected a developmental learning process beginning with significant challenges followed by positive clinical changes and positive clinician changes, culminating in overall buy-in regarding the importance of client feedback for nearly all clinicians. The results support the literature that client feedback directly informs the therapeutic process while suggesting important recommendations for training new clinicians in learning to use client feedback.     

Psychometric Evaluation of a Controlled Social Affiliation Paradigm: Findings From Anxiety,Depressive Disorder,and Healthy Samples

Social impairments are common across many psychiatric conditions. Standardized dyadic assessments intended to elicit social affiliation between unacquainted partners are used to elucidate mechanisms that disrupt relationship formation and inform possible treatment targets; however, the psychometric properties of such paradigms remain poorly understood. This study evaluated the psychometric properties of a controlled social affiliation paradigm intended to induce connectedness between a target participant and trained confederate. Individuals with an anxiety or depressive disorder diagnosis (clinical group; n = 132) and those without (control group; n = 35) interacted face-to-face with a trained confederate; partners took turns answering a series of increasingly intimate questions about themselves. Social connectedness, affect, and affiliative behavior measures were collected during the interaction. Participant symptom and social functioning measures were collected to examine validity. The paradigm elicited escalating social connectedness throughout the task for both participants and confederates. Parallel forms (i.e., different question sets) elicited similar affiliation outcomes. Self-reported (but not behavioral) affiliation differed across some demographic variables (e.g., participant gender, Hispanic ethnicity). Within-task affiliation measures were associated with one another and with global social connectedness and social anxiety symptom measures, but not with somatic anxiety measures. Clinical participants reported lower social affiliation and positive affect reactivity and higher negative affect reactivity than healthy participants. These findings provide initial psychometric support for a standardized and controlled dyadic affiliation paradigm that could be used to reliably probe social disconnection mechanisms across psychopathology.     

Emotion Dysregulation in Comorbid Posttraumatic Stress Disorder and Substance Use Disorders: A Narrative Review

Co-occurrence of substance use disorders (SUDs) and posttraumatic stress disorder (PTSD) is extremely common and is associated with elevated dropout and relapse rates. Given that PTSD/SUD co-occurrence rates among veterans have been found to be as high as 55?75%, it is important to identify mechanisms that may affect the interplay of both disorders. Emotion dysregulation (ED) presents a candidate mechanism that may underlie poor treatment response in co-occurring PTSD/SUD. This article proposes a transdiagnostic emotion regulation framework that considers ED conceptualized as a combination of low ability to tolerate emotional distress (low distress tolerance) and difficulties in the goal-directed use of emotion regulation strategies as a key risk factor in co-occurring PTSD/SUD. The authors review empirical findings from self-report and laboratory-based studies of ED in PTSD. They describe psychological explanations of the emotion-substance relationship and review studies documenting ED in SUDs and in co-occurring PTSD/SUD. The literature on ED in PTSD/SUD suggests that (a) patients with PTSD may resort to substances to cope with trauma-related symptoms due to ED, and (b) ED may maintain SUD symptoms and interfere with psychological treatment. Longitudinal studies on bidirectional relationships between ED and substance use in PTSD are needed, particularly research examining the course of ED in PTSD patients who use substances versus those who do not.     

Self‐Efficacy to Avoid Suicidal Action: Factor Structure and Convergent Validity among Adults in Substance Use Disorder Treatment

Individuals with substance use disorders (SUDs) are at high risk of suicidal behaviors, highlighting the need for an improved understanding of potentially influential factors. One such domain is self‐efficacy to manage suicidal thoughts and impulses. Psychometric data about the Self‐Efficacy to Avoid Suicidal Action (SEASA) Scale within a sample of adults seeking SUD treatment (N = 464) is provided. Exploratory factor analysis supported a single self‐efficacy construct. Lower SEASA scores, or lower self‐efficacy, were reported in those with more severe suicidal ideation and those with more suicide attempts, providing evidence for convergent validity. Implications of measuring self‐efficacy in the context of suicide risk assessment are discussed.     

Behavioral Telehealth: Emerging Practice,Research, and Policy Opportunities

Behavioral telehealth, the use of electronic and communication technologies to provide and support behavioral health care when distance separates the participants, has the potential to address the nationally significant problems of access, cost, and distribution of behavioral health care and providers. Using examples of developing behavioral clinical practice, research, and policy opportunities, this article outlines the promise of this field while discussing the barriers to the development of behavioral telehealth networks, including the lack of clinical protocols, solid evaluative research, payment for telehealth/telemedicine services, uniform state licensure, and uniform privacy/confidentiality policy. It is argued that behavioral practitioners, researchers, and advocates must actively participate in this rapidly developing field, and these professionals are ideally suited to supply ongoing federal and state policy initiatives with much needed empirical clinical data and evaluative research that will help to generate sound policy.     

The Use of Mindfulness Practice in the Treatment of a Case of Obsessive Compulsive Disorder in Sri Lanka

For over 20 centuries, Buddhism has been the spiritual practice of the majority of Sri Lankans. Though Buddhist practices have been increasingly influencing psychotherapy in the West, the use of such practices in psychotherapy in Sri Lanka is not common. This paper attempts to bridge this gap by presenting a case study where Buddhist mindfulness practice was used successfully in the treatment of a case of obsessive compulsive disorder. This paper also presents an outline of the association between Buddhist mindfulness practice and mindfulness practices used in modern-day psychotherapy and discusses issues in the use of mindfulness practice in psychotherapy.     

The Munroe-Meyer Approach: Continuous Integration of Didactic Instruction,Research, and Clinical Practice

Increased demand for applied behavior analysis (ABA) services has increased the need for additional masters-level practitioners and doctoral-level academicians and clinical directors. Based on these needs, the University of Nebraska Medical Center’s (UNMC) Munroe-Meyer Institute has developed a PhD program. The academic structure at UNMC allowed us to create our PhD program in a relatively quick and efficient manner. Our PhD program has many unique features, including (a) close integration of didactic instruction with clinical and research training provided by leading experts in ABA in which students immediately apply concepts introduced in the classroom during coordinated clinical and research practica; (b) structured grant writing training in which students learn to write and submit an NIH-level grant; (c) financial support in the form of a stipend of $23,400 per year, free health benefits, and a full-tuition waiver for up to 12 credits per semester for UNMC courses (a benefits package worth approximately $50,000 per year for an out-of-state student); and (d) encouragement and financial support to present papers at local, regional, and national behavior analysis conferences.     

Expanding the Conceptualization of Workplace Violence: Implications for Research,Policy, and Practice

Workplace violence generally refers to interpersonal aggression, sexual harassment, bullying, and other forms of discrimination and oppression occurring within the confines of the paid workplace. Workplace violence affects women across the globe, resulting in a wide range of health, economic, and social problems. We advocate for broader, transdisciplinary, intersectional, and transnational conceptualizations of workplace violence in research, policy, and practice. Supported by findings from research conducted around the globe, we argue that workplace violence occurs not only within the context of women’s paid employment in the formal workplace, but also within the contexts of other types of work in which women of all ages engage. An expanded, more inclusive conceptualization of women’s workplaces in research, policy, and practice will promote broader recognition and acknowledgement of women’s experiences of interpersonal violence in the contexts of their multiple work roles in unpaid and informal work, as well as the paid labor force. Incorporating intersectional, transnational, and transdisciplinary perspectives into research, policy, and practice related to workplace violence will expand understandings and interpretations of women’s experiences of workplace violence across the lifespan; within their own multi-faceted cultural contexts and racial, ethnic, gender, and class identities; and will facilitate transnational, cross-cultural comparisons. Implementation of policies based on expanded conceptualizations of workplace violence can contribute to more effective education and prevention efforts, improved reporting procedures, and enhanced post-violence support services and treatment programs that meet the needs of women across a wider spectrum of workplace contexts.