Perhaps you have heard these common misconceptions about trauma therapy for treatment court participants:
- “Trauma therapies are too harsh—they could relapse and they won’t graduate.”
- “Better to treat the substance use first, THEN address the trauma.”
- “Whatever trauma-focused therapy is available, that will be good enough.”
- “It is expensive (for providers) to learn trauma-focused therapies, and they are too complicated.”
The National Drug Court Resource Center provides free resources to enable treatment courts to implement evidence-based practices and maximize the effectiveness of their programs. In this fourth article in our series on trauma-informed practices, we provide a brief overview of trauma-specific treatments that have the most scientific support, why these therapies are a good fit for many treatment court participants with trauma, and ways to facilitate greater access to these effective treatments.
Importance of integrating treatment for PTSD and substance use treatment
It is well known that trauma and substance use disorders co-occur at very high rates, and treatment courts are well positioned to provide treatment for both, concurrently. This integrated model offers outcomes that are far superior to the outdated, sequential approach that requires treating substance use disorder first, THEN the trauma (Flanagan et al., 2016). Integrated treatment allows clients to address PTSD symptoms that are directly linked to substance use, and vice versa. A sequential model that focuses on treating substance use “first” reduces the chances that trauma will ever be addressed before the treatment court participant either drops out or completes the program. Providers may fear that clients with PTSD are too fragile in that encouraging clients to face their trauma memories and intense emotions directly could lead to relapse or dropping out of treatment. Conversely, treatment court participants have greater supports and structure in place than in any other time in their lives, so treatment courts are encouraged to take advantage of this window of opportunity.
Trauma-focused therapies with the best outcomes
The following trauma-focused treatments have been rigorously studied and are recommended/strongly recommended by the American Psychological Association and the U.S. Department of Defense (Veteran’s Services). All are fairly brief (8-16 sessions), and share a direct focus on exposure to memories of the trauma. Some also emphasize changing clients’ maladaptive beliefs about the trauma and themselves. All the approaches involve temporary discomfort, as distressing memories are activated through exposure (imagined or real-life) and processed in a structured, systematic manner under the direction of the therapist (Watkins et al., 2018). Decisions about which treatment approach is the best fit will depend on nature of the trauma (e.g., combat-related, victim of sexual assault, witness to a violent event), the complexity of the trauma, client preference, and realistically, availability of clinical providers who offer the intervention.
Cognitive Processing Therapy (CPT). People who have experienced trauma try to make sense of the occurrence and can develop distorted beliefs about themselves and the trauma. These “stuck points” can keep the individual from healing, and include beliefs such as “I have myself to blame” and “As long as I trust no one, I will be safer.” Treatment extends over 12 sessions and involves activating the traumatic memory, which includes writing and reading a narrative account of the trauma. At the same time, the therapist helps the client to identify the maladaptive cognitions associated with the traumatic event and shift them to become more accurate and helpful (Resick, Monson & Chard, 2017).
Prolonged Exposure (PE). After educating the patient about the nature of PTSD and how PE works, the therapist uses exposure to both imagined and real-life situations, as well as people and places associated with the client’s unique trauma. After repeated exposures, the client ultimately learns that the feared (avoided) consequence will not occur and is able to move forward and use more adaptive coping strategies as opposed to avoidance. The therapy typically takes 8–15 sessions (e.g., Foa et al, 2007).
Trauma-focused Cognitive Behavior Therapy (TFCBT). Many have heard of this as an evidence-based therapy for children. However, adults also benefit from the integration of behavioral (e.g., imaginal exposure to the distressing memory) and cognitive components. Clients learn to identify triggers of re-experiencing, practice discriminating between “then vs. now,” identify and dispute dysfunctional thoughts, as well as reshape beliefs about themselves, the trauma, and the world.
Eye Movement Desensitization Reprocessing (EMDR). In this treatment the therapist utilities exposure to the traumatic memory, coupled with eye movements (left and right) and sometimes tapping and sounds. EMDR differs from the other recommended approaches in that cognitions are not explored, exposure to the distressing memory is briefer, and there is no assigned homework. The therapy typically takes 6-12 sessions (Shapiro, 2017).
These therapies have been found to be very effective for people who are actively using substances, have thoughts of suicide (but low intent), are unhoused, or have minimal education. There are a few exclusions. Trauma specific treatment is not recommended for people who currently have unmedicated mania or psychosis, or who are at current high-risk for suicide, or who require immediate detoxification services.
Who should receive these therapies?
First, assessment of trauma symptoms is critical. Treatment court participants may not report or display trauma symptoms at the initial screening and assessment for admission to treatment court, as they may have normalized their experiences or may not be ready to disclose such sensitive information. However, members of the treatment court team should be on alert for signs of trauma and refer participants to trauma therapy providers for assessment. Providers should routinely assess participants for PTSD and continue to assess throughout treatment.
When working with justice-involved individuals with SUD or COD, SAMHSA (2015) recommends the use of the following trauma screening instruments:
PTSD Checklist for DSM-5 (PCL-5)
Select 1 of the following publicly available resources:
Similarly, SAMHSA (2015) recommends the use of one of the following trauma assessment instruments, which should be administered by a licensed clinician:
How available are trauma specific therapies to treatment court participants?
There are few studies on the use of trauma therapies in treatment court populations, and more work needs to be done to assess barriers to access as well as mental health and substance use outcomes. Veterans Treatment Courts (VTCs) are likely to be more familiar with and offer trauma specific therapies. The U.S. Veterans Administration has been a leader in funding the development, research, training and dissemination of these interventions. The therapies are applicable to non-veteran populations, and clinicians are encouraged to receive training to provide these interventions. All approaches are related to aspects of cognitive and behavior therapies, and most providers should already be familiar with the theories and be able to utilize the therapy manuals, handouts, and free phone apps for patients (e.g. “PE Coach” and “CPT Coach”).
Treatment Courts are encouraged to pursue training for providers in these strongly recommended trauma-specific approaches and to utilize the free and low-cost resources below to learn more.