Journal of Substance Abuse Treatment xxx (2014) xxx–xxx

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Journal of Substance Abuse Treatment

Coping among military veterans with PTSD in substance use disorder treatment Matthew Tyler Boden, Ph.D. a,⁎, Rachel Kimerling, Ph.D. a, b, Madhur Kulkarni, Ph.D. c, Marcel O. Bonn-Miller, Ph.D. a, b, d, e, Christopher Weaver, Ph.D. c, f, Jodie Trafton, Ph.D. a a

Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, 94025, USA National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, CA, 94025, USA VA Palo Alto Health Care System, Menlo Park, CA, 94025, USA d Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, 19104, USA e Center of Excellence in Substance Abuse Treatment and Education, Philadelphia VAMC, Philadelphia, PA, 19104, USA f Palo Alto University, Palo Alto, CA, 94304, USA b c

a r t i c l e

i n f o

Article history: Received 30 August 2013 Received in revised form 4 March 2014 Accepted 24 March 2014 Available online xxxx Keywords: Substance use disorder Substance abuse Posttraumatic stress disorder Coping Seeking safety Dual diagnosis

a b s t r a c t We longitudinally investigated coping among male military veterans (n = 98) with posttraumatic stress disorder (PTSD) symptomatology and a co-occurring substance use disorder (SUD) who participated in a randomized controlled trial of seeking safety (SS). Participants were randomized to SS or intensive treatmentas-usual (TAU) for SUD. Coping (active, avoidant, emotional discharge), and PTSD and SUD symptomatology were measured prior to and at the end of treatment, and at 6- and 12-month follow-ups. Among the total sample, we found that: (a) avoidant and emotional discharge, but not active, coping tended to be positively associated with PTSD and SUD symptomatology at baseline; (b) active coping increased and avoidant and emotional discharge coping decreased during the 12-month time-period; and (c) avoidant and emotional discharge, but not active, coping longitudinally covaried with PTSD and SUD symptomatology. Results suggest the utility of targeting maladaptive coping in treatments for individuals with co-occurring PTSD and SUD. Published by Elsevier Inc.

1. Introduction Posttraumatic stress disorder (PTSD) has been shown to be particularly harmful to the biopsychosocial health of patients with substance use disorders (SUD; Ouimette, Brown, & Najavits, 1998; Ouimette, Moos, & Brown, 2002). Research demonstrates that comorbid PTSD symptoms directly worsen SUD symptoms and make recovery less likely (Clark, Masson, Delucchi, Hall, & Sees, 2001; Ouimette et al., 2002; Saladin et al., 2003). Individuals diagnosed with co-occurring PTSD and SUD continue to experience high levels of symptoms and related dysfunction following treatments for PTSD, SUD and combined PTSD-SUD (e.g., Ouimette et al., 1998). In other words, SUD symptoms are particularly difficult to treat among individuals with comorbid PTSD (Hein et al., 2010; Najavits, 2013). Therefore, examining factors that contribute to treatment gains among individuals with comorbid PTSD-SUD can inform the refinement of existing treatments and development of new interventions to more effectively target these factors, and thus improve the clinical and cost effectiveness of treatments for comorbid PTSD-SUD (Kazdin, 2007). In this study, we examine coping strategies, which are directly targeted as a potential mechanism for improving PTSD-SUD outcomes ⁎ Corresponding author at: Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park Division (152), 795 Willow Road, Menlo Park, CA 94025. Tel.: + 1 650 493 5000x27529; fax: + 1 650 617 2690. E-mail address: [email protected] (M. Tyler Boden).

in most existing treatments, among male military veterans with cooccurring PTSD symptomatology and an SUD receiving specialized treatment for SUD. The frequency with which individuals with PTSD or SUD use specific strategies to cope with symptoms of their mental disorders and related consequences is a key factor that influences the maintenance of those disorders (Feeny & Foa, 2005; Moos, 2007). We expect avoidance coping to be especially influential for maintenance of PTSD and SUD. Avoidance coping is a strategy in which the person orients their thoughts, emotions and behaviors away from unpleasant experience (e.g., denying the existence or consequences of a particular problem, choosing not to confront or solve the problem or to engage cues of the problem; Litman, 2006; Roth & Cohen, 1986). Many studies have found that patients with PTSD tend to manage the enormous psychological demands of their trauma(s) by using avoidant strategies that paradoxically increase their symptoms (e.g., Badour, Blonigen, Boden, Feldner, & Bonn-Miller, 2012; Gutner, Rizvi, Monson, & Resick, 2006; Krause, Kaltman, Goodman, & Dutton, 2008; Pineles et al., 2011). Avoidance coping is also associated with SUD (e.g., Hasking & Oei, 2004; Vernig & Orsillo, 2009), as numerous studies have shown that a primary motive for using drugs and alcohol is the alleviation and avoidance of unpleasant experiences and emotional states (e.g., Cooper, Frone, Russell, & Mudar, 1995; Cooper, Russell, Skinner, Frone, & Mudar, 1992). Logically, the likelihood that alcohol/drugs are used (and thus increase the risk of developing psychological and physical dependence) will increase the more that

http://dx.doi.org/10.1016/j.jsat.2014.03.006 0740-5472/Published by Elsevier Inc.

Please cite this article as: Tyler Boden, M., et al., Coping among military veterans with PTSD in substance use disorder treatment, Journal of Substance Abuse Treatment (2014), http://dx.doi.org/10.1016/j.jsat.2014.03.006

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M. Tyler Boden et al. / Journal of Substance Abuse Treatment xxx (2014) xxx–xxx

alcohol/drugs help to alleviate/avoid unpleasant experiences, thoughts, and emotions. The use of avoidance coping potentially helps to explain the high co-occurrence of PTSD and SUD. For individuals with PTSD, alcohol and/or drugs may be used as an avoidant strategy aimed at the alleviation of symptoms and related consequences (Baker, Piper, McCarthy, Majeskie, & Fiore, 2004; Khantzian, 1985; Ullman, Relyea, Peter-Hagene, & Vasquez, 2013). Furthermore, individuals with PTSD may lack the resources and skills to cope through other means. The use of substances for this purpose may increase the risk of developing an SUD. Maintenance of the SUD may occur in part because individuals with PTSD are particularly fearful of, and emotionally reactive to, the type of experiences that occur during alcohol/drug use reduction and discontinuation (e.g., PTSD-like withdrawal symptoms such as sleep disturbances, anxiety, and irritability; e.g., Boden, Babson, Vujanovic, Short, & Bonn-Miller, 2013). At least one study has supported the link between PTSD, alcohol/drugs, and avoidant coping, by demonstrating that posttraumatic stress symptoms were more strongly associated with avoidance coping among motor vehicle accident survivors with versus without an alcohol use disorder history (Hruska, Fallon, Spoonster, Sledjeski, & Delanty, 2011). Few studies have examined associations between avoidance coping and symptoms among individuals dually-diagnosed with PTSD and SUD. In contrast to avoidance coping, some active coping strategies may be adaptive for individuals with PTSD and/or SUD (Boden, BonnMiller, Vujanovic, & Drescher, 2012; Ilgen, Wilbourne, Moos, & Moos, 2008). Active coping strategies are oriented toward unpleasant experiences and associated thoughts and emotions, and include specific strategies such as positive reappraisal (e.g., positively reframing a problem and its consequences) and problem solving (e.g., planning for future occurrences of a problem; Litman, 2006; Roth & Cohen, 1986). Emotional discharge coping (e.g., venting of unpleasant emotions), on the other hand, is an active coping strategy that has generally been found to be maladaptive, including among individuals with PTSD and SUD (e.g., Hasking & Oei, 2007; Olatunji, Ciesielski, & Tolin, 2010; Ouimette, Ahrens, Moos, & Finney, 1997). Thus, in this study, we investigate emotional discharge coping separately from active coping. Evidence-based treatments for PTSD and SUD (see Institute of Medicine report, 2007) include cognitive and/or emotional strategies designed to reduce avoidance coping (e.g., in vivo exposure) and to increase the use of active coping strategies, such as positive reappraisal and problem solving (Hamblen, Schnurr, Rosenberg, & Eftekhari, 2009). In fact, coping is a primary target and hypothesized mechanism of change (Kazdin, 2007) of the most prominent integrative therapy for co-occurring PTSD and SUD, seeking safety (SS; Najavits, 2002). SS is a present-focused therapy that is designed to help clients explore links between trauma/PTSD and substance use without having clients delving into specific details regarding their trauma history or experience of PTSD. SS provides clients with psychoeducation and teaches them to use adaptive coping skills to manage the symptoms of their disorders and associated consequences and the demands of recovery from these disorders. Several studies have demonstrated the positive effects of active coping and the negative effects of avoidance coping on PTSD- and SUD-related outcomes among patients receiving treatment for PTSD or SUD (e.g., Badour et al., 2012; Boden, Bonn-Miller et al., 2012; Chung, Langenbucher, Labouvie, Pandina, & Moos, 2001). For example, Badour et al. (2012) found that, among a large sample of military veterans receiving residential treatment for PTSD, greater avoidance coping prior to treatment predicted increased PTSD symptoms at treatment discharge, and increased PTSD symptoms at treatment discharge predicted increased avoidance coping 4-months after treatment discharge. At least two studies have specifically examined PTSD-SUD patients receiving treatment for PTSD or SUD (Ouimette, Finney, & Moos, 1999; Ouimette et al., 1997). For example,

Ouimette et al. (1998) found that statistically adjusting for the use of avoidance and active coping partially reduced the association between PTSD and substance use among patients with PTSD-SUD receiving cognitive–behavioral or 12-step-oriented treatment for SUD. In other words, PTSD and substance use were associated to a greater degree among patients in this sample who used more avoidance coping and less active coping. Several studies have also examined coping among patients in an integrated treatment for co-occurring PTSD and SUD (Boden, Kimerling, et al., 2012; Gatz et al., 2007; Lynch, Heath, Matthews, & Cepeda, 2012; Najavits, Weiss, Shaw, & Muenz, 1998). Najavits et al. (1998) found that, among 17 women with comorbid PTSD and SUD receiving SS, coping related to “willingness to work hard” significantly increased over the course of treatment. However, significant changes in none of the other 13 coping strategies or higher level factors that could potentially be assessed (e.g., expressing feelings; problem avoidance) using the measure included in this study were reported, and it is unclear whether subscales comprising active or avoidance coping, or the higher order factors themselves were examined. Gatz et al. (2007) examined coping skills specifically targeted in SS (e.g., distraction) among 402 women with an SUD and a history of violent/ traumatic experiences receiving outpatient SUD treatment that did or did not include SS groups. Women receiving SS significantly increased in SS-related coping skills relative to those not receiving SS. Increases in coping skills were associated with improved drug, but not alcohol use outcomes in the total sample. However, the association between changes in coping skills and improved drug use outcomes did not vary by treatment condition. Similar to the study by Najavits et al. (1998), findings regarding active and avoidance coping were not reported. Among 114 incarcerated women, Lynch et al. (2012) found that adaptive coping, which included measures of positive reframing and planning, significantly increased and maladaptive coping, which included measures of disengagement and denial, significantly decreased among women receiving SS relative to those serving as a waitlist control. Boden, Kimerling, et al. (2012) found that active coping significantly increased during the 6-months following treatment initiation among 98 male military veterans receiving SS relative to those receiving an intensive treatment-as-usual. However, similar to the study by Gatz et al. (2007), these increases were not associated with corresponding decreases in drug use over time. Boden, Kimerling, et al. (2012) did not examine any other type of coping, or the association of coping with PTSD and alcohol use outcomes. In summary, the literature examining coping among patients receiving SS is limited in terms of the types of coping examined, especially in relation to PTSD and SUD outcomes. However, this literature demonstrates that the frequency of use of a few types of coping changes in adaptive ways during SS, but these changes are generally not associated with changes in PTSD and SUD outcomes. The current study was intended to add to existing literature by examining coping among male military veterans receiving SUD treatment for an alcohol or drug use disorder and diagnosed with comorbid PTSD symptomatology who were randomly assigned to receive SS or an intensive treatment-as-usual (TAU) for SUD. This randomized controlled trial included an adequate sample size and had excellent follow-up rates (see Boden, Kimerling, et al., 2012; Weaver, Boden, Kimerling, & Trafton, 2014). Military veterans are an ideal sample within which to examine these relations as veterans with SUD treated in the U.S. Veterans Health Administration (VA) have high rates of comorbid PTSD and SUD, with approximately 30% of patients with SUD diagnosed with co-occurring PTSD (Ouimette et al., 2002). Expanding upon the only study that has examined associations between avoidance coping among individuals with co-occurring PTSD and SUD symptomatology (Hruska et al., 2011), we hypothesized that greater PTSD symptom severity and alcohol and drug use would be associated with greater use of avoidance and emotional discharge coping and lesser use of active coping among patients prior to entry

Please cite this article as: Tyler Boden, M., et al., Coping among military veterans with PTSD in substance use disorder treatment, Journal of Substance Abuse Treatment (2014), http://dx.doi.org/10.1016/j.jsat.2014.03.006

M. Tyler Boden et al. / Journal of Substance Abuse Treatment xxx (2014) xxx–xxx

into treatment. Second, we hypothesized that avoidance and emotional discharge coping would decrease and active coping would increase across the 12-month time-frame due to the effect of treatment, and these changes would occur to a greater extent among individuals receiving SS relative to TAU. Our third hypothesis was that PTSD symptom severity and alcohol and drug use would be positively associated with use of avoidance and emotional discharge coping and negatively associated with use of active coping over time. We did not expect the relation between coping and PTSD symptom severity and alcohol and drug use to vary as a function of treatment condition based on a study conducted with the same sample by Weaver et al. (2014), which demonstrated reductions in PTSD symptom severity, and alcohol and drug use over a 12-month time-frame among the current patient sample, with no significant differences by treatment condition. Weaver et al. (2014) did not include coping-related variables in their study. 2. Materials and methods 2.1. Participants Participants were 98 male veterans (Mage = 54.0, SDage = 9.6) with a DSM-IV (American Psychiatric Association, 1994) diagnosis of any current alcohol or drug use disorder, and meeting full or partial DSM-IV (American Psychiatric Association, 1994) criteria for current PTSD. Partial PTSD patients met criteria for 2 out of 3 PTSD symptom clusters, or at least one symptom in each symptom cluster (Boden, Kimerling, et al., 2012; Mylle & Maes, 2004; Schnurr, Lunney, Sengupta, & Waelde, 2003; Weaver et al., 2014). PTSD diagnoses were based on clinical evaluation using the Clinician Administered PTSD Scale (CAPS; Weathers, 1996). In terms of the CAPS index trauma (i.e., criterion A), the majority of participants reported experiencing combat-related trauma (26.8%), followed by physical assault (15.5%), assault with weapon (10.3%), natural disaster (9.3%), transportation accident (8.2%) and sudden violent death (5.2%). Alcohol/Drug use diagnoses were based on chart review. Scores obtained from the Addiction Severity Index (ASI; McLellan et al., 1992) demonstrated that, prior to the start of the study, approximately 20.6% of participants were using alcohol only, and 79.4% of participants were using both alcohol and drugs. Additionally, for study entry, participants were required to have veteran status and VA healthcare eligibility, and to have completed an intake for outpatient SUD treatment at the VA Oakland outpatient mental health clinic. Participants were excluded from participation if they: (a) were concurrently participating in any other day or inpatient mental health treatment; and/or (b) experienced acute psychosis, mania, dementia or suicidal intent. The majority of participants reported their race/ ethnicity as Africa-American (60.2%), followed by Caucasian (19.4%), Hispanic/Latino (7.1%), “other” (5.1%), and Native American (2.0%). See Boden, Kimerling, et al. (2012) for more details regarding sample demographics. A total of 125 participants expressed interest in study participation, with 117 participants formally enrolled in the study and randomized to treatment condition using block randomization within stratification groups (i.e., partnered status, OEF/OIF participation, illicit use of drugs). Nineteen participants were lost to follow-up between initial assessment and disclosure of treatment assignment due to: (1) experiencing symptoms of psychosis or mania (n = 4), (2) high suicide risk (n = 1), (3) participation in court-ordered treatment for SUD (n = 1), (4) not meeting partial or full criteria for PTSD (n = 2), and (5) being lost to follow-up (n = 11). As reported in Boden, Kimerling, et al. (2012), participants who were included (n = 98) and not included in the analyses reported below (n = 27) did not differ in demographic status with one caveat: significantly more participants included versus not included in analyses were currently married or in a long-term relationship. Furthermore, participants

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randomly assigned to SS and TAU did not significantly differ on measures of PTSD or alcohol/drug use at the baseline assessment (see Boden, Kimerling, et al., 2012). 2.2. Procedure Participants were recruited from a high volume VA outpatient SUD treatment clinic. Patients in the initial phases of treatment were informed of the study and, if interested, were screened for PTSD and exclusion criteria. Patients who screened positive for PTSD and did not meet exclusion criteria were invited to participate. Prior to randomization, participants were assessed via interview for coping, PTSD, and alcohol and drug use. Following the baseline assessment, participants were randomized to SS or TAU. Subsequent assessments were conducted at 3 months, corresponding to the planned end of SS sessions, 6 months (i.e., 3 months post-treatment), and at 12 months (i.e., 9 months post-treatment). All participants provided informed consent, and the procedures followed were consistent with the standards of the Institutional Review Boards of Stanford University and VA Northern California Health Care System. 2.3. Treatment condition Participants received treatment-as-usual (TAU track) or TAU with the substitution of seeking safety groups for time-matched bi-weekly TAU core treatment sessions (SS track). Participants in either treatment track started by attending at least three group therapy sessions focused on motivational enhancement and encouraging treatment engagement. Participants in the TAU track then entered twice weekly treatment groups (led by therapists and social workers with bachelor's- or master's-level of education), focusing on building and maintaining abstinence. Participants in the SS track entered twice weekly SS groups (led by psychologists with a Ph.D.-level of education) held at the same time as TAU treatment groups to insure that patients substituted SS for these core treatment groups rather than added them on. Patients were encouraged to attend 24 group sessions (3 months of twice weekly groups) of SS, plus weekly individual case management sessions, which were conducted in a manner consistent with the SS manual. SS was conducted as one topic per session, with all topics covered; in keeping with the manual's flexibility, there was no prescribed sequence to the sessions. Therefore, a rolling admission to the SS groups was maintained, as was done in TAU treatment groups. All patients were assigned a case manager and case management, and individual therapy was available as deemed appropriate. As indicated by their treating clinician or as desired, all patients made use of clinic services, including attending additional groups (e.g., smoking cessation, sobriety support, cocaine recovery, alcohol recovery, dual diagnosis recovery). Participants assigned to TAU attended an average of 9.1 (SD = 8.5) group and 2.7 (SD = 3.5) individual TAU treatment sessions during the 3 month trial treatment period. Participants assigned to SS attended an average of 13.3 (SD = 7.9) group and 5.9 (SD = 5.3) individual SS treatment sessions during the 3 month trial treatment period. As described by Boden, Kimerling, et al. (2012), close adherence to the SS treatment was maintained. 2.4. Measures 2.4.1. Coping Coping was measured using the Coping Responses Inventory (CRI; Moos, 1993). The CRI includes 24 items that assess patients' typical use of several strategies (positive reappraisal, taking problem-solving action, cognitive avoidant, emotional discharge) to cope with PTSD symptoms. For each item (e.g., “Try to deny how serious the problem really was”, “Try to see the good side of the situation”), respondents were asked to indicate how frequently they use a particular coping

Please cite this article as: Tyler Boden, M., et al., Coping among military veterans with PTSD in substance use disorder treatment, Journal of Substance Abuse Treatment (2014), http://dx.doi.org/10.1016/j.jsat.2014.03.006

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M. Tyler Boden et al. / Journal of Substance Abuse Treatment xxx (2014) xxx–xxx

Table 1 Descriptive statistics for all variables at all time-points. Baseline

3-month

6-month

12-month

M (SD)

M (SD)

M (SD)

M (SD)

Coping variables Active 2.89 Avoidance 3.08 Emotional 2.43 discharge Criterion variables PTSD 47.21 severity Alcohol use 0.24 Drug use 0.10

(0.59) (0.66) (0.66)

3.07 (0.65)⁎ 2.70 (0.90)⁎⁎ 2.20 (0.64)⁎⁎

3.08 (0.62) 2.84 (0.84)⁎ 2.18 (0.63)⁎⁎

3.14 (0.67)⁎ 2.78 (0.89)⁎⁎ 2.19 (0.65)⁎

substance-related problems (e.g., “How troubled or bothered were you in the past 30 days by alcohol problems?”), and SUD treatment (e.g., “How many days were you treated in an outpatient setting for alcohol or drugs in the past 30 days?”). The composite scores are derived from complicated conversions of ratings and responses, and are highly reliable and valid (McLellan et al., 1992).

2.5. Data analysis (17.86) 41.60 (20.96)⁎⁎ 37.77 (16.75)⁎⁎ 34.69 (19.05)⁎⁎ (0.25) (0.08)

0.16 (0.16)⁎⁎ 0.08 (0.08)⁎⁎

0.14 (0.16)⁎⁎ 0.07 (0.08)⁎⁎

0.14 (0.15)⁎⁎ 0.06 (0.06)⁎⁎

⁎ Value significantly different than baseline value at p b .05. ⁎⁎ Value significantly different than baseline value at p b .01.

strategy for problems that occurred during the previous 12 months (for baseline assessment) and 3 months (for 3-, 6- and 12-month assessments) using a 4-point scale (1 = no; 4 = yes, fairly often). The CRI has been extensively used in research on substance use treatment outcomes (e.g., Ouimette et al., 1997, 1999). To determine whether higher-order coping scales could be constructed from CRI subscales we examined inter-correlations of the four CRI subscales across the four time-points at which the CRI was administered. 1 Since positive reappraisal and problem solving scales were consistently highly correlated (range of rs = .60 to .67), and not consistently correlated with any other subscale (range of rs = − .06 to .27) we formed an active coping subscale by taking the mean of items from these subscales. As cognitive avoidant and emotional discharge subscales were only moderately correlated (range of rs = .25 to .40), we separately investigated these subscales (formed by taking the mean of items for a given subscale) in analyses below. The mean internal reliability (Cronbach's α) of active, avoidant, and emotion discharge coping scales at the four time-points was .69. Descriptive statistics for all scales at all time-points can be found in Table 1. 2.4.2. PTSD symptom severity PTSD symptom severity was measured using the Impact of Events Scale-Revised (IES-R; Weiss & Marmar, 1997). The IES-R includes 22items that correspond to DSM-IV symptoms of PTSD. Participants rated the extent to which each symptom resulting from the event that was self-identified as causing their PTSD was distressing in the previous 7 days using a 5-point scale (0 = not at all; 4 = extremely). The IES-R has been found to have excellent psychometric properties and reasonable evidence of convergent and discriminant validity. The mean internal reliability (Cronbach's α) of the scale assessed at four time-points was .91. 2.4.3. Alcohol & drug use The ASI (McLellan et al., 1992), a semi-structured interview, was used to assess alcohol and drug use. The ASI includes questions assessing the severity of alcohol/drug related problems in several general areas (medical, employment, alcohol use, drug use, legal, family/social). We used the alcohol and drug composite scores to index alcohol/drug use in the previous 30 days. These composite scores include questions assessing use of all major classes of drugs of abuse (e.g., “How many days in the past 30 days did you use heroin?”), 1 We did not base our determination of higher-order coping scales on an exploratory factor analysis with all 24 CRI items because of the potential unreliability of results caused by small sample size-to-item ratio (e.g., 3.59: 1 at baseline assessment) and limited communality of items (MacCallum, Widaman, Zhang, & Hong, 1999)

We began by conducting zero-order correlation analyses between coping and criterion variables at baseline. Next, we investigated change in coping, and then associations between the three coping variables and three criterion variables (PTSD severity, alcohol use, drug use) over four time-points (baseline, discharge, 6- and 12-month follow-ups) using generalized linear mixed modeling (GLMM) as implemented by the statistical program R (Ihaka & Gentleman, 1996). The restricted maximum likelihood estimation method and an unstructured covariance specification were used. Based on examination of plotted coping and criterion variable scores we found that a linear model best accounted for the data. To investigate change in coping over time, in separate GLMM analyses predicting each coping variable, a trajectory for each participant was modeled yielding estimates of each participant's: (a) score at the end of the 12-month time frame, which served as the intercept so that we might test whether treatment groups differed in coping at the end of the 12-month time frame rather than at baseline, when random assignment would have likely washed out any group differences, (b) slope (change over time), and (c) error (the fit of the linear model to participant's data). We first conducted these analyses to examine whether the intercept or slope differed between treatment groups. However, results demonstrated that parameters representing the effect of being in SS on the average intercept and average slope were not significant for any coping variable (range coefficient = − 0.12 to 0.00, range Z = − 1.33 to 0.37, all ps N .18). We therefore conducted GLMM analyses after collapsing across treatment condition. Thus, between-person parameters were estimated for: (1) the average coping score at the end of the 12-month time-frame (i.e., intercept), (2) the average change in coping score over time, and (3) treatment dose, which served as a covariate in these analyses. We next conducted GLMM analyses predicting change in each criterion variable from change in each coping variable. We did not include treatment group as a predictor in these analyses due to the lack of association between treatment group and coping variables (reported above) or criterion variables (Weaver et al., 2014) over time. In each analysis, a trajectory for each participant was modeled yielding estimates of each participant's score for a given criterion variable at the end of the 12-month time-frame (intercept), slope (change over time), and error (the fit of the linear model to participant's data). 2 Additionally, between-person parameters were estimated for: (1) the average criterion variable score at the end of the 12-month time-frame; (2) the average change in criterion variable score over time; (3) treatment dose; (4) the association between coping and criterion variables across time (i.e., longitudinal covariation), after accounting for the non-independence of observations; and (5) the effects of the coping variable on the average slope of the criterion variable (i.e., influence of coping on rate of change of criterion variable), which estimates of the per unit time changes in trajectory of a criterion variable associated with coping, a timevarying predictor, after accounting for average scores at the intercept and the non-independence of observations. 2 Results obtained when including a random, within person effect for the timevarying coping variable in each model were similar in significance and degree of effect to those reported in Table 2.

Please cite this article as: Tyler Boden, M., et al., Coping among military veterans with PTSD in substance use disorder treatment, Journal of Substance Abuse Treatment (2014), http://dx.doi.org/10.1016/j.jsat.2014.03.006

M. Tyler Boden et al. / Journal of Substance Abuse Treatment xxx (2014) xxx–xxx Table 2 Parameter estimates for generalized linear mixed modeling analyses predicting coping variables. Coping variable

Intercept β (SE), Z

Change in coping over time β (SE), Z

Treatment dose β (SE), Z

Active 2.91 (0.10), 27.69⁎⁎⁎ 0.02 (0.01), 2.32⁎ 0.01 (0.00), 3.22⁎⁎ Avoidance 2.73 (0.15), 18.54⁎⁎⁎ −0.02 (0.01), −2.17⁎ −0.00 (0.01), −0.27 Emo. 2.04 (0.12), 17.64⁎⁎⁎ −0.02 (0.01), −2.89⁎⁎ 0.01 (0.01), 1.23 discharge ⁎⁎⁎ p b .001. ⁎⁎ p b .01. ⁎ p b .05.

3. Results 3.1. Associations between coping and criterion variables at baseline In support of our first set of hypotheses, zero-order correlation analyses revealed that PTSD symptoms at baseline were positively associated with both avoidance coping (r(98) = .28, p b .01) and emotional discharge coping (r(98) = .29, p b .01), and avoidance coping was positively associated with drug use (r(98) = .31, p b .01). In contrast to our hypotheses, at baseline, active coping was not significantly associated with PTSD symptoms, alcohol use or drug use (p's N .11), avoidance coping was not significantly associated with alcohol use (r(98) = .11, p = .26), and emotional discharge coping was not significantly associated with alcohol or drug use (p's N .17). 3.2. Change in coping over time As shown in Table 2, in support of our hypotheses, coping scores significantly (a) increased for active coping and decreased for (b) avoidance, and (c) emotional discharge coping over time. Additionally, average scores for all participants at the end of treatment (i.e., the intercept) were significantly different than zero for all coping variables. Furthermore, treatment dose was a significant predictor in the active coping, but not avoidant or emotional discharge coping models. 3.3. Associations between coping and criterion variables over time In support of our hypotheses, avoidance coping and emotional discharge coping were longitudinally positively associated with PTSD severity and alcohol use, and emotional discharge coping was longitudinally positively associated with drug use (see Table 3). Although avoidance and emotional discharge coping longitudinally covaried with PTSD severity and substance use, in no case did these coping variables influence the rate of change, or slope, of PTSD

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severity or substance use variables. In contrast to our hypotheses, active coping was not longitudinally associated with PTSD severity, or alcohol or drug use, and avoidance coping was not longitudinally associated with drug use. 4. Discussion In several ways, the current research adds to the literature on coping among patients with comorbid PTSD and SUD receiving treatment for SUD. First, expanding upon a study by Hruska et al. (2011), at baseline we found that both avoidance and emotional discharge coping were positively associated with PTSD symptoms, avoidance coping was also positively associated with drug use, and active coping was not associated with either PTSD or SUD symptomatology. Second, expanding upon studies of dually diagnosed patients receiving treatment for SUD (Ouimette et al., 1997, 1999), broadly, and receiving SS (Boden, Kimerling, et al., 2012; Gatz et al., 2007; Lynch et al., 2012; Najavits et al., 1998), specifically, we found that active coping significantly increased and avoidance and emotional discharge coping significantly decreased during a 12-month timeframe beginning with the initiation of therapy, with no differences between treatment groups. Also expanding upon this literature, among the sample as a whole, we found that avoidance coping and emotional discharge coping longitudinally covaried with PTSD severity and alcohol use, and emotional discharge coping longitudinally covaried with drug use, but these coping variables did not influence the rate of change, or slope, of PTSD severity or substance use variables. In contrast, active coping did not longitudinally covary with PTSD severity, or alcohol or drug use, and avoidance coping did not longitudinally covary with drug use. Last, expanding upon previous studies of coping in SS which were generally limited to samples of women and non-veterans (i.e., Gatz et al., 2007; Lynch et al., 2012; Najavits et al., 1998; however see Boden, Kimerling, et al., 2012), our findings were obtained from a male veteran sample. Our results demonstrate that coping significantly changed during and following intensive treatment for SUD, with no differences between SS and TAU conditions. SS directly targets coping for change. Additionally, coping strategies were directly addressed as part of TAU. Coping skills and strategies are a target of many intensive SUD treatments (e.g., e.g., cognitive–behavioral therapy; Magill & Ray, 2009), and in our experience, aspects of outpatient treatment for SUD more broadly. Our results suggest that directly targeting coping for change through intensive treatment for SUD does in fact lead to increases in active coping and decreases in avoidant and emotional discharge coping that are maintained beyond the termination of treatment. Combined with results from studies investigating coping in SUD treatments characterized by twelve-step orientations, and cognitive–behavioral orientations

Table 3 Parameter estimates for generalized linear mixed modeling analyses predicting criterion variables from coping variables and treatment dose. Criterion variable

Coping variable

Intercept β (SE), Z

Change in outcome over time β (SE), Z

Treatment dose β (SE), Z

Longitudinal covariation between coping and criterion variable β (SE), Z

Influence of coping on rate of change of criterion variable β (SE), Z

PTSD severity

Active Avoidance Emo. discharge Active Avoidance Emo. discharge Active Avoidance Emo. discharge

35.71 7.53 −2.37 0.06 −0.01 −0.03 0.07 0.04 −0.01

−0.77 −0.48 −1.76 −0.01 −0.01 −0.00 −0.01 0.00 −0.01

0.14 0.17 0.09 0.00 0.00 0.00 −0.00 0.00 −0.00

−1.36 8.68 15.98 0.01 0.04 0.06 −0.00 0.01 0.03

−0.07 −0.11 0.44 0.00 −0.00 −0.00 0.00 −0.00 0.00

Alcohol use

Drug use

(9.00), (5.72), (6.23), (0.07), (0.05), (0.06), (0.03), (0.02), (0.02),

3.97⁎⁎⁎ 1.32 −0.38 0.80 −0.19 −0.47 2.10⁎ 1.75 −0.25

(0.92), (0.63), (0.63), (0.01), (0.01), (0.01), (0.00), (0.00), (0.00),

−0.83 −0.76 −2.79⁎⁎ −1.44 −0.92 −0.43 −2.21⁎ 0.65 −2.56⁎

(0.15), (0.13), (0.13), (0.00), (0.00), (0.00), (0.00), (0.00), (0.00),

0.93 1.28 0.71 1.64 1.79 1.63 −0.86 −1.18 −1.34

(2.73), (1.80), (2.55), (0.02), (0.02), (0.02), (0.01), (0.01), (0.01),

−0.50 4.82⁎⁎⁎ 6.28⁎⁎⁎ 0.41 2.10⁎ 2.49⁎ −0.17 1.25 3.38⁎⁎⁎

(0.29), (0.21), (0.27), (0.00), (0.00), (0.00), (0.00), (0.00), (0.00),

−0.23 −0.53 1.64 0.56 −0.16 −0.65 1.47 −1.69 1.63

⁎⁎⁎ p b .001. ⁎⁎ p b .01. ⁎ p b .05.

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other than SS (Ouimette et al., 1997, 1999), these results suggest the ubiquity of coping as a target of therapy for SUD. However, we must temper this hypothesis, as previous studies have also demonstrated no substantial benefit in terms of PTSD and SUD outcomes for therapies that address coping skills, including seeking safety versus control conditions that do not (e.g., Hein, Wells, & Nunes, 2009). Our study did not permit for a valid test of whether increases in adaptive coping and reductions in maladaptive coping causally influenced PTSD and SUD outcomes. SUD treatments attempt to increase adaptive coping, including strategies included as part of our “active” coping variable (i.e., problem solving, positive reappraisal), and decrease maladaptive coping, such as avoidance and emotional discharge coping. Yet, our results demonstrate that maladaptive coping is more consistently associated with primary treatment outcomes than is adaptive coping. Specifically, we found that active coping was not associated with PTSD or SUD symptomatology at baseline, or longitudinally associated with PTSD or SUD symptomatology across the entire period of study, including the portion of time patients spent in treatment and during the follow-up. In contrast, higher levels of avoidance and emotional discharge coping were associated with higher levels of PTSD and SUD symptoms at baseline, and across the period of study. These results are broadly consistent with metaanalytic results demonstrating that strategies such as avoidance and suppression are associated with anxiety and substance use psychopathology to a greater extent than are strategies such as problem solving and reappraisal (Aldao, Nolen-Hoeksema, & Schweizer, 2010; also see Aldao & Nolen-Hoeksema, 2012). Furthermore, our finding regarding emotional discharge coping is consistent with Ouimette et al. (1997), who demonstrated the maladaptive effects of emotional discharge coping on treatment outcomes among individuals with comorbid PTSD and a SUD. We theorize that a combination of heightened reactivity to trauma-related cues and a lack of resources and skills to cope through adaptive means increase the likelihood that individuals with PTSD and SUD will use avoidance and emotional discharge to cope. The use of avoidance and emotional discharge coping may be preferable relative to active coping strategies to individuals with PTSD and an SUD because resources are low, or symptoms are perceived to be extremely threatening or substantial (e.g., Roth & Cohen, 1986). Additionally, alcohol and drugs may be used to cope with and psychologically distance oneself from the experience of PTSD symptoms. Thus, the use of alcohol and drugs may serve as a form of avoidance coping for individuals with PTSD (see Cooper et al., 1995; 1992), thus increasing their mutual associations and the likelihood of developing and maintaining an SUD. Although treatment for SUD may reduce PTSD and SUD, as suggested by our results, avoidance and emotional discharge coping strategies may continue to be used to cope with these symptoms as long as they persist. This hypothesis is further supported by our finding demonstrating that although avoidance and emotional discharge coping were longitudinally associated with PTSD and SUD symptoms, the effect of coping on symptoms did not vary over time (i.e., time x coping was not significant in any model). In other words, the association of avoidance and emotional discharge coping to PTSD and SUD symptoms is similar at all time-points. While the interpretations of results presented in the preceding paragraphs are parsimonious and to a great extent, consistent with existing theories and empirical research, we note that there exist at least two issues that complicate these interpretations. First, our results are somewhat nuanced. For example, emotional discharge, but not avoidance coping was associated with drug use over time. These nuances may be related to variation in the psychological and physiological effects of different substances, and variation in the motives that contribute to the use of various substances (Simons, Correia, & Carey, 2000). Following our previous example, some

substance (e.g., alcohol) may help some individual's to disengage with and avoid the experience of PTSD symptoms while others (e.g., cocaine) don’t, and still other substances (e.g., methamphetamine) may increase the propensity to vent one's emotions and may be used for the purpose of doing so. Second, a variety of unmeasured factors potentially mediate or moderate links between coping, and especially, maladaptive coping (e.g., avoidance coping) and use of alcohol and drugs among individuals with PTSD. These factors include beliefs about the negative effects of alcohol (i.e., negative expectancies), and about one's ability to achieve desired goals and outcomes (i.e., self-efficacy; Hasking & Oei, 2007). Thus, to the extent that these variables are also targeted by intensive SUD therapies of various sorts, they may contribute to observed changes in coping, and the relations between coping and substance use among individuals receiving therapy for SUD. Future research testing these hypotheses may benefit from assessing motivations and perceived and actual effects of all substances used by participants, and by more directly assess coping, including assessment of how effectively participants cope using a given strategy (e.g., through the use of laboratory assessments). The current study had several prominent strengths, including an adequate sample size, good follow-up rates, excellent adherence to the treatment manual in the SS condition, and increased ecological validity resulting from our implementation of this study in a high volume outpatient SUD treatment clinic. These strengths are somewhat tempered by several limitations. First, the generalizability of results is limited by the composition of our sample: male, veterans. Future studies will benefit from extending these results to female samples, and samples consisting of participants experiencing a range of different trauma types (e.g., motor vehicle accidents). Second, we were limited in our use of retrospective, self-report questionnaire (albeit, administered in an interview format) to measure coping and criterion variables at baseline and follow-ups. In regard to criterion variables, this limitation was somewhat tempered by our implementation of frequently used measures that have been extensively psychometrically validated. Furthermore, although coping is most commonly measured by self-report questionnaire, there remains noted controversy regarding how best to operationalize and measure coping in populations both with and without psychopathology (Coyne & Gottlieb, 1996; Coyne & Racioppo, 2000). Future research might address this limitation by using a laboratory assessment of the choice and implementation of various coping strategies in response to the presentation of PTSD and SUD-relevant cues. Alternatively, the relations between coping, PTSD and SUD might be captured by methods with increased temporal resolution and ecological validity, such as experience sampling methods, which would provide data on coping strategy use to manage PTSD and SUD symptoms as they occur in approximate realtime and in-situ. We were unable to directly test directional/causal hypotheses, leading to potential problems with reciprocal causation. In other words, coping and criterion variables were assessed at the same time, and we were unable to stagger the prediction of criterion variables from coping variables (e.g., baseline avoidant coping is linked with PTSD severity at follow-up 1) due to constraints on the number of follow-up assessments and the loss of data equal to one time-point if we did so. Thus, it is not clear in this sample whether coping behavior influenced PTSD/SUD symptomatology or vice versa. Again, we believe that experience sampling methods combined with crosslagged analyses may be the best manner to test causal relations between coping and PTSD/SUD symptomatology. Additional limitations include: (a) the diagnosis of alcohol and/or drug use disorders through chart review rather than through direct assessment (e.g., structured clinical interviews); and (b) different sets of therapists, who varied in clinical training background and years of experience, provided SS versus TAU, thus increasing the chance that

Please cite this article as: Tyler Boden, M., et al., Coping among military veterans with PTSD in substance use disorder treatment, Journal of Substance Abuse Treatment (2014), http://dx.doi.org/10.1016/j.jsat.2014.03.006

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results were in part attributable particular characteristics of the therapist (i.e., therapist effects). Despite these limitations, the results of this study have notable implications for the understanding and treatment of comorbid PTSD and SUD. PTSD and SUD are associated with the use of avoidance and emotion discharge coping strategies. While this may not be surprising, our finding that a treatment designed specifically to target coping, SS, leads to similar changes in coping as an intensive TAU, is more so. However, this finding combined with our results demonstrating associations between coping and PTSD/SUD symptomatology suggest the trans-therapeutic utility of targeting coping, and especially the reduction of maladaptive coping, in treatments for co-occurring PTSD and SUD.

Acknowledgments This work was supported by IIR 04-175-3 “Effectiveness of Screening and Treatment for PTSD in SUD patients” from VA Health Services Research & Development Service, granted to Drs. Trafton and Kimerling. Dr. Weaver was supported by a VA Office of Academic Affiliations training grant (TPP 97–006). The views expressed here are those of the authors and do not necessarily represent those of the Department of Veterans Affairs. For their help and guidance in conducting this study, we would like to acknowledge the staff of the out-patient substance use clinic at the Veterans Administration Northern California Health Care System in Oakland, California, and especially David Joseph, Matt Moore, James Howard, Cynthia Mitchell, Michael Hoston, Sam Durkin, Key Levine, Cynthia Wright, Joe Lococco, Danilo Dauz, Tracy Cascio, Joshua Orlans, Mac Dulaney, Carol JiteOgbuehi and Pamela Planthara. All authors declare that they have no conflicts of interest. World Health Organization clinical trial registration number: NCT00265564.

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