Prolonged Exposure for Treating PTSD Among Female Methadone Patients Who Were Survivors of Sexual Abuse in Israel.

Social Work in Health Care

ISSN: 0098-1389 (Print) 1541-034X (Online) Journal homepage: http://www.tandfonline.com/loi/wshc20

Prolonged Exposure for Treating PTSD Among Female Methadone Patients Who Were Survivors of Sexual Abuse in Israel Miriam Schiff PhD, Nitsa Nacasch MD, Shabtay Levit PhD, Noam Katz MSW & Edna B. Foa PhD To cite this article: Miriam Schiff PhD, Nitsa Nacasch MD, Shabtay Levit PhD, Noam Katz MSW & Edna B. Foa PhD (2015) Prolonged Exposure for Treating PTSD Among Female Methadone Patients Who Were Survivors of Sexual Abuse in Israel, Social Work in Health Care, 54:8, 687-707, DOI: 10.1080/00981389.2015.1058311 To link to this article: http://dx.doi.org/10.1080/00981389.2015.1058311

Published online: 23 Sep 2015.

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Date: 03 February 2016, At: 17:56

Social Work in Health Care, 54:687–707, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0098-1389 print/1541-034X online DOI: 10.1080/00981389.2015.1058311

Prolonged Exposure for Treating PTSD Among Female Methadone Patients Who Were Survivors of Sexual Abuse in Israel

Downloaded by [Orta Dogu Teknik Universitesi] at 17:56 03 February 2016

MIRIAM SCHIFF, PhD Paul Baerwald School of Social Work and Social Welfare, Hebrew University, Jerusalem, Israel

NITSA NACASCH, MD Brill Mental Health Center, Tel-Aviv, Israel

SHABTAY LEVIT, PhD Paul Baerwald School of Social Work and Social Welfare, Hebrew University, Jerusalem, Israel

NOAM KATZ, MSW Association for Public Health, Methadone Maintenance Treatment Programs in Ashdod, Ashdod, Israel

EDNA B. FOA, PhD Center for the Treatment and Study of Anxiety (CTSA), School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA

The aims of this pilot study were: (a) to test the feasibility of prolonged exposure (PE) therapy conducted by a social worker staff on female patients in methadone program clinics who were survivors of child sexual abuse or rape and (b) to examine preliminary outcomes of PE on posttraumatic stress disorder (PTSD), depression, and illicit drug use at pre- and posttreatment, and up to 12-month follow-ups. Twelve female methadone patients who were survivors of child sexual abuse or rape diagnosed with PTSD were enrolled in 13–19 weekly individual PE sessions. Assessments were conducted at pre-, mid-, and posttreatment, as well as at 3, 6, and 12-month follow-ups. The treatment outcomes measures included PTSD symptoms, depressive symptoms, and illicit drug use. Ten of the 12 study patients completed treatment. PTSD and Received January 5, 2015; accepted June 1, 2015. Address correspondence to Miriam Schiff, Paul Baerwald School of Social Work and Social Welfare, Hebrew University, Mount Scopus, Jerusalem 91905, Israel. E-mail: miriam.schiff@mail. huji.ac.il 687

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depressive symptoms showed significant reduction. No relapse to illicit drug use was detected. These preliminary results suggest that PE may be delivered by methadone social workers with successful outcomes. Further research should test the efficacy of PE among methadone patients in a randomized control trial with standard care as the control condition.


KEYWORDS child sexual abuse, drug abuse, evidence-based practice, Israel, methadone maintenance treatment, pilot study, posttraumatic stress symptoms, prolonged exposure (PE) therapy, PTSD, social workers, women

Prevalence of child sexual abuse among female methadone patients ranges between 40% to 64% (Cohen et al., 2009; Engstrom, El-Bassel, & Gilbert, 2012; Peles, Potik, Schreiber, Bloch, & Adelson, 2012). This rate exceeds by far the prevalence of child sexual abuse among females in the general population (8–14%) (Afifi et al., 2014; Cavanaugh, Martins, Petras, & Campbell, 2013; Iffland, Brahler, Neuner, Hauser, & Glaesmer, 2013). (Engstrom et al., 2012) The prevalence of posttraumatic stress disorder (PTSD) among female methadone patients also exceeds by far the prevalence of PTSD among the general population. Of female methadone patients, 25–30% meet the criteria for PTSD (Engstrom et al., 2012; Engstrom, El-Bassel, Go, & Gilbert, 2008; Hien, Nunes, Levin, & Fraser, 2000; Kidorf et al., 2013) versus less than 10% of females in the general population (Brady, Back, & Coffey, 2004; Cavanaugh et al., 2013). The rate of PTSD among female methadone patients in Israel is even higher. A study among female methadone patients conducted in Israel found that more than half of the women (54.2%) reported symptoms that met DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision [American Psychiatric Association, 2000]) criteria for PTSD and most indicated child sexual abuse as their major trauma (Schiff, Levit, & Cohen-Moreno, 2010). Although female methadone patients suffer from multiple traumatic events (Amaro, Chernoff, Brown, Arevalo, & Gatz, 2007; Barry et al., 2011; Peles et al., 2014), childhood sexual abuse (CSA) had the most devastating effects including more severe substance use (Ullman, Relyea, Peter-Hagene, & Vasquez, 2013), greater level of depression (Schiff, El-Bassel, Engstrom, & Gilbert, 2002), intimate partner violence in adulthood (Engstrom et al., 2008) sexual risk behavior (Arriola, Louden, Doldren, & Fortenberry, 2005), greater use of benzodiazepines (Bartholomew, Rowan-Szal, Chatham, Nucatola, & Simpson, 2002), and lower retention in drug treatment programs (Petry, Ford, & Barry, 2011). Therefore, we focused the pilot study on female methadone patients who were survivors of CSA or rape before age 18.


Prolonged Exposure Among Female Methadone Patients

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There are several explanations for how trauma leads to PTSD and substance use dependence (SUD). The first is the self-medication hypothesis, which argues that individuals turn to SUD as a means to alleviate the psychological pain associated with the intrusive thoughts, memories, and negative feelings brought on by the traumatic event (Khantzian & Albanese, 2008). Another proposed explanation is the high-risk and susceptibility hypotheses (Chilcoat & Breslau, 1998; Hien, Litt, Cohen, Miele, & Campbell, 2009). This hypothesis argues that substance use is associated with an increased risk for traumatic exposure thereby indirectly increasing the likelihood of PTSD. PTSD–SUD can also be seen as an interruption in the individual’s ability for emotional regulation (i.e., the ability to monitor, evaluate, and modify internal emotional states and processes, including tolerating stressful emotional experiences). PTSD is accompanied by problems in emotional regulation. SUD can serve as a means to regulate emotions (Hien et al., 2009). A fourth explanation points to genetics and the disruption in the neurophysiologic systems that either preceded both PTSD and SUD, or developed as a result of exposure to traumatic events (McCauley, Killeen, Gros, Brady, & Back, 2012; Sinha, 2008). SUD–PTSD co-morbid patients have less successful treatment outcomes than those of patients with no PTSD diagnosis (Staiger, Melville, Hides, Kambouropoulos, & Lubman, 2009). They relapse more quickly, and are more likely to leave the SUD treatment prematurely (McCauley et al., 2012). Therefore, there is a growing consensus that PTSD–SUD patients should be treated for their posttraumatic symptoms concurrently to any drug treatment therapy (Hien, Cohen, & Campbell, 2005). Treatment for PTSD–SUD can be divided into exposure-based and non-exposure therapies. Exposure-based therapies include revisiting traumatic memories (i.e., imaginal exposures) and facing trauma related distressing places or situations regularly avoided (i.e., in-vivo exposures). Non-exposure therapies do not include imaginal or in-vivo exposures; rather they focus on the responses to the trauma and the impact of the trauma symptoms with psychoeducation and regulating symptoms and negative emotions (McCauley et al., 2012). A well-known and efficacious exposure-based therapy is the Prolonged Exposure (PE) therapy (Foa, Hembree, & Olasov-Rothbaum, 2007). It is an evidence-based practice (EBP) with substantial demonstrated efficacy with the widest range of trauma populations (rape, physical assault, refugees, motor vehicle accidents, combat, terrorism, and childhood sexual abuse (Bryant et al., 2008; Nacasch et al., 2011; Rauch, Eftekhari, & Ruzek, 2012; Resick, Williams, Suvak, Monson, & Gradus, 2012). It was acknowledged by the Institute of Medicine (2008) as the only treatment for PTSD with sufficient evidence for its efficacy. Nonetheless, it is not widely disseminated (Ruzek et al.,


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2014) due to barriers at the practitioner and organizational levels. At the practitioner level, PE treatment includes imaginal exposure in which the patient is asked to tell repeatedly, in great detail, their most distressing traumatic event, eliciting the often painful emotions associated with it. Many practitioners are concerned that this process will cause patient retraumatization, dropout, and symptom exacerbation (Resick et al., 2012). Despite contradicting evidence (Foa, Zoellner, Feeny, Hembree, & Alvarez-Conrad, 2002), and despite evidence that withholding treatment for PTSD is harmful, many clinicians feel unease at conducting PE therapy and do not adapt other EBP treatments for PTSD (Jayawickreme et al., 2014). At the organizational level, PE as with other evidence-based interventions, might be perceived as too rigid and as ignoring other organizational needs. Dissemination of PE therapy requires a stable organization with low staff turnover. It also demands training and ongoing staff supervision, which might take organizational resources at the expense of meeting other short-term clients’ needs (Foa, Gillihan, & Bryant, 2013). Thus, the feasibility of staff conducted PE (Bowen et al., 2009) at a methadone clinic in an organizational climate prioritized stabilization of patients on methadone dozes and preventing relapse to illicit drug use (Peles, Linzy, Kreek, & Adelson, 2008) is questionable. Feasibility of EBP is defined by the participation rate, attendance, treatment adherence, and retention (Gilbert et al., 2006). Because PE in the present study was conducted by the methadone staff rather than by trained facilitators hired by the study researchers, we expanded the definition of feasibility to include the acceptability of PE by practitioners, and whether it could be fully implemented according to its protocol (Bowen et al., 2009). Beyond feasibility, there is also a notable dearth of research examining the efficacy of PE among SUD patients. Many cognitive behavioral interventions targeting sexually assaulted women exclude women with substance abuse or dependence co-morbidity (Vickerman & Margolin, 2009). (Najavits, 2002; Najavits et al., 2009) (Najavits & Hien, 2013) Preliminary results of PE among an uncontrolled study of 39 patients with cocaine dependence and PTSD found that treatment completers showed significant reductions in PTSD symptoms, depression, and cocaine use, and improvements were maintained over a six-month period (Back, Dansky, Carroll, Foa, & Brady, 2001). A Randomized Control Trial (RCT) utilizing PE among alcohol-PTSD patients randomly assigned patients to four groups: (1) PE and naltrexone; (2) PE and placebo; (3) supportive counseling and naltrexone; and (4) supportive counseling and placebo. Initial findings revealed that there was a reduction in PTSD symptoms in all four groups, but that the main effect of prolonged exposure therapy was not statistically significant. At the six- month follow-up, participants in all four groups had increases in percentage of



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days drinking. However, those in the PE therapy and naltrexone group had the smallest increases (Foa, Yusko, et al., 2013). Another RCT conducted in Australia with 103 SUD–PTSD patients who experienced a wide range of civilian traumas and engaged in poly-substance use found that at the nine-month follow-up, a reduction in PTSD symptoms was found in both treatment and control groups, although a greater reduction was achieved in the treatment group (Mills et al., 2012). Thus, PE is a potential successful treatment to reduce PTSD among SUD–PTSD patients, with no evidence of relapse during treatment or in the followups. However, no previous study has tested PE treatment in methadone maintenance treatment clinics. Its feasibility has never been addressed so far. Research hypotheses: 1. PE intervention for female methadone patients delivered by the social worker staff of methadone clinics will be feasible. 2. A clinically significant reduction from pre- to posttreatment in PTSD and depressive symptoms will be found, and that this reduction will hold at the 3-, 6-, and 12-month follow-ups. 3. Patients’ substance use will not increase during treatment, posttreatment or at follow-ups.

METHODS This pilot study involved a pre- (beginning of session 1) mid- (sixth or seventh session), and posttest (beginning of last session) and 3-, 6-, and 12-month follow-ups of PE therapy among female methadone patients who were sexually abused in childhood or were raped in young adulthood. Participants were not compensated for their participation in the study. PE sessions were conducted in one of the offices of the methadone clinic. All sessions were videotaped for the purpose of supervision and to increase fidelity. PE was conducted by the counselor (therapist) of the patient. In Israel, all therapists in methadone clinics are social workers (with at least a BSW degree) or clinical criminologist (MA). Unlike the United States and some other countries, under the Social Workers Law of 1996 a BSW degree is required for professional licensing in Israel. The 3-year Bachelor’s degree (BSW) program is the basic qualification for all forms of professional activity in the field. The course of studies focuses on a generalist approach to practice and includes extensive (two days a week in the second and third year of studies) field training. Thus, graduates of the BSW program may provide psycho-social treatment and psychotherapy in a variety of services including drug-treatment services. Treatment outcome measures were PTSD symptoms, depressive symptoms, and illicit drug use.

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Treatment Overview We adopted the Foa et al. protocol for PE treatment for individuals diagnosed with PTSD (Foa et al., 2007). The treatment was delivered by five therapists: three licensed social workers at a MSW level, one licensed social worker at a BSW level, and one clinical criminologist (with a MA degree). All five were employees in one of the two methadone clinics in the study (three in the larger methadone clinic and two in the smaller) for between 3 to 10 years. Each participated in a four-day (about 35-hour) PE workshop conducted by Foa and the second author. During the training, practitioners went through the PE protocol through lectures, clinical demonstration, and role playing. This was a standard training workshop congruent with the PE model (Eftekhari et al., 2013; Nacasch et al., 2015). Biweekly two-hour clinical group supervision by the second author was provided until the conclusion of all treatment sessions (about 2.5 years). The supervisor had cognitive behavioral therapy (CBT) expertise, and was an expert trainer who has supervised PE cases for eight years prior to the beginning of the study. Supervision included viewing all video-taped sessions (at least one third of each session for each patient), preparing the therapist for the coming session, and discussing patient and therapist barriers (if any) to engage in the treatment process. The PE treatment consisted of 13–19 individual weekly sessions of 90 minutes each. In session 1, patients were introduced to the treatment rationale, their trauma history was assessed and breathing training was taught. Session 2 included discussions regarding common reactions to trauma, and the associations between PTSD and their substance use and relapse over time. In session 3 the therapist reviewed the rationale for in-vivo exposure; that these encounters reduce trauma-related distress, enable the patient to realize that the avoided situations and places are not dangerous and that he/ she is able to cope with distress (Foa et al., 2007). Following the exploration of its rationale, therapist and patient create an in-vivo hierarchy and choose an initial target for an in-vivo assignment for that week’s homework. The therapist assists the patients with their first in-vivo tasks when needed. In session 4 the therapists provided the rationale for imaginal exposure. The imaginal encounter enhances the processing of the traumatic memories and helps attain a realistic perspective on the trauma. From this session until the one before the last, the patients recount their traumatic memory with eyes closed and in the present tense for 45–60 minutes, while engaging with their emotions and continually processing thoughts and feelings associated with the trauma. After recounting, the patient and the therapist process aspects of the traumatic event such as shame and guilt. As homework, patients were instructed to listen daily to the audiotape of the



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imaginal exposure and to continue with in-vivo exposure exercises. Therapists were accessible to the patients by phone and called the patients as needed to monitor their homework assignments. Two patients had incidents of illicit drug use after the first two imaginal exposure sessions. We addressed it during sessions and repeated the rationale of the treatment and its psycho-educational component. From session 8 on, imaginal exposure was focused on “hot spots,” the most distressing parts of their memory. The therapists continued addressing the barriers and motivators for listening to the audiotape of the imaginal exposure every day between sessions or for completing the patient’s in-vivo home assignments. In the last session, termination of treatment was addressed and plans were made for the patients’ return to standard care.

Sample A baseline study assessing trauma history and PTSD in 4 out of 11 methadone clinics in Israel (a convenient sample) included 144 female patients interviewed on their trauma history and PTSD using standardized scales (Schiff et al., 2010). In that study we found that 72% (104 patients) reported undergoing childhood sexual abuse or rape. Of the females who experienced child sexual abuse or rape, 50% reported symptoms indicating likelihood for PTSD (52 female patients). Given that the screening in the baseline study was based on a self-report scale, the Posttraumatic Diagnostic Scale (PDS; Foa, Cashman, Jaycox, & Perry, 1997), and PTSD diagnosis should be accompanied by a clinical diagnosis (Powers, Gillihan, Rosenfield, Jerud, & Foa, 2012), we could not proclaim a PTSD diagnosis at that stage, only likelihood for PTSD. Two (one larger and one smaller) out of four clinics that participated in the baseline study were willing to train their staff for the PE treatment. The directors of the two other clinics preferred to wait until the results of the pilot. In these clinics 28 female patients with trauma history of childhood abuse or rape had a profile of symptoms that showed likelihood for PTSD. However, at the beginning of the PE study (about a year later) only 22 female patients from the baseline study still attended one of the two clinics. Further diagnosis by the psychiatrist of the clinics excluded five patients for lack of PTSD diagnosis or other mental health problems that precluded them from participating in the study. Seventeen patients who were stable on methadone and had PTSD were offered the treatment; 5 refused and the remaining 12 underwent PE therapy (8 from the larger methadone clinic and 4 from the smaller). One patient dropped out due to psychosocial problems (housing evacuation and heavy financial debts), and the treatment of the other was stopped because of suicidal thoughts. All 12 patients, including the 2 dropouts, were interviewed at all time-points and

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their data was analyzed using the intention to treat principle (i.e., analyzing the results of all patients who were assigned to treatment whether or not they completed it) (Montori & Guyatt, 2001). The intention to treat principle provides an unbiased estimate of the treatment effect (Gupta, 2011). The average age of the 12 female participants was 41.50 (SD = 9.96). Their average time in the methadone clinic prior to therapy was 6.00 years (SD = 5.05; range = 1–17 years). Average length of the patients’ drug dependence was 16.00 years (SD = 9.59; range = 4– 33 years). Most (10 patients) were single or divorced.

The Treatment Sites At the time of the study, the two methadone clinics where this study was conducted were treating 587 patients (357 in the larger clinic and 230 in the smaller clinic); 15% (n = 88) were female (Cohen-Moreno et al., 2010). Treatment in these clinics typically includes individually adjusted daily doses of methadone in the clinic, or “take home” dosages based on good conduct and prolonged drug abstinence. In addition, a new patient is required to participate in several activities: she or he must join a mandatory adjustment group that supports her or him in the rehabilitation process, undergo detoxification from heroin and other illicit drugs, stabilize on methadone, accept the rules of the clinic, and generally shift from life as an addict to a more normative life. As soon as the patient completes the adjustment group successfully, meaning no or rare traces of illicit substances is found in the urine tests, she or he is assigned to weekly or bi-weekly psycho-social treatment sessions with the social worker or the clinical criminologist. “Heavy” users are required to participate in a self-control group. Other groups are elective and include parenting groups, art groups, and so on (Peles et al., 2008; Peles, Schreiber, & Adelson, 2010).

Inclusion Criteria Inclusion criteria into the study included; (1) Diagnosis of PTSD based on the DSM-IV-TR for at least 6 months (i.e., chronic PTSD) related to childhood sexual abuse or rape; (2) ability to provide informed consent; and, (3) agreement to not seek concurrent trauma-related mental health treatment. Exclusion criteria were: (1) psychosis; (2) dissociative identity disorder; (3) current suicidal ideation deemed serious enough to warrant immediate treatment; and (4) homicidal ideation.


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Measures


All measures were provided by the therapists who conducted the PE therapy. The Posttraumatic Diagnostic Scale (PDS) and the Beck Depression Inventory (BDI) self-reported scales were filled privately by the patients and were submitted to the therapists upon completion. Interviews of the MINI and PTSD Symptom Scale, Interview Version (PSS-I) were conducted by the therapists after receiving training by the clinical supervisor. SCREENING MEASURES To assess inclusion and exclusion criteria we used the MINI International Neuropsychiatric Interview 5.0 (Sheehan et al., 1998). This is a short, structured diagnostic interview used to determine that the primary diagnosis was PTSD and to detect the presence of other Axis I disorders of the DSM-IV (American Psychiatric Association, 1994). Delivering MINI is part of the assessment protocol of the PE therapy (Nacasch et al., 2015; Smith et al., 2015). OUTCOME MEASURES The PSS-I includes a 17-item clinical interview that evaluates DSM-IV PTSD symptoms on a frequency/severity scale (Foa, Riggs, Dancu, & Rothbaum, 1993). Items are rated on 0–3 scales for the frequency and severity in the past two weeks. Psychometric studies (Foa & Tolin, 2000) revealed Cronbach’s α of .91 for the full scale and .78, .80, .82 for the re-experiencing, avoidance, and arousal clusters, respectively. The interview is highly correlated with the self-report PDS (Foa & Tolin, 2000). PDS (Foa et al., 1997) is a 49-item self-report measure that provides total and subscale severity scores and categorical classification of PTSD based on the DSM-IV categories. Respondents are asked to rate the severity of the symptom from 0 (“not at all or only one time”) to 3 (“5 or more times a week/almost always”). Inter-item reliability in a longitudinal National survey among the adult population in Israel was α = .87 at Time 1 and .89 at Time 2 (Hobfoll et al., 2009). The BDI (Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961) is a 21-item self-report measure assessing depression. This scale is widely used in Israel with Israeli norms for depression based on it (Iancu, Horesh, Lepkifker, & Drory, 2003). Illicit drug use assessment was based on the results of the urine tests that are conducted on a routine basis at the methadone maintenance treatment program. The tests are analyzed for traces of heroin, cocaine, benzodiazepines, cannabis, and methadone in authorized laboratories by the Israeli

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Ministry of Health (Peles, Schreiber, & Adelson, 2006). The scale ranges from “0” meaning no traces of the substances in any of the urine tests to “100” traces of the substance were found in all urine tests.

RESULTS


Feasibility The practitioners willingly participated in the four-day workshop introducing them to the PE treatment, happily participated in the bi-weekly clinical supervision, all funded by a research grant and the methadone clinic, and successfully conducted the videotaped PE interventions. They preferred treating female patients who were “clean” of illicit drug use, and therefore our sample is somewhat biased toward patients with less relapse to heroin (see results). Practitioners adhered to the protocol despite their distress from repeatedly hearing about the traumatic events in the imaginal exposure part of the treatment. The case example, presented in the Appendix, of the PE treatment by a social worker with long training in psychodynamic orientation, and no background with CBT or manualized evidence-based therapies in general, illustrates the feasibility of PE in methadone maintenance clinics.

Changes from Pre- to Posttreatment and Follow-Ups We found a marked reduction in PTSD symptoms among nine patients. The two patients who did not complete the treatment did not show a reduction in symptoms (one patient had a score of 33 and 30 on the PDS scale at the beginning and end of treatment, respectively; another had a score of 46 and 42 at the beginning and end of treatment, respectively) and one patients who completed the treatment showed reduction in symptoms only at the follow-up (score of 19 at the beginning and end of treatment but 11 in the 3-month follow-up). We used intention to treat analyses whereby all 12 participants who began treatment were included in all statistical analyses. Mean PTSD symptoms before the beginning of treatment was 30.50 (SD = 2.53) and Mean posttreatment = 14.33 (SD = 3.51). Mean of depressive symptoms before the beginning of treatment was 31.92 (SD = 2.92) and Mean posttreatment = 15.58 (SD = 3.75). Friedman’s Analysis of Variance (ANOVA) tests were used to test the effect of the PE treatment on the reduction of PTSD symptoms (total scale and by clusters). Friedman’s tests were conducted for two reasons: it allowed for measurements across time and the sample size was small. Table 1 presents the results.

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TABLE 1 PTSD and Depressive Symptoms: Mean Ranks from the Friedman’s ANOVA (N = 12)

Variables


Posttraumatic total Re-experiencing symptoms Avoidance symptoms Hyper-arousal symptoms Depressive symptoms

3-Month 6-Month 12-Month MidFollow- FollowFollowPretreatment Treatment Posttreatment Up Up Up 5.62 5.67

4.21 4.04

2.83 3.04

3.04 3.12

2.75 2.62

2.54 2.50

5.54

4.21

2.62

2.88

3.21

2.54

4.50

4.08

3.17

3.25

2.71

3.29

5.38

4.25

2.71

3.00

3.00

2.67

Posttraumatic Symptoms (Scores on the Total Scale) We found a significant reduction of posttraumatic symptoms, Q(5) = 27.03, p = .000. Pairwise comparisons revealed a significant reduction in posttraumatic symptoms between pre- and posttreatment (p = .004); pre- and 3-month follow-up (p = .011), pre- and 6-month follow-up (p = .003), and pre- and 12-month follow-up (p = .001).

Re-Experiencing Symptoms Similar reductions following PE treatment were found in re-experiencing symptoms, Q(5) = 29.83, p = .000. Pairwise comparisons revealed a significant reduction in re-experiencing symptoms between pre- and posttreatment (p = .009); pre- and 3-month follow-up (p = .013), pre- and 6-month follow-up (p = .001), and pre- and 12-month follow-up (p = .001).

Avoidance Symptoms A reduction in avoidance symptoms was also found following PE treatment, Q(5) = 26.51, p = .000. Pairwise comparisons revealed a significant reduction in avoiding symptoms between pre- and posttreatment (p = .002); pre- and 3-month follow-up (p = .007), pre- and 6-month follow-up (p = .034), and pre- and 12-month follow-up (p = .001).

Hyper-Arousal Symptoms A reduction in hyper-arousal symptoms was not demonstrated following PE treatment, Q(5) = 8.23, p = .144.

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Depressive Symptoms A reduction in depressive symptoms was also found following PE treatment, Q (5) = 22.36, p = .000. Pairwise comparisons revealed a significant reduction in depressive symptoms between pre- and posttreatment (p = .007); pre- and 3month follow-up (p = .028), pre- and 6-month follow-up (p = .028), and preand 12-month follow-up (p = .006).


Illicit Drug Use The general relapse rate among female patients in methadone clinics in Israel is low. The median for the one year use of heroin is 5% (Schiff et al., 2010). The median use of the patients who participated in the present study, 12 months pretreatment, was even lower—0% of the urine tests (eight patients did not use heroin at all, two had used all the time with 100% of their urine tests indicating traces for heroin use, one patient had 20%, and one patient 33% of their urine tests showing traces for heroin). Thus, in general, these patients did not use illicit drugs to begin with. Nonetheless, despite the reminder of the traumatic memory through the imaginal and in-vivo exposure, they have managed to “stay clean.” Table 2 presents the participants’ illicit drug use at 12-months pretreatment and up to 12-months posttreatment. It shows that there was no relapse in use of opiates [Q(5) = 2.93, p = .711], cocaine [Q(5) = 5.07, p = .408], cannabis [Q(5) = 3.37, p = .644], and benzodiazepines [Q(5) = 6.06, p = .300].

DISCUSSION The results of this pilot study indicate that female methadone patients suffering from PTSD who underwent PE treatment showed marked reduction in PTSD and depressive symptoms at the end of the treatment, and that the reductions remained at the 12-month follow-up. At the end of the treatment, scores on the PDS of the 10 patients who completed treatment ranged TABLE 2 Illicit Drug Use: Mean Ranks from the Friedman’s ANOVA (N = 12)

Variables Opiates (other than methadone) Cocaine Cannabis Benzodiazepines

3-Month 6-Month 12-Month MidFollow- Follow- FollowPretreatment Treatment Posttreatment Up Up Up 3.50

3.58

3.46

3.33

3.12

4.00

3.79 3.58 2.67

4.00 3.62 3.75

3.21 3.12 3.62

3.21 3.58 3.88

3.42 3.38 3.71

3.38 3.71 3.38



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between 0 and 19. These scores show symptom levels that do not indicate PTSD and that held or were even a bit lower at the three follow-up points. The two patients who dropped out remained with a high level of PTSD symptoms (30 and 42, respectively, in the posttest). Moreover, similar to previous studies (Henslee & Coffey, 2010), results show that addressing the traumatic experience by imaginal and in-vivo exposure do not increase illicit substance use. It should be noted that these patients received supportive therapy before PE, by the same clinicians who conducted PE. Yet, they continued to suffer from PTSD symptoms until given PE therapy. The dropout rate in this complex population was even lower than what is reported in the literature (Foa et al., 2005; Rizvi, Vogt, & Resick, 2009). The low dropout rate may suggest a high engagement in treatment, which is usually a great challenge among methadone patients (Kidorf et al., 2013). Patients’ engagement in the therapy might be a product of the strong therapeutic alliance with the social work clinicians, which was found in a previous study that took place in these methadone clinics (Schiff & Levit, 2010). Another interpretation of the low dropout rate is the nature of the setting where this study was conducted. Methadone patients come to the clinic to get their methadone doses between 1–5 times a week (Schiff, Levit, & Cohen-Moreno, 2007), regardless of the PE treatment, and during their clinic visits they are in touch with the staff. The low dropout rate may be unique to Israel in general, as retention rates in methadone clinics in Israel (between 74–80% (Peles et al., 2006; Schiff et al., 2007) are higher than in the United States (52–57% (Amato et al., 2005; Villafranca, McKellar, Trafton, & Humphreys, 2006), and other places such as the United Kingdom (62%) (Gossop, Marsden, Stewart, & Kidd, 2003) and China (55.3–69.9%) (Zhang et al., 2013). This pilot intervention was conducted by the methadone social workers with no prior CBT training and who were not trauma experts. Nonetheless, based on the supervisor’s viewing of at least one third of each video-recorded PE session, we conclude that they were capable to conduct PE with adherence to the protocol despite the complexity and chronic nature of PTSD and SUD symptomatology among these patients. In addition, consistent clinical supervision is thought to be a key element in the dissemination of evidencebased therapies (Foa, Gillihan, & Bryant, 2013; McLean & Foa, 2013). Thus, we suggest that with a short PE training before the beginning of treatment and with group supervision, PE can be delivered by the methadone social workers with encouraging preliminary outcomes. Study limitations include the small number of participants, the fact that most of them were “clean” from illicit substance use to begin with, the absence of a measurement for the patient therapeutic alliance with the therapist, and the lack of an RCT. The small size and convenient sample limit any generalization of present findings to female methadone patients with a history of child sexual abuse or rape and PTSD. Thus any conclusion regarding the efficacy of PE in methadone clinics is premature. The


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absence of a measurement on patient therapeutic alliance with the therapist limits our ability to test the potential moderation effect of therapeutic alliance in the reduction of PTSD symptoms. In addition, because of limited funding, fidelity to the PE protocol was based on the clinical judgment of the supervisor and not on standard fidelity measures. The absence of the RCT design threatens the internal validity, including selection bias (i.e., more motivated and committed patients), history (standard care by therapists who are now aware of the devastating effects of trauma), and testing. These threats open up the results to alternative interpretations. One potential interpretation is that the marked improvement in PTS and depressive symptoms might be due to the ongoing relationships therapists had with patients rather than the PE therapy itself. The costs of the training and supervision relative to the small number of patients who benefited from the treatment is also a concern but might be related to the pioneering work and the therapists’ concerns about harming the patients through imaginal exposure, a well-known barrier for therapists using PE (Resick et al., 2012). Expanding PE to female methadone patients that are frequent illicit drug users may need the adoption of COPE therapy, which is a combination of PE and relapse prevention for SUD (Back et al., 2015). Further research should test the efficacy of PE among a large group of female methadone patients, with local staff as the therapists in a randomized control trial.

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APPENDIX Case Example “Aline,” a 50-year-old Caucasian woman, divorced and mother of 4 (ages 21–33) was admitted to treatment at the methadone clinic 3 years earlier. Aline was born in Israel, the oldest of two children. Her father was away from home due to his service in the Israeli Defense Forces. At age 4 her parents divorced and a stepfather entered her life. From age 6 to 8 she experienced severe sexual abuse by her stepfather. At age 8 she attempted suicide by jumping off the balcony and was admitted to a psychiatric ward for a month. Four years later she left home and moved between several residential care-settings. At age 16 she was involved in an intimate relationship with her former husband who was a drug addict when she began using with him. One year later, her eldest son was born. At age 24, while high, she was raped by a couple of men and eventually became a prostitute. She was arrested several times for prostitution and illicit drug use felonies. At age 47 she was admitted for the first time to treatment at one of the methadone clinics in Israel. She suffered from severe and chronic PTSD, which included flashbacks about her multiple traumatic experiences and especially the continuous sexual assault by her stepfather. She avoided crowded places like malls and restaurants, and other triggering situations like being alone with a man in a store or looking at her body in the mirror. She had difficulties staying alone at home during the night. She lived at home with her former husband who verbally abused her. Aline was offered the PE therapy. At the first session, the social worker therapist introduced the rationale of the PE therapy. Then the therapist introduced the two main procedures of PE: The in-vivo and the imaginal exposure. During her treatment she began systematically



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confronting places and situations she had avoided, such as being alone at home, entering a store and talking to the salesman. In session 3, she began to revisit the traumatic memory which haunted her the most; the sexual assault at age 8. In the first imaginal exposure, she appeared and sounded very distressed, regressive and immature. She was sobbing while describing the traumatic event and the narrative was very fragmented. As the therapy proceeded, the narrative became more organized and she processed her negative perceptions of guilt and shame. She realized how cruel her stepfather was as she remembered him threatening that he would set her on fire if she told her mother about the assault. As a result of remembering, Aline began to feel less guilty. She successfully recounted the trauma without distress and began to experience fewer intrusive symptoms. During the in-vivo exposure she overcame her fears and felt more competent. She began to stay home alone and removed her abusive partner from there. She began to visit crowded places like malls, went shopping, and reported enjoying these activities. She also improved her appearance. At the end of the treatment her posttraumatic symptoms (measured by the PSSI) decreased from 39 to 7 and her depressive symptoms (measured by the BDI) were reduced from 39 to 4. In a follow-up 1 year after the conclusion of her treatment, she read a letter she wrote symbolically to her deceased father. “Father, I want to tell you a secret that I kept all my life about a trauma that I went through during my childhood. How much I suffered and my life was ruined. . . . But today I would like you to know that your little girl is not suffering anymore. . . . I hope you are proud to look at my new life and how I became brave and strong.”

Female sexual abuse survivors as patients: avoiding retraumatization.

Extending the evidence base for prolonged exposure: significant effectiveness noted with sexual abuse-related PTSD in adolescent girls.

Prolonged exposure vs supportive counseling for sexual abuse-related PTSD in adolescent girls: a randomized clinical trial.

An exploratory study of domains of parenting concern among mothers who are childhood sexual abuse survivors.

Avoidant and compulsive sexual behaviors in male and female survivors of childhood sexual abuse.

Characteristics of U.S. veterans who begin and complete prolonged exposure and cognitive processing therapy for PTSD.

Sexual revictimization, PTSD, and problem drinking in sexual assault survivors.

Gender-related sexual abuse experiences reported by children who were examined in an emergency department.

Residential PTSD treatment for female veterans with military sexual trauma: does a history of childhood sexual abuse influence outcome?

Group cognitive analytic therapy for female survivors of childhood sexual abuse.

Sexual Issues in Treating Trauma Survivors.

Prolonged exposure therapy for PTSD in sexually abused adolescents.

Feasibility and Efficacy of Prolonged Exposure for PTSD among Individuals with a Psychotic Spectrum Disorder.

Changes in PTSD and Depression During Prolonged Exposure and Client-Centered Therapy for PTSD in Adolescents.

Mental health: counselling sexual abuse survivors.

Network therapy using videotape disclosures for adult sexual abuse survivors.

The role of dissociation in self-injurious behavior among female adolescents who were sexually abused.

Impact of traumatic events on posttraumatic stress disorder among Danish survivors of sexual abuse in childhood.

Advances in pharmacotherapy for treating female sexual dysfunction.

Countertransference in the family therapy of survivors of sexual abuse.

Primum non nocere (first do no harm): symptom worsening and improvement in female assault victims after prolonged exposure for PTSD.

A comparison of Narrative Exposure Therapy and Prolonged Exposure therapy for PTSD.

abuse and PTSD exposure among the active-component U.S. military, 2001 to 2008.

Sexual health as a survivorship issue for female cancer survivors.