Targeting Trauma-related Interventions and Improving Outcomes for Women with Co-occurring Disorders

  • Karen J. CusackEmail author
  • Joseph P. Morrissey
  • Alan R. Ellis
Original Paper


National attention to the effects of interpersonal trauma has led mental health systems to adopt policies on trauma-related services; however, there is a lack of clarity regarding targeting of these services. Data from the Women, Co-occurring Disorders and Violence Study (WCDVS) were reanalyzed by grouping women on their baseline PTSD and substance abuse presentation and assessing the differential response to an integrated mental health/substance abuse intervention. Treatment effects were largest for subgroups characterized by high levels of PTSD, whereas the effects for those in the low symptom group were near zero. These findings underscore the need for clinicians to conduct careful assessments of trauma-related symptoms and to target the most intensive trauma-related interventions to individuals with PTSD symptoms.


PTSD Interventions Substance abuse 



This work was supported in part by MH019117 from the National Institute of Mental Health and the Guidance for Applicants (GFA) No. TI 00-003 entitled Cooperative Agreement to Study Women with Alcohol, Drug Abuse and Mental Health (ADM) Disorders who have Histories of Violence: Phase II from the Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Administration’s three centers: Center for Substance Abuse Treatment, Center for Mental Health Services, and Center for Substance Abuse Prevention (March, 2000). Portions of this paper were previously presented at the annual meeting of the International Society for Traumatic Stress Studies in Hollywood (November, 2006).


  1. Back, S. E., Sonne, S. C., Killeen, T., Dansky, B. S., & Brady, K. T. (2003). Comparative profiles of women with PTSD and comorbid cocaine or alcohol dependence. The American Journal of Drug and Alcohol Abuse, 29(1), 169–189.PubMedCrossRefGoogle Scholar
  2. Beck, J. C., & van der Kolk, B. A. (1987). Reports of childhood incest and current behavior of chronically hospitalized psychotic women. American Journal of Psychiatry, 144, 1474–1476.PubMedGoogle Scholar
  3. Becker, M. A., Noether, C. D., Larson, M. J., Gatz, M., Brown, V., Heckman, J. P., et al. (2005). Characteristics of women engaged in treatment for trauma and co-occurring disorders: Findings from a multisite study. Journal of Community Psychology, 33(4), 429–443.CrossRefGoogle Scholar
  4. Binder, R. L., McNiel, D. E., & Goldstone, R. L. (1996). Is adaptive coping possible for adult survivors of childhood sexual abuse? Psychiatric Services, 47, 186–188.PubMedGoogle Scholar
  5. Bisson, J. I., Ehlers, A., Mattews, R., Pilling, S., Richards, D., & Turner, S. (2007). Psychological treatments for chronic post-traumatic stress disorder: Systematic review and meta-analysis. British Journal of Psychiatry, 190, 97–104.PubMedCrossRefGoogle Scholar
  6. Brady, K. T., Back, S. E., Coffey, S. F. (2004). Substance abuse and posttraumatic stress disorder. Current Directions in Psychological Science, 13(5), 206–209.CrossRefGoogle Scholar
  7. Breslau, N., Davis, G. C., Peterson, E. L., & Schultz, L. R. (2000). A second look at comorbidity in victims of trauma: The posttraumatic stress disorder-major depression connection. Biological Psychiatry, 48, 902–909.PubMedCrossRefGoogle Scholar
  8. Breslau, N., Kessler, R. C., Chilcoat, H. D., Schultz, L. R., Davis, G. C., Andreski, P. (1998). Trauma and posttraumatic stress disorder in the community: The 1996 Detroit area survey of trauma. Archives of General Psychiatry, 55(7), 626–632.PubMedCrossRefGoogle Scholar
  9. Briere, J., Woo, R., McRae, B., Foltz, J., & Sitzman, R. (1997). Lifetime victimization history, demographics, and clinical status in female psychiatric emergency room patients. Journal of Nervous and Mental Disease, 185, 95–101.PubMedCrossRefGoogle Scholar
  10. Carmen, E., Rieker, P. P., & Mills, T. (1984). Victims of violence and psychiatric illness. American Journal of Psychiatry, 141, 378–383.PubMedGoogle Scholar
  11. Cascardi, M., Mueser, K. T., DeGirolomo, J., & Murrin, M. (1996). Physical aggression against psychiatric inpatients by family members and partners: A descriptive study. Psychiatric Services, 47, 531–533.PubMedGoogle Scholar
  12. Chilcoat, H. D., & Breslau, N. (1998). Posttraumatic stress disorder and drug disorders: Testing causal pathways. Archives of General Psychiatry, 55, 913–917.PubMedCrossRefGoogle Scholar
  13. Cocozza, J. J., Jackson, E. W., Hennigan, K., Morrissey, J. P., Reed, B. G., Fallot, R., et al. (2005). Outcomes for women with co-occurring disorders and trauma: Program-level effects. Journal of Substance Abuse Treatment, 28, 109–119.PubMedCrossRefGoogle Scholar
  14. Craine, L. S., Henson, C. E., Colliver, J. A., & MacLean, D. G. (1988). Prevalence of a history of sexual abuse among female psychiatric patients in a state hospital system. Hospital and Community Psychiatry, 39, 300–304.PubMedGoogle Scholar
  15. Cusack, K. J., Grubaugh, A. L., Knapp, R., & Frueh, B. C. (2006). Trauma and PTSD in public mental health consumers with serious mental illness. Community Mental Health Journal, 42, 487–500.PubMedCrossRefGoogle Scholar
  16. Derogatis, L. (1993). A brief form of the SCL-90-R: A self-report symptom inventory designed to measure psychological stress: Brief Symptom Inventory (BSI). Minneapolis: National Computer Systems.Google Scholar
  17. Domino, M. E., Morrissey, J. P., Chung, S., Huntington, N., Larson, M. J., & Russel, L. A. (2005a). Service use and costs for women with co-occurring mental and substance use disorders and a history of violence. Psychiatric Services, 56, 1223–1232.PubMedCrossRefGoogle Scholar
  18. Domino, M., Morrissey, J. P., Nadlicki-Patterson, T., & Chung, S. (2005b). Service costs for women with co-occurring disorders and trauma. Journal of Substance Abuse Treatment, 28(2), 135–143.PubMedCrossRefGoogle Scholar
  19. Drake, R. E., & Mueser, K. T. (2001). Managing comorbid schizophrenia and substance abuse. Current Psychiatry Reports, 3, 418–422.PubMedCrossRefGoogle Scholar
  20. Elhai, J. D., North, T. C., & Frueh, B. C. (2005). Health service use predictors among trauma survivors: A critical review. Psychological Services, 2, 3–19.CrossRefGoogle Scholar
  21. Fallot, R. D., & Harris, M. (2002). The trauma recovery and empowerment model (TREM): Conceptual and practical issues in a group intervention for women. Community Mental Health Journal, 38(6), 475–485.PubMedCrossRefGoogle Scholar
  22. Foa, E. B., Keane, T. M., & Friedman, M. J. (2000). Effective treatments for PTSD: Practice guidelines from the international society for traumatic stress studies. New York: Guilford.Google Scholar
  23. Foa, E. B., Riggs, D. S., Dancu, C. V., & Rothbaum, B. O. (1993). Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. Journal of Traumatic Stress, 6, 459–473.CrossRefGoogle Scholar
  24. Frueh, B. C., Cusack, K. J., Hiers, T. G., Monogan, S., Cousins, V. C., & Cavenaugh, S. D. (2001). Improving public mental health services for trauma victims in South Carolina. Psychiatric Services, 52(6), 812–814.PubMedCrossRefGoogle Scholar
  25. Goodman, L. A., Dutton, M. A., & Harris, M. (1995). Physical and sexual assault prevalence among episodically homeless, seriously mentally ill women. Violence and Victims, 11, 159–174.Google Scholar
  26. Gray, M. J., & Litz, B. T. (2005). Behavioral interventions for recent trauma: Empirically informed practice guidelines. Behavior Modification, 29(1), 189–215.PubMedCrossRefGoogle Scholar
  27. Hair, J. F. Jr., Anderson, R. E., Tatham, R. L., & Black, W. C. (1998). Multivariate data analysis. Upper Saddle River, NJ: Prentice-Hall.Google Scholar
  28. Hanson, R. F., Saunders, B., Kilpatrick, D., Resnick, H., Crouch, J. A., & Duncan, R. (2001). Impact of childhood rape and aggravated assault on adult mental health. American Journal of Orthopsychiatry, 71(1), 108–119.PubMedCrossRefGoogle Scholar
  29. Hartigan, J. A. (1975). Clustering algorithms. New York: Wiley.Google Scholar
  30. Jacobsen, L. K., Southwick, S. M., & Kosten, T. R. (2001). Substance use disorders in patients with posttraumatic stress disorder: A review of the literature. American Journal of Psychiatry, 158, 1184–1190.PubMedCrossRefGoogle Scholar
  31. Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59(1), 12–19.PubMedCrossRefGoogle Scholar
  32. Jennings, A. (2004). Models for developing trauma-informed behavioral-health systems and trauma-specific services. National Association of Mental Health Program Directors, National Technical Assistance Center for State Mental Health Planning.Google Scholar
  33. Kendall-Tackett, K. A., Williams, L. M., & Finkelhor, D. (1993). Impact of sexual abuse on children: A review and synthesis of recent empirical studies. Psychological Bulletin, 13, 164–180.CrossRefGoogle Scholar
  34. Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Study. Archives of General Psychiatry, 52(12), 1048–1060.PubMedGoogle Scholar
  35. Kilpatrick, D. G., Resnick, H. S., Saunders, B. E., & Best, C. L. (1998). Rape, other violence against women, and posttraumatic stress disorder. In B. P. Dohrenwend (Ed.), Adversity, Stress, and Psychopathology. New York: Oxford Press.Google Scholar
  36. McCaffrey, D. F., Ridgeway, G., & Morral, A. R. (2004). Propensity score estimation with boosted regression for evaluating causal effects in observational studies. Psychological Methods, 9(4), 403–425.PubMedCrossRefGoogle Scholar
  37. McHugo, G. J., Caspi, Y., Kammerer, N., Mazelis, R., Jackson, E. W., Russell, L., et al. (2005a). The assessment of trauma history in women with co-occurring substance abuse and mental disorders and a history of interpersonal violence. Journal of Behavioral Health Services & Research, 32(2), 113–127.CrossRefGoogle Scholar
  38. McHugo, G. J., Kammerer, N., Jackson, E. W., Markoff, L. S., Gatz, M., Larson, M. J., et al. (2005b). Women, co-occurring disorders, and violence study: Evaluation design and study population. Journal of Substance Abuse Treatment, 28(2), 91–107.PubMedCrossRefGoogle Scholar
  39. McLellan, A., Luborsky, L., O’Brien, C. P., & Woody, G. (1980). An improved diagnostic evaluation instrument for substance abuse patients: The addiction severity index. Journal of Nervous and Mental Disease, 168, 26–33.PubMedCrossRefGoogle Scholar
  40. Morrissey, J. P., Ellis, A. R., Gatz, M., Amaro, H., Reed, B. G., Savage, A., et al. (2005a). Outcomes for women with co-occurring disorders and trauma: Program and person-level effects. Journal of Substance Abuse Treatment, 28(2), 121–134.PubMedCrossRefGoogle Scholar
  41. Morrissey, J. P., Jackson, E. W., Ellis, A. R., Amaro, H., Brown, V. B., & Najavits, L. M. (2005b). Twelve-month outcomes of trauma-informed interventions for women with co-occurring disorders. Psychiatric Services, 56(10), 1213–1222.PubMedCrossRefGoogle Scholar
  42. Muenzenmaier, K., Meyer, I., Struening, E., & Ferber, J. (1993). Childhood abuse and neglect among women outpatients with chronic mental illness. Hospital and Community Psychiatry, 44, 666–670.PubMedGoogle Scholar
  43. Mueser, K. T., Goodman, L. B., Trumbetta, S. L., Rosenberg, S. D., Osher, F. C., Vidaver, R., et al. (1998). Trauma and posttraumatic stress disorder in severe mental illness. Journal of Consulting and Clinical Psychology, 66, 493–499.PubMedCrossRefGoogle Scholar
  44. Mueser, K. T., Noordsy, D. L., Drake, R. E., & Fox, L. (2003). Integrated treatment for dual disorders. New York: Guilford Press.Google Scholar
  45. Mueser, K. T., Rosenberg, S. D., Goodman, L. A., & Trumbetta, S. L. (2002). Trauma, PTSD, and the course of severe mental illness: An interactive model. Schizophrenia Research, 53, 123–143.PubMedCrossRefGoogle Scholar
  46. Najavits, L. M., Weiss, R. D., & Shaw, S. R. (1997). The link between substance abuse and posttraumatic stress disorder in women: A research review. American Journal of Addictions, 6, 273–283.CrossRefGoogle Scholar
  47. Pimlott-Kubiak, S., & Cortina, L. M. (2003). Gender, victimization, and outcomes: Reconceptualizing risk. Journal of Consulting and Clinical Psychology, 71(3), 528–539.PubMedCrossRefGoogle Scholar
  48. R Development Core Team (2004). R: A language and environment for statistical computing. Vienna: R Foundation for Statistical Computing.Google Scholar
  49. Rauch, S. A., Hembree, E. A., & Foa, E. B. (2001). Acute psychosocial preventive interventions for posttraumatic stress disorder. Advances in Mind-Body Medicine, 17(3), 187–190.PubMedGoogle Scholar
  50. Rosenbaum, P. R., & Rubin, D. B. (1984). Reducing bias in observational studies using subclassification on the propensity score. Journal of the American Statistical Association, 79, 516–524.CrossRefGoogle Scholar
  51. Saladin, M. E., Brady, K. T., & Kilpatrick, D. G. (1995). Understanding comorbidity between PTSD and substance use disorders: Two preliminary investigations. Addictive Behaviors, 20(5), 643–655.PubMedCrossRefGoogle Scholar
  52. Surrey, J., Swett C. Jr., Michaels, A., & Levin, S. (1990). Reported history of physical and sexual abuse and severity of symptomatology in women psychiatric outpatients. American Journal of Orthopsychiatry, 60, 412–417.PubMedCrossRefGoogle Scholar
  53. Switzer, G. E., Dew, M. A., Thompson, K., Goycoolca, J. M., Derricott, T., & Mullins, S. D. (1999). Posttraumatic stress disorder and service utilization among urban mental health center clients. Journal of Traumatic Stress, 12, 25–39.PubMedCrossRefGoogle Scholar
  54. Tjaden, P., & Thoennes, N. (2000). Prevalence and consequences of male-to-female and female-to-male intimate partner violence as measured by the National violence against women survey. Violence Against Women, 6(2), 142–161.CrossRefGoogle Scholar
  55. U.S. Department of Health and Human Services. (1999). Mental health. A Report of the Surgeon General..Google Scholar
  56. Wolfe, J., & Kimerling, R. (1997). Gender issues in the assessment of posttraumatic stress disorder. In J.P. Wilson & T. M. Keane (Eds.), Assessing psychological trauma and PTSD (pp. 192–238). New York: Guilford.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • Karen J. Cusack
    • 1
    Email author
  • Joseph P. Morrissey
    • 1
  • Alan R. Ellis
    • 1
  1. 1.Cecil G. Sheps Center for Health Services ResearchUniversity of North Carolina at Chapel HillChapel HillUSA

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