VA Boston Healthcare System
Trauma and Addiction Recovery
Substance Abuse (Jamaica Plain)
Trauma and Addiction Recovery
The Trauma and Addiction Recovery rotation, formerly named the Dual Diagnosis Posttraumatic Stress Disorder (PTSD) and Substance Use Disorders (SUD) rotation, was developed to provide high quality of training for treating these co-occurring disorders. Historically, the treatment of PTSD and SUD has been separated; in fact, patients frequently were denied treatment for one problem if the other was present. Clinically, the PTSD and SUD clinics are increasingly integrating their treatment whenever possible, which is often preferred by veterans. Whenever indicated, veterans will receive treatment in more than one clinic (e.g. both the outpatient PTSD and SUD clinics), with clinicians working together to develop appropriate treatment plans. Or, a veteran may receive integrated PTSD-SUD treatment within one clinic (e.g. either the outpatient PTSD clinic or the SUD clinic), particularly when they have more moderate SUD. While the majority of the intern's caseload will be dually-diagnosed, there also will be opportunities to assess and/or treat patients with one primary diagnosis. Interns gain exposure to veterans across eras from our younger population who served in Iraq and Afghanistan to those who served in Vietnam and Korea. Interns work with patients in different stages of recovery and with differing levels of symptom severity.
The intern receives training by providing mental health care within two outpatient clinics. The primary placement will be in the Brockton PTSD Clinic (about 55% of their clinical time) with the remaining time spent in the Intensive Alcohol and Drug Addiction Program of Treatment (I-ADAPT), an abstinence-based intensive outpatient program in the Alcohol and Drug Treatment Program (ADTP). There are options for interns to receive training in areas that are of particular interest to them (i.e., motivational interviewing, Acceptance and Commitment Therapy, 12-step approaches, contingency management, mindfulness, and evidence-based trauma focused therapy treatments). Supervision will continually explore what treatments are the most appropriate to address symptoms of PTSD and problematic substance use. Considering the many opportunities available in this rotation, supervisors will help the intern develop a training plan that ensures a manageable and diverse caseload allowing for both depth and breadth of experiences. The intern will also receive guidance on professional development and balancing training goals with self-care.
The clinics within this rotation are optimal for trauma and addiction recovery work, since the outpatient clinics for PTSD, ADTP, and the Center for Returning Veterans are all conveniently located on the same floor. Residential dual diagnosis treatment programs are also located on the Brockton campus, in different buildings (e.g., CIRCA, WITRP). All clinics have high volume and diverse referrals. Care will be taken to ensure that the intern receives a varied caseload including veterans from all eras, with all types of trauma and substance use histories, both male and female, with diverse backgrounds. Although outpatient care is the primary focus of training, the intern will have the opportunity to interact with patients across the continuum of care, through consultation with patients and staff in residential and inpatient units, through treatment of long-term cases as they move through different levels of care, and through treatment experiences in I-ADAPT. Interns participate in a monthly Addictions Journal Club and SUD-PTSD clinical forum. Interdisciplinary opportunities for collaboration are widely available within the PTSD and ADTP teams that include professionals from other disciplines such as psychiatry staff, social work staff, and trainees from multiple disciplines. Additionally, interns often communicate with other VA and community programs (e.g. other outpatient clinics, psychiatric inpatient staff, Suicide Prevention Coordinators, local Vet Center staff) in order to facilitate referrals for individuals entering the PTSD and ADTP clinics through the intake process.
The Trauma and Addictions Recovery intern works primarily in an office in the main outpatient mental health building in Brockton, fluidly transitioning on a daily basis between clinical activities within the Brockton PTSD Clinic and Brockton Intensive Alcohol and Drug Addiction Program of Treatment.
- Brockton PTSD Clinical Team (PCT): 55% of time. The Brockton PCT provides comprehensive outpatient services to almost 1200 veterans per year with PTSD and comorbid diagnoses, and averages 25 new consults per month, about 50% of which are returning veterans. There is a high rate of comorbid SUDs, mood disorders, and other anxiety disorders. The clinic shares staff with the Center for Returning Veterans (CRV); roughly 50% of CRV referrals are diagnosed with PTSD, and interns may also carry cases from the CRV..
- Assessment: Interns will receive training in weekly intake assessments along with more comprehensive assessments for particularly complex cases. Assessment training will include diagnostic interview methods (including informal and formal, such as the CAPS and the SCID when indicated).
- Treatment: The focus of this experience will be on the provision of empirically based treatments for this dually diagnosed population. The PTSD Clinic provides comprehensive programming within a stage model of treatment that includes (1) stabilization and psychoeducation, (2) focused trauma work, and (3) relationship building and recovery maintenance.
There are ample opportunities to provide short-term focused treatments to veterans of all eras. The intern will have the opportunity to receive training and supervision in state of the art treatments for PTSD, SUD, and co-occurring disorders, including Cognitive Processing Therapy, Prolonged Exposure, Relapse Prevention, Acceptance and Commitment Therapy, and Dialectical Behavioral Therapy. There are many therapy groups running in the clinic at a given time, ranging from modular PTSD Skills and psychoeducation, relaxation/stress management, Seeking Safety, Dialectical Behavior Therapy Skills, and support. The eight-month intern will also have the opportunity to provide more intensive, longer-term treatment for some veterans. Supervisors: Julie Klunk-Gillis, Ph.D. and Julie Weismoore, Ph.D.
- Brockton Intensive Alcohol and Drug Addiction Program of Treatment (I-ADAPT): 45% of time. I-ADAPT is a part of the outpatient ADTP. It is an abstinence-based intensive outpatient program that provides an intermediate level of care between residential and standard outpatient addictions treatment. The program receives approximately 15-20 new consults per month and is administered by psychologist Dr. Travis Cook and staffed by Mr. Richard Lapierre, LICSW and Dr. Julie Weismoore. Interns may co-lead groups with Dr. Cook, Mr. Lapierre, Dr. Weismoore, or the Psychology Postdoctoral Dual Diagnosis Fellow.
New patients are admitted weekly on a rolling basis, and up to eight veterans are enrolled concurrently. I-ADAPT patients attend group therapy each Monday, Wednesday, and Friday for approximately six weeks. I-ADAPT is a group-based treatment program that utilizes evidence based psychotherapies to address multiple domains of functioning impacted by addiction. It is based on CBT and integrates Twelve-Step Facilitation, Contingency Management and Acceptance and Commitment Therapy approaches. Rates of trauma within our SUD programs are very high. Approximately 75% of patients in I-ADAPT are diagnosed with PTSD.
Interns are trained in multiple aspects of clinical care in an intensive treatment setting, with particular attention to the co-occurring diagnoses patients carry, and how these are addressed within an addictions treatment program. They will be supervised on comprehensive assessments for patients referred to the outpatient ADTP clinic and I-ADAPT, and will have the opportunity to co/lead a variety of groups such as Relapse Prevention, Emotion Regulation, and Acceptance and Commitment Therapy. They will also participate in aftercare planning for I-ADAPT members, serving as a liaison with the PTSD clinic. Joint supervision may occur with the ADTP psychology intern or the Dual Diagnosis postdoctoral fellow. Supervisor: Travis Cook, Ph.D.
Throughout the rotation, the intern will attend PTSD and I-ADAPT or ADTP interdisciplinary clinical meetings; trainees of all disciplines participate as integral members of these teams. The intern will be expected to present several cases across teams, and will have the opportunity to participate in team meetings when psychiatry residents present cases. As they conduct screening assessments for the clinic, the intern will learn how to consult with referral sources from a variety of disciplines such as inpatient psychiatry and outpatient social work.
The intern will participate in a seminar designed to foster both staff and trainee professional development across the PTSD and SUD diagnoses. The monthly Brockton SUD-PTSD Clinical Forum is open to all psychology interns on Brockton rotations, as well as multidisciplinary staff from substance abuse and PTSD clinics in Brockton. This forum is facilitated by Dr. Weismoore. The primary focus of this semi-structured forum is on issues unique to the assessment and treatment of PTSD and/or SUDs. The forum includes the opportunity for informal case presentation as well as discussions related to clinician self-care, relevant research articles, and other topics initiated by the interdisciplinary staff and trainees who attend.At the beginning of the rotation, the intern will participate in several training activities. The intern will attend 1-2 seminars specific to assessment and treatment of co-occurring PTSD and SUD; these will be attended in conjunction with the ADTP psychology intern(s). The intern will also participate in selected joint trainings with National Center for PTSD interns, including trainings in PTSD assessment and treatment, PTSD-SUD research and clinical issues, and a seminar on exposure therapy. More individualized training will be provided by supervisors in the specific clinics. Interns will also participate in a two-day training in Cognitive Processing Therapy.
All supervisors are well versed in the treatment of dual (and multiple) diagnosis veterans, and have experience sharing veterans' care and working across clinics, which will serve as models for the interns' experience. Primary supervisors include Julie Klunk-Gillis, Ph.D., Julie Weismoore, Ph.D., and Travis Cook, Ph.D. Additional supervision may be provided by Karen Krinsley, Ph.D., Jillian Scott, Ph.D., and Erin Daly, Ph.D.
Drs. Klunk-Gillis and Cook will supervise one intake/week from their respective clinics during the intern's one hour/week individual supervision, and group supervision on assessment will also be provided. Dr. Weismoore will also provide one hour/week of individual supervision focused on treatment and consultation issues. Interns will co-lead a therapy group with at least two of their supervisors. Additional supervision (half hour per session) may be provided by the leader of the Seeking Safety group the intern co-leads, if that psychologist is not one of the primary supervisors. Interns also will participate in one hour of weekly group consultation in Cognitive Processing Therapy.
Interns have the opportunity to participate in four hours/week of research or program evaluation and development. Primary supervisors will work with the interns early in the year to design a program that best fits their needs.
Dr. Cook facilitates the Addictions Journal Club, a monthly meeting to review and discuss recent empirical research and theoretical literature in the field of addiction. The goals of the Addictions Journal Club are: 1) to promote the scientist-practitioner model of clinical practice by examining emerging empirical and theoretical literature in the field of addiction; 2) to develop clinical research competency through critical discussion of the reviewed research; 3) to understand the results of the reviewed research as they relate to clinical practice; and 4) to provide clinicians with useful information that can inform case conceptualization. The Addictions Journal Club uses rotating facilitators including permanent VA staff as well as trainees at the postdoctoral and internship level who volunteer to lead discussions.
Through Dr. Krinsley’s appointment with the National Center for PTSD, she is able to coordinate research experience with National Center staff members based in JP (in this case, interns may need to travel to JP at times).
Dr. Enggasser is the Section Chief for Substance Abuse Treatment Programs at VA Boston, and is available as a research mentor for interns interested in SUD related research. Dr. Enggasser is involved primarily in research focused on developing new treatment models and treatment delivery methods for individuals with substance use disorders and co-occurring PTSD. Current research opportunities with Dr. Enggasser include involvement in ongoing research efforts focused on 1) developing and evaluating Web and mobile phone based self-help interventions for veterans with problem drinking and trauma symptoms or 2) identifying predictors of treatment retention and outcomes of IM Naltrexone (Vivitrol) treatment for opioid use disorder. Specific activities connected with these projects can vary depending on a trainee’s interest and goals, as well as the status of the project at the time the trainee is available.
Alternatively, interns may design and conduct program evaluation of ongoing services. Both the PCT and ADTP clinics are beginning to gather client satisfaction data and track consults and other information about clinic flow, in order to guide program development efforts. Information about depression, alcohol use, and PTSD symptoms is collected at intake in both the PCT and I-ADAPT clinics. As the clinics continue program development and move toward more in-depth program evaluation, the intern would have the unique opportunity to shape the collection of data, as well as the methods and measures utilized toward this end. The intern may help design and select evidence-based outcome measures and aid in data collection and analysis of the Seeking Safety group and several other therapy groups within Brockton outpatient services. Interns will also have the option of learning more about PTSD clinic administration through work with Dr. Krinsley.
Selected recent publications from our staff (highlighted):
Keane, T. M., Rubin, A., Lachowicz, M., Brief, D.J., Enggasser, J., Roy, M., Hermos, J., Helmuth, E., Rosenbloom, D. (2014) Temporal stability of DSM–5 posttraumatic stress disorder criteria in a problem-drinking sample. Psychological Assessment, 26: 1138-1145.
Martin, R. A., MacKinnon, S. M., Johnson, E. J., Myers, M. G., Cook, T.A.R., Rohsenow, D. J. (2011). The alcohol relapse situation appraisal questionnaire: Development and validation. Drug and Alcohol Dependence, 116, 45-51.
Enggasser, J.L., Hermos, J., Rubin, A., Lachowicz, M., Rybin, D., Brief, D.J., Roy, M., Helmuth, E., Rosenbloom, D., Keane, T. M. (2015) Drinking goal choice and outcomes in a Web-based alcohol intervention: Results from VetChange. Addictive Behaviors, 42: 63-68.
Langdon, K. J., Rubin, A., Brief, D. J., Enggasser, J.L., Roy, M., Solhan, M., Helmuth, E., Rosenbloom, D., & Keane, T. M. (2016) Sexual traumatic event exposure, posttraumatic stress symptomatology, and alcohol misuse among women: A critical review of the empirical literature. Clinical Psychology: Science and Practice, Doi:10, 1111/epsp.12167.
Brief, D.J., Solhan, M., Rybin, D., Enggasser, J.L., Rubin, A., Roy, M., Helmuth, E., Schreiner, A., Heilman, M., Vittorio, L., Rosenbloom, D., Keane, T.M. (2017) Web-Based Alcohol Intervention for Veterans: PTSD, Combat Exposure, and Alcohol Outcomes. Psychological Trauma, Jun 01. PMID: 28569525.
Castro, F., AhnAllen, C. G., Stirman, S.W., Lester, K. M., Klunk-Gillis, J., Dick, A., Resick, P. A. (2015). African American and European American Perspectives on Mental Health Care: Implications for Evidence Based Practice. Psychological Services, 2, 1541-1559.
Niles, B. L., Klunk-Gillis, J., Ryngala, D. J., Silberbogen, A. K., Paysnick, A., & Wolf, E. J. (2012). Comparing mindfulness and psychoeducation treatments for combat-related PTSD using a telehealth approach. Psychological Trauma: Theory, Research, Practice, and Policy, 4, 538-547.
Keen, S., Kutter, C., Niles, B.L., & Krinsley, K.E. (2008). Psychometric Properties of the PTSD Checklist in a Sample of Male Veterans. Journal of Rehabilitation Research and Development, 45, 465-474.
Weismoore, J.T. & Esposito-Smythers, C. (2010). The role of cognitive distortion in the relationship between abuse, assault, and non-suicidal self-injury. Journal of Youth and Adolescence, 39, 281-29.
Miller, A. B., Esposito-Smythers, C., Weismoore, J. T., & Renshaw, K. D. (2013). The relation between child maltreatment and adolescent suicidal behavior: A systematic review and critical examination of the literature. Clinical Child and Family Psychology Review, 1–27.