Professional Abstract

Objective

To compare cognitive behavioral therapy intervention groups led by certified peer support workers with groups led by behavioral health counselors for trauma survivors with posttraumatic stress disorder (PTSD) or substance use disorder

Study Design

Design Element	Description
Design	Randomized controlled trial
Population	291 trauma survivors with PTSD and/or substance use disorder
Interventions/ Comparators	12 weekly sessions of a cognitive behavioral therapy intervention led by certified peer support workers Same intervention led by behavioral health counselors
Outcomes	Primary: PTSD symptoms, coping skills Secondary: drug and alcohol addiction severity, drug and alcohol cravings, therapeutic alliance, overall mental health, overall physical health
Timeframe	6-month follow-up for primary outcomes

This randomized controlled trial examined whether Seeking Safety therapy group sessions led by certified peer support workers were as effective as group sessions led by behavioral health counselors for treating PTSD and substance use disorder among trauma survivors. Seeking Safety is a present-focused cognitive behavioral therapy program that is effective for treating PTSD and substance use disorder. Present-focused means that participants focus on issues they are currently facing, rather than delving into past experiences. Primary outcomes for this study included improvement in PTSD symptoms and coping skills. Secondary outcomes included drug and alcohol addiction severity therapeutic alliance, which is the bond between a client and counselor, and overall mental and physical health. The study also examined drug and alcohol cravings as an exploratory outcome.

The study included adult trauma survivors with PTSD symptoms, substance use symptoms, or both. The research team recruited participants from a peer-run wellness center and a residential substance abuse treatment program in rural New Mexico. Of the 291 participants who completed a baseline interview, half were male, 85% were Hispanic, and 77% were unemployed. The mean participant age was 35. Nine percent had PTSD only, 26% had substance use disorder only, and 65% had both.

The research team randomly assigned participants to one of two treatment groups. In one group, participants attended treatment sessions led by certified peer support workers. In the other group, participants attended sessions led by behavioral health counselors. Peer support workers had a history of mental illness or substance use disorder, had completed 40 hours of training, and had taken a certification exam. Counselors included a licensed mental health counselor and a licensed substance use counselor, each with a master’s degree.

The intervention included 12 Seeking Safety topics delivered in 90-minute weekly sessions. Each session focused on a coping skill and aimed to build cognitive, behavioral, and interpersonal skills. Participants had to attend at least 6 of the 12 sessions in order to complete the intervention.

The research team interviewed participants at baseline and then three months and six months after the baseline interview to collect study data.

Throughout the study, the research team worked with people receiving behavioral health treatment, their family members, and clinicians. These stakeholders provided input on the research question and design, intervention, outcome measures, recruitment and retention strategies, and interpretation of results.

Results

Over six months, participants in both groups showed a reduction in PTSD symptoms (95% confidence interval [CI], -7.2 to -2.7) and an increase in coping skills (95% CI, 2.6-8.5). Participants in both groups also showed reductions in drug and alcohol addiction severity (95% CI, 0.11-0.65) and drug and alcohol cravings (95% CI, -4.3 to -2.0), and an increase in mental health functioning (95% CI, 4.0-8.7) over six months. Neither group showed a significant change in physical health.

At six months after baseline, there were no significant differences between the two treatment groups for changes in PTSD symptoms, coping skills, alcohol and substance use, alcohol and substance cravings, mental health, or physical health. Participants in the peer-led sessions reported higher therapeutic alliance (95% CI, 0.3-7.7) than those in the counselor-led sessions.

Limitations

The sample size may have been too small to detect differences between the two groups. Attrition may have biased the results, because only 69% of the 420 eligible, randomized people participated in the study, and only 48% of those participants completed both the second and third interviews. Due to errors with survey administration, the research team excluded data about addiction severity for 94 participants (68%) at baseline, 64 participants at three months after baseline (66%), and 67 participants at six months after baseline (61%). Excluding these data may limit the interpretation of findings about changes in substance use over time. The study participants were from one rural county, and most participants were Hispanic; findings may be different for participants in other treatment programs or locations, or for people from other ethnic groups.

Conclusions and Relevance

Outcomes were similar for participants who attended peer-led groups and counselor-led groups. Using peer support workers to deliver treatment for PTSD and substance use disorder could help meet the demand for these services in areas without enough licensed mental health providers.

Future Research Needs

Future studies could continue to examine if certified peer support workers are as effective as counselors for treating PTSD and substance use disorder among trauma survivors. In addition, future research could help determine whether sessions led by certified peer support workers are effective with people in other ethnic groups or other geographic locations. Future research could also help clarify the impact of Seeking Safety on drug and alcohol severity.