Are Treatment Groups Led by Peers as Effective as Groups Led by Counselors for Treating Posttraumatic Stress Disorder and Substance Use Disorder?

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What was the research about?

People who have had serious trauma may develop posttraumatic stress disorder (PTSD) or a substance use disorder. PTSD is a mental health problem in which people relive trauma over and over again. People with PTSD may have bad dreams or scary thoughts. Substance use disorder involves long-term use of alcohol or drugs. People with a substance use disorder may have health problems and may not do well at work, home, or school.

Seeking Safety is a treatment program to help people who have lived through trauma and have PTSD or a substance use disorder. Counselors with training and licenses in behavioral health usually lead Seeking Safety therapy sessions. The research team wanted to learn if sessions led by certified peer support workers would help people as much as sessions led by licensed counselors do. Certified peer support workers are people who have previously received treatment for a mental illness or a substance use problem and had training to lead Seeking Safety sessions.

What were the results?

People in both the peer-led and the counselor-led groups reported fewer PTSD symptoms and better mental health after attending the Seeking Safety sessions. People in both groups also reported that they used drugs and alcohol less, craved drugs and alcohol less, and had better coping skills. Coping skills are the ways people handle a stressful situation.

The peer-led sessions helped people as much as the counselor-led sessions in improving PTSD symptoms, alcohol and substance cravings, coping skills, mental health, and physical health, and reducing alcohol and substance use.

People in groups led by peer support workers reported having a stronger connection with session leaders than those in groups led by counselors.

Who was in the study?

The study included 291 people in rural New Mexico. All had survived trauma and had PTSD, substance use symptoms, or both. People in the study were mostly Hispanic (85 percent). Most people had both PTSD and a substance use disorder (65 percent). About the same number of men and women were in the study. The average age was 35.

What did the research team do?

The research team assigned people to one of two treatment groups by chance. Certified peer support workers led the sessions for one group. Behavioral health counselors led the sessions for the other group. Each treatment session focused on a coping skill and lasted 90 minutes. The sessions took place once a week for 12 weeks.

The research team interviewed people in the study. Interviews took place when the study began, three months later, and then again three months after that. The team asked questions about PTSD symptoms and coping skills. The team also asked about drug and alcohol use, drug and alcohol cravings, mental and physical health, and participants’ connection to their group leader.

Patients, family members, and clinicians worked with the research team and gave feedback throughout the study.

What were the limits of the study?

Only 141 people (48 percent) finished all parts of the study. The results might have been different if more people stayed in the study. This study took place in only one location, and most people in the study were Hispanic. Results might be different in other locations or for people from different ethnic groups. The research team couldn’t use some of the substance use data because of data collection problems. As a result, the substance use findings are not as strong as the other findings.

Future studies could continue to see if sessions led by certified peer support workers help people as much as sessions led by counselors do. Future research could also see if certified peer support workers can help treat people who have different ethnic backgrounds and who live in different locations.

How can people use the results?

Many parts of the country don’t have enough mental health and substance use counselors. Peer support workers may be able to help provide care for people in these areas.

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

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.