Consider the epidemiological data and the clinical challenges of treating patients who evidence concurrent comorbid psychiatric diagnoses of PTSD and Substance Abuse Disorders (SUDs). As summarized by Brady et al. (2009), Mueser et al. (2003) and Ouimette and Brown (2003):
- A majority of patients (80%) seeking treatment for SUDs report having experienced intense trauma.
- Approximately 50% of women and 20% of men in chemical dependency recovery programs report having been victims of childhood sexual abuse (CSA). CSA doubles the number of alcohol abuse symptoms in adulthood.
- PTSD is three times more common among SUDs patients than it is in the general population.
- Trauma victims report greater involvement and higher expected future involvement for engaging in substance abuse than do non victims.
- SUDs patients with PTSD show a more severe substance abuse profile and they tend to use drugs to reduce the impact of negative affect and hyperarousal symptoms (exaggerated startle response, nightmares).
Patients with comorbid disorders of PTSD and SUDs have more severe levels of psychopathology, with greater symptomatology for each disorder; more life stressors (e.g., more medical problems, higher unemployment, higher arrest records); higher health care utilization; less effective coping strategies and poorer response to treatment than do patients with either PTSD or SUDs alone. They are also more likely to experience additional comorbid affective disorders (panic attacks, major depressive disorders, suicidality, personality disorders). In addition, there are important gender differences that require gender-specific treatments (Brady et al. 2009).
Given the complexity of the clinical picture, there are several assessment implications that should inform treatment planning. These include the need for a life-span perspective that considers the sequence of the respective disorders. In most instances, mental health problems precede the onset of SUDs. There is a need for an ongoing risk assessment, given the high incidence of suicidal behaviors in this comorbid clinical population. In addition, there is a need to allow enough time to elapse in order to ensure that the respective disorders are not masked. A comprehensive Case Conceptualization Model that includes the range and severity of presenting problems, current and past patterns of use, polysubstance abuse, family history and signs of strengths and resilience should be included. As the adage goes:
“A clinician without a Case Conceptualization is like a captain of a ship without a rudder, aimlessly floating about with little or no direction.”
The Case Conceptualization Model provides a means to collaboratively establish with the patient and significant others doable, measureable short-term, intermediate and long-term goals and the means (and possible barriers) by which they can be achieved.
There are three major sets of findings that should guide treatment decision-making with patients who have PTSD and SUDs. First, there is an increasing appreciation that such treatment should be conducted on an integrative, rather than on a parallel or sequential basis, and that doing so improves long-term effectiveness (Mueser et al. 2003). Second, a series of meta-analyses of both the treatment research on PTSD (Benish et al. 2008) and on SUDs (Imel et al 2008) have demonstrated the comparability of various treatment approaches and the critical role of the therapeutic alliance and engagement treatment strategies. As Mee-Lee et al (2010) highlight, the quality of the therapeutic alliance contributes 5 to 10 times more to outcome than does the specific treatment approach that is used. Given the high dropout and noncompliance rates by patients with comorbid disorders, there is a critical need to focus on facilitation procedures using Motivational Interviewing. A critical feature in treatment is the need for the development of a Recovery-oriented System of Care and on relapse prevention treatment procedures.
Finally, the third major research focus has been on evidence-based treatment approaches that use integrative cognitive-behavioral interventions that educates patients about the interconnectedness between trauma exposure and the development of PTSD and SUDs (See Ford et al 2009 and Najavits, 2002).
At the Clearwood Treatment Center in Grand Rapids, Michigan, where I am a consultant, we are training clinical and front-line staff to provide a total integrative milieu treatment approach. Treatment includes such features as a carefully detailed assessment and an accompanying Case Conceptualization Model that all staff members use to coordinate services; collaborative goal-setting with patients in order to nurture hope and to build into treatment a person-centered, strengths-based approach; individual and group treatments that build intra- and interpersonal coping skills with a major emphasis on including generalization procedures; the integration of 12-Step AA and family-based activities, and ways to build and sustain a balanced lifestyle. A comprehensive treatment approach that recognizes the “chronic” nature of such comorbid disorders and provides long-term continuity of care is a treatment objective of the Clearwood residential program. The clinical decision-making at Clearwood will be “data-driven”, using ongoing feedback to both patients and the clinical staff.
Benish, S.G., Imel, Z.E. & Wampold, B.E. (2008). Relative efficacy of bona fide psychotherapy for treating PTSD: A meta-analysis. Clinical Psychology Review, 28, 746-758.
Brady, K.T., Back, S.E., and Greenfield, S.F. (2009). Women and addiction: A comprehensive handbook. New York: Guilford Press.
Ford, J.D., Fallot, S. & Harris, M. (2009). A trauma-focused, patient-centered, emotional self-regulation approach to integrated treatment for posttraumatic-stress and addiction. American Journal of Psychotherapy, 60, 335-385.
Imel, Z.E. & Wampold, B.E. & Miller, S.D. (2008). Distinctions without a difference: Direct comparisons of psychotherapies for alcohol use disorders. Psychology of Addictive Behaviors, 22, 533-543.
Mee-Lee, D., McLellen, T. & Miller, S.D. (2010). What works in substance abuse and dependence treatment. In B.L. Duncan, S.D. Miller, B.S. Wampold & M.R. Hubble (Eds.), The heart and soul of change. (2nd Ed.). (pp. 393-417). Washington, DC: American Psychological Association.
Meichenbaum, D. (2009). Trauma and substance abuse. Guidelines for treatment. Counselor: The Magazine for Addiction Professionals, 10, 10-15.
Mueser, K.T., Noorday, D.L., Drake, R.L., & Fox, L. (2003). Integrated treatment for dual diagnoses: A guide to effective practice. New York: Guildford Press.
Najavits, L.M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York: Guilford Press.
Ouimette, P., & Brown, P.J. (2003). Trauma and substance abuse. Washington, DC: American Psychological Association.