The co-occurrence of post-traumatic stress disorder (PTSD) and substance use disorder (SUD) is of increasing concern to treatment professionals. Estimates of PTSD prevalence rates among persons presenting for substance abuse treatment range from 35 to 50% (Boden et al., 2012). This is clinically significant because persons who present with co-occurring PTSD and SUD exhibit high symptom severity in both disorders and worse treatment outcomes, including higher relapse rates, than those with only one of the conditions (van Dam, Vedel, Ehring, & Emmelkamp, 2012).
Furthermore, men experience lifetime rates of trauma which are significantly higher than that experienced by women (60.7% as compared to 51.2%) (Najavits, Schmitz, Gotthardt, & Weiss, 2005). Studies have shown that men with PTSD are at greater risk to develop SUD with lifetime rates of alcohol use disorder estimated at 51.9% and other substance use disorders at 34.5% (Najavits et al., 2005). Given these numbers, evaluating which approaches are most effective in treating men with co-occurring PTSD and SUD is of paramount importance. As such, the purpose of this article shall be to address the following effectiveness-based question through survey of the research literature: For men who present with co-occurring PTSD and SUD, what interventions are most effective in improving treatment outcomes by reducing symptoms of both disorders.
In October 2014, the following bibliographic databases were searched via the University of Louisville library: Academic Search Premier, Criminal Justice Abstracts, Psychological and Behavioral Sciences Collection, PsycINFO, Social Services Abstracts, and Social Work Abstracts Plus. Keywords searched were post-traumatic stress disorder, PTSD, substance use disorder, SUD, treatment, trauma, and substance abuse. Wildcards were used where appropriate. MOLES were included in the searches by either using built-in database filters (such as in PsycINFO) or by entering terms (such as meta-analysis) directly in the search fields. Titles of articles and abstracts were reviewed and documents were eliminated that did not meet the following inclusion criteria: 1) effectiveness study related to intervention; 2) intervention must address both substance abuse and PTSD; 3) sample must include men; and 4) study must be quantitative, qualitative, meta-analysis, or systematic review. All searches were further limited by publication date (year 2000 through present) and by article source (peer-reviewed from scholarly journal). The reference sections of articles were reviewed and additional relevant articles that had been missed in prior search efforts were identified and included. From this process, a total of 35 potentially relevant articles were identified. Each of these articles was reviewed in detail and 15 were identified as relevant to the research question based upon application of the above-described inclusion criteria.
Treatment approaches for co-occurring PTSD and SUD can be broadly divided into three categories: sequential, parallel, or integrated models (Torchalla, Nosen, Rostam, & Allen, 2012). In sequential models, clients receive treatment for one disorder and are then referred to another provider for treatment of the other disorder. Within this model, SUD is typically treated first based on the assumption that methods which elicit exposure to traumatic memories might disrupt substance abuse treatment and that a period of recovery is first necessary to safely and effectively address trauma-related issues (Torchalla et al., 2012). In parallel models, SUD is treated concurrently with PTSD though in separate programs by different treatment teams (Torchalla et al., 2012). Of more recent interest, and the focus of this paper, are integrated models which treat both disorders simultaneously within the same facility by the same clinicians (Torchalla et al., 2012).
Within the integrated model, treatment approaches with respect to PTSD symptomology are generally past-focused (sometimes referred to as “trauma-focused”) or present-focused (sometimes referred to as “non-trauma-focused”) (van Dam et al., 2012). Past-focused treatments involve focusing on the memory of the traumatic event and its meaning and usually employ a combination of imaginal and in vivo exposure (van Dam et al., 2012). Even though past-focused treatments have long been considered appropriate for treating PTSD only, until recently clients with co-occurring SUD were usually excluded as candidates for this approach. The thought was that it was necessary for clients to achieve a measure of abstinence and recovery without which exposure to traumatic memories would lead to increased substance use and/or other iatrogenic effects – the proverbial opening of “Pandora’s box” (Najavits & Hien, 2013). If anything, however, the research literature demonstrates that this concern is likely exaggerated as none of the studies reviewed herein found increased substance use over time, and many found both improved substance use outcomes and PTSD symptoms when exposure techniques were integrated into standard substance abuse treatment (though most studies were plagued by high attrition rates) (Brady, Dansky, Back, Foa, & Carroll, 2001; Coffey, Stasiewicz, Hughes, & Brimo, 2006; Donovan, Padin-Rivera, & Kowaliw, 2001; Foa et al., 2013; Mills et al., 2012; Sannibale et al., 2013; van Dam, Ehring, Vedel, & Emmelkamp, 2013). On the other hand, present-focused treatments do not require patients to revisit or reprocess past traumatic experiences directly and instead focus on providing clients with coping skills necessary to manage trauma symptoms and improve overall functioning (van Dam et al., 2012). Most present-focused treatments include elements of cognitive-behavioral therapy, and like past-focused approaches, the research reveals that present-focused treatments generally result in improved substance use outcomes and PTSD symptomology (Boden et al., 2012; Frisman, Ford, Hsiu-Ju, Mallon, & Chang, 2008; Searcy & Lipps, 2012; McGovern, Lambert-Harris, Acquilano, Xie, Alterman, & Weiss, 2009; McGovern, Lambert-Harris, Alterman, Xie, & Meier, 2011). Within the present-focused model, Seeking Safety, a manualized intervention for integrated treatment of co-occurring PTSD and SUD, has arguably been the most rigorously studied.
Najavits (2002) developed Seeking Safety as an integrated, present-focused means to treat PTSD and SUD. The approach is based on a combination of cognitive-behavioral therapy and psychodynamic psychotherapy (Searcy & Lipps, 2012). A manual detailing the approach was published in 2002. According to Najavits (2002), the method was developed from “traditions of literature on substance abuse treatment, PTSD treatment, CBT, women’s treatment, and educational research” (p. 15). Seeking Safety includes 25 topical sessions which “across cognitive, behavioral, and interpersonal domains emphasizing coping skills” (Searcy & Lipps, 2012, p. 240). Sessions may be delivered sequentially or independently depending on counselor preference and in group or in individual sessions (Searcy & Lipps, 2012). As Searcy & Lipps (2012) observe, flexibility is the hallmark of Seeking Safety in terms of both its design and in the ability of practitioners of various educational and skill levels (including peer support staff) to effectively deliver its contents.
In a systematic review conducted by Najavits & Hien (2013), Seeking Safety comprised 22 of the 35 studies under review including 13 pilots, 3 controlled studies, and 6 randomized controlled trials. Within these studies, clients consistently presented with complex trauma/PTSD, co-morbidity, high severity and chronicity, and multiple life problems (Najavits & Hien (2013). Several studies had strong representation of minorities (Najavits & Hien, 2013). Most of the studies applied few exclusion criteria, and often occurred in real-world clinical settings (Najavits & Hien, 2013). All of these factors indicate that the results across studies are generalizable. In general, these studies have demonstrated positive outcomes on a number of important variables including PTSD and SUD outcomes, psychopathology, cognitions, and coping (Najavits & Hien, 2013).
The two studies which utilize Seeking Safety and captured by the search inclusion criteria demonstrated generally positive results for samples which include male participants. Searcy & Lipps (2012) utilized a convenience sample of 40 participants (12 males) drawn from a 28-day residential substance abuse treatment program. The researchers utilized a one group pre-test/post-test design to evaluate the effectiveness of Seeking Safety in reducing PTSD symptoms. Study participants met twice weekly for one hour in gender-specific groups devoted to covering material from Seeking Safety. The results of the study indicate that trauma symptoms were significantly reduced at the post-test stage as compared to the pre-test stage which may be due in part to replacing old coping skills (such as substance abuse) with coping skills learned by participating in Seeking Safety groups. Of course, because of the pre-experimental study design, threats to internal validity were not controlled and the findings are not generalizable. Nevertheless, the study does provide at least some support for the effectiveness of reducing PTSD symptoms in a short-term, residential substance abuse setting.
Boden et al. (2012) utilized a RCT design with a sample size of 117 male veterans to evaluate the effectiveness of Seeking Safety across a number of different outcomes. Participants were randomized into TAU (initially group therapy focusing on motivational enhancement and encouraging treatment engagement; then twice-weekly recovery groups focusing on building and then maintaining abstinence) or the Seeking Safety Treatment Track (TAU with twice-weekly recovery groups replaced by Seeking Safety groups). All outcome variables were measured at baseline, 3-months, and 6-months. Results indicated that Seeking Safety as compared to TAU was associated with better drug use outcomes, though both groups showed similar improvements in alcohol use outcomes and PTSD symptoms. Seeking Safety as compared to TAU was associated with increased treatment attendance, client satisfaction, and active coping. It should be noted that this study was limited to male veterans, and therefore external validity is limited to this population.
It is widely accepted in the field of substance abuse treatment that diagnosis and treatment of co-occurring disorders is a necessary component of the individual achieving long-term recovery. One of the most common co-occurring disorders among the population of those with SUD is PTSD. The research demonstrates that a number of different integrated approaches are effective in treating both PTSD and SUD in men. With that being said, it should be noted that while all of the studies demonstrated improvement on at least one outcome measure, there was considerable variability across studies on which outcomes clients demonstrated improved functioning. In sum, it is not yet clear that the integrated approaches, whether past or present-focused, are superior to one another in any significant way, or consistently superior to SUD TAU. Seeking Safety is the most rigorously studied of the integrated approaches and of those methods reviewed it has demonstrated external validity. Its flexibility in terms of format and qualifications for delivery make it the most appealing of all the currently available methods. Moving forward, it will be necessary for research professionals to continue to dedicate resources towards determining which treatment methods best serve particular clients presenting with PTSD and SUD.
(This paper was originally submitted in November 2014 by the Site Administrator in partial fulfillment of the Masters of Science in Social Work degree at the University of Louisville)
Boden, M., Kimerling, R., Jacobs‐Lentz, J., Bowman, D., Weaver, C., Carney, D., & … Trafton, J. A. (2012). Seeking Safety treatment for male veterans with a substance use disorder and post‐traumatic stress disorder symptomatology. Addiction, 107(3), 578-586.
Brady, K. T., Dansky, B. S., Back, S. E., Foa, E. B., & Carroll, K. M. (2001). Exposure therapy in the treatment of PTSD among cocaine-dependent individuals: Preliminary findings. Journal of Substance Abuse Treatment, 21(1), 47-54.
Coffey, S. F., Stasiewicz, P. R., Hughes, P. M., & Brimo, M. L. (2006). Trauma-focused imaginal exposure for individuals with comorbid posttraumatic stress disorder and alcohol dependence: Revealing mechanisms of alcohol craving in a cue reactivity paradigm. Psychology of Addictive Behaviors, 20(4), 425-435.
Donovan, B., Padin-Rivera, E., & Kowaliw, S. (2001). ‘Transcend’: Initial outcomes from a posttraumatic stress disorder/substance abuse treatment program. Journal Of Traumatic Stress, 14(4), 757-772.
Foa, E. B., Yusko, D. A., McClean, C. P., Suvak, M. K., Bux, D. A., Jr., Oslin, D. . . . Volpicelli, J. (2013). Concurrent naltrexone and prolonged exposure therapy for patients with co-morbid alcohol dependence and PTSD. Journal of the American Medical Association, 310(5), 488-495.
Frisman, L., Ford, J., Hsiu-Ju, L., Mallon, S., & Chang R. (2008). Outcomes of trauma treatment using the TARGET model. Journal of Groups in Addiction and Recovery, 3(3/4), 285-303.
McGovern, M. P., Lambert-Harris, C., Acquilano, S., Xie, H., Alterman, A. I., & Weiss, R. D. (2009). A cognitive behavioral therapy for co-occurring substance use and posttraumatic stress disorders. Addictive Behaviors, 34, 10.
McGovern, M. P., Lambert-Harris, C., Alterman, A. I., Xie, H., & Meier, A. (2011). A randomized controlled trial comparing integrated cognitive behavioral therapy versus individual addiction counseling for co-occurring substance use and post-traumatic stress disorders. Journal of Dual Diagnosis, 7(4), 207-227.
Najavits, L. M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York, NY: Guilford Press.
Najavits, L. M., Schmitz, M., Gotthardt, S., & Weiss, R. D. (2005). Seeking safety plus exposure therapy: An outcome study on dual diagnosis men. Journal Of Psychoactive Drugs, 37(4), 425-435.
Najavits, L., & Hien, D. (2013). Helping vulnerable populations: A comprehensive review of the treatment outcome literature on substance use disorder and PTSD. Journal of Clinical Psychology, 69(5), 433-479.
Mills, K. L., Teesson, M., Back, S. E., Brady, K. T., Baker, A. L., Hopwood, S., & … Ewer, P. L. (2012). Integrated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence: A randomized controlled trial. JAMA: Journal of The American Medical Association, 308(7), 690-699.
Sannibale, C., Teesson, M., Creamer, M., Sitharthan, T., Bryant, R. A., Sutherland, K., & … Peek‐O’Leary, M. (2013). Randomized controlled trial of cognitive behaviour therapy for comorbid post‐traumatic stress disorder and alcohol use disorders. Addiction, 108(8), 1397-1410.
Searcy, V., & Lipps, A. (2012). The effectiveness of Seeking Safety on reducing PTSD symptoms in clients receiving substance dependence treatment. Alcoholism Treatment Quarterly, 32(2), 238-255.
Torchalla, I., Nosen, L., Rostam, H., & Allen, P. (2012). Integrated treatment programs for individuals with concurrent substance use disorders and trauma experiences: A systematic review and meta-analysis. Journal Of Substance Abuse Treatment, 42(1), 65-77.
van Dam, D., Vedel, E., Ehring, T., & Emmelkamp, P. (2012). Psychological treatments for concurrent posttraumatic stress disorder and substance use disorder: A systematic review. Clinical Psychology Review, 32(3), 202-214.
van Dam, D., Ehring, T., Vedel, E., & Emmelkamp, P. (2013). Trauma-focused treatment for posttraumatic stress disorder combined with CBT for severe substance use disorder: A randomized controlled trial. BMC Psychiatry, 13.