Seeking Safety is a cognitive-behavioral therapy (CBT) program that is designed to help people with co-occurring PTSD and substance use disorders. The program teaches participants skills to manage PTSD symptoms and reduce their reliance on substances. Seeking Safety has been shown to be effective in reducing PTSD symptoms, substance use, and overall distress. Posttraumatic stress disorder (PTSD) and substance abuse co-occur for a very large number of people, particularly women. There is a new awareness becoming increasingly recognized, based on clinical and scientific evidence:

The most recent statistics on the prevalence of PTSD and substance use disorders

• The National Institute on Mental Health (NIMH) estimates that 3.5% of adults in the United States have PTSD at any given time.
• The Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that 14.4 million adults in the United States have a substance use disorder.
• Approximately 40% of people with PTSD also have a substance use disorder.

What percentage of people in substance abuse treatment have experienced trauma in their lifetime?

• A study by the National Institute on Drug Abuse found that 85% of people in substance abuse treatment have experienced trauma in their lifetime.
• The most common types of trauma reported by people in substance abuse treatment include physical and sexual abuse, neglect, and witnessing violence.

What percentage of people in substance abuse treatment have PTSD?

• A study by SAMHSA found that 25% of people in substance abuse treatment have PTSD.
• The prevalence of PTSD in people in substance abuse treatment is higher among women, veterans, and people with a history of childhood abuse.

Prevalence rates across race, ethnicity, gender, and cultures

• The prevalence of PTSD and substance use disorders varies across race, ethnicity, gender, and cultures.
• For example, African Americans and Native Americans are more likely to experience trauma and PTSD than White Americans.
• Women are more likely to experience PTSD than men.
• People from low-income and marginalized communities are more likely to experience trauma and PTSD.

Several studies have confirmed that becoming abstinent from substances does not resolve PTSD; indeed, some PTSD symptoms become worse with abstinence. Both should be treated simultaneously. Treatment outcomes for patients with PTSD and substance abuse are worse than for other dual-diagnosis patients and for patients with substance abuse alone People with PTSD and substance abuse tend to abuse “hard drugs” (cocaine and opiates); prescription medications, marijuana, and alcohol are also common. Substance abuse is often viewed as “self-medication” to cope with the overwhelming emotional pain of PTSD.

People with PTSD and substance abuse are vulnerable to repeated traumas, and more so than those with substance abuse alone. People with both disorders suffer a variety of life problems that may complicate their clinical profile, including other DSM disorders, interpersonal and medical problems, maltreatment of their children, custody battles, homelessness, HIV risk, and domestic violence.

People with PTSD and substance abuse have more severe symptoms (experience of sensations, emotions, thoughts, behaviors) than those with just one of these disorders. Among patients in substance abuse treatment, this dual diagnosis is two to three times more common in women than in men. Most women with this dual diagnosis experienced childhood physical and/or sexual abuse; men with both disorders typically experienced crime victimization or war trauma. PTSD and substance abuse have consistently been found to co-occur, regardless of the nature of the trauma or the type of substance used.

A “downward spiral” is common. For example, substance use may increase vulnerability to new traumas, which in turn can lead to more substance use. From patients’ perspective, PTSD symptoms are common triggers of substance use, which in turn can heighten PTSD symptoms. Various subgroups have high rates of this dual diagnosis, including combat veterans, prisoners, victims of domestic violence, the homeless, and adolescents. The connection between PTSD and substance abuse appears to be enduring, rather than simply an artifact of substance use, withdrawal, or overlapping DSM criteria. Perpetrators of violent assault use substances at the time of assault in a high percentage of domestic abuse (50%) and rape (39%) cases.

Most clinical programs treat PTSD or substance abuse, but rarely both. Yet an integrated model—treating both disorders at the same time—is recommended by both clinicians and researchers as more likely to succeed, more cost-effective, and more sensitive to patient needs. Patients too favor integrated treatment of these disorders. The majority of patients with PTSD and substance abuse do not receive PTSD focused treatment. Many patients are never even assessed for both PTSD and substance abuse. It is common for patients to report multiple substance abuse treatments during which they were never asked about trauma, never informed that they met the diagnosis of PTSD, and never told that PTSD is a treatable disorder for which specific treatments exist. Similarly, some mental health clinicians do not routinely assess for substance abuse. It can be difficult to predict patients’ course of recovery. Paradoxically, both abstinence and continued use of substances may make PTSD symptoms either better or worse, depending
on the patient.

Treatment can be effective, but is often difficult and may be marked by unstable treatment alliances, multiple crises, erratic attendance, and relapse to substance use. Both in the culture at large and among clinicians, views of patients with substance abuse and/or PTSD may be quite negative. Countertransference reactions are common. Patients are sometimes perceived as “crazy,” “lazy,” or “bad,” both by others and by themselves. Treatments that are effective for PTSD or substance abuse separately may not be advisable when the two disorders occur together. For example, PTSD treatments such as benzodiazepines or exposure therapy may not be indicated if a patient is addicted to substances; substance abuse treatment such as twelve-step groups may not work when a patient has PTSD. Patients with this dual diagnosis may have intensive case management needs, which
may go beyond the training of some clinicians and sometimes lead to “burnout”. The need for cross-training is common: The cultures, assumptions, and treatments for substance abuse and PTSD can be quite different, and most therapists do not have equal expertise in both. Substance abuse counselors are not typically trained to work on severe mental health problems, and thus PTSD may be ignored or misunderstood. Similarly, most mental health therapists are not trained to work on substance abuse.

What other effective treatment options exist?

• There are a number of other effective treatment options for co-occurring PTSD and substance use disorders. These include:
  • Cognitive processing therapy (CPT)
  • Prolonged exposure therapy (PE)
  • Eye movement desensitization and reprocessing (EMDR)
  • Dialectical behavior therapy (DBT)
  • Motivational interviewing (MI)