Four Content Areas: Cognitive, Behavioral, Interpersonal, Case Management

CBT is the basis for this treatment because it so directly meets the needs of first-stage, “safety” treatment. Beck, Emery, and Greenberg (1985) have described several key features of CBT. It is present- and problem-oriented, to reduce current symptoms. It is brief, timelimited, and structured, with the goal of strong treatment gains over a short time frame. It is educational, with emphasis on rehearsal of new skills. It is directive and collaborative, guiding patients (much as a good parent would) while emphasizing patients’ mature contribution to their own treatment.

These processes provide, in the very format of the treatment, an antidote for the powerlessness and lack of control inherent in PTSD and substance abuse. CBT also teaches self-control strategies, to help patients acquire functional behaviors that may never have been developed or may have deteriorated due to substance abuse and PTSD (e.g., problem solving, cognitive control, relationship skills, self-care). Such coping skills are specifically
recommended by experts on PTSD and substance abuse (Ouimette et al., 1999). CBT offers explicit training in relapse prevention, which is commonly used to prevent substance abuse relapses (Beck, Wright, Newman, & Liese, 1993; Carroll et al., 1991; Marlatt & Gordon, 1985) and is directly applicable to PTSD as well (Foy, 1992). Finally, according to research, CBT has been found to be one of the most promising approaches, independently, for
PTSD (Marks, Lovell, Noshirvani, Livanou, & Thrasher, 1998; Ruzek et al., 1998; Solomon et al., 1992) and substance abuse (Carroll et al., 1991; Maude-Griffin et al., 1998; Najavits & Weiss, 1994a).

In the behavioral topics, patients are encouraged to commit to action. The “behavioral bottom line” is taught: that it is not sufficient to talk about action, but real action, however small, is essential. At each session, patients make a commitment of one concrete step to promote healing (see Chapter 2). Therapists are encouraged to listen to patients’ behavior more than their words to hear them most effectively (e.g., self-destructive behavior as a “cry for help”). With the Safe Coping Sheet, patients are guided to “own” their actions—that is, no matter what happens in their lives, they can learn to cope without substances.

The importance of cognition is addressed through standard cognitive therapy interventions, such as identification of beliefs and restructuring. In addition, patients are guided to explore the meaning of substances in the context of their PTSD (e.g., self-medication? compensation? slow suicide? revenge?). Cognitive distortions (Burns, 1980) are identified for PTSD and substance abuse (such as “Deprivation Reasoning,” “Beating Yourself Up,” and
“Time Warp”) and contrasted with healthier meaning systems (such as “Live Well,” “Honor Your Feelings,” and “You Have Choices”). The topic Compassion is used as a means to connect cognition and emotion: to understand, at a deep level, the reasons behind one’s actions rather than judging them. Thus PTSD does not mean “crazy” but rather overwhelming emotional pain; substance abuse does not mean “bad” but rather a misguided attempt to solve a problem.

In short, the meanings patients create for their lives may vary widely. One may tell the sad story of someone who was destroyed by life; another may tell the uplifting story of someone who overcame adversity. The goal of the cognitive topics is thus to help patients shift their meaning systems toward self-respect and adaptation.

Originally, the treatment was solely cognitive and behavioral. The interpersonal and case management domains were added after it became apparent, from work with patients, that these were equally important. Interpersonal topics now constitute a third of the topics, and case management is begun in the first session and addressed at every session throughout the treatment. The interpersonal domain is an area of special need because most PTSD arises from trauma inflicted by others (in contrast to natural disasters or accidents, for example; Kessler et al., 1995). Whether the trauma was childhood physical or sexual abuse, combat, or crime victimization, all have an interpersonal valence that may evoke in the survivor distrust of others, confusion over what can be expected in relationships, and concern over reenactments of abusive power (Herman, 1992; Shay, 1994) both as victims and as perpetrators.

Similarly, substance abuse is often precipitated and perpetuated by relationships. Many patients grew up in homes with substance-abusing family members, and substance use may be an attempt to gain acceptance by others (Miller, Downs, & Testa, 1993) and manage interpersonal conflict (Marlatt & Gordon, 1985). As Trotter (1992) has noted, patients with PTSD and substance abuse are often much more concerned with interpersonal issues than with issues of autonomy (e.g., work functioning), which may represent a later developmental step.

Thus the interpersonal topics of the treatment seek to help patients maximize the presence of supportive people and let go of destructive people. There is an option to invite significant others to a session to help support patients’ recovery (in Getting Others to Support Your Recovery). Patients are encouraged to communicate honestly when it is safe to do so, but also to recognize that they can only change themselves at this point, and that trying to change others while in early recovery is not usually a productive focus. They are guided to explore parallels between their relationship with themselves and with others (e.g., it is common to have problems setting boundaries both internally within oneself and externally with others), and to
notice extreme relationship dynamics that reevoke trauma (e.g., overcompliance, enmeshment) and substance abuse (e.g., “friends” who keep offering substances).

The case management component arose from data in the Seeking Safety pilot study that showed many patients’ having received few treatment services prior to joining the program (Najavits et al., 1998e; Najavits, Dierberger, & Weiss, 1999a). This was the opposite of what had been expected, which was that they would be heavy utilizers of treatment. Some people with PTSD and substance abuse may indeed receive a lot of treatment, particularly if they are connected to a treatment system such as Department of Veterans Affairs (VA) services or inpatient hospitalization (e.g., Brown & Wolfe, 1994). In contrast, patients for our study were recruited via newspaper advertisements, which likely drew a different sample. Most required significant assistance in getting the care they needed (psychopharmacology, job counseling, housing, etc.). An extensive discussion of the rationale and methods for case management is provided in the topic Introduction to Treatment/Case Management. In short, it is assumed that psychological interventions can work only if patients have an adequate treatment base.