Integrated Treatment of PTSD and Substance Abuse

The treatment is designed to continually address both PTSD and substance abuse. That is, both disorders are treated at the same time by the same clinician. This integrated model contrasts with a sequential model in which the patient is treated for one disorder, followed by treatment of the other; a parallel model, in which the patient receives treatment for both but by different treaters; or a single model, in which the patient receives only one type of treatment (Weiss & Najavits, 1998).

An integrated model is consistently recommended as the treatment of choice for this dual diagnosis (Abueg & Fairbank, 1991; Bollerud, 1990; Brady et al., 1994; Brown et al., 1995; Evans & Sullivan, 1995; Fullilove et al., 1993; Kofoed et al., 1993). In practice, however, most settings do not treat the two disorders simultaneously (Abueg & Fairbank, 1991; Bollerud, 1990; Evans & Sullivan, 1995). If patients enter a PTSD or general psychiatric setting, they usually address only trauma issues. If they enter a substance abuse setting, they are usually encouraged to work only on the substance abuse (Abueg & Fairbank, 1991; Bollerud, 1990; Evans & Sullivan, 1995). Indeed, one patient reported that she had to lie about her substance abuse to enter a PTSD program because the program did not accept patients with substance abuse—a not uncommon policy. In many settings clinical staff may be reluctant to assess for the “other” disorder (Bollerud, 1990; Fullilove et al., 1993), sometimes because they are unsure how to treat it if it is discovered. Patients’ own shame and secrecy about trauma and substance abuse can also reinforce treatment splits (Brown et al., 1995). Whereas dual-diagnosis treatment settings may, by design, attend to co-occurring disorders, they also tend to provide generic rather than specialized treatment by diagnosis. Yet the treatment needs of a patient with schizophrenia and substance abuse may be quite different from those of a patient with PTSD substance abuse, for example (Weiss, Najavits, & Mirin, 1998b).

Integration is ultimately an intrapsychic goal for patients as well as a systems goal: to “own” both disorders, to recognize their interrelationship, and to fall prey less often to each disorder triggering the other. Thus the content of this treatment provides opportunities for patients to discover connections between the two disorders in their lives—in what order they arose and why, how each affects healing from the other, and their origins in other life problems (such as poverty).

In addition, therapists are guided to use each disorder as leverage to help patients overcome the other disorder. Patients rarely emphasize each disorder equally. Some want to talk at length about PTSD and believe that their substance abuse is not really a problem. Others acknowledge substance abuse, but are afraid to address PTSD. The wish to deny aspects of one’s experience is much more characteristic of these disorders than of many other Axis I disorders (e.g., major depression or generalized anxiety disorder). The shame and secrecy surrounding trauma and substance use, and fear of others’ judgment, converge toward substantial disavowal. The denial can be intrapsychic, as in dissociative phenomena, or external, as in dishonesty about substance use. In any event, it requires deft therapeutic skill to continually help patients maintain focus on both disorders.

Integration of the treatment also occurs at the intervention level. Each topic can be applied to both PTSD and substance abuse. For example, Setting Boundaries in Relationships can apply to PTSD (e.g., leaving an abusive relationship) and to substance abuse (e.g., asking one’s roommate to stop growing marijuana plants in the house). Integration is also created by fluid movement among the four target areas of the treatment—cognitive, behavioral, interpersonal, and case management. Weaving in and out of these areas helps patients recognize the links among their thoughts, actions, and relationships, and between their internal experience and their functioning in the external world.

It is important to note that “integration” means attention to both disorders at the same time in the present. It is not asking patients to talk in detail about the past; indeed, that is specifically not part of this treatment (see the section below, “What Is Not Part of This Treatment”). Rather, it means helping patients learn what the two disorders are and why they cooccur; exploring their interrelationship in the present (e.g., using crack last week to cope with PTSD flashbacks); understanding the course of the disorders in recovery (e.g., with abstinence, PTSD may feel worse before it feels better); increasing compassion by viewing substance abuse as an attempt to cope with the pain of trauma; and teaching safe coping skills that apply to both. In short, patients are encouraged to see that healing from each disorder requires attention to both disorders. However, it does not mean telling patients, “You have to get clean first before you can deal with your PTSD,” or “Once you deal with your PTSD your substance abuse will go away” (messages patients sometimes hear in treatment programs). Instead, the idea is to gain control over the notorious downward spiral in which each disorder sets off the other. Themes common to both disorders are highlighted as well, such as “secrecy” and “control” as hallmarks of both.