This study investigated challenges involved in treating patients with SUDs, PTSD, or co-occurring SUD/PTSD. Clinicians (N = 423) from varying training backgrounds and treatment settings participated. The findings underscore how challenging and intense SUD/PTSD clinical work can be, even for experienced clinicians (the average number of years of clinical experiences was 14.4 years).
Consistent with previous research,31
clinicians rated comorbid SUD/PTSD as the most difficult group to treat. One of the most unique and challenging issues for therapists in treating SUD/PTSD is understanding when and how to best integrate the different treatment components for trauma and SUDs. Typically, SUD/PTSD patients who present for treatment are still actively using substances or in early remission. Many SUD/PTSD patients will relapse at some point during treatment, whether enrolled in an integrated or standard substance use treatment program. How much “clean time,” therefore, is needed before working on the trauma? When is the optimal time to introduce trauma/PTSD work? Should trauma work be discontinued if the patient relapses? Can patients who significantly decrease but still continue to use substances still benefit from trauma work? Clearly, these are important questions that need to be addressed in future research so that treatment guidelines may be established.
Although inconclusive at this point, the extant literature does provide some information to help address these concerns and guide clinical efforts. First, many of the empirically investigated integrated SUD/PTSD treatments strongly encourage, but do not require, abstinence from substance use before beginning trauma work.27, 33
These treatments have been shown to result in significant improvements in both SUD and PTSD symptoms, demonstrating that abstinence is not absolutely essential before patients can benefit from concurrent trauma work. Indeed, addressing the trauma may help facilitate reduction in substance use for patients who are continuing to use in order to cope with trauma-related symptoms.
Regarding the ideal time in treatment to initiate trauma work, integrated treatments generally introduce trauma work following an initial phase focused on substance use. During the initial phase, which may last from one to three months,17,31,32
patients are taught coping skills (eg, drug refusal skills, coping with triggers, problem solving, relaxation training) to help achieve or maintain abstinence or significantly reduce alcohol and drug intake. Patients receive psychoeducation beginning at the very first session, however, about the interrelationship between PTSD and SUDs. Indications that a SUD/PTSD patient is prepared to engage in trauma work (eg, prolonged exposure) include, for example, significant reductions in substance use, significant reductions in or absence of self-harming behaviors or suicidal ideation, a solid understanding of the rationale for trauma work and what it will involve, adequate learning and adoption of healthy coping skills, a collaborative patient-therapist agreement to begin trauma work, and realistic expectations regarding the potential initial difficulties of engaging in trauma work and the importance of sticking with it by using healthy coping skills.32,34,35
In summary, some length (eg, one to three months) of abstinence or significantly reduced substance use is encouraged before beginning trauma work, although it remains unclear exactly how much time is necessary for trauma work to be beneficial.
The findings from this study identify severe symptomatology and self-destructive behaviors as another common challenge of treating SUD/PTSD patients. In the event of a crisis, the decision to move forward with trauma work in would depend on several factors (eg, successful resolution of the crisis, extent of the crisis, patient’s willingness). Because avoidance is strongly characteristic of both PTSD and substance abuse, clinicians working with SUD/PTSD patients need to consider whether a patient might be attempting to avoid discussing the trauma through such a crisis. As indicated earlier, many patients relapse during treatment. A lapse does not necessarily represent a crisis and does not always require a delay in trauma work. In fact, it may not be beneficial (from an avoidance perspective) to defer trauma work when a patient lapses. Rather, relapse prevention skills should be reviewed, the difference between a lapse and a full-blown relapse emphasized to protect against the abstinence violation effect, and a functional analysis performed to help identify antecedents of the use.
Supervision of SUD/PTSD clinicians can be improved by addressing these common challenges and by helping clinicians to build the necessary skills and expertise. Given the common challenges associated with severe symptomatology and self-destructiveness, it is important for supervisors to instruct and review with SUD/PTSD therapists their crisis intervention skills, distress tolerance techniques, anger management and disarming techniques, negative affect management, and ways to handle patient dissociation. Because of the extensive case management needs that many SUD/PTSD patients have, therapists and supervisors should have available a list of local services in the community (eg, housing, vocational rehabilitation, domestic violence shelters) that patients can access. This will help take some of the burden off the clinician.
Supervisors can also assist by helping clinicians balance the more challenging aspects of treating SUD/PTSD patients with the sources of gratification. This may help prevent or reduce therapist burn out. The top three sources of gratification in working with SUD/PTSD patients were developing expertise in working with these clients, teaching clients new coping skills, and helping clients become abstinent from substances. Surveys such as the one used in this study can be modified and used by supervisors to assess challenges and sources of gratification among SUD/PTSD their supervisees, and then tailor supervision efforts and goals accordingly.
While this study was anonymous, the findings are based on self report and, as such, biases may exist. Clinicians from four national organizations were invited to participate. As such, the findings may not generalize well to clinicians outside of those organizations. Data on treatment outcome was not collected in this study; thus, it is unclear how clinicians’ perspectives impact treatment outcome. A strength of the study is the large sample of clinicians who participated with diverse training backgrounds, work settings, and theoretical orientations.