The goal of the study presented here was to assess how cognitive-behavioral therapy affected a range of outcomes in a sample of urban women with comorbid substance use disorders and PTSD. Results show that a majority of participants reported repeated experiences of interpersonal abuse with exposure to trauma beginning at a relatively early age. In addition to PTSD and substance use disorders, a significant portion of participants also met criteria for having an affective disorder. Severity of depression and dissociative symptoms was high, as were rates of poly-substance abuse, impulsivity, somatic complaints, and interpersonal problems.
After three months participants in the cognitive-behavioral therapy group had significant reductions in PTSD and alcohol use disorder symptoms. A trend was found toward a decrease in drug use disorder symptoms, although it did not reach significance. No significant differences existed between groups on depression, dissociation, and social and sexual functioning outcomes. These findings demonstrate that although short-term cognitive-behavioral interventions may decrease some symptom clusters, other problems associated with complex trauma may be less amenable to this type of treatment.
Results of this study highlight a number of important clinical points. First they serve to underscore that this population has multiple comorbid conditions, which are associated with significant functional disabilities and enduring symptoms. The scope and chronicity of these problems present formidable treatment challenges. The numerous obstacles faced by this patient group (for example, limited resources in social environment, ongoing exposure to revictimization, relapsing nature of their disorders, and financial and medical problems) also affect treatment attendance and retention rates. Although the attrition rate in this investigation was reasonably good, more attention to issues of patient engagement and compliance is needed in planning treatment for this chronic, hard-to-reach population.
Second, although it is encouraging that short-term cognitive-behavioral therapy can have a substantial impact on symptoms of PTSD and substance use disorders in this population, the lack of effect on depression, dissociative symptoms, and interpersonal and sexual functioning raises questions and concerns. Interventions designed for one or two discrete problem areas are not likely to consider the whole clinical picture and may not be practical for this population. In practice, more comprehensive multimodel treatments are often recommended for these patients.
Incorporating interventions that specifically target features associated with complex trauma in this population may extend treatment results. For example, treatment focusing on deficits in emotional regulation and social functioning in addition to PTSD symptoms has been used successfully in a non–substance-abusing population of women with extensive trauma histories (25
). These problems have been conceptualized as a relatively distinct feature of the consequences of childhood trauma and derive from the trauma’s disruptive impact on the achievement of the developmental goals of affect regulation and interpersonal relatedness (29
). This type of treatment is likely to be applicable to the vulnerabilities in self-regulation that have also been implicated in the development and maintenance of substance use disorders (30
Another option would be lengthening the course of treatment. In clinical practice the presence of comorbid disorders and multiple impairments strongly influences the duration of treatment that is provided. Given the severity and range of pathology, as well as the multiple impediments to recovery in this population, treatments longer than those typically used in treatment protocols (for example, three months) may result in superior outcomes, although this practice needs to be empirically tested.
Whereas most trials of interventions for substance use disorders have stringent exclusion criteria that can result in unrepresentative samples largely composed of stable, Caucasian patients with few comorbid psychiatric conditions (31
), a major strength of the study presented here is the focus on an understudied population of urban women with chronic interpersonal trauma, multiple co-occurring conditions, and associated problems. Other strengths include the use of intent-to-treat analyses to measure improvement and assessment of multiple outcome domains.
The study’s limitations must also be considered. For example, we cannot rule out the potential for type II error—that is, because of small samples, null effects may have been erroneously accepted. Clearly a clinical trial that sets out to specifically examine outcomes associated with complex trauma, which includes random assignment to a well-defined and larger control group and longer follow-up periods, would address some of the shortcomings of our investigation. Also, the relative efficacy of simultaneous versus sequential treatment for trauma-related disorders among women who abuse substances is still unknown. Longitudinal designs that go beyond the end-of-treatment follow-up period are needed to shed more light on this important question.