Old-school therapy dictates that before post-traumatic stress symptoms, or indeed any mental health symptoms could be treated in someone experiencing active addiction, they first had to be in remission. This is consistent with what many addiction programs teach, and historically this was the only way that substance abuse and co-occurring disorders were treated. The logic states that as long as someone is numbing out, they can’t engage emotionally to process the important issues. Further, there was a fear that having someone address their trauma issues would lead to a relapse or increase in substance use. However, while this argument makes sense, more and more evidence suggests that integrative treatment works better for both substance abuse and PTSD symptoms.
Why is that?
Sequential treatment acts like the PTSD and substance abuse are separate issues and to do so ignores some key elements of the interaction between them. People with co-occurring disorders often self-medicate to cope with their symptoms and taking away someone’s coping strategy doesn’t take away their symptoms. Higher levels of mental health symptoms have been observed during initial abstinence from substances and it’s been hypothesized that this is a reason for high rates of relapse in individuals with co-occurring disorders (Navajits). As someone who works with survivors of sexual violence, many of whom have complex trauma as a result of chronic childhood sexual abuse by caregivers, I can’t imagine insisting that someone relinquish their primary coping skills before I offer them any others. This is consistent with clients’ preference to address both disorders, rather than waiting to work on trauma symptoms.
If the theory that many people are self-medicating is true, then you might expect that treating PTSD symptoms would result in a reduction of someone’s substance abuse. In fact, this is exactly what happens, as has been shown repeatedly.
Integrated dual-diagnosis treatment
In one study of over 350 women who had both PTSD and substance abuse disorder symptoms, participants were randomized into treatment groups that addressed either integrative (Seeking Safety) or addiction symptoms (groups had similar levels of each) in order to compare the two treatments.
They were evaluated during and up to a year after treatment had ended. Their conclusion was clear: the group that received trauma therapy saw a significant decrease in both their trauma symptoms and their substance abuse symptoms. The other group saw a reduction in their substance abuse, but no reduction in their trauma symptoms.
In another randomized control trial by Weiss et al, integrated (bipolar and substance use) group treatment was compared to substance use only group treatment. Substance use decreased considerably for the integrated treatment group, whereas the substance abuse in the drug treatment group stayed about the same. As a result, despite starting with the same baseline levels of abuse and bipolar symptoms, substance use was lower in the integrated treatment group in both the trial and in follow up assessments.
What are the official recommendations from the major trauma research bodies?
It should also be noted that all six of the evidence-based treatments recommended for PTSD and substance abuse dual-diagnosis by the International Society for Traumatic Stress Studies (ISTSS), the standard bearer for evidence-based trauma treatment, were integrative treatment. ISTSS does not recommend sequential treatment for PSTD and substance use disorders.
The Substance Abuse and Mental Health Services Administration (SAMHSA) is the federal agency responsible for the prevention, treatment and study of mental health and substance abuse. Their National Registry of Evidence-based Programs and Practices (NREPP) is not a comprehensive list of evidence-base practices, so this is not all of the evidence based treatments available. Here is what they list:
- Boston Consortium Model: Trauma-Informed Substance Abuse Treatment for Women
- Dialectical Behavior Therapy
- Double Trouble in Recovery
- Dynamic Deconstructive Psychotherapy
- Family Behavior Therapy
- Helping Women Recover and Beyond Trauma
- Pathways’ Housing First Program
- Phoenix House Academy
- Seeking Safety
- The Seven Challenges
- Trauma Affect Regulation: Guide for Education and Therapy (TARGET)
PTSD treatment but implemented with individuals who were concurrently in outpatient substance abuse treatment
- Trauma Recovery and Empowerment Model (TREM)
Clearly, there are a lot of choices for treating co-occurring substance abuse and PTSD. If you are someone or someone you know is struggling with these co-occurring disorders, and you’ve been told you can’t work on your PTSD until you’ve been clean for awhile, know that there are other options out there, and you have a right to get relief from your trauma symptoms and find healthier coping alternatives before you give up the ones that have gotten you through for so long.