Post a (200 word APA Format) brief description of the natural disaster you chose. Then provide three PTSD-related early interventions that might contribute to the stabilization of survivors in the specific natural disaster you chose. Explain how and why t

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Assessment & Diagnosis

© 2007 by the American Counseling Association. All rights reserved.

Historically, administrators and clinicians have been hesitant  to address posttraumatic stress disorder (PTSD) in the treat- ment of substance use disorders (SUDs). However, a growing  body  of  research  literature  provides  support  for  integrating  PTSD and SUD treatment. PTSD is prevalent among individu- als with SUDs (Chilcoat & Menard, 2003; Dansky, Saladin,  Brady,  Kilpatrick,  &  Resnick,  1995;  Fullilove  et  al.,  1993;  Najavits et al., 1998), and SUDs are prevalent among adults  with PTSD (Chilcoat & Menard, 2003; Jacobsen, Southwick,  & Kosten, 2001). Specifically, epidemiologic studies indicate  that adults with SUDs (particularly involving opiates or co- caine) are 2.6 to 10.8 times more likely to have PTSD than  adults  who  do  not  have  SUDs  (Chilcoat  &  Menard,  2003).  Comparable findings were reported in epidemiologic studies  with adolescents, with alcohol, marijuana, and hard-drug (e.g.,  heroin, cocaine) abuse or dependence associated with a 1.6 to  2.9 times increased risk of PTSD. When the focus is shifted  to the risk of SUD conferred by PTSD, studies indicate that  adults with PTSD are between 1.4 and 4.5 times more likely  to have an SUD (including alcohol or other drugs) than adults  who do not have PTSD. Among adolescents, PTSD is associ- ated with a 3.2 to 14.1 times greater risk of SUD (Chilcoat  & Menard, 2003). 

A history of exposure to traumatic violence, such as physical  or sexual assault in childhood, is common and such a history  often leads to PTSD (i.e., 30%–59% prevalence) among women  with chronic SUDs (Najavits, Weiss, & Shaw, 1997). Exposure  to recent violence also is prevalent among women with comor- bid PTSD–SUD. More than 50% of women seeking treatment  for  comorbid  PTSD–SUD  reported  having  been  exposed  to    and/or having engaged in physically assaultive behavior with a 

primary partner in the past year, and 45% reported having been  exposed to sexual coercion by a partner (Najavits, Sonn, Walsh,  & Weiss, 2004). In community epidemiological studies of men  and women, traumatic violence was associated with substan- tially greater risk of developing PTSD (e.g., 46%-65%) than  were other forms of trauma (e.g., nonviolent traumas; 8%–20%  risk of PTSD; Chilcoat & Menard, 2003). PTSD and SUD also  often co-occur after traumatic violence (Fullilove et al., 1993).  For example, women in a national survey of crime victims were  3 times more likely to have an SUD if they had PTSD than if  they did not have PTSD (Dansky et al., 1995). 

Across  both  gender  and  diverse  ethnocultural  background,  as many as 90% of SUD treatment recipients report a history of  sexual or physical assault, and as many as 59% have PTSD (Chil- coat & Menard, 2003; Dansky et al., 1996; Najavits et al., 1997).  Moreover, comorbid PTSD–SUD may result from particularly  severe trauma exposure and may cause particularly severe PTSD  symptoms. For example, women seeking SUD treatment who  had comorbid PTSD–SUD had more extensive trauma histories  and severe PTSD symptoms (particularly avoidance, emotional  numbing,  and  sleep  difficulties)  than  did  women  with  PTSD  alone (Saladin, Brady, Dansky, & Kilpatrick, 1995). 

Several  hypotheses  have  been  advanced  to  explain  why  PTSD and SUD co-occur, with the strongest empirical support  accrued  by  the  self-medication  hypothesis,  which  proposes  that SUDs are the result of attempts by people with PTSD to  use substances to cope with PTSD symptoms such as intrusive  memories, hypervigilance, sleep disturbance, irritability, and  physical reactivity. Both epidemiological (Chilcoat & Menard,  2003) and SUD treatment (Stewart & Conrod, 2003) studies  indicate that PTSD more often (i.e., in 53% to 85% of cases) 

Earn 1 CE credit now for reading this article. Visit www.counseling.org/resources, click on Continuing Education Online, then JCD articles.

Julian D. Ford, Department of Psychiatry, University of Connecticut School of Medicine; Eileen M. Russo, private practice, Water- bury, Connecticut; Sharon D. Mallon, Connecticut Department of Mental Health and Addiction Services, Hartford. The writing of this article was supported by a National Institute of Mental Health K23 career development grant, MH01889-01A1, Julian D. Ford, principal investigator. The authors thank Rocio Chang for her valuable input concerning the clinical issues and safety planning. Correspondence concerning this article should be addressed to Julian D. Ford, Department of Psychiatry, MC1410, University of Connecticut Health Center, 263 Farmington Avenue, Farmington CT 06030 (e-mail�� Ford�Psychiatry.uchc.edu�e-mail�� Ford�Psychiatry.uchc.edu�.

Integrating Treatment of Posttraumatic Stress Disorder and Substance Use Disorder Julian D. Ford, Eileen M. Russo, and Sharon D. Mallon

Historically, administrators and clinicians have been hesitant to address posttraumatic stress disorder (PTSD� in the treatment of substance use disorders (SUDs�. However, research shows that SUD treatment recruitment and outcomes may be adversely affected if co-occurring PTSD is left untreated. The authors provide guidelines for screening and as- sessment, treatment services, and workforce and organizational development that are designed to facilitate integrated PTSD–SUD treatment. Case examples illustrate the necessary precautions related to and the potential benefits of integrating treatment of PTSD and SUD.

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predates  SUD  than  vice  versa,  with  only  one  exception  in  which 18-year-olds were slightly more likely (54%) to report  that alcohol dependence preceded PTSD than vice versa (46%;  Giaconia et al., 2000). A prospective study of primarily White,  middle-class adults in a health maintenance organization (ages  21–35 years) found that having PTSD led to a fourfold increased  risk of developing an SUD independent of the influence of prior  conduct problems or depression, but having an SUD did not  increase  the  risk  of  either  exposure  to  trauma  or  developing  PTSD (Chilcoat & Menard, 2003). The strongest relationship  between PTSD and SUD was with abuse of or dependence on  prescription drugs but not street drugs (i.e., drugs obtained il- licitly or illegally), which is consistent with the higher levels of  use of prescription drugs versus street drugs by this particular  subgroup  of  young  adults.  Similar  findings  of  SUD  leading  to an increased risk of PTSD (but not of trauma exposure per  se) have been reported with alcohol and street drugs in studies  of women, military veterans, and disaster victims (Stewart &  Conrod, 2003). Thus, SUD may predate PTSD, but it is more  likely that SUDs develop or are worsened as a result of attempts  to cope with PTSD. 

PTSD and SUD also may exacerbate and sustain each other  over time. Men and women with alcohol- or cocaine-related  SUDs who also had PTSD were more likely than those without  PTSD to report a craving for substances if reminded of past  trauma or substance use (Saladin et al., 2003). Accident survi- vors or women who have been raped were more likely to have  persistent PTSD if they had prior alcohol disorders than were  those with no alcohol disorder (Stewart & Conrod, 2003).

Despite these consistent and disturbing findings of PTSD– SUD  comorbidity,  most  adults  receiving  SUD  treatment  are  neither evaluated for PTSD nor offered PTSD treatment, or PTSD  services are provided only after lengthy periods of substance use  abstinence (Ouimette et al., 2003). Yet, adults with co-occurring  PTSD and SUD often want to receive treatment for both PTSD  and SUD and to do so in an integrated manner rather than ad- dressing one disorder at a time (Brown, Read, & Kahler, 2003).  Moreover, SUD treatment recruitment, retention (Brown et al.,  2003), and outcomes (Ouimette et al., 2003; Palacios, Urmann,  Newel, & Hamilton, 1999) may be adversely affected if co-oc- curring PTSD is undetected and untreated. 

On the positive side, PTSD treatment has been shown to  reduce not only immediate but also long-term risk of SUD re- lapse if provided during the transitional period beginning soon  after discharge from inpatient SUD treatment and during the  long-term recovery period (Ouimette et al., 2003). Although  they did not provide integrated PTSD–SUD treatment in their  study, Ouimette et al.’s findings suggest that SUD and PTSD  recovery  and  treatment  are  not  incompatible—indeed  they  may be essential to each other (see also Dansky et al., 1996).  Although several models of PTSD treatment have been em- pirically validated in the past 2 decades, most PTSD therapies  have  not  been  adapted  to  address  co-occurring  SUD  (Ford,  Courtois, van der Hart, Nijenhuis, & Steele, 2005). Recently, 

however, several integrated PTSD–SUD therapies have been  developed  (see  Donovan,  Padin-Rivera,  &  Kowaliw,  2001;  Ford  et  al.,  2005;  Najavits,  2002; Triffleman,  2003)  with  promising although preliminary outcome evaluations (Coffey,  Dansky, & Brady, 2003; Donovan et al., 2001; Frisman, Ford,  & Lin, 2004; Hien, Cohen, Miele, Litt, & Capstick, 2004). 

Clinical Strategies for Integrated PTSD–SUD Treatment

Although promising intervention models are in development for  integrated PTSD–SUD treatment, at this early stage in the devel- opment of evidence-based practices for integrated PTSD–SUD  treatment, clinicians need pragmatic strategies for handling the  clinical issues that arise during this complex endeavor (Sullivan  & Evans, 1994). Shavelson (2001) has noted: 

I  am  certain  of  one  thing: When  an  addict,  no  matter  how  together he or she seems, works vigorously to get into rehab,  persists in the program with clear and sincere intentions of  overcoming addiction, and yet still repeatedly relapses to drug  use, there is invariably an additional psychological disturbance  underlying that failure to stay clean. (p. 300)

When  PTSD  is  the  additional  psychological  disturbance,  the  challenge  is  to  treat  PTSD  without  exacerbating  SUD  and  precipitating  relapse  or  safety  crises. We  discuss  les- sons learned in the course of implementing and evaluating  (Frisman et al., 2004) an approach to integrated PTSD–SUD  treatment  called  “TARGET”  (Trauma Adaptive  Recovery  Group  Education  and  Therapy  (Ford  &  Russo,  2006).  TARGET teaches a sequential skill set for recognizing and  managing PTSD, SUD, and affect dysregulation that is sum- marized by a readily remembered acronym: FREEDOM. For  example, the letter f represents the first step in responding  effectively to stress reactions, focusing. The focusing step  involves three skills, which are also summarized in a simple  and  memorable  mnemonic,  SOS  (i.e.,  slow  down;  orient  yourself; self-check your current level of distress, positive  personal control, and urges to engage in maladaptive coping  behaviors such as using substances). TARGET also uses a  creative  arts  exercise  in  which,  over  the  course  of  several  treatment sessions, each client uses such techniques as col- lage, drawing, writing poetry, crafts, or music, to develop a  representation of significant life experiences and the meaning  (e.g., feelings, beliefs, goals, changes in self-concept, hopes,  and relationships) that these experiences had for them in the  past and continue to have in the present. 

In  the  following  sections,  we  frame  the  lessons  learned  from our work with TARGET in general terms applicable to  any approach to integrated PTSD–SUD treatment. Through- out,  we  refer  to  two  composite  clinical  scenarios  (Case  1  and  Case  2,  disguised  to  ensure  confidentiality)  as  a  basis  for discussing clinical dilemmas and potential solutions for  clinicians treating co-occurring SUD and PTSD. 

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Case 1

Susan  is  a  34-year-old African American  woman  who  began  using marijuana and alcohol, with her mother’s encouragement,  at age 11. Susan was also being prostituted by her mother and  her mother’s boyfriend. Susan had been able to put together three  periods of abstinence since the death of her boyfriend from a drug  overdose 5 years previously and when threatened with the loss of  her parental rights (of her two young daughters), but each time  she relapsed after a few months. She keeps returning to treatment,  using both inpatient and intensive outpatient levels of care. Susan  typically is very reserved and suspicious, but she has begun to  connect with other women in a sobriety support group. Overall,  she has done well in the group sessions, but if she talks about her  childhood sexual abuse, the group leaders tell her to wait to deal  with trauma until after she has been sober for 1 year. Meanwhile,  she is experiencing nightmares, anxiety, and exaggerated startle  responses (e.g., “I feel like I’m going to jump out of my skin”).  Susan diligently works on a family reunification plan mandated  by the Department of Children and Families, often visiting her  daughters  in  a  foster  home. This  is  Susan’s  fifth  admission  to  outpatient treatment. She fears another relapse and wonders what  to do to break the cycle of partial recovery. 

Case 2

Edward is a 44-year-old Caucasian man who was referred to  an outpatient jail diversion program after being arrested for  burglary while high on heroin and crack cocaine. As a child,  Edward saw his father beat his mother on a regular basis. His  mother alternately treated Edward as her “perfect little man” or  as “having the devil in him, a little monster who never should  have  been born.” Edward describes his mother in idealized  terms  and continues to seek her approval. He also longs to  be a husband and father in what he calls a “perfect family.”  When he was 15, he began drinking alcohol and quickly pro- gressed to snorting and shooting heroin and smoking crack  cocaine. Edward witnessed the killing of two friends during  a drug deal, but he says, “that’s life on the streets, nothing in  the past bothers me.” Edward is easily angered, has bouts of  depression  (particularly  when  relationships  are  conflicted),  and trusts no one “except my mother.” He is hypervigilant and  has cognitive impairment consistent with chronic drug use.  Edward does not seem to retain or use the skills he has been  taught in sobriety support and anger management groups. He  says, “I like group but I don’t remember nothing from it.” His  care coordinator fears that a PTSD group will destabilize him  and precipitate a relapse.

Reconsidering Common Assumptions Concerning the Treatment of Trauma, PTSD, and SUD

A  key  underlying  philosophy  of  early  addiction  treatment  programs was “if it don’t itch, don’t scratch” (White, 1998,  p. 203). Addiction treatment was assumed to work best by ad-

dressing only obvious SUD behavior patterns because delving  into  psychological  issues  was  viewed  as  colluding  with  the  client’s avoidance of taking responsibility for sobriety or (as in  Edward’s case) as opening Pandora’s box and precipitating a  relapse. In addition, 12-step groups often recommended that no  one in early recovery should make major changes for a year (as  in Susan’s case) in order to avoid impulsive or poorly considered  life choices. Even in later stages of recovery, addressing issues  other than SUD symptoms is often assumed to interfere with  12-step  recovery  or  to  trigger  relapses.  Several  myths  about  trauma survivors and PTSD treatment perpetuate the philosophy  of don’t tell, don’t treat with co-occurring PTSD–SUD. 

A common myth is that prior to attaining sobriety and be- coming psychosocially stable, an individual (such as Susan)  is  too  fragile,  impulsive,  and  reactive  to  deal  with  trauma.  Another  myth  portrays  addiction  treatment  clients  such  as  Edward as feeling revictimized and falling to pieces if trauma  issues or memories are opened up. The corollary to this myth  is that trauma recovery requires dredging up awful feelings  and  traumatic  memories  for  detailed  examination. A  third  myth is that sobriety requires a distinct set of commitments  and skills that differ fundamentally from those involved in the  treatment of other psychological disorders, including PTSD.  A fourth myth is that traumatic events are all in the past, and  therefore  there  is  no  need  to  reopen  old  wounds  and  cause  the individual to experience further distress or to be preoc- cupied with memories that are better treated as water under  the bridge. A final myth is that there is no cure for PTSD, so  it is best not to set clients up for failure by giving them hope  that treatment can eliminate PTSD.

We propose several alternative views to such myths based  on the research literature and on observations by clinicians  and  case  managers  who  have  been  trained  to  conduct  an  integrated  PTSD–SUD  treatment.  Recovery  from  PTSD  is  complementary  with  recovery  from  SUD  because  recovery  from  PTSD  involves  learning  how  to  deal  with  unfinished  emotional business resulting from trauma without denial and  with personal responsibility (i.e., sobriety). Trauma survivors  with PTSD are not fragile but rather are highly resilient be- cause they have had to develop ways of coping with extreme  stressors.  If  this  were  not  true,  they  would  not  be  seeking  sobriety. Trauma survivors with PTSD have developed highly  reactive  stress  response  systems  in  their  bodies  that,  if  not  modified  therapeutically,  can  precipitate  SUD  (Jacobsen  et  al., 2001). With awareness of and skills for managing PTSD  symptoms, trauma survivors such as Susan or Edward may  be able to face rather than avoid the symptoms, just as they  manage SUD symptoms by acknowledging them and learning  constructive skills to manage them. 

Trauma recovery neither requires nor necessarily includes  dredging  up  or  repetitively  recalling  trauma  memories  but,  instead, can be accomplished by helping the survivor to man- age and even gain control over the unwanted trauma memories  that are core symptoms of PTSD. Skills for managing PTSD 

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provide a foundation for trauma survivors to make thoughtful  choices  about  if,  how,  when,  and  with  whom  to  reexamine  trauma memories, so that this is an informed choice rather than  a  retraumatizing  or  destabilizing  experience. When  trauma  survivors with PTSD are helped to examine stressful here-and- now experiences and to recognize PTSD symptoms as self- protective responses (Harris & Fallot, 2001), they can manage  unwanted trauma memories in the same way that they manage  SUD urges. Susan specifically asked her counselor for help  with flashbacks to incidents of sexual abuse because these in- trusive memories often appeared to trigger relapses. Although  there is no way to eradicate memories of traumatic experiences  nor any total permanent cure for PTSD, this situation is no  different than it is for SUD. Most survivors never completely  eliminate PTSD symptoms, but they can reduce the distress  caused by these symptoms by learning how to manage them  rather than feeling powerless in the face of unwanted trauma  memories and the associated stress reactions. The solution is  not to develop such a thick skin that trauma memories are not  upsetting but, instead, to learn to deal with trauma memories  and PTSD symptoms thoughtfully and effectively. For many  people, full recovery from SUD is not possible without ad- dressing trauma recovery in this manner.

Case 1

Susan introduced herself in her first trauma recovery group by  interrupting  another  group  member  and  saying,  “maybe  this  isn’t the right group for me because I was raped by my mother’s  boyfriend  and  then  made  into  a  ‘ho’  by  them.”  She  became  agitated and said she needed to leave. One of the group leaders  immediately  went  to  sit  next  to  Susan  and  quietly  reassured  Susan that she could be in the group without having to go back  to those painful experiences. The leader helped Susan to ground  herself and gradually come back from the dissociative state she  had slipped into. Simultaneously, the other group leader softly  spoke with the rest of the group. The counselor let them know  that  Susan’s  pain  might  be  frightening  or  disturbing,  but  the  group would be able to help her and themselves by learning  new ways to deal with bad memories so they would not get lost  in them. Several group members expressed skepticism (e.g.,  “That’s what they tell you in every group, but it hasn’t helped  me yet!”). The group leader acknowledged that members’ past  experiences could make this seem impossible, adding that the  group  could  test  this  immediately  by  using  a TARGET  skill  right at that moment to see if it would be helpful to Susan and  to other members. The leader modeled and coached the group  members, with a special emphasis on Susan, in using the first  TARGET skill for trauma recovery, that is, focusing. Susan and  other group members gradually became more present-focused  and calmer, and the group leaders were able to explain why these  PTSD reactions occur and how the FREEDOM skills could help  them to reset a survival alarm in their brains. 

The group leader helped the group discuss how their intense  reactions could be healthy self-protective responses that their  bodies  had  learned  as  a  means  to  help  them  survive  terrible 

experiences.  Susan  asked  if  this  meant  that  she  had  to  talk  about the abuse in order to get over these alarm reactions. The  group leader clarified that this was not the case, and that during  the group sessions, the leaders would teach skills to help them  decide when they were ready and if they needed to talk about  past traumas. When Susan asked if this meant she had “messed  up” by “saying too much and upsetting the group,” the group  leader responded that this was not a “mess” but instead was a  courageous way for her to let the group know how hard she  has been working on her own recovery from very painful past  experiences. The group leader also commented that Susan had  used the focusing skills effectively in group, despite learning  them for the first time while having an alarm reaction.

The group leaders chose to get to know Susan and other group  members better in subsequent group sessions before addressing  several possible treatment issues that were raised by Susan’s spon- taneous disclosure of her past sexual abuse. For example, Susan  may have been replaying a personal script of being exposed in  her past experiences of sexual abuse and forced prostitution. She  may also have been testing the leaders and the group by exposing  them to her traumatic past and to her intense distress, either to  see if they would reject her or to learn if they were strong enough  to tolerate her intense distress and terrible memories. The group  leaders’ use of the education concepts regarding the body’s alarm  system provided a way to reframe Susan’s impulsive disclosure  as an expression of the core dilemma that the group would help  each member to address. This dilemma is the question of how  to  recover  from  traumatic  experiences  and  to  manage  intense  stress reactions without escalating into a state of crisis or shutting  down emotionally, isolating from other people, avoiding healthy  activities, or lapsing into substance use. Susan was particularly  interested in the idea that she might have used drugs to try to  turn off the stress alarm in her brain, and she expressed a sense  of new hope because she believed that learning how to adjust  this inner alarm might reduce or give her greater control over  her urges to use substances.

Case 2

Edward participated very little in the first two trauma group  sessions, except to say that nothing really bothered him since  he had learned in another group to just forget the past. In the  third group session, Edward said he did not think this group  was helping him because he had gotten in trouble for yelling  at another patient in his program, and none of the skills had  helped  once  he  “lost  it.”  Group  leaders  helped  Edward  to  reexamine that incident, beginning with what he was feeling  and thinking about earlier that day that might have affected  his reaction to the other patient. Then Edward was helped to  identify specific triggers for his alarm reaction. Edward said  the first trigger was that “he was disrespecting me,” and with  further thought and therapeutic guidance he was able to pin- point a facial expression and tone of voice that “was just like  my mother did when she told me I was the devil and beat me.”  Edward expressed anger toward the group leaders for “making  me think about things I don’t want to remember” and got up 

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as if to storm out of the room. Rather than focusing on the  content of this trauma memory, the leaders gently but firmly  asked Edward to see if they could work this out without his  leaving, while also giving him permission to leave if he felt he  needed a time out (this was done to prevent emotional escala- tion by inadvertently leading Edward to feel trapped). 

Edward stopped and angrily said, “I don’t need a time out,  I  need  to  be  left  alone,  and  you’re  not  leaving  me  alone  with  this  therapy  stuff.” The  group  leaders  responded  by  empathi- cally validating his goal of being able to put the bad memories  behind  him  and  have  a  good  life  and  good  relationships  now  and in the future. They said that anger often was a very positive  sign of a strong commitment to a very important goal, and that  participation in the group sessions might be able to help Edward  channel his anger in a way that would allow him to achieve his  goals. As Edward began to de-escalate, the leaders commented  supportively that that was what Edward was doing right at that  moment by recovering his focus but also holding firmly to his  personal goals. Rather than assuming that Edward was too early  in his recovery or too cognitively impaired to deal with PTSD,  they helped Edward understand and manage his PTSD reaction  in the session. The leaders emphasized that the group’s goal was  to help each participant move forward and not dwell on the past  by strengthening each group member’s skills for dealing with this  type of alarm reaction and refocusing on positive steps toward  their personal goals. The leaders asked other group members if  they felt that Edward’s success in recovering his focus despite  his anger alarm was a helpful example for them. Several group  members  thanked  Edward  for  handling  the  situation  well  and  giving them hope that they could do the same at times in the  future when they felt triggered into an alarm reaction. 

Edward was surprised and then seemed not only calmer  but  also  proud  to  be  receiving  the  genuinely  supportive  acknowledgements. At  the  close  of  the  session,  when  the  group leaders went round the group circle to get a self-check  from each member, Edward reported feeling a lower level of  distress and little urge to use substances as well as a higher  level of personal control than he had described earlier in the  session or in the past two sessions. The group leaders asked  him if he thought that the work he had done in that session  to  strengthen  his  focusing  skills  might  actually  help  him  with  his  sobriety  and  his  ability  to  manage  anger,  and  for  the first time he paused (instead of simply saying no) and  said he would “think about that.” As illustrated by the case  examples,  the  myths  that  trauma  and  addiction  recovery  are  disconnected,  or  even  mutually  incompatible,  are  not  borne  out  by  clinical  experience  that  involves  integrated  PTSD–SUD treatment.

Meta-Models of PTSD and SUD Fundamental to integrated PTSD–SUD treatment is address- ing  how  PTSD  and  SUD  are  understood  by  the  clinician  and the client, that is, their meta-models for conceptualizing  PTSD and SUD. 

Disease Models of PTSD and SUD

The  disease  model  views  PTSD  and  SUD  as  conditions  requiring  cure  or  correction,  similar  to  the  situation  with  a  medical illness. PTSD and SUD may also be seen as chronic  disabilities that cannot be eliminated but can be managed bio- logically and behaviorally like other persistent health problems  or “handicaps.” Although there is ample scientific evidence  that  PTSD  and  SUD  are  potentially  chronic  and  disabling  conditions  that  involve  dysregulation  in  several  biological  systems, there also is evidence that both psychological and  biological  therapies  can  improve  each  disorder  and  at  least  partially  restore  healthy  bodily  self-regulation  (Ford  et  al.,  2005; Jacobsen et al., 2001). 

Cognitive–Behavioral Models of PTSD and SUD

From a cognitive–behavioral standpoint, PTSD and SUD are  the result of dysfunctional (i.e., threat-based or addiction-based)  beliefs, cognitive biases, and reactive behavior patterns that  lead  to  an  escalating  sense  of  anxiety,  anger,  and  helpless- ness  (Brewin  &  Holmes,  2003).  From  a  stress  and  coping  perspective,  PTSD  and  SUD  involve  maladaptive  coping  in response to stressors that range in intensity from mild to  traumatic (Stewart & Conrod, 2003). From an empowerment  or strengths-based perspective, PTSD and SUD involve a loss  or a breakdown of the person’s psychological and interpersonal  resources (e.g., sense of safety, self-efficacy, motivation; Ford  et  al.,  2005).  The  newer  interventions  for  co-occurring  PTSD–SUD, therefore, consistently teach complementary  cognitive  and  behavioral  skills  for  building  or  acquiring  personal strengths or interpersonal resources and for cop- ing  with  the  effects  of  both  current  and  past  stressors  or  threats to sobriety. 

Developmental and Cultural Models of PTSD and SUD

In  a  developmental  framework,  PTSD  and  SUD  involve  disrupted learning and maturation, such that the person does  not  develop  self-regulatory  capacities  and  healthy  attach- ments (Ford et al., 2005). When a stable sense of self is not  achieved by people experiencing multiple adversities, identity  confusion may exacerbate posttraumatic stress (Asner-Self  & Marotta, 2005). Although traumatic stressors in adulthood  may be factors in the etiology or course of either PTSD or  SUD,  traumatic  stressors  experienced  in  childhood  (par- ticularly traumas involving a betrayal of trust) can alter core  psychological  or  biological  development  in  ways  that  lead  to complex and chronic forms of PTSD or SUD (Ford et al.,  2005; Jacobsen et al., 2001). 

Finally, from a cultural perspective, PTSD and SUD involve  larger  sociocultural  forces,  barriers,  and  norms  that  influence  the impact that traumatic events have on entire communities or  societies and on people’s core beliefs and on their ways of life.  Similarly,  from  a  spiritual  viewpoint,  PTSD  and  SUD  can  be  seen as crises of faith, hope, and moral values (Manson, 1996).  Each individual experiences and responds to trauma, addiction,  and  recovery  in  unique  ways  that  require  an  idiographic  (i.e., 

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person-centered  rather  than  purely  standardized)  approach  to  counseling (Lee & Tracey, 2005). Treatments for co-occurring  PTSD–SUD tend to address the cultural and spiritual dimensions  of trauma or addiction by focusing on these issues as important  but not primary aspects of the individual’s psychological adjust- ment  and  recovery. Approaches  to  conceptualizing  SUD  and  PTSD and the recovery process that place culture or spirituality  in a central position are rare. For example, Hardy and Laszloffy  (1995)  have  described  the  impact  of  racial  oppression  on  the  therapeutic issues involved in the treatment of African American  families. Also, Brende (1993) has developed a 12-step recovery  model that focuses specifically on spiritual and cultural healing  and growth in recovery from co-occurring PTSD–SUD. 

Synthesis of Meta-Models: Memory and Emotion Regulation in PTSD and SUD

The meta-models of PTSD and SUD just described are not  mutually exclusive but are often treated as such. All of these  meta-models  intersect  in  two  core  domains,  memory and  emotion regulation, which provide a basis for understand- ing  co-occurring  PTSD–SUD  that  can  guide  integrated  PTSD–SUD treatment. 

PTSD  and  SUD  involve  a  loss  of  control  over  one’s  own  memory  (Harvey,  1996).  In  PTSD,  this  takes  the  form  of  unwanted, persistent, and fragmented memories of traumatic  experiences. In SUD, memory tends to be fragmented, over- whelmingly painful, and, at times, frustratingly elusive. There- fore, integrated PTSD–SUD treatment must enable survivors to  regain mastery of memory (Harvey, 1996). Traditionally, this  has involved telling the personal story of trauma or addiction  in order to gain the emotional and moral support of significant  others (Harvey, 1996). This can be done either in the context of  a variety of culturally sanctioned rituals or in formal counsel- ing settings (Herman, 1992). Reclaiming mastery of memory  involves a fundamental developmental shift in personal identity  that includes but goes well beyond the resolution of traumatic  memories. In a qualitative study of seven women who had ex- perienced childhood sexual abuse, Phillips and Daniluk (2004)  identified the following crucial recovery themes: “[gaining] an  increasing sense of visibility, congruence, and connection, an  emerging sense of self-definition and self-acceptance, a shift  in worldview, a sense of regret over what has been lost, and a  sense of resiliency and growth” (p. 179). Reclaiming memory  thus involves clarifying and integrating both memories of the  past and new memories that are created in the present, and this  process leads to fundamental shifts in how the person views  herself (e.g., from viewing self as a victim, to a survivor, to a  woman). In cases such as Edward’s in which memory may also  be compromised by chronic substance use or organic problems,  the  development  of  the  psychological  capacity  to  enhance  memory coherence is a crucial prerequisite to any form of PTSD  treatment that involves recalling trauma memories. 

In the 12-step tradition, the fourth step involves accurately  recalling past experiences and actions that are often painful. 

Rejoining a community of peers and honestly facing and telling  one’s story of addiction and recovery (the fifth step) is another  core element in the 12-step approach to treatment of SUD. Al- though Brende (1993) has adapted the 12-step model to PTSD,  there is no integrated model to guide the simultaneous telling  of the personal story of SUD and PTSD. For clients such as  Susan, for whom PTSD and SUD are intimately intertwined,  treatment must provide a basis for reclaiming a life story without  compartmentalizing PTSD and SUD experiences.

Although  trauma  and  addiction  are  painful  to  remember,  the major barrier to memory is not the events themselves but  the extreme emotion dysregulation that traumatic memories or  reminders evoke (Cloitre, Scarvalone, & Difede, 1997). Chronic  PTSD and SUD both involve mood shifts that encompass in- tense rage, grief, fear, despair, guilt, and shame, as well as pro- found emotional cut-offs such as dissociation, alexithymia, and  numbing. Integrated PTSD–SUD treatment, therefore, focuses  on enhancing emotional regulation to increase clients’ ability  to recognize and manage both SUD and PTSD symptoms and  the often complex interplay of these symptoms (e.g., intense  denial, rage, and urges to use substances when experiencing  painful unwanted memories or hypervigilance). 

Case 1

Susan  initially  was  restless  and  fidgety  during  the  trauma  group sessions, stating that she was trying to keep her mind  empty by distracting herself. As Susan practiced the TARGET  focusing skills in each group session and as she learned ways  to identify manageable emotions, thoughts, and personal goals  using  the  FREEDOM  skill  set,  she  experienced  moments  in  which  she  could  consciously  choose  to  pay  attention  to  thoughts, feelings, and memories rather than avoiding them.  Correspondingly,  Susan  began  to  recall  and  draw  on  very  basic goals and values that had once been important to her  but that she had forgotten or given up on (e.g., “to be smart  enough to figure out problems” and “to be able to speak my  mind  without  being  rejected  or  punished”). A  creative  arts  exercise  (the  lifeline;  Ford  &  Russo,  2006,  p.  347)  helped  Susan to see in a tangible way how these goals had been an  integral part of her development in childhood but were lost  when trauma became the defining force in her life in her ado- lescence. In this way, Susan learned that she had the ability to  remember what she chose to remember and when she chose  to  remember  it,  and,  consequently,  she  became  less  phobic  about her memory.

Case 2

Edward  was  able  to  use  focusing  and  trigger  identification  skills  during  the  group  sessions,  but  said  that  he  could  not  remember  these  skills  outside  of  the  group  setting;  he  also  stated that if he was already angry, it was too late to focus on  himself anyway. However, while doing the lifeline exercise,  Edward disclosed that he used to write rap lyrics and had kept  a personal notepad full of them until his stepfather had torn  it  up  to  punish  him. A  group  leader  asked  if  he  would  like 

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to experiment with writing rap-style entries on the personal  practice  worksheets  that  were  used  in  the  group  sessions  to  help  members  break  down  stressful  experiences  into  the  FREEDOM steps. Edward found that this gave him a struc- tured and safe way to re-access his knack for pithy phrases  and rhymes. He created a series of “FREEDOM Raps” that he  illustrated with drawings and a collage on his lifeline to show  visually how he was using the FREEDOM steps to reexamine  and make sense of important current and past experiences in  his life. Edward reframed his actions into choices that he made  in an effort to live up to the values he expressed in his raps.  He  found  that  creating  the  FREEDOM  raps  was  especially  helpful and productive when he started to feel angry because  he  could  use  the  energy  and  determination  from  his  anger  to  “speak  truth  to  the  powers  that  be,”  instead  of  reacting  impulsively or shutting down emotionally. 

Edward surprised the group in a session near the end of the  treatment by spontaneously telling the leaders that he now was  able to remember things that used to “go in and out of my mind  like a sieve when I started this group.” He remembered the  leaders saying in the first session that he could learn to channel  and use his anger but that, at that time, he had thought that was  impossible. Now, he said, “my raps are proof that I can do it!”  The group leaders and members responded that the raps also  were proof that Edward could use his inner alarm to harness  the power of creativity and truth. This vignette illustrates how  PTSD–SUD skills can enable clients both to gain mastery of  memory and to achieve emotion regulation even when they  have begun treatment with doubt and distress. 

Preliminary Best Practices Guidelines for Integrated PTSD–SUD Treatment

With the goals of facilitating mastery of memory and emo- tional self-regulation, we next suggest best practices guide- lines for integrated PTSD–SUD treatment in three domains:  screening and assessment, treatment services, and workforce  and organizational development.

Screening and Assessment

Screening as motivational enhancement. For  most  clients,  PTSD symptoms are strongly and problematically linked to  SUD symptoms, but treatment providers rarely, if ever, discuss  this relationship; thus, the two sets of symptoms have been  treated as totally separate concerns. In addition to providing  information about clients’ current functioning and treatment  needs,  initial  trauma  screening  provides  an  opportunity  to  begin  educating  the  client  about  the  treatment  model.  For  example, during the screening interaction, the counselor can  briefly  explain,  using  a  statement  like  the  following,  that  unwanted PTSD memories are actually signs that the brain’s  survival system is being activated:

These unwanted memories and the feeling of being tense and  in danger all the time actually are your body’s alarm system 

trying  to  protect  you,  but  the  problem  is  that  you’re  not  in  control of the alarm because you don’t know how to turn it  off when you really are safe. The treatment will help you learn  some skills for controlling your body’s alarm reactions without  slipping up and using alcohol to try to turn off the alarm.

Such empathic and practical psychoeducation can motivate  the client to engage in treatment by giving the client a new  way to think of her or his PTSD and SUD symptoms, which  has immediate practical relevance and resonates with clients’  personal experiences and goals. The assessor can also discuss  how urges to use substances may stem, in part, from an internal  response to turn down the brain’s inner alarm system. 

In  addition,  as  a  result  of  chronic  SUD,  many  individu- als with extensive trauma histories are not able to gauge the  severity of their PTSD symptoms and, thus, may unintention- ally under- or overreport PTSD symptoms. Education about  PTSD and SUD in the screening process can facilitate a more  accurate identification and estimation of PTSD symptoms. If  this appears to be the case, the assessor can explain that trying  to suppress or ignore emotional and bodily alarm reactions  such as anger or craving for substances is an understandable  attempt to cope with these reactions that provides short-term  relief (i.e., “helps you get through the day, or the night”) but  unfortunately makes the alarm reactions more frequent and  disruptive  in  the  long  run. The  assessor  can  then  ask  if  the  client has observed that feelings of being unsafe or angry or  being tempted to use substances can build up and become a  problem if they are ignored and not dealt with. The assessor  can then offer the client an encouraging new perspective by  explaining that the PTSD–SUD treatment is designed to teach  new skills for giving the client more control over the body’s  stress alarm system so that the client can escape this vicious  cycle of feeling distressed, avoiding or denying these alarm  signals, and then feeling worse in the long run. This approach  provides the client with an opening to disclose symptoms that  may initially have been denied or minimized and to engage  in treatment. 

Containment-focused screening. A thorough review of PTSD  and associated traumatic stress symptoms can be upsetting or  demoralizing for some clients. Screening does not automatically  involve obtaining a detailed trauma history. Many PTSD–SUD  clients do not feel ready to disclose more than small amounts  of  information  about  traumatic  experiences  until  they  have  established a trusting therapeutic alliance. In some cases, the  client may not be able to tolerate the intensity of his or her own  reactions to disclosing the details of terrible personal memo- ries. For other clients, this is merely a fairly rote recitation of  a familiar list of problems that they believe will never change.  Still other clients feel compelled to tell all, either to justify their  distress and their right to treatment or because they do not know  how to select manageable amounts of past memories. Screening  should not focus singularly on past traumatic events but on the  way in which stressful past experiences have interfered with  the client’s current relationships and life goals—and the way 

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in which treatment can help to enhance current relationships  and  achieve  life  goals. A  containment-focused  approach  to  screening demonstrates that it is possible to examine trauma  and addiction in a carefully structured and titrated manner, and  this can become a model for managing unwanted memories or  emotional distress. 

Prescreening: Safety planning and follow-up. Questioning  the client about past traumas, even when done with caution and  sensitivity, is stressful. Therefore, the first step in the screening  and assessment process should be the development of a safety  plan for the client. Safety planning is appropriate for any dis- cussion of traumatic past experiences, and it can be valuable to  help prepare clients for a screening or assessment interview. In  our experience, safety planning takes as little as 2 to 3 minutes,  and  it  is  a  useful  way  to  let  clients  know  that  their  difficult  experiences are heard with compassion and to begin to help  them attend to their own safety in healthy ways. The purpose of  safety planning is to begin to teach clients that it is possible to  enhance their own safety, especially if their lives have been or  still are unsafe in some ways as the result of trauma (Najavits,  2002). Safety planning is a skill that will be developed over  the course of treatment, not a one-time intervention applicable  only to an initial screening or assessment. The safety plan itself  should include a practical list of steps to follow should the client  become distressed after the screening or assessment interview  has concluded. (See Appendix for a sample client safety plan.)  The plan can include names and telephone numbers of support  persons, such as family members, friends, sponsors, or a trusted  therapist or case manager. It should also include the agency’s  telephone numbers for during and after business hours, and, if  possible, a specific contact person. Some clients find it helpful  to have a list of self-reported stress management strategies or  activities that they find relaxing or soothing on their safety plan.  Every safety plan should include simple directions on what to  do in a crisis, such as call a friend, therapist, sponsor, hotline,  or mobile crisis team or go to the nearest hospital emergency  department. The  plan  should  have  a  readable  list  of  names,  places, and telephone numbers because, in a crisis, people often  cannot recall such basics, especially if they are experiencing  PTSD symptoms. Safety planning should address the client’s  emotional  and  physical  safety,  including  distress  related  to  assessment  and  treatment,  but  should  also  take  into  account  objective danger related to domestic or community violence. 

Susan took safety planning a creative step further and  wrote  a  script  that  she  gave  to  the  mobile  crisis  team  at  the  agency  where  she  was  in  treatment. The  script  was  a  verbatim  statement  she  wanted  the  mobile  crisis  hotline  staff to read to her if she called them in a state of crisis,  and it included several key thoughts that she had formulated  based  on  what  she  was  learning  in  PTSD–SUD  therapy.  Susan came up with the idea of the script in a group session  devoted to safety planning and using the SOS skills to deal  with extreme alarm reactions such as feeling suicidal. She  wrote the script on her own and shared it with the group  members  and  leaders  by  reading  it  out  loud  as  a  part  of 

her  check-in  during  the  next  group  session.  The  mobile  crisis team was surprised, having never before had a client  script his or her response. Ultimately, the team was very  appreciative when they found that using the script was very  calming for Susan and actually helped to prevent hospital- izations on several occasions when she made crisis calls to  the team. In the past, virtually every hotline call by Susan  had led to involuntary hospitalizations because the crisis  team could not sufficiently help her modulate her intense  agitation and distress.

Stepwise screening and assessment.  Screening  leads  to  assessment in four sequential stages. Stages 2 and 3, although  helpful,  may  be  bypassed  or  postponed  when  time  and  re- sources are limited.

Stage 1 involves identifying PTSD symptoms from data  routinely gathered in assessment services (e.g., psychosocial  and  family  history  intake,  progress  monitoring).  However,  counselors  should  guard  against  both  false  positives  and  false  negatives  when  using  existing  clinical  data  in  PTSD  screening, for two reasons. First, there are no symptoms that  definitively indicate that a traumatic experience has occurred.  Many symptoms that appear to reflect PTSD may actually be  due to other disorders or current stressors. It is important for  the counselor to give careful consideration to other possible  diagnoses rather than to assume that stresslike symptoms are  always  due  to  PTSD.  Second,  many  traumatic  experiences  and PTSD symptoms are not disclosed by clients without the  counselor’s careful and sensitive interviewing to assist the cli- ent in recognizing trauma and PTSD. Many clients assume that  traumas and symptoms either are the norm or are too shameful  or stigmatizing to be divulged. Therefore, Stage 1 screening  involves the formulation of tentative clinical hypotheses about  trauma history and PTSD. Further structured diagnostic as- sessment is necessary for definite clinical conclusions.

In  Stage  2,  when  resources  and  time  permit,  a  brief  screening instrument can be used to identify potential past or  current traumatic experiences and PTSD symptoms. Several  brief validated questionnaires or interviews are available for  focused  trauma  screening  (see  http://www.ncptsd.va.gov/ ncmain/assessment/). The goal is to identify key events and  “traumagenic dynamics” (i.e., powerlessness, stigmatization,  sexualization, isolation; Browne & Finkelhor, 1986, p. 66),  as  well  as  the  PTSD–SUD  symptoms  that  most  interfere  with current functioning. At this stage, education about how  PTSD–SUD symptoms have made sense as adaptive survival  reactions but now must be managed to prevent interference  with daily living can bolster the client’s sense of safety and  engagement in treatment. It is important to conduct screen- ing for trauma history and PTSD symptoms in a gentle and  respectful manner, with very specific behaviorally anchored  descriptions of types of potentially traumatic experiences.

It  can  be  helpful  for  counselors  to  prepare  clients  for  Stage  2  screening  with  a  brief  introduction  during  which  clients are informed about the types of questions they will  be asked. For example, 

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Now I’d like to ask you about stressful experiences that may  have happened to you at any time in your life. All that I need  to know is if each type of experience ever happened to you,  if  it  was  very  upsetting  to  you  at  the  time  (because  not  all  stressful experiences are upsetting at the time they happen),  and how old you were when it happened. Please let me know  if you’d like to pause or stop at any time. 

It is also essential to give clients the option of declining to ac- knowledge or discuss any experience they do not feel ready or  able to disclose or of stopping the process altogether. Providers  must be prepared to sensitively validate clients’ often intense  feelings  evoked  by  disclosing  and  thinking  about  traumatic  experiences and to assist clients in managing these feelings and  reactions during and after the screening (e.g., by using a safety  plan protocol). Providers also should assist clients in limiting  the extent and detail of memory disclosures so that screening  is a therapeutic as opposed to an overwhelming experience for  clients. The goal of Stage 2 screening is not only to learn about  the client but to help the client begin to learn that she or he  can choose to recall and disclose a limited amount about past  traumas  (and  current  symptoms)  in  a  personally  meaningful  way, while managing the often intense feelings and reactions  that are triggered. Successful screening or assessment, thus, can  demonstrate to the client that, with therapeutic guidance, he or  she has the personal resources to deal with PTSD. 

Following an initial screening, Stage 3 involves a diagnostic  assessment of PTSD–SUD and co-occurring disorders (Read,  Bollinger,  &  Sharkansky,  2003).  PTSD  occurs  in  several  forms that may require different treatment strategies. If trauma  occurred within the past month, the individual may experi- ence PTSD symptoms complicated by acute stress reactions  in the form of an acute stress disorder that is distinct from  PTSD (American Psychiatric Association, 1994; see Ehlers  & Clarke, 2003, for treatment strategies). If PTSD symptoms  are not sufficient to constitute a PTSD diagnosis, they may  warrant  clinical  attention  as  subthreshold  PTSD  (Mylle  &  Maes, 2004). If co-occurring PTSD–SUD is complicated by  co-occurring psychiatric or personality disorders, treatment  must  address  symptoms  across  the  full  array  of  disorders  rather than just PTSD and SUD (Ford, 1999).

Finally,  Stage  4  involves  identifying  specific  traumatic  experiences  and  posttraumatic  stress  symptoms.  Trauma- specific assessment tends to be most helpful to clients, and  most complete and accurate, when it is done on an ongoing  basis. Treatment  and  other  services  can  build  in  periodic  assessments of relevant past experiences and reviews of the  clients’ current or recent symptoms. This can improve the  client’s  ability  to  recognize  and  manage  their  symptoms.  Brief questionnaires (see http://www.ncptsd.va.gov/ncmain/ assessment/) can be useful for monitoring change and fine- tuning ongoing services. Creative arts exercises such as the  lifeline (Ford & Russo, 2006, p. 347) can provide a vehicle  for safe and therapeutic disclosure of trauma memories in the  context of enhancing the client’s full set of life memories.

Treatment Services

Establishing the therapeutic frame. Before  or  during  the  screening and assessment process, client engagement is maxi- mized if an orientation is provided that describes the treatment  and reassures the client that he or she will not have to disclose  painful memories or situations. Orientation is particularly well  received when the presenters include clients who are actively  involved in or have completed the integrated treatment model.  Such peer mentors can speak to the personal fears and ques- tions that prospective clients have about PTSD treatment and  about the benefits of engaging in PTSD–SUD treatment. 

Individual counseling or case management. Although  it  can be difficult logistically, we recommend that each client  involved in PTSD–SUD treatment has a primary counselor,  clinician,  or  case  manager  guiding  their  PTSD–SUD  treat- ment and ensuring that this is complementary with all other  aspects  of  the  treatment  plan.  The  frequency  of  contacts  with a primary provider can be individualized and may vary  depending on the stage of treatment. For example, more fre- quent,  regular  individual  visits  or  telephone  check-ins  may  be  helpful  at  the  beginning  of  treatment  or  at  times  during  treatment when the client is experiencing intense symptoms.  The goal of individual counseling or case management is to  provide clients with enough therapeutic structure and support  to enable them to focus on recovery and life management in  an organized manner despite the interference caused by PTSD  and SUD (Ford et al., 2005).

Group treatment. Ideally,  PTSD–SUD  therapy  groups  will have coleaders in order to provide immediate back-up if  one leader is unable to attend or if one of the leaders needs  to assist a group member privately because of severe stress  or dissociative reactions (as illustrated previously by the case  of  Susan).  Clients  in  PTSD–SUD  treatment  occasionally  experience flashbacks, affective flooding, or suicidality in a  group session, and, although this is rare, when it occurs it is  essential that the group leader provides intensive one-to-one  intervention until the client has stabilized. Often this can be  done in the group setting, and, if so, the coleader can assist  other group members in managing their own strong feelings  while supporting the group member who is in crisis. In some  cases, it is best for one coleader to leave the group and assist  the client in a more private location while the other coleader  actively  helps  the  remaining  group  members  discuss  and  process their reactions and feelings about the crisis. 

If a formal coleader pairing is not possible, we have found  that it can be sufficient to designate another on-site clinician  or case manager to be on call during group sessions and to  be available to come into the group to assist in the event of a  crisis. If there is only one group leader, we recommend keep- ing the group size small (e.g., 4 to 5 clients). In addition to the  many obvious advantages of having coleaders involved in any  approach to group therapy, in PTSD–SUD groups, coleaders  also provide a level of safety and shared responsibility that  sets a positive example for clients who are in recovery from 

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PTSD and SUD and who, therefore, often tend to expect that  they must face life alone.

In most cases, PTSD–SUD groups should be gender spe- cific, at least in the initial phases of treatment. In our experi- ence,  female  clients  have  been  more  vocal  than  men  about  this,  but  the  principal  advantage  is  no  different  for  either  gender. Many trauma survivors have never (or only rarely or  intermittently)  had  the  opportunity  to  reflect  on  the  impact  that traumatic stress has had in their lives or the chance to give  and receive support with others of their gender. There are as  many differences as there are similarities among same-gender  trauma survivors, but a key similarity not shared with members  of the opposite sex is the impact that the trauma has had on  each person’s sense of self, whether that person is a woman  or  a  man.  Same-gender  groups  provide  an  opportunity  for  men as well as for women to experience counseling in ways  that  add  depth  and  richness  to  recovery  both  from  trauma  and addiction, which Williams (2005, p. 280) has described  as including “community building, self-determination, com- passion, and empowerment through interpersonal connection  as  key  modes  of  resistance  to  oppression.” Although  these  experiences  may  be  of  particular  importance  to  women  of  color, we have found that they can be life-transforming for  clients  of  all  backgrounds.  Clients  often  move  from  same- gender groups to mixed-gender groups with a greater sense  of self-confidence and readiness to engage in honest dialogue  after having benefited from their preliminary recovery work  in a gender-specific PTSD–SUD group. 

The gender of the group leaders also warrants careful con- sideration. The leader’s gender can symbolically evoke transfer- ence reactions and may also be an inadvertent reminder of past  traumas. This is most often seen in a situation in which there  are male leaders and female clients. However, it is interesting  to note that in the later developmental stages of some groups,  group members have requested opposite gender coleaders for  occasional sessions or on an ongoing basis in a new cycle of  the group. Such requests can be fruitfully discussed in group  sessions in order to help the clients decide if having a group  leader of the opposite gender is likely to help them to address  gender-related PTSD–SUD issues at this stage.

Here-and-now self-regulation focus. Prior  to,  or  instead  of, delving in great detail into specific traumatic memories  or situations, PTSD–SUD clients benefit from learning skills  that enhance their mastery of memory and emotion regulation  in their current lives. These skills can be applied to incidents  in  which  they  are  troubled  by  unwanted  trauma  memories  or PTSD symptoms. Focusing on helping clients make, and  successfully implement, self-enhancing choices when faced  with trauma’s unfinished emotional business (i.e., disrupted  memory; dysregulated emotions) in current stressful situations  is  consistent  with  all  meta-models  of  PTSD. As  previously  noted, we recommend reframing PTSD as a sensitization of  the self-protective bodily alarm system that requires regula- tion in current stressful experiences. This enables clients to  make connections between current stress reactions and past 

traumatic experiences while maintaining an adaptive here-and- now focus on current functioning, symptom management, and  personal goals. Using this approach, we have found that few  clients choose to tell their trauma memories at length. Instead,  they tend to disclose key portions of traumatic memories us- ing the self-regulation skill-set. The self-regulation skill-set  involves clients reorganizing their recollection with a focus  on their inner experience and the personal resources they were  able to access to survive at the time. 

When a client does disclose aspects of a trauma memory,  it is important for clinicians to guide the disclosure so that  the  client  safely,  consciously,  and  voluntarily  experiences  stress  reactions  in  the  present  moment.  This  is  in  contrast  to past experiences of these self-protective reactions, which  would have occurred largely without protection, awareness,  or  choice  during  or  after  traumas. We  have  found  that  this  type of therapeutic reexperiencing is best done with a focus  on  current  alarm  reactions  (rather  than  on  exploration  of  detailed memories) and with the client explicitly in control  of how much, how fast, and how deeply these reactions are  experienced. This process can be done in several ways. One  way is to help the client focus not only on the impact of the  traumatic experience but also on the core personal goals that  she or he was pursuing during times of trauma and that she  or he continues to pursue right up to the present. Another way  to control therapeutic reexperiencing is to regularly shift the  client’s frame of reference from past experiences to the im- pact that memories of these experiences have on the client’s  current life and functioning in order to retain a here-and-now  focus  as  a  counterbalance  to  the  tendency  for  people  with  PTSD  to  ruminate  about  or  feel  lost  in  trauma  memories.  The here-and-now focus also offers opportunities to shift the  therapeutic focus from the memory to what the client and the  counselor can do right now to help the client to manage and  channel her or his alarm reactions as they are occurring in the  counseling session. The goal is to help the client to experience  a better paced and focused exploration of what otherwise can  be overwhelmingly complex stress reactions. Another goal is  to safely use very specific self-regulation skills and to invest  memories  with  current  relevance  and  meaning,  rather  than  merely automatically regurgitating memory fragments without  a sense of control and meaning. 

When treatment is mandated. PTSD–SUD treatment may  occur in a context of SUD services that are legally mandated  and monitored. The requirements imposed on clients by the  legal system can be valuable tools to enforce behavior change  for  the  sake  of  the  client’s  and  society’s  safety.  However,  these mandates may also inadvertently replicate coercive or  punitive  aspects  of  the  client’s  past  traumatic  experiences  and  can  thereby  be  counterproductive  to  trauma  recovery.  In such cases, integrating PTSD–SUD services actually can  strengthen clients’ engagement by providing assistance with  stress reactions and emotion dysregulation that could other- wise contribute to legal problems. When a client must report  to probation officers, courts, or child protective services for 

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legal purposes of tracking and enforcing compliance, this of- ten exacerbates anxiety and reluctance to engage in treatment.  However, external mandates cannot be ignored because to do  so would collude with the client’s wish to be free from  ac- countability and with the punitive aspects of the legal system.  We have found that PTSD–SUD treatment is most successful  in providing skills that enable clients to achieve responsibility  and accountability if the provider is not in a dual relationship  of being both the counselor and the compliance monitor. Other  types of services, such as addiction education, may be more  appropriate  for  compliance  reporting.  If  PTSD–SUD  treat- ment provides a place for clients to examine their posttrau- matic dilemmas and develop the ability to respond effectively  to the here-and-now challenges posed by legal mandates, this  simultaneously supports the legal system’s objectives and the  client’s trauma recovery. 

Enhancing the creative process. Creativity and flexibility  are crucial to effective PTSD–SUD services and to evaluat- ing their success. Clients in recovery from PTSD often feel  powerless and, therefore, may develop nontraditional ways to  empower themselves within the group process. For example,  initially  during  the  group  sessions,  Susan  felt  best  able  to  talk if she could keep her back partially turned to the group.  Edward  spent  many  group  sessions  writing  in  a  personal  journal, which he said was not meant to show disrespect for  other  clients  or  the  group  leaders  but  because  this  helped  him  to  avoid  feeling  overwhelmed. Also,  Edward  often  got  up and walked around the room during the group sessions.  These  behaviors  would  be  frowned  on  in  traditional  group  settings and viewed as indicating a lack of involvement in the  process. However, we view these behaviors as self-protective  and as an opportunity for leaders to empathically help clients  to  become  more  aware  of  their  behavior  and  what  they  are  attempting to accomplish, such as managing stress reactions.  If a client’s feelings, thoughts, and goals in relation to these  behaviors  can  be  sensitively  discussed  and  clarified  in  the  therapeutic dialogue, rather than leading to disruption during  the group session, this fosters therapeutic awareness and group  cohesion. Similarly, the outcomes of PTSD–SUD treatment  are highly variable in form and timing. It is not good to set  the standard, explicitly or implicitly, that clients must report  reduced  distress  and  increased  self-efficacy  consistently  as  treatment proceeds. Instead, if leaders help clients track their  internal levels of reactivity (distress), efficacy (personal con- trol), and relapse risk (urges), it is important to consistently  emphasize that it is the act of responsible self-monitoring and  the use of good judgment in coping with stressors or distress that are more important than always feeling better or doing  well. Therefore, clients are encouraged to notice when self- check ratings reflect higher levels of distress or lower levels  of personal control, as well as improvement, in order to foster  the expectation that increases in distress and decreases in per- sonal control are to be expected and are not signs of failure.  Detecting early warning signs also provides an opportunity  for relapse prevention. As PTSD–SUD treatment proceeds, 

most clients gradually shift their self-ratings, both within and  across sessions, toward reduced distress and weaker urges to  use substances and toward greater self-efficacy—but this is  highly variable. Rather than setting the unattainable expecta- tion that all clients should change in a positive direction on  every outcome measure, it is best to help each client recognize  and develop ways to manage positive and negative fluctuations  throughout the recovery process.

Tangible transitional objects and learning generalizers. It  is axiomatic that PTSD–SUD treatment must be done in an  atmosphere of safety, nurturance, and respect for each person’s  unique experience and strengths. This can be done in several  tangible  ways.  For  example,  we  give  each  client  a  journal  with  personal  practice  worksheets  in  which  to  record  how  the FREEDOM skills are used outside the group setting. We  encourage clients to choose what they feel ready to share from  this journal in individual and group therapy. This provides an  implicit statement that each client’s emotions, thoughts, goals,  and observations are of importance and potentially helpful if  shared with others but are also the client’s private business.  We have also used laminated letters from the acronyms used  as  memory  aids  for  skills  sets  (e.g.,  FREEDOM),  so  that  clients have a colorful immediate reminder of the skills they  are learning. Having the treatment room and materials ready  ahead of time sets a tone of planful proactive organization.  These are good practices in any counseling process but are  especially useful when working with trauma survivors who  are  poised  to  react  to  small  changes  and  disruptions  with  hypervigilance.

Workforce and Organizational Development

Organizational or systematic “buy-in.” When  introducing  integrated  PTSD–SUD  treatment  into  an  agency  or  a  prac- tice group, key participants (e.g., colleagues, administrators)  must  be  committed  to  this  approach  to  treatment  from  the  outset. This requires taking the time to discuss concerns and  to actively seek input from everyone involved. It is critical to  know if anyone has had any negative experiences with trauma  treatment and, if so, to address their concerns immediately.  Moreover,  a  plan  should  be  established  to  ensure  that  such  past  negative  experiences  are  not  repeated  in  the  current  implementation of PTSD–SUD treatment. Open discussion  and  brainstorming  tend  to  enhance  buy-in  even  among  the  skeptical or wary, who often join in only when satisfied that  PTSD–SUD services not only are helpful to their clients but  also  do  not  cause  problems  or  increase  the  already  heavy  workloads of the staff.

Clinician personal buy-in. Integrated PTSD–SUD services  are most sustainable when clinicians are interested in doing  this type of work both professionally and personally. This does  not mean that only trauma survivors can provide PTSD–SUD  services. Health care providers who take seriously the frame  of reference of people who have experienced traumatic shock  and loss can be highly effective. Three qualities distinguish  effective PTSD–SUD clinicians. The first quality is genuine 

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respect  for  the  courage  and  resilience  of  trauma  survivors.  The  second  is  a  commitment  to  a  developmental  treatment  model  that  is  based  on  strengths,  regardless  of  theoretical  orientation. The third quality is openness to using skills and  concepts from PTSD–SUD treatment models along with those  from other psychotherapy, counseling, and health promotion  interventions. The least successful clinicians are those who  view  trauma  survivors  as  “disabled,”  troublesome,  overly  demanding or dependent, or in need of corrective education  (e.g., “borderlines”). Clinicians who accept only one treatment  philosophy or model as correct, or who simply are not commit- ted to PTSD–SUD treatment and are doing the work largely  for economic reasons or because of professional necessity or  convenience, are also unlikely to be effective. 

Blended rather than compartmentalized treatment menus. PTSD–SUD services are not necessarily the best modality for  a given client at any particular point in her or his treatment  and  recovery,  even  if  PTSD  is  a  key  issue  for  that  client.  Trauma recovery takes many forms and can occur in many  types  of  treatment.  Therefore,  we  recommend  establishing  PTSD–SUD treatment as one item in a menu of recovery ser- vices and encouraging clients and clinicians to consider how  other complementary services may equally or better address a  client’s recovery goals and stage of change. Also, PTSD–SUD  concepts and skills can be infused into many other services  (e.g., relapse prevention; stress, pain, or anger management;  social/leisure  skills;  art  therapy;  body  therapy)  rather  than  used as a completely separate treatment regimen.

Training.  Not  only  clinicians  but  also  case  managers,  social services providers, health care providers, clergy, and  support staff should receive training in integrated PTSD–SUD  services. All of these individuals have valuable informal inter- actions with clients that can support or detract from the treat- ment model, depending on whether they are knowledgeable  about and invested in PTSD–SUD treatment. Such training  can  familiarize  every  staff  member  with  key  concepts  and  skills and enable them to apply relevant portions to their own  stress  experiences.  This  approach  also  conveys  the  crucial  message that every helper is a valued professional colleague.  Clinicians  who  specialize  in  PTSD–SUD  treatment  should  also  be  included  because  they  often  discover  that  they  can  adapt elements of the integrated treatment model within the  groups  or  other  services  they  provide.  Inclusiveness  also  supports truly multidisciplinary services, takes the mystery  out  of  trauma  work,  and  amplifies  the  support  given  to  the  clients and clinicians who are involved in specific PTSD–SUD  treatment services.

It  is  very  important  that  treatment  for  PTSD–SUD  not  be done on an ad hoc basis without the treatment providers  receiving adequate training and consultation. However, it is  equally  important  to  help  providers  who  are  not  specialists  in PTSD treatment to learn about PTSD–SUD concepts and  tools and to incorporate them into their practice—especially  if they treat clients who are involved in formal PTSD–SUD  treatment. If only certain providers are authorized to assist cli-

ents with trauma-related issues or to use the treatment model,  both clients and staff can come to view PTSD treatment as  a  separate  domain  apart  from  other  services. This  artificial  split also leaves openings for staff to use other PTSD treat- ment  models  or  their  own  idiosyncratic  methods  for  doing  trauma work in ways that set up a false competition between  the approaches. An inclusive approach provides a forum for  clinicians to discuss views about PTSD–SUD treatment and  its pros and cons, rather than avoiding it. 

Ongoing consultation.  Clinical  consultation  groups  for  staff members are essential because training alone does not  lead to sustained changes in counseling practice. Often, clini- cians attend training, become excited about it, but then lose  enthusiasm because lack of time, peer support, and admin- istrative buy-in make it difficult to implement new services.  Clinical  consultation  ideally  occurs  on  a  weekly  basis  in  a  group setting that encourages both the primary PTSD–SUD  staff and other interested staff to discuss treatment issues. If  the focus is on the challenges immediately facing counselors  with their current clients and groups, PTSD–SUD treatment  concepts,  skills,  and  techniques  can  support  constructive  clinical  problem  solving  and  mutual  peer  support  among  staff. Having a regular time and place to step back from the  pressures  of  providing  services  to  highly  stressed  clients  while working in demanding organizations sets a model for  staff self-care and reflective processing that is professionally  and personally rejuvenating. We have found that the optimal  combination is that of an external expert facilitator, who is a  skilled clinical consultant and knowledgeable in the applica- tion of the treatment model, and an internal local champion,  who serves as the leader in the agency for the treatment model  and the staff using it. 

However,  depending  on  how  they  are  actually  conducted,  consultation groups can be inclusive or divisive and can sup- port or detract from the personal well-being and professional  development of participating counselors. The potential down- side occurs if a consultation group is set up to involve only a  few select staff members who can come to view themselves  as the only trauma experts in an agency. The second potential  pitfall in consultation groups is to focus mainly on technical  or administrative discussions of case management. The staff  then miss the valuable opportunity to debrief with other clini- cians, gain support, and engage in personal and professional  self-reflection and self-care. In our experience, the best way to  prevent or reduce the potential negative effects of conducting  PTSD treatment (e.g., burnout, vicarious traumatization) is to  provide an open forum through ongoing consultation groups in  which counselors can discuss personal reactions and dilemmas  raised by providing services as well as professional, technical,  or operational issues. 

Ideally, the skills and process for trauma recovery taught  in the treatment model will be mirrored in the facilitation of  the clinical consultation group. If this parallel process occurs,  participating counselors gain an understanding of and develop  constructive  ways  to  address  their  own  stress  reactions  in 

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the  consultation  group  discussion. This  does  not  mean  that  counselors can or should “do therapy” with one another or that  the consultation group facilitator(s) should treat participants  as if they were clients receiving personal therapy. Instead, by  staying within the boundaries of respectful interprofessional  relationships,  consultation  group  participants  can  examine  their  own  reactions  using  the  framework  provided  by  the  treatment model as a guide. Staff can also work together to  develop creative approaches to addressing clinical challenges  and to ensuring their own personal self-care.

Vicarious traumatization (VT). Also referred to as “second- ary traumatization” or “compassion fatigue,” VT refers to the  emotional impact counselors experience from clients’ intense  traumatic  stress  reactions  (Trippany,  Kress,  &  Wilcoxon,  2004). VT is intensified if PTSD counseling involves detailed  trauma  memory  disclosure—this  is  an  additional  reason  for  considering adopting a here-and-now rather than a there-and- then approach to PTSD–SUD counseling. VT may be related  to the clinician’s degree of sympathy for client suffering, yet  empathic attunement does not appear related to VT. Empathy,  the ability to take another person’s internal frame of reference  seriously, involves personal and professional boundaries that  do not prevent a clinician from feeling the impact of client suf- fering but do help the clinician reflect on and work through that  impact, rather than just absorbing it as inchoate distress (Kohut  & Wolf, 1978). On the other hand, sympathy, while laudable  and probably inevitable unless the clinician is overly detached  (which, paradoxically, can result from excess sympathy), in- volves  excessively  permeable  emotional  boundaries  that  can  lead to overidentification or enmeshment with clients. In our  experience,  sustained  empathy  requires  reflective  processing  and  open  dialogue  with  peers.  Empathy  may  protect  against  extreme VT, but it is not an antidote for VT. Intense sympathy  (e.g., feeling a need to rescue a client) may intensify VT and is  best addressed by regaining an empathic balance of involvement  and separateness in relation to clients and clinical work.

VT  is  more  likely  to  occur  and  to  be  heightened  if  a  clinician’s personal issues are activated (affectively or sym- bolically) by clients’ current suffering or traumatic memories.  Working through personal issues is the responsibility of every  helping professional, as is deciding when it is necessary to  place limits on the amount or type of therapeutic work being  done  for  the  sake  of  the  clinician’s  self-care  and  the  well- being of clients. We have found that VT is minimized when  agencies and clinicians carefully apply their PTSD treatment  model’s core principles to themselves. For example, the agency  whose  administrators  support  a  thorough  organizational  self-examination on a regular basis to maintain a genuinely  trauma-informed and growth-oriented milieu, for staff as well  as for clients (Harris & Fallot, 2001), is likely to maximize  clinical effectiveness of the staff. 

Conclusion Integrated PTSD–SUD treatment requires a shift from ask- ing “whether” to treat to asking “how best” to treat PTSD in 

an effective and integrated manner with clients in recovery  from SUD. The principal pitfall, therefore, is not choosing the  wrong integrated PTSD–SUD treatment model or technical  approach. Each evolving model has strengths and limitations  that  can  be  considered  in  developing  an  approach  that  best  suits one’s clients, milieu, and approach (Ford et al., 2005).  Equally  or  more  important  than  specific  PTSD–SUD  treat- ment  models  is  the  development  of  practice  guidelines  for  PTSD–SUD  treatment  that  reflect  the  scientific  literature  and clinicians’ practical knowledge and experience (Westen,  Novotny, & Thompson-Brenner, 2004) as well as the diverse  types  and  levels  of  organizational  and  workforce  readiness  to undertake and sustain a paradigm shift (Simpson, 2002).  This article is an attempt to contribute to the paradigm shift  that  is  occurring  in  the  mental  health  and  substance  abuse  counseling  fields  (Harris  &  Fallot,  2001)  by  outlining  key  issues  that  counselors,  administrators,  and  researchers  face  as  they  contemplate  or  engage  in  a  shift  to  an  integrated  PTSD–SUD treatment.

We  believe  that  the  principal  pitfall  is  to  provide  PTSD  treatment  without  addressing  addiction  recovery  or  SUD  treatment without addressing trauma recovery. Blending these  treatment  agendas  is  a  complex  but  attainable  goal  that  will  require  careful  planning  and  evaluation  simultaneously  per- formed by individual practitioners, by treatment agencies and  organizations,  and  by  the  counseling  field  at  large. We  have  not addressed the fiscal or political issues that are involved in  the transfer of science and technology to the field (Simpson,  2002) but have focused instead on describing a conceptual and  clinical paradigm that we hope can be a model not only for the  practitioner and the agency but also for the larger behavioral  health systems in which PTSD–SUD treatment can be provided  in an integrated manner. 

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APPENDIX

Sample Client Safety Plan

Personal Safety Plan

It is natural that during times of extreme stress, we all need support. Having people available to talk to about our feelings and needs can help. Here are some steps to help you feel safe and be safe.

Step 1: ➢ Talk with a support person with whom you feel safe.

Names of Support Persons Telephone Numbers

Step 2: ➢ Do something right now that gives you a feeling of safety and enjoyment.

Activities or Programs You Can Get Involved With First Step to Start the Activity

Step 3: ➢ If you feel you need more help, contact your therapist, case manager, or treatment team.

Names of therapist, case manager, treatment team members Telephone Numbers

Step 4: ➢ If you need help right away and can’t contact a therapist or case manager, you can call the Mobile Crisis Team 24-hours a

day, 7-days-a-week to talk or have them come help you.

Mobile Crisis Team (860� XXX-YYYY

I agree to use this guide, to the best of my ability, to keep myself safe and to build the life I want.

Participant’s signature Witness Date

Other Resources to Learn More About Healthy Recovery: ➢ To learn more about trauma, contact The Connecticut Trauma Coalition 1-800-XXX-YYYY or visit a Trauma Internet Web site��

http��//www.trauma-pages.com/index.htm ➢ To learn more about addiction and trauma recovery, visit the Connecticut Clearinghouse Web site��

http��//www.ctclearinghouse.org

Journal of Counseling & Development  ■  Fall 2007  ■  Volume 85490

Ford, Russo, & Mallon

Test to Earn CE Credit  Please  complete  the  following  test  and  send  your  answers  (with  payment)  to  the  address  listed  in  the  form  below.  Note: Correctly completing 3 of 3 test questions earns 1 continuing education contact hour.

Integrating Treatment of Posttraumatic Stress Disorder and Substance Use Disorder (JCD, Volume 85, Number 4, Fall 2007�

Return your completed test, form, and payment (with check or money order made payable to American Counseling Association) to: Professional Learning/JCD, American Counseling Association, 5999 Stevenson Avenue, Alexandria, VA 22304 For further assistance, please contact Debbie Beales at 800-347-6647, x306, or [email protected] 

Examination Questions  1.  One hypothesis advanced by the authors to explain why 

posttraumatic stress disorder (PTSD) and substance  use disorder (SUD) can co-occur suggests that SUD  results  from  attempts  by  people  with  PTSD  to  use  substances to cope with PTSD symptoms.

   a.  True    b.  False

 2.  In  the  integrated  approach,  which  of  the  following  outcomes  can  be  achieved  if  treatment  is  provided  during  the  transitional  period  beginning  soon  after  discharge from inpatient SUD treatment and during  the long-term recovery period?

   a.  Reduction in immediate risk of SUD relapse    b.  Reduction in long-term risk of SUD relapse    c.  Reduction in not only immediate, but also long- 

    term risk of SUD relapse    d.  No effect on SUD relapse

 3.  Vicarious traumatization, as discussed in this profes- sional article, can best be defined as:

   a.  The emotional dilemmas experienced by family       and  friends  of  clients  engaged  in  PTSD-SUD       treatment

   b.  Client reactions when there is an imbalance in       PTSD and SUD treatments

   c.  The  emotional  impact  counselors  experience       from clients’ intense traumatic stress reactions

   d.  None of the above

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