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Integrating treatment of posttraumatic stress disorder and substance use disorder.

Historically, administrators and clinicians have been hesitant to address posttraumatic stress disorder (PTSD) in the treatment of substance use disorders (SUDs). However, a growing body of research literature provides support for integrating PTSD and SUD treatment. PTSD is prevalent among individuals 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 cocaine) 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 associated 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 comorbid 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 substantially 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 (Chilcoat & 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) 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 illicitly 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 SLID 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, SLID 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 survivors 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 addressing 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-occurring 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 relapse 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 empirically 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 development 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 lessons 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 summarized 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 collage, 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. Throughout, 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.

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 fights (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 progressed 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 addressing 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 becoming 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 preoccupied 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 because 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 manage and even gain control over the unwanted trauma memories that are core symptoms of PTSD. Skills for managing PTSD 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 intrusive 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 addressing 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 spontaneous 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 pinpoint 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 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 escalation 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 empathically 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 addressing 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 biologically 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 helplessness (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 coping 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 attachments (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 (particularly 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., 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 adjustment 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 understanding 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, overwhelmingly painful, and, at times, frustratingly elusive. Therefore, 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 counseling 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 experienced 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 SLID. Although 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 intense rage, grief, fear, despair, guilt, and shame, as well as profound 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 adolescence. 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 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 structured 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 emotional self-regulation, we next suggest best practices guidelines 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 individuals with extensive trauma histories are not able to gauge the severity of their PTSD symptoms and, thus, may unintentionally 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 memories. 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 fight 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 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 discussion 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 hospitalizations 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 resources 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 client 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 assessment 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 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 screening 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,
   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 acknowledge 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 experience 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 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 maximized 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 questions 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 treatment 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 frequent, 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 keeping 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 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 specific, at least in the initial phases of treatment. In our experience, 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, compassion, 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 consideration. The leader's gender can symbolically evoke transference 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 recta-models of PTSD. As previously noted, we recommend reframing PTSD as a sensitization of the self-protective bodily alarm system that requires regulation 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 using 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 fight 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 impact 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 otherwise contribute to legal problems. When a client must report to probation officers, courts, or child protective services for legal purposes of tracking and enforcing compliance, this often 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 accountability 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 treatment provides a place for clients to examine their posttraumatic 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 evaluating 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 control), 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 personal 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 expectation 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 practice 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 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 committed 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 services 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 interactions with clients that can support or detract from the treatment 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 clients 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 treatment 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, clinicians attend training, become excited about it, but then lose enthusiasm because lack of time, peer support, and administrative 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 application 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 support or detract from the personal well-being and professional development of participating counselors. The potential downside 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 clinicians, 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 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 "secondary 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 suffering 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), involves 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 symbolically) 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.


Integrated PTSD-SUD treatment requires a shift from asking "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 treatment 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 performed 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.


Sample Client Safety Plan



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Julian D. Ford, Department of Psychiatry, University of Connecticut School of Medicine; Eileen M. Russo, private practice, Waterbury, 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:
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Title Annotation:Assessment & Diagnosis
Author:Ford, Julian D.; Russo, Eileen M.; Mallon, Sharon D.
Publication:Journal of Counseling and Development
Article Type:Case study
Geographic Code:1USA
Date:Sep 22, 2007
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