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Individuals can get help for alcohol use and PTSD at the same time: A movement toward integrated treatment approaches

The following article was recently published on the research page of the Recovery Research Institute website. The study indicates that individuals with post-traumatic stress disorder (PTSD) are at increased risk of having co-occurring alcohol use disorder. However, it is not known whether the first-line treatment for PTSD (i.e., prolonged exposure therapy) is also effective in reducing problematic drinking. This study replicated prior findings suggesting prolonged exposure therapy is superior in treating PTSD symptoms, but was not more effective in reducing heavy drinking days than an intervention intended primarily to increase coping skills. However, findings from this study do challenge the notion that alcohol use disorder may be a barrier to receiving gold-standard treatment for PTSD. 

WHAT PROBLEM DOES THIS STUDY ADDRESS?

Individuals with PTSD are more likely to have an alcohol use disorder than individuals in the general population. One representative survey of adults in the United States found individuals with PTSD were 1.2 times as likely to have an alcohol use disorder in their lifetime than those without PTSDPTSD is also associated with a more problematic course of alcohol useincluding greater difficulty quitting, briefer abstinence periods, and more associated medical, legal, and psychological consequences. These disparities in alcohol use outcomes in individuals with PTSD underscore the need to identify treatments that are effective in treating both symptoms of PTSD as well as problematic alcohol use. To address this need, Norman and colleagues studied the immediate, 3-month, and 6-month outcomes among 119 adult veterans with co-occurring PTSD and alcohol use disorder who received one of two competing treatment approaches. The table below outlines key components of each treatment approach. The first treatment, called Concurrent Treatment for PTSD and Substance Use Disorder Using Prolonged Exposure, or “COPE,” was integrated with prolonged exposure therapy that involves 1) helping individuals gradually approach trauma-related memories, feelings, and situations, and 2) relapse prevention for alcohol use disorder using cognitive and behavioral therapeutic techniques. The second tested treatment, called Seeking Safety (an empirically-supported treatment for co-occurring PTSD and substance use disorder), was a present-focused coping intervention that aimed to teach individuals skills to cope with both symptoms of PTSD and alcohol use disorder. The ultimate goal of this research study was to determine which treatment modality was most effective in supporting the recovery of individuals living with both PTSD and alcohol use disorder. 

Figure 1. Chart comparing the features of both the COPE and Seeking Safety treatment approaches, including general timeframe of treatment, and specific therapy techniques.

HOW WAS THIS STUDY CONDUCTED?

Study authors examined 119 adult veterans (90% male, average age of 41 years, 66% White) with current symptoms of PTSD who were receiving care at the San Diego Department of Veterans Affairs (VA). While individuals were encouraged to avoid other treatment for their PTSD, they were able to receive standard mental health treatment at the VA while participating in this study. For example, 65% were taking psychotropic medication during the study. Participants also needed to have current alcohol use disorder, at least 20 days of heavy alcohol use (see below for heavy drinking definition) in the past three months, and a stated desire to quit or cut back on alcohol use. Participants were randomly assigned to receive either 12-16 90-minute sessions of COPE (i.e., integrated prolonged exposure therapy) or Seeking Safety (i.e., coping skills–focused therapy). Sessions were administered preferably once to twice per week on consecutive weeks, but could span across a 6-month period of time. 

Participants completed assessments of PTSD symptoms and problematic drinking behavior after treatment and at 3- and 6-months posttreatment, and these assessments were administered by study staff who were not aware of (i.e., “blinded” to) the treatment received.The Clinician Administered PTSD Scale for DSM-5 (CAPS-5) was the primary measure used to quantify PTSD symptoms and diagnosis, with scores >=12 suggestive of a PTSD diagnosis (range: 0-80). Frequency and quantity of alcohol use were ascertained via a calendar-based interview (i.e., Timeline Follow-Back), which was used to deduce A) the percent of heavy drinking days defined as the number of days in which 5 or more drinks for men or 4 or more drinks for women were consumed since the last assessment, and B) percent days abstinent for alcohol. A breathalyzer was administered to any participant who appeared intoxicated. 

WHAT DID THIS STUDY FIND?

PTSD symptoms declined more in veterans who received integrated prolonged exposure therapy compared to the present-focused coping intervention.

PTSD symptoms improved over time regardless of therapy assignment; however, the COPE group improved more than did the Seeking Safety group. Immediately after treatment, over 20% of individuals went from having a PTSD diagnosis to no longer meeting criteria for the condition (“remission”), compared to only 7% in the present-focused coping intervention. The advantage for the COPE group became slightly weakened over time but was nevertheless maintained; the greater PTSD symptom gains for the COPE group were still present 6 months after completing treatment.

Figure 2.

Drinking outcomes improved similarly across treatment groups.

All participants showed reductions in the percent of heavy drinking days over time, though the extent of decrease was similar in those who received integrated prolonged exposure and the present-focused coping intervention. Findings were similar – both groups displayed similarly improved drinking – when the outcome was percent days abstinent as well.

Figure 3.

Figure 4.

WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

This study is responsive to the urgent need to identify treatments that are effective in mitigating both symptoms of PTSD and alcohol use disorder, the co-occurrence of which is both highly common and linked with greater negative outcomes compared to either disorder alone. Findings from this study build upon a robust literature suggesting that prolonged exposure therapy is the gold standard for mitigating PTSD symptoms. Importantly, this study demonstrates that prolonged exposure therapy is effective even among individuals with an active alcohol use disorder. This study, plus a growing body of literature, challenges a commonly held belief that individuals with alcohol use disorder cannot tolerate exposure-based approaches, addressing the notion of alcohol use disorder as a potential barrier to receiving widely–supported, evidence–based therapy for PTSD.

Contrary to the authors’ hypotheses, however, prolonged exposure therapy was no more effective in reducing problematic alcohol use than the present-focused coping intervention. The fact that this PTSD reduction benefit did not translate into lower problematic alcohol use suggests that, whereas some PTSD patients may have initially drunk (and still drink) alcohol to help “medicate” the distress caused by PTSD, for many others, the alcohol use may persist fairly independently of PTSD. Although group differences were not found with regard to drinking use, it is notable that both groups showed significant reductions in drinking over time, suggesting that simultaneous treatment for alcohol use disorder can be integrated into the framework of PTSD treatment without interfering with the treatment of PTSD itself. Future studies are needed to determine which PTSD treatment modalities may have the most beneficial impact on drinking behaviors. Some findings from other groups provide promising preliminary support for approaches that involve teaching individuals to challenge and modify maladaptive beliefs (cognitive processing therapy and cognitive behavioral therapy) and guided eye movements with the goal of diminishing negative feelings associated with traumatic events (eye movement desensitization and reprocessing therapy).LIMITATIONS

BOTTOM LINE

  • For individuals and families seeking recoveryThis study demonstrated that the simultaneous attention to both PTSD symptoms and alcohol use disorder is possible, and attention to both disorders in an integrated treatment approach is linked with improved functioning. Therefore, patients with both conditions should feel empowered to have both PTSD symptoms and problematic drinking behavior as treatment targets that can be addressed in tandem rather than in parallel. This is comparable to other studies that find integrated approaches to be successful in cases of co-occurring substance use and other neuropsychiatric disorders such as depression and ADHD
  • For treatment professionals and treatment systemsPatients with PTSD and alcohol use disorder benefitted from integrated treatment approaches. Findings suggest that individuals with comorbid PTSD and alcohol use disorder should not be excluded from receiving front-line PTSD treatment on account of their untreated alcohol use. Rather, alcohol use should be identified as a core treatment target and addressed in tandem with PTSD. Further work is needed, though, to determine the most effective treatment modality for addressing problematic alcohol use in the context of PTSD.  
  • For scientists: Findings point to the efficacy of prolonged exposure therapy, even in the presence of co-occurring alcohol use, in mitigating symptoms of PTSD. While findings suggest a reduction in heavy drinking days, this effect was not specific to the therapeutic approach of prolonged exposure therapy. This finding does not align with “self-medication” as a maintaining condition for alcohol use disorder, at least for some. While more work is needed to determine the most effective approach for reducing alcohol use among PTSD patients, this study represents an important first step in decreasing barriers to access to empirically-validated and integrated treatments. Additionally, while prolonged exposure therapy is commonly viewed as a gold standard approach for trauma treatment, retention particularly in real-world settings is often low. Co-occurring substance use has been found to be one patient factor robustly associated with dropout. Therefore, future studies aimed at enhancing engagement and retention, especially among patients with co-occurring disorders, is critical for the widespread dissemination of this approach. 
  • For policy makersFindings lend preliminary support for the efficacy of integrated treatment approaches, which runs contrary to the outdated, yet still pervasively present notion, that substance use disorders need to be fully remitted prior to the treatment of co-occurring other mental health concerns (e.g., PTSD, depression, anxiety disorders). Integrated treatment approaches that allow for substance use disorders and other mental health disorders to be addressed simultaneously will undoubtedly decrease barriers to treatment access for the large proportion of patients seeking recovery from multiple conditions. Therefore, it is imperative that clinician trainees and all patient-facing staff in mental health facilities receive proper education and training in issues related to substance use disorders. Such training may involve early identification of problematic substance use and management of acute signs of overdose. Additionally, as demonstrated in this study, it remains unknown which integrated treatments are optimally effective in treating substance use disorders in the context of PTSD and other co-occurring mental health conditions. Therefore, the field would benefit from continued funding to support research on novel treatment development and evaluation.  

CITATIONS

Norman, S. B., Trim, R., Haller, M., Davis, B. C., Myers, U. S., . . . Mayes, T. (2019). Efficacy of integrated exposure therapy vs integrated coping skills therapy for comorbid posttraumatic stress disorder and alcohol use disorder: A randomized clinical trial. JAMA Psychiatry, (Epub ahead of print). doi: 10.1001/jamapsychiatry.2019.0638 

The Council on Recovery is the leader in providing a wide range of prevention and education resources aimed reducing alcohol use, especially among adolescents and young adults. We also offer therapeutic counseling and an intensive outpatient treatment program (IOP) for those affected by alcoholism. For more information, please call 713-942-4100 or contact us online.

The Lifelong Quest For Sobriety…The Ultimate Hero’s Journey—Part 59

Guest Blogger and long-time Council friend, Bob W. presents Part 59 of a series dealing with Alcoholism and Addiction from a Mystical, Mythological Perspective, reflecting Bob’s scholarly work as a Ph.D. in mythological studies.

For those of us who have achieved a certain level of committed sobriety, i.e., multiple years of living and working actively in the Fellowships of AA and its sister programs, we begin to find ourselves moving into a realm of peace and serenity that seems other worldly. We still must face the normal struggles of life and we experience crises and trauma with friends and family that challenge our sense of presence, but there is a growing calm in all of it.  We have learned that staying in the here and now of today, avoiding the tendency to obsess about outcomes, gives us an inner peace and a power to face the world with grace and resolution.

The journey to this state, for each of us, was as mythic as all the great stories of literature and history. At the depths of our bottoms, we may have felt like Edmund Dantes in the dungeons of Chateau d’If, in The Count of Monte Cristo…alone, cold and dissolute in the deep recesses of that dreaded island prison in the Bay of Marseilles.  The feeling of hopelessness, doom and isolation was overwhelming.  As in the story, fellows like Abbe Faria, a fellow prisoner for Dantes, may have given us a process to begin the journey of relief.  Also like Dantes, the journey may have been long; our own “rocketing into the Fourth Dimension” may have progressed much less like a rocket than a speed akin to the Lexington Avenue Local.

The working of the Steps, the constant renewal of self-examination, a continual reinforcement of the focus on a Higher Power, and an untiring commitment to service elevate our personal psyches to an unusual extent.  We begin to feel, slowly and purposefully, a deep need to focus on service, service to all things and to all people, service that is an unflinching, almost unconscious, process attending each and everyone one of our daily waking moments.

I have come to see this evolving state of consciousness to be an unusual spiritual presence, one that speaks to a new and enlightened way of being in the world, for all of us, individually and collectively.  To have come from those terribly dark and hopeless places of our disease, to work along a journey of love and commitment, to and from our fellows in the programs, in our journey to sobriety, and then to arrive at a point where uncompromising and selfless service becomes the primary focus of our lives, is truly mythic…and maybe it is so deeply mythic that it begins to defy imagination.

Our alcoholism may have provided us with a “dark portal” to a life that will take generations for all of us to fully understand.

As Addiction Boils Over, Expert Advice for Saving Your Kids’ Lives

The opioid epidemic is boiling over. Addiction, including alcoholism, is killing hundreds of thousands and destroying millions of lives. Especially tragic is addiction’s ravaging effects on teenagers and young adults. Their developing brains are being chemically altered by drugs and alcohol. That’s creating a whole new generation who will suffer from addiction. Many will die. Parents everywhere are looking for solutions to save their kids. They are desperately seeking an understanding of how and why addiction occurs. But more importantly, what can be done right now to save their children’s lives? We take you inside the problem and shine light on immediate and effective solutions. We talk with Lori Fiester, a highly-regarded clinical therapist and well-known mental health and addiction expert. She has helped thousands through her knowledge, compassion, and commitment in the field of recovery. By the end of this podcast, you will have the information, ideas, and inspiration you need to help save the lives of people you love….Or maybe your own.

Council Podcast Launched!

The Council on Recovery Podcast with Howard Lester

The Council on Recovery Podcast, with host Howard Lester, explores the diseases of alcoholism, drug abuse, other addictions, and co-occurring mental health disorders by looking at prevention, education, treatment, and recovery. Through deep and meaningful interviews, we cover every point of view by talking with doctors, educators, researchers, therapists, judges, policymakers, clergy, law enforcement, rehab and mental health professionals, the media, and most importantly, people in recovery.  This long-needed approach brings everyone together for frank discussion of the problems and the sharing of realistic, viable solutions that inspire optimism and hope.

Episode 1 | One Father’s Nightmare: His Daughter’s Life-and-Death Struggle with Addiction

Howard interviews Bob C. who shares his extraordinary story of a father’s incredible efforts to save his daughter’s life during her 15 year odyssey with drug addiction and mental illness. At times, he thought he’d lost her. But he also realized that desperately trying to save his daughter might just kill him. With other family tragedies swirling around him at the same time, he somehow found the solutions for staying alive and helping his daughter survive. One man’s quest for the answers that parents all over are searching for.

Episode 2 | Unspoken Legacy: Claudia Black on the Destructive Impact of Trauma and Addiction within the Family

Howard’s sits down with Dr. Claudia Black, a senior fellow at Meadows Behavioral Healthcare. Claudia is a Ph.D. in Social Psychology who is internationally known and respected for her pioneering and contemporary work with family systems and addictive disorders. Claudia’s cutting-edge work was instrumental in creating the solid foundation for the entire field of codependency. Since the mid-1970s, she’s been a passionate leader in the field of addiction and has helped the world gain a greater understanding of the impact of family trauma and its connection with addiction. Claudia designs and presents training workshops and seminars to professional audiences in the field of family service, mental health, and addictive disorders. She has authored fifteen books, most notably Intimate Treason, It Will Never Happen to Me, and her latest, Unspoken Legacy. Claudia is also Clinical Architect for the Claudia Black Young Adult Center at The Meadows Treatment Center in Arizona.

Subscribe & Download Our Podcasts Today

There are many ways to download and subscribe to The Council on Recovery Podcast, including at Apple Podcasts, Android, Google Podcasts, Stitcher, or wherever you get your podcasts. For more information about how to subscribe and download, please just visit the Podcast page of our website.

Unspoken Legacy: Claudia Black on the Destructive Impact of Trauma and Addiction within the Family

Dr. Claudia Black, one of the world’s leading experts on family systems and addiction, reveals the startling connection between the psychological injuries experienced in childhood and the long-term trauma and addictive disorders that are destroying families everywhere. In this in-depth interview, Dr. Black discusses how trauma and addiction literally change the brain, and why the unspoken effects of these conditions can reverberate for generations, uprooting family trees and perpetuating both shame and denial. But, recovery from trauma and addiction is possible, and Dr. Black illuminates a simple, yet powerful and effective process for both healing and creating a new narrative for living. This podcast coincides with the release of Claudia Black’s 16th book, ‘Unspoken Legacy’, a far-ranging examination of how the combination of addiction and trauma causes family dysfunction and why it’s one of the most potent negative forces in people’s lives. Filled with vignettes highlighting the various causes of trauma, ‘Unspoken Legacy’ helps readers understand the physiology and psychology of trauma and how it intersects with addition. The second half of the book covers the vital process for self-examination, and gives readers proactive steps for healing, recovery, and building healthier relationships.

The Lifelong Quest For Sobriety…The Ultimate Hero’s Journey—Part 58

Guest Blogger and long-time Council friend, Bob W. presents Part 58 of a series dealing with Alcoholism and Addiction from a Mystical, Mythological Perspective, reflecting Bob’s scholarly work as a Ph.D. in mythological studies.

In 1861, at the outset of the Civil War, poetess Julia Ward Howe penned the lyrics to The Battle Hymn of the Republic, to the tune of the earlier work, John Brown’s Body. Both were part of the Abolitionist movement, which had been trying for past decades to bring an end to Slavery in America. The initial stanza to Howe’s rendition is as follows:

Mine eyes have seen the Glory of the coming of the Lord.

He is trampling out the Vintage where the Grapes of Wrath are stored.

He has loosed the fateful Lightening of his terrible swift Sword.

His Truth is marching on…

In my view, the idea of the “grapes of wrath” in this song could be seen as the need for retribution against the institution of slavery, a deep felt sense that is coming forth into the consciousness of the people of America in a manner similar to that of a vintner bringing forth the sweetness of a wine by the crushing of grapes.  The virulence of this song and of Howe’s expressed opposition to slavery parallels the intensity that gripped the nation in the lead-up to the Civil War.  

Interestingly, John Steinbeck used these same words as the title of his 1939 Pulitzer Prize winning book about the plight of the “Okie” migrants from the Plains’ states to California, in the aftermath of the devastation of the Dust Bowl in the 1930’s.  I would see his vision as that of equating the “grapes of wrath” with the need to address the deplorable conditions imposed on these migrants in their flight from the Plains and their efforts to find a place of “home” in the wine and agricultural regions of California.  It is clear to many that Steinbeck thought just about as negatively toward the banks that he believed forced the Okies off their farms and out of the Plains and toward the large corporate farming companies and vintners that exploited them as migrant workers in California, just about as strongly as Howe and others might have thought of the institutionalized system of Slavery in America.

There is another parallel here for me.  Would it not seem logical to see our despicable behavior in the depths of our drinking and using as something similar to the “grapes of wrath.” How we behaved with the world around us, the pain and trauma we created for those we otherwise really did love, could be seen as negatively as Howe and Steinbeck saw their themes. To get sober and develop a sustainable life of sobriety, we had to trample those grapes, those legions of behavior, and repair the devastation that they created.  The fascinating play of the words of “vintage” and “grapes” and the volume of wine and spirits that attended our lives in our disease adds another fascinating element of synchronicity here.  We had to work to allow the authenticity of our inner most selves to emerge as wine does from the trampling of grapes.

How wonderful it is today that, as we work diligently to build a life in Sobriety and to allow the Truth of who and what we really are to fully develop, we are working for our own indomitable Truth to be “marching on…’