(p. 1) Introductory Information for Therapists
This treatment plan and manual are designed for use by a therapist who is familiar with the principles and application of cognitive behavioral therapy (CBT) or who has undergone intensive training workshops by experts in this therapy. The manual will guide therapists and clinicians to implement this brief CBT program that targets posttraumatic stress disorder (PTSD) and co-occurring substance use disorders (SUD). The therapist manual is accompanied by a patient workbook.
Background Information and Purpose of This Program
What is COPE?
COPE is a cognitive behavioral psychotherapy designed for use with patients who have PTSD and a co-occurring alcohol and/or drug use disorder. COPE represents an integration of two empirically supported, manual-based treatments. One of these treatments, developed by Dr. Edna B. Foa, is a cognitive behavioral therapy for posttraumatic stress disorder (PTSD) called prolonged exposure (PE) (Foa, Hembree, & Rothbaum, 2007). The other treatment, developed by Dr. Kathleen Carroll, is a cognitive behavioral approach to treat substance use disorders (SUD) (Carroll, 1998; Kadden et al., 1992). COPE is an integrated psychotherapy, which means that both PTSD and SUD are addressed simultaneously in therapy by the same clinician. COPE includes the following procedures:
• Education about the relationship between PTSD and SUD;
• Education about common reactions to trauma;
(p. 2) • Techniques to help patients manage cravings and thoughts about using alcohol or drugs, and to identify both PTSD-related as well as substance-related triggers for use;
• Coping skills to help prevent relapse to substances, for example, awareness and management of anger, and drink/drug refusal skills;
• Breathing retraining relaxation exercise that teaches the patient how to breathe in a calming way;
• Repeated in vivo (i.e., real life) exposure to safe situations, places, people, or activities that the patient is avoiding because of trauma-related distress or anxiety;
• Repeated imaginal exposure to the trauma memories (i.e., revisiting the trauma memory in imagination);
• Review of treatment progress and anticipation of future challenges to enhance relapse prevention for both PTSD and SUD symptoms.
Why Was COPE Developed?
COPE was developed in response to the increased recognition that individuals with PTSD/SUD comorbidity have unique needs and demonstrate poorer treatment outcome in standard treatment (Back, 2010). Historically, the standard of care has been to treat the SUD first and then treat the PTSD; this approach is known as the sequential model. If the patient follows up on PTSD treatment, a different clinician usually provides the treatment at a separate clinic, with little provider cross-communication. Although the exact numbers are unknown, many PTSD/SUD patients are likely lost in this process. Proponents of the sequential model state that continued substance use during therapy will impede therapeutic efforts and/or that PTSD treatment may induce relapse (Nace, 1988; Pitman et al., 1991). However, little empirical data exist to support these concerns. On the contrary, accumulating research now shows that therapies based on the integrated model, such as COPE, which address both PTSD and SUD together in treatment, may also lead to significant improvements in PTSD symptoms, SUD severity, and associated problems (e.g., depression, physical health) (Back, 2010; Back et al., 2012; Brady et al., 2001; Hien et al., 2010; Mills et al., 2012; Najavits et al., 1998, 2005; Triffleman, 2000; van Dam, Vedel, Ehring, & Emmelkamp, 2012). (p. 3) Concerns that PTSD/SUD patients who receive trauma-focused care will experience an increase in substance use, relapse rates, and/or attrition rates have not been borne out by the data. Insofar as substance use represents self-medication of PTSD symptoms, addressing the trauma and PTSD symptoms early in treatment and providing some concurrent relief from PTSD symptoms will likely improve SUD outcomes (Back, 2010; Brady et al., 2001; Hien et al., 2010; Ouimette et al., 1997). Furthermore, a substantial proportion of PTSD/SUD patients indicate that they would prefer to receive integrated treatment delivered by the same clinician (Back et al., 2014; Back et al., 2006c; Brown, Stout & Gannon-Rowley, 1998; Najavits, 2004).
Two studies highlight the centrality of PTSD improvement in the treatment of PTSD/SUD patients. Among 353 PTSD/SUD patients, Hien et al. (2010) found that subjects who demonstrated improvements in PTSD were significantly more likely to show subsequent improvements in SUD symptoms, but the reciprocal relationship was not observed. Only minimal evidence indicated that improvement in SUD symptoms results in improvement in PTSD. Rather, for every unit of PTSD improvement made (as evidenced by the Clinician Administered PTSD Scale), the odds of being a heavy substance user at follow-up decreased by 4.6%. These findings show that if a PTSD/SUD patient can achieve PTSD symptom reduction, he will likely also experience a reduction in SUD symptoms. However, if only SUD symptom reduction is attained, PTSD symptoms will likely remain. These findings are similar to those reported in an earlier study examining temporal changes in improvement among 94 outpatients with PTSD and alcohol dependence (Back et al., 2006a). Several other smaller studies have also observed this relationship (Back et al., 2006b; Brown, Stout, & Gannon-Rowley 1998; c.f. Read, Brown, & Kahler, 2004). Taken together, the findings from these studies show that co-occurring PTSD symptoms have a strong impact on substance-related outcomes and that integrated interventions that include critical elements of evidence-based treatment for PTSD may be important in optimizing treatment for PTSD/SUD patients.
What is the Main Goal of COPE?
The main goal of COPE is to treat PTSD in a way that is effective for individuals who also have an SUD. COPE is designed for use with (p. 4) men and women exposed to a variety of different types of civilian and combat-related traumas. The COPE treatment seeks to help patients reduce both the severity of PTSD symptoms and the severity of alcohol and drug use, and to minimize the negative impact that PTSD and SUD have on the patient’s life. COPE does not attempt to produce personality changes or solve problems not directly related to PTSD or SUD.
• The substance use treatment component of COPE is designed to help patients (1) recognize and effectively manage triggers for cravings, including environmental, physical, cognitive, and emotional triggers; (2) recognize and modify high-risk thoughts about using alcohol and drugs; and (3) learn effective coping skills (e.g., drug refusal skills).
• The PTSD treatment is designed to help patients understand the interrelationship between PTSD and substance use and follows the prolonged exposure (PE) manual, which includes education about common reactions to trauma, and two exposure techniques: (1) imaginal exposure to the most upsetting traumatic memory, followed by processing of the experience, and (2) in vivo exposure.
What is Posttraumatic Stress Disorder?
Posttraumatic stress disorder (PTSD) is a chronic, debilitating psychiatric disorder that may develop after direct or indirect exposure to a “Criterion A” event (“Criterion A” refers to the Diagnostic and Statistical Manual of Mental Disorders [5th ed.; DSM-5] diagnostic criteria; American Psychiatric Association, 2013). Criterion A events involve exposure to actual or threatened death, serious injury, or sexual violence. Such exposure may occur through directly experiencing an event, witnessing an event, or through learning that a traumatic event occurred to someone close, such as a family member. PTSD may result from exposure to a single traumatic event (e.g., a single serious car accident or exposure to a single terrorist attack), or it may involve repeated exposure (e.g., repeated child sexual abuse incidents, multiple combat exposure over the course of deployment). Certain professionals may be repeatedly exposed to aversive details of traumatic event(s) over their course of their profession, such as first responders who collect human remains, or police officers who are repeatedly exposed to details of child (p. 5) sexual and physical abuse. Exposure through electronic media, television, movies, or pictures would not quality for Criterion A, unless the exposure is work related (e.g., a soldier whose duty is to photograph human remains).
PTSD is characterized by four symptom clusters: (1) intrusion, (2) avoidance, (3) negative cognitions and mood, and (4) alterations in arousal and reactivity. Examples of intrusion symptoms include recurrent and distressing memories of the traumatic event, distressing dreams, and flashbacks in which the individual feels or acts as if the event is happening again. When exposed to internal or external cues that resemble the traumatic event(s), the person may experience physiologic reactivity such as increased heart rate and sweating. Avoidance symptoms include, for example, persistently avoiding thoughts about the trauma, conversations and about the trauma, feelings associated with the trauma (e.g., fear), and people, places, or activities that remind them of the trauma. Negative alterations in cognitions and mood may include an inability to remember important aspects of the traumatic event(s). This is typically due to dissociative amnesia and is not due to other factors such as substance use or head injury. In addition, symptoms may involve persistent and exaggerated negative beliefs and expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”). The person may experience persistent negative emotional states (e.g., fear, horror, anger, guilt, or shame) and may feel detached or estranged from others. Finally, marked alterations in arousal and reactivity may involve irritable behavior, angry outbursts (with little or no provocation), verbal or physical aggression toward people or objects, and reckless or self-destructive behavior, including excessive substance use. The person may be hypervigilant and, for example, may constantly scan the environment for signs of danger and only sit with his back toward the wall. Other examples of marked alterations in arousal and reactivity include problems with concentration and trouble sleeping (e.g., difficulty falling or staying asleep or restless sleep), as well as an exaggerated startle response.
The symptoms of PTSD must last more than one month; they must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning; and they must not be attributable to substances or another medical condition. For more (p. 6) information and for a complete list of the diagnostic criteria for PTSD, please refer to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013).
Traumatic events are quite common. In fact, most individuals will experience at least one traumatic event in their life (Breslau, 2009; Elklit, 2002; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Mills et al., 2011). In the United States, the lifetime prevalence rate of PTSD is estimated to be 7%–8% (Kessler, Berlung, Demler, Jin, Merikangas, & Walters, 2005). As a testimony to the human capacity for resilience and recovery, the large majority of individuals who experience a traumatic event do not develop PTSD. Only about 8%–20% will go on to meet criteria for PTSD (Breslau et al., 1998; Brunello et al., 2001). Exposure to a traumatic event can also lead to a condition known as acute stress disorder (ASD). The primary distinction between PTSD and ASD is the duration of symptoms. ASD can occur from 2 days after exposure to the traumatic event and can last up to 1 month. In order to meet criteria for PTSD, symptoms must have lasted 1 month or longer in duration.
PTSD was first added to the Diagnostic and Statistical Manual of Mental Disorders (DSM) nomenclature in 1980 with the third edition of the DSM. Before that time, the diagnostic condition presently known as PTSD was recognized primarily in combat survivors and was known by various names, including soldier’s heart, irritable heart, shell shock, and combat neurosis (Sadock & Sadock, 2003).
Assessment of PTSD
Accurate assessment of PTSD is a critical first step in treatment planning. As part of the baseline or initial assessment, it is necessary to identify the index trauma (i.e., the trauma that causes the most distress and is the primary focus of attention in treatment) and to find out additional details about the index trauma to help plan the exposure sessions. It is important to survey the types of traumas the patient has experienced in addition to the index trauma. PTSD assessment should be conducted after a patient has emerged from acute alcohol or drug intoxication and (p. 7) withdrawal. See Wilson & Keane (2004) or McCauley et al. (2012) for more information regarding assessment of trauma and PTSD.
We recommend using both interview and self-report instruments in the assessment process.
✓ Therapist Note
Once a PTSD diagnosis has been established, be sure to assess the patient’s PTSD symptoms regularly throughout treatment (e.g., weekly self-report measurements). This is critical for monitoring progress and guiding treatment decisions. Share the results of both the initial and ongoing symptom assessments with the patient as part of the treatment. A good time to present the weekly scores to the patient is mid-treatment (i.e., session 6). It can be helpful to present the scores in a line graph or other visual form.
Interviewer-rated assessments (based on DSM-IV diagnostic criteria) that we recommend include:
• Trauma Interview Form (Foa, Hembree, & Rothbaum, 2007), which assesses trauma exposure and identifies the index trauma, patient’s support system, suicide risk, and substance use;
• Clinician-Administered PTSD Scale (CAPS; Blake et al., 1995), which includes a Life Events Checklist of potentially traumatic events to assess lifetime trauma exposure, and assesses frequency and intensity of diagnostic PTSD symptoms related to traumatic events;
• Structured Clinical Interview for DSM-IV (SCID; First et al., 2002), a semi-structured interview designed to diagnose most Axis I disorders;
• MINI International Neuropsychiatric Interview PTSD Module (Sheehan et al., 1998), which also evaluates most major Axis I psychiatric disorders.
(p. 8) Self-Report Assessments
Recommended self-report assessment include:
What is a Substance Use Disorder?
Like PTSD, substance use disorders (SUD) are often chronic and relapsing conditions. Substances of abuse include alcohol, licit drugs (e.g., cocaine, marijuana, heroin, methamphetamine), and prescription drugs (e.g., opioid analgesics, benzodiazepines). The DSM-5 (American Psychiatric Association, 2013) defines SUD as a maladaptive pattern of use that leads to significant impairment in important areas of life (e.g., work, social) or significant distress.
SUD are characterized by a loss of control over the substance use. Symptoms include, for example, taking more of the substance than intended; a persistent desire or unsuccessful efforts to cut down or control substance use; spending a lot of time obtaining, using, or recovering from the effects of a substance; experiencing a craving, strong desire, or urge to use the substance; failure to fulfill major role obligations at work, school, or home; continued use despite having problems caused or exacerbated by using (e.g., arguments with spouse, legal problems, medical or psychological problems); giving up important social, occupational, or recreational activities because of the substance use; recurrent use of substances in situations in which it is physically hazardous; (p. 9) exhibiting tolerance, which is defined as a need for markedly increased amounts of the substance in order to achieve the desired effect, or markedly diminished effect with continued use of the same amount of the substance; and experiencing withdrawal as manifested by the characteristic withdrawal syndrome for that particular substance, or if the person takes the same (or closely related) substance in order to relieve or avoid withdrawal symptoms.
The severity of the SUD is rated as mild (2–3 symptoms), moderate (4–5 symptoms), or severe (6 or more symptoms). Patients may be classified as being in early remission (3–12 months during which none of the SUD criteria other than cravings has been met) or sustained remission (12 months or longer during which none of the SUD criteria other than cravings has been met. For more information and for a complete list of the diagnostic criteria for SUD, please refer to the Diagnostic and Statistical Manual of Mental Disorders (5th ed., DSM-5) (American Psychiatric Association, 2013).
Substance use disorders are among the most prevalent of all psychiatric disorders (Merikangas et al., 1998). The National Comorbidity Survey Replication (NCS-R), which assessed a nationally representative sample of 9,282 adults in the United States, found that the lifetime prevalence rate for any SUD was 14.6% and the past 12-month prevalence rate was 3.8% (Kessler, Berglund, Demler, Jin, Merikangas, & Walters, 2005). Among military personnel and Veterans, rates of SUD are significantly higher (Brady et al., 2009; McKenzie et al., 2006; SAMHSA, 2005). Data from the National Survey on Drug Use and Health (NSDUH) estimates that approximately 7.1% of Veterans meet criteria for a past 12-month SUD (SAMHSA, 2007). This rate is almost twice as high as data in the general population (Kessler et al., 2005). Furthermore, examination of Veterans 18–53 years of age reveals a 12-month SUD prevalence rate of 18.2%, which is almost five times as high as the general population (SAMHSA, 2007).
Assessment of Substance Use Disorders
As with PTSD, both interviewer and self-report forms (based on DSM-IV diagnostic criteria) are recommended for a thorough (p. 10) assessment of SUD. Share the results of both the initial and ongoing symptom SUD assessments with the patient as part of the treatment. A good time to do this is mid-treatment (i.e., session 6) when you can present, for example, a line graph of the patient’s substance use. Using the Time Line Follow Back (TLFB) or other weekly assessment of substance use, therapists can chart the patient’s changes in the percent of days using substances (e.g., from 6/7 days or 86% to 3/7 days or 43%), amount of money spent on drugs, number of standard drinks consumed, or the number of joints smoked or pills taken.
In order to diagnose SUD, we recommend:
For self-report assessments we recommend:
To assess the impact of SUD on a variety of biopsychosocial areas (e.g., medical, legal, psychiatric, social) we use the Addiction Severity Index (ASI-Lite; Cacciola et al., 2007).
(p. 11) ✓ Therapist Note
During the course of the initial assessment:
• Get additional information about substance use.
• Find out when the patient first started using alcohol or drugs, what his “substance of choice” is, how often and what substances he uses, what type of substance abuse treatment he has received in the past and what the outcome was, any family history of drug or alcohol abuse, what his relationship status is and if any significant use of alcohol or other drugs, and if he attends NA or AA meetings or has any other additional supports in the community.
• As with PTSD symptoms, it is critical to assess substance use periodically throughout the treatment (e.g., weekly self-report measure or the TLFB) in order to monitor progress and guide treatment decisions.
How Often Do PTSD and Substances Use Disorders Co-occur?
Over the last 20 years, evidence of the frequent co-occurrence of PTSD and SUD, and the negative impact of this comorbidity on treatment outcomes, has increased (Back & Brady, 2008, 2010; Brady et al., 2001, 2009; Breslau et al., 2003: Hien et al., 2004; Mills, 2005a, 2007, 2009). Kessler and colleagues found that adults with PTSD were 2 to 4 times more likely than those without PTSD to have a comorbid SUD (Kessler et al., 1995). Similarly, data from the Australian National Survey of Mental Health and Well-Being (N > 10,000) found that 34.4% of respondents with PTSD had at least one SUD, with alcohol use disorders being the most common (Mills et al., 2006). Among treatment-seeking substance abusers, the prevalence of lifetime PTSD has been reported as high as 50% or greater (Dansky, Brady, & Roberts, 1994; Dore et al., 2012; Mills et al., 2005a; Triffleman, Marmar, Delucchi, & Ronfeldt, 1995; Torchalla et al., 2012). In the majority of cases, the development of PTSD precedes the development of the SUD (Back et al., 2005, 2006b; Breslau, Davis, & Schultz, 2003; Jacobsen, Southwick, & Kosten, 2001; Stewart & Conrod, 2003), thereby lending support to the notion that alcohol or drugs are used by patients to help diminish PTSD symptoms (i.e., self-medication hypothesis; Khantzian, 1985).
(p. 12) Negative Impact of PTSD and SUD Comorbidity
In both civilian and veteran populations, research demonstrates a more complicated clinical course and worse treatment outcomes in persons with comorbid PTSD and SUD, as compared to persons with either disorder alone (Back et al., 2000; Brady et al., 1998; Cottler et al., 1992; Mills et al., 2007; Ouimette & Brown, 2003; Ruzek, 2003). A series of associated problems are common, including medical issues, family dysfunction, homelessness, HIV risk behaviors, and intimate partner violence (Brady et al., 1998; Hien, 2009; Ouimette et al., 2006). Mills and colleagues (2005) conducted the largest study to date of comorbid PTSD and SUD in a clinical setting (N = 615) and found that individuals with, as compared to without, PTSD had more extensive polydrug use histories, poorer physical and mental health, higher rates of attempted suicide (48% lifetime), and more extensive health service utilization.
PTSD/SUD Comorbidity Among Military Populations
In comparison to the general population, military personnel and Veterans are at increased risk of developing both PTSD and SUD (Hoge et al., 2004, 2006; Vasterling et al., 2008). Initial reports among military personnel focused on Vietnam Veterans with PTSD, in which 64%–84% met lifetime criteria for an alcohol use disorder (Keane & Kaloupek, 1998). A more recent study (Smith et al., 2008) of a large military cohort (N = 50,184) found that personnel with problem drinking had significantly higher odds of new onset PTSD following deployment, as compared with personnel without problem drinking (odds ratio 1.73). If left untreated, military personnel with SUD and/or PTSD are at risk for other psychiatric problems (e.g., depression, sleep disturbances), neuropsychological impairment, suicidal ideation and attempts, physical health problems, increased mortality, reduced resiliency, unemployment, and family/couples impairment (Brady et al., 2009; Marx et al., 2009; Pietrzak et al., 2009; Tanielian et al., 2008). Veterans with comorbid PTSD and SUD tend to have both a longer duration of substance use and more symptoms of substance dependence, and to undergo more episodes of substance abuse treatment (p. 13) as compared to Veterans without dual diagnosis PTSD/SUD (Young et al., 2005).
Prolonged exposure (PE) is a treatment program that has been shown to be highly effective for the treatment of PTSD (Powers et al., 2010). To date, there are over 30 published randomized controlled trials (RCTs) on PE showing statistically and clinically significant improvement in PTSD, including studies with Veterans (McNally, 2007; Schnurr et al., 2007). PE was endorsed as the most appropriate form of psychotherapy to manage PTSD by the International Consensus group on Depression and Anxiety (Ballenger et al., 2000). Moreover, the Institute of Medicine (IOM) reviewed all published RCTs for PTSD and the only modality of psychotherapy deemed by the IOM to have sufficient empirical evidence to be considered effective in ameliorating PTSD was exposure-based therapy (IOM, 2008). Thus, PE therapy is the “gold standard” psychosocial treatment for PTSD.
Emotional Processing Theory
The conceptual backbone of PE is emotional processing theory, which was developed by Foa and Kozak (1985, 1986) as a framework for understanding the anxiety disorders and the mechanisms underlying exposure therapy. The starting point of emotional processing theory is the notion that fear is represented in memory as a cognitive structure. This fear structure includes representations of the feared stimuli (e.g., bear), the fear responses (e.g., heart rate acceleration), the meaning associated with the stimuli (e.g., bears are dangerous), and the responses to the stimuli (e.g., fast heartbeat means I am afraid). When a fear structure represents a realistic threat, we refer to it as a normal fear that acts as a template for effective action to threat. Thus, feeling fear or terror in the presence of a bear and acting to escape are appropriate responses and can be seen as normal and adaptive fear reactions.
1. Associations among stimulus elements do not accurately represent the world;
2. Physiological and escape/avoidance responses are evoked by harmless stimuli;
3. Excessive and easily triggered response elements interfere with adaptive behavior; and
4. Harmless stimulus and response elements are erroneously associated with threat meaning.
Foa and Kozak (1985) suggested that the anxiety disorders, such as PTSD, reflect specific pathological fear structures and that treatment reduces anxiety disorder symptoms via modifying the pathological elements in the fear structure. These modifications are the essence of emotional processing, which is the mechanism underlying successful treatment, including exposure therapy.
How Prolonged Exposure Works
According to Foa and Kozak, two conditions are necessary for successful modification of a pathological fear structure, and thereby amelioration of the anxiety symptoms.
1. The fear structure must be activated, otherwise it is not available for modifications;
2. New information that is incompatible with the erroneous information embedded in the fear structure must be available and incorporated into the fear structure. When this occurs, information that previously evoked fear and anxiety symptoms will no longer do so.
Deliberate, systematic confrontation with stimuli (e.g., situations, objects) that are feared despite being safe or having low probability of producing harm meets these two conditions. How so? Exposure to feared stimuli results in the activation of the relevant fear structure and at the same time provides realistic information about the likelihood and the cost of feared consequences. In addition to the fear of external threat (e.g., being attacked again), the person may have (p. 15) erroneous cognitions about anxiety itself that are disconfirmed during exposure, such as the belief that anxiety will never end until the situation is escaped, or that the anxiety will cause the person to “lose control” or “go crazy.” This new information is encoded during the exposure therapy session, altering the fear structure (or forming a new structure that does not include the erroneous elements), modifying the erroneous cognitions and thereby resulting in symptom reduction. Foa and colleagues subsequently refined and elaborated on the original theory of emotional processing, offering a comprehensive theory of PTSD that accounts for natural recovery from traumatic events, the development of PTSD, and the efficacy of cognitive behavioral therapy in the treatment and prevention of chronic PTSD (Foa, Steketee, & Rothbaum, 1989; Foa & Cahill, 2001; Foa, Huppert, & Cahill, 2006; Foa & Jaycox, 1999; Foa & Riggs, 1993).
PTSD and Trauma
According to emotional processing theory, the fear structure underlying PTSD is characterized by a particularly large number of stimulus elements that are erroneously associated with the meaning of danger, as well as representations of physiological arousal and of behavioral reactions that are reflected in the symptoms of PTSD. Because of the large number of stimuli that are perceived as dangerous, individuals with PTSD may perceive the world as entirely dangerous. In addition, representations of how the person behaved during the trauma, her subsequent symptoms, and negative interpretation of the PTSD symptoms are associated with the meaning of self-incompetence. These two broad sets of negative cognitions (“The world is entirely dangerous” and “I am completely incompetent to cope with it”) further promote the severity of PTSD symptoms, which in turn reinforce the erroneous cognitions (for more details, see Zalta et al., 2014).
Trauma survivors’ narratives of their trauma have been characterized as being fragmented and disorganized. Foa and Riggs (1993) proposed that the disorganization of trauma memories is the result of several mechanisms known to interfere with the processing of information that is encoded under conditions of intense distress. Consistent with hypotheses that PTSD would be associated with a disorganized memory for (p. 16) the trauma, Amir, Stafford, Freshman, and Foa (1998) found that a lower level of articulation of the trauma memory shortly after an assault was associated with higher PTSD symptom severity 12 weeks later. In a complementary finding, Foa, Molnar, and Cashman (1995) reported that treatment of PTSD with prolonged exposure was associated with increased organization of the trauma narrative. Moreover, reduced fragmentation was associated with reduced anxiety, and increased organization was associated with reduced depression.
As noted earlier, high levels of PTSD symptoms are common immediately following a traumatic event, but most individuals will show a decline in their symptoms over time. However, a significant minority of trauma survivors fail to recover and continue to suffer from PTSD symptoms for years. Foa and Cahill (2001) proposed that natural recovery results from emotional processing that occurs in the course of daily life. This process occurs through repeated activation of the trauma memory, and engagement with trauma-related thoughts and feelings and sharing them with others, and approaching safe situations that serve as reminders of the trauma. In the absence of additional traumas, these natural exposures contain information that disconfirms the common post-trauma perception that the world is a dangerous place and that the person is incompetent. In addition, talking about the event with supportive others and thinking about it help the survivor organize the memory in a meaningful way.
Why, then, do some trauma victims go on to develop PTSD? Within the framework of emotional processing theory, the development and maintenance of PTSD is conceptualized as a failure to adequately process the traumatic memory because of extensive avoidance of trauma reminders. Accordingly, therapy for PTSD should promote approaching safe trauma reminders and engaging in emotional processing. Paralleling natural recovery, PE for the treatment of PTSD is assumed to work through (1) activation of the fear structure, by the patients deliberately approaching trauma-related thoughts, images, and situations via imaginal and in vivo exposure, and (2) corrective learning that their perceptions about themselves and the world are inaccurate.
(p. 17) How Prolonged Exposure Reduces PTSD Symptoms
How does PE lead to improvement in PTSD symptoms? Avoidance of trauma memories and related reminders is maintained through the process of negative reinforcement, that is, through the reduction of anxiety in the short run. In the long run, however, avoidance maintains trauma-related fear by impeding emotional processing. By approaching trauma memories and reminders, PE reduces the habit of diminishing distress via cognitive and behavioral avoidance, thereby reducing one of the primary factors that maintains PTSD. Another mechanism involved in emotional processing is habituation of anxiety, which disconfirms erroneous beliefs that anxiety will last forever or will diminish only upon escape. Patients also learn that they can tolerate their symptoms and that having them does not result in “going crazy” or “losing control,” -fears commonly held by individuals with PTSD.
Imaginal exposure followed by processing (discussing) the imaginal experience and in vivo exposure also help patients to differentiate the traumatic event from other similar but non-dangerous events. This allows them to see the trauma as a specific event occurring in space and time, which helps to refute their perception that the world is entirely dangerous and that they are completely incompetent. Importantly, PTSD patients often report that thinking about the traumatic event feels to them as if it is “happening right now.” Repeated imaginal exposure to the trauma memory promotes discrimination between the past and present by helping patients realize that remembering the trauma is not the same as being in the trauma again, and therefore, thinking about the event is not dangerous. Repeatedly revisiting the trauma memory also provides the patient with the opportunity to accurately evaluate aspects of the event that are actually contrary to their beliefs about danger and self-incompetence that may otherwise be overshadowed by the more salient threat-related elements of the memory. For example, individuals who feel guilty about not having done more to resist an assailant may come to the realization that the assault likely would have been more severe had they resisted. All of these changes reduce PTSD symptoms and bring about an increased sense of mastery and competence. The corrective information that is provided via imaginal and in vivo exposure is further elaborated during the processing part of the session that follows the imaginal exposure.
(p. 18) How is COPE Different From Existing Integrated Therapies?
Several integrated treatments for PTSD/SUD patients have been developed. The most widely researched thus far is “Seeking Safety” (SS; Najavits, 2002), a 25-session psychotherapy that provides psychoeducation and coping skills training to help individuals gain more control over their lives. SS was originally designed for women with PTSD and to focus on healing from the effects of childhood physical and sexual abuse (Najavits, 1998). In contrast to COPE, SS does not include imaginal or in vivo exposure therapy techniques. SS has been shown to lead to improvements in PTSD and SUD symptoms, but the question of whether patients evidence better outcomes after receiving SS versus a non-integrated therapy that only targets the SUD is unclear (Hien et al., 2004, 2009).
To date, six investigations have examined the integrated use of PE techniques among SUD patients with civilian and combat-related traumas (Back et al., 2012; Brady et al., 2001; Coffey, Stasiewicz, Hughes & Brimo, 2006; Mills et al., 2012; Najavitz et al., 2005; Triffleman et al., 1999). The findings demonstrate that addressing PTSD among SUD patients via exposure-based techniques results in significant improvements in substance use severity, PTSD symptomatology, and global functioning. Triffleman and colleagues (1999, 2000) first applied in vivo exposure to civilian PTSD/SUD patients. “Substance Dependence Posttraumatic Stress Disorder Therapy” (SDPT) is a 40-session treatment that utilizes relapse prevention, coping skills, and in vivo exposure. In a pilot trial (N = 19) with methadone-maintained, cocaine-dependent subjects, SDPT was contrasted to twelve-step facilitation therapy and was found to be equivalent with regard to improvements in drug use and PTSD. Of relevance, SDPT does not include imaginal exposure. In an uncontrolled pilot study (N = 5), Najavits et al. (2005) examined the use of adding imaginal exposure to SS and found that it resulted in significant reductions in PTSD and SUD symptoms. In vivo exposure was not included in that study. In addition, Coffey et al. (2006) examined the use of adding imaginal exposure to treatment-as-usual for SUD among 43 outpatients and found positive results. Notably, no psychotherapy treatments other than COPE have been developed that (p. 19) incorporate both key elements of PE: (1) imaginal exposure followed by emotional processing, and (2) in vivo exposure techniques.
Which Patients Should Be Considered for COPE?
Not every person with PTSD and a co-occurring SUD needs or will be appropriate for the COPE treatment. On the basis of treating and studying hundreds of individuals with PTSD and SUD, we recommend that COPE be considered for use with:
• Individuals with current PTSD. The COPE treatment has been designed for use with those who meet diagnostic criteria for PTSD. The program may also be useful, however, for individuals with subsyndromal PTSD, where the person exhibits significant symptoms of PTSD (in particular avoidance and re-experiencing symptoms) that are distressing and interfering with his life.
• Individuals with sufficient memory of the traumatic event(s). Trauma memories are often fragmented, and often some parts of the memory cannot be fully remembered. The patient’s ability to describe the traumatic event is vital to the treatment. Ideally, the narrative would have enough details and have a beginning, middle, and end. However, PE has been shown to be effective with short and fragmented memories, which often occur when the trauma was child sexual abuse.
• Individuals with a substance use disorder. This treatment targets patients who are experiencing significant misuse or have an alcohol or drug use disorder within the past year.
A large percentage of PTSD/SUD patients present with multiple comorbid problems (e.g., major depression, other anxiety disorders, high levels of anger or shame, Axis II symptoms). We have found that these patients can also benefit from COPE and should not be excluded. The related symptomatology, however, should not be the primary diagnosis.
Which Patients Should Not Be Considered for COPE?
COPE is not recommended if the following comorbidities or problems are present. Instead, these problems should take priority in the clinical (p. 20) intervention, and COPE should not be implemented until after such intervention has occurred and the condition is stabilized:
• Imminent threat of suicidal or homicidal behavior. While current suicidal ideation and history of suicide gestures or attempts are common in PTSD/SUD patients, if the person is currently at risk for acting on these impulses, the suicidal or homicidal behavior requires immediate clinical attention. A sustained period of stabilization (e.g., 6 months) and a written commitment (safety contract) by the patient not to harm himself during treatment would be necessary prior to initiation of COPE or any other trauma-focused treatment. It is important to gather data on previous attempts (e.g., how long ago, lethality of attempt, treatment following attempt) and the context in which they occurred (e.g., during times of abstinence, when trauma symptoms were triggered), and to involve significant others when appropriate.
✓ Therapist Note
If a patient expresses suicidal ideation at the initial assessment, or any other time during the course of treatment, it will be critical that you assess intent, plan, means, and ability to contract for safety on a regular basis (e.g., weekly, each session) in order to monitor the patient’s safety and for treatment planning purposes.
• Serious self-injurious behavior. If self-injurious behaviors, such as cutting or burning or otherwise deliberately injuring herself, are currently active, COPE should be deferred until the person has acquired skills or tools to manage these impulses without acting on them. We recommend a period of at least 3 months with no self-injurious behavior. During treatment, therapists tell patients that they may have urges to harm themselves but that is not an option during COPE treatment, as they need to learn that they can tolerate negative emotions without efforts to avoid, escape, or distract in unhealthy ways, including using substances.
• Ongoing domestic violence. Many of our patients have lived in dangerous environments that carry a significant risk of negative events and were successfully treated with COPE. But if the patient is currently in a living situation in which there is ongoing abuse or domestic violence of high magnitude, this matter should be the focus of (p. 21) treatment. Safety is paramount. COPE should be delayed until the person is away from the ongoing violent living situation.
• Lack of memory of a traumatic event(s). COPE should not be employed as a means of helping the patient “recover” his traumatic memories. While patients do sometimes recall more details of the trauma through the course of the treatment, we strongly discourage using this treatment with patients who present with only a “sense” or a vague feeling that they have experienced a trauma.
• Lack of desire to significantly reduce or cease alcohol or drug use. Most PTSD/SUD patients present with ambivalence about whether or not, and to what extent, they want to reduce their substance use. However, if a patient is adamant about not wanting to stop or significantly reduce alcohol or drug use, COPE should be deferred. A motivational enhancement therapy approach may be more useful to facilitate resolution of this ambivalence before beginning COPE. In fact, being able to work on trauma symptoms could serve as a source of motivation for patients unwilling or uninterested in reducing substance use. Patients should be expected to demonstrate some level of clinically significant improvement in frequency and/or intensity in substance use over the course of the first 3 sessions, before the exposures begin. If during the first 3 sessions no improvement in substance use is observed or an increase in substance use (relative to baseline) occurs, therapy should focus on the substance use until significant reductions in frequency and intensity are evidenced.
With regard to alcohol use, we encourage clinicians to use the guidelines set forth by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), which define low-risk drinking as no more than 7 standard drinks per week for women (and no more than 3 drinks in one day) or no more than 14 standard drinks per week for men (and no more than 4 drinks per day) (see Figure 1.1).
The recommended levels are different for men and women because research shows that women develop more severe alcohol-related problems at lower drinking levels and at a faster rate than men. This is due to physiological differences in men and women, such as women generally weighing less than men and having less total body water as compared to men. Alcohol disperses in body water, so after a man and woman of the same weight drink the same amount of alcohol, the woman’s blood (p. 22) alcohol concentration will likely be higher, putting her at greater risk for harm.
Note that the NIAAA guidelines are for low-risk, not no-risk, drinking. Even if drinking within these limits, patients can still experience problems. Clearly, it is best for patients to stay within these low-risk limits in order to minimize harm and maximize the benefits of the integrated treatment. For many patients, achieving low-risk drinking levels will be very challenging, and abstinence will be the ideal option (e.g., if they have a medical condition made worse by alcohol use, a positive family history of addiction, or previous unsuccessful attempts at cutting down).
• Current psychosis. COPE has not been systematically studied with this population and is not recommended for individuals with current psychosis.
• Medical emergencies. Depending on the patient’s level of substance use, medically supervised detoxification or other medical emergencies may need to be addressed and stabilized before the patient begins this program. Clinicians should determine this during the first session. Ask whether the patient has a history of detox, seizures, or delirium tremens. Assess whether the patient experiences physiological (p. 23) symptoms when trying to cut down or stop using substances (e.g., nausea, vomiting, headaches, tremors, sweating). You can also use measures such as the Clinical Institute Withdrawal Assessment Scale for Alcohol - Revised (CIWA-AR) to help assess the need for detoxification from alcohol. Generally, a score of 10 or above on the CIWA-AR indicates the need for medication.
In addition to these exclusionary criteria, another commonly encountered issue to consider in determining whether to offer COPE therapy is comorbid dissociative disorder. Clinicians sometimes express reservations about using exposure therapy to treat patients with severe dissociative symptoms or disorders due to concern that the exposure will increase their dissociation. In considering whether to use COPE with such patients, we recommend that the therapist consider the severity of the dissociative symptoms relative to the PTSD. If the patient’s dissociation experiences outweigh the PTSD-related symptoms in severity and in degree of interference, effective implementation of PE may not be possible, and the patient may not be able to benefit from the treatment. In such cases, as when other disorders are of primary clinical importance (i.e., severe depression with suicidal risk), the more severe or life-threatening disorder should take precedence in clinical intervention.
In summary, individuals with PTSD presenting with all types of trauma, who have a relatively clear memory of their traumatic experience(s) and a desire to abstain from or significantly reduce their use of alcohol and/or drugs, are good candidates for COPE. If medically supervised detoxification is required, patients need to first obtain detox and be stabilized before beginning this COPE therapy.
Studies show that PE reduces depression, anxiety, guilt, and anger as well as PTSD, so its use is warranted in patients with complex trauma histories and complicated clinical presentations. Comorbidity of other Axis I and Axis II disorders, as well as multiple life difficulties (e.g., unemployment, financial difficulties, chronic health problems, relationship and family troubles, social isolation) are extremely common among PTSD/SUD patients, and COPE has been used successfully in the presence of these problems.
(p. 24) ✓ Therapist Note
In general, we recommend that if another disorder or problem is present that is life-threatening or otherwise clearly of primary clinical importance, it should be treated and stabilized prior to initiation of this treatment.