As the public becomes more aware of the impact of trauma and addiction, therapists are feeling an urgency to find better ways to help those suffering from both posttraumatic stress disorder (PTSD) and substance use disorder. Outcome studies confirm that clients with both disorders struggle in therapy more than do those with either disorder (Flanagan, Korte, Killeen, & Back, 2016). Dropout during treatment, relapse, and other factors hindering recovery are routinely greater for those with comorbid problems.
We can say with confidence that trauma and addiction are linked. Most studies report between 17 and 40 percent of those suffering from PTSD have substance use disorders (Gielen, Havermans, Tekelenburg, & Jansen, 2012; Norman, Haller, Hamblen, Southwick, & Pietrzak, 2018). And rates for PTSD found among those seeking treatment for substance use disorders are about 25 to 40 percent (see, for example, Driessen et al., 2008), although Berenz et al. (2017) argue that about half of those seeking addiction treatment qualify for a diagnosis of PTSD. Vujanovic and Back (2019) suggest that 50 percent of individuals with PTSD or substance use disorder meet the criteria for the other disorder.
Current Therapeutic Approaches
Historically, therapists would treat the addiction first, under the argument that the use of substances complicated PTSD symptoms. Today, however, we treat both conditions concurrently. The most common version of this approach is to offer clients separate treatments during the week, such as a trauma treatment group and a substance use disorder group, typically facilitated by two therapists, each an expert in either trauma or addictions.
A more cutting edge version focuses on integrating both therapies, usually with a single therapist. This approach is typically based on some idea of why the disorders are linked. In reality, however, we’re still not sure what the link is. Studies of identical and fraternal twins have shown that both genetics and shared environment play a role in comorbidity. As a general rule, the link appears to be bidirectional and influenced mainly by the age of onset. The earlier the trauma, the more likely an addiction will develop; the earlier the addiction, the more likely PTSD will develop. Addiction is considered a risk factor for trauma, and trauma for addiction (Berenz, McNett, & Paltell, 2019).
Trauma, rather than addiction, experts have done the most work exploring the link. Although current research suggests the link is bidirectional, most traumatologists tend to argue that those suffering from trauma use drugs to self-medicate nightmares, anxiety, and other symptoms of trauma (see, for example, Padykula & Conklin, 2010). Addiction psychologists, on the other hand, don’t hold the self-medication theory of addiction in as high regard, though they are silent on what the link is. In my own work as a clinician, I’ve discovered it’s a rare client who uses substances solely to alleviate trauma symptoms. When I ask trauma clients if they were eager to be intoxicated at a New Year’s Eve party, on their birthday, or on a Sunday afternoon when they were bored, they inevitably answer, “Yes.” It seems that self-medication is only a half-truth.
Some suggest that environment may explain the link. For example, those who suffer from a substance use disorder tend to have a lifestyle that pushes them into more dangerous situations, such as a criminal act or a motor vehicle accident. Conversely, those who suffer from PTSD often live in environments where substance use has been normalized or is expected, such as military soldiers in active duty or kids growing up in addicted families.
There are a dozen treatments designed specifically to help those suffering from both disorders (see, for example, Ford & Russo, 2006; Najavits, 2002). Yet even these targeted treatments—designed by trauma experts—mainly mix-and-match current treatments for each disorder. Most often, the treatments are manualized, cognitive-behavioral therapies. And so far, these therapies have not had any inspired success.
We need much more research.
A Meaning-Focused Perspective
From the perspective of meaning, what’s interesting is that both trauma and addiction share several dynamics, even though each condition is different. At a surface level, most people who experience a traumatic event do not succumb to a stress injury, just as most people who use substances do not plunge into addiction. In other words, there appears to be something in certain individuals that makes them vulnerable to the condition.
That vulnerability may be that they are not living personally meaningful lives. At the facility where I work, we conduct therapy for clients with comorbid PTSD and addiction based on this assumption. The clients are adult male soldiers and first-responders. Similar to Tronick’s approach (noted in the article on Trauma and Meaning), the program includes psychiatric interventions, somatic therapies, and emotion-focused therapies. However, we pay a special focus on how these clients make sense of themselves, the world around them, and their motivations and goals.
During the eight years we’ve been developing the program, we have consistently observed that clients are stuck because of the way they make sense of self and the world. They construct an identity based solely on being a soldier or a first responder. They position themselves as victims of both disorders and of their managers at work. They believe they are defective because by having PTSD, they failed in their job: “From hero to zero” is a common statement. They believe they are different from clients who do not suffer from PTSD. They believe that no one can understand them. They lack self-efficacy—in fact, most are very interested in ketamine, psilocybin, and ayahuasca treatments, believing they can simply take the drug, sit back, and wait for the magic to happen.
Such beliefs do not leave space for personal responsibility, relationships, and hope for the future. Our therapy works with clients to help them recognize authentic values, strengths, and limitations. It helps them form authentic connections with others. It promotes motivations and goals that are personally meaningful. There are, of course, barriers that clients need to overcome, which therapy addresses. But our goal is always to help them begin to pursue a meaningful life, in spite of their diagnoses.
Berenz, E. C., McNett, S., & Paltell, K. (2019). Development of comorbid PTSD and substance use disorders. In A. A. Vujanovic & S. E. Back (Eds.), Posttraumatic stress disorder and substance use disorder: A comprehensive clinical Handbook (Chap. 2). New York, NY: Routledge.
Berenz, E. C., Roberson-Nay, R., Latendresse, S., Mezuk, B., Gardner, C. O., Amstadter, A. B., & York, T. P. (2017). Posttraumatic stress disorder and alcohol dependence: Epidemiology and order of onset. Psychological Trauma: Theory, Research, Practice, and Policy, 9(4), 485-492. https://doi.org/10.1037/tra0000185
Driessen, M., Schulte, S., Luedecke, C., Schaefer, I., Sutmann, F., Ohlmeier, M., Kemper, U., … & TRAUMAB-Study Group (2008). Trauma and PTSD in patients with alcohol, drug, or dual dependence: A multi-center study. Alcoholism: Clinical and Experimental Research, 32(3), 481-488. https://doi.org/10.1111/j.1530-0277.2007.00591.x
Flanagan, J. C., Korte, K. J., Killeen, T. K., & Back, S. E. (2016). Concurrent treatment of substance use and PTSD. Current Psychiatry Report, 18(8), 70. https://doi.org/10.1007/s11920-016-0709-y
Ford, J. D., & Russo, E. (2006). Trauma-focused, present-centered, emotional self-regulation approach to integrated treatment for posttraumatic stress and addiction: Trauma Adaptive Recovery Group Education and Therapy (TARGET). American Journal of Psychotherapy, 60(4), 335-355. https://doi.org/10.1176/appi.psychotherapy.2006.60.4.335
Gielen, N., Havermans, R., Tekelenburg, M., & Jansen, A. (2012). Prevalence of post-traumatic stress disorder among patients with substance use disorder: It is higher than clinicians think it is. European Journal of Psychotraumatology, 3(1). https://doi.org/10.3402/ejpt.v3i0.17734
McNally, R. J. (2006). The expanding empire of posttraumatic stress disorder. Medscape General Medicine, 8(2), 9. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1785189/
Najavits, L. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York, NY: Guilford.
Norman, S. B., Haller, M., Hamblen, J. L., Southwick, S. M., & Pietrzak, R. H. (2018). The burden of co-occurring alcohol use disorder and PTSD in U.S. Military veterans: Comorbidities, functioning, and suicidality. Psychology of Addictive Behaviors, 32(2), 224-229. https://doi.org/10.1037/adb0000348
Padykula, N. L, & Conklin, P. (2010). The Self Regulation Model of attachment trauma and addiction. Clinical Social Work Journal, 38(4), 351-360. https://doi.org/10.1007/s10615-009-0204-6
Vujanovic, A. A., & Back, S. E. (2019). PTSD and substance use disorders: A clinical overview. In A. A. Vujanovic & S. E. Back (Eds.), Posttraumatic stress disorder and substance use disorder: A comprehensive clinical handbook (Chap. 1). New York, NY: Routledge.