Concurrent Treatment
Concurrent Treatment
T R E AT M E N T S T H AT W O R K
Editor-In-Chief
David H.Barlow, PhD
T R E AT M E N T S T H AT W O R K
Concurrent Treatment
of PTSD and
SubstanceUse
Disorders Using
Prolonged Exposure
(COPE)
THERAPIST GUIDE
SUDIE E .BACK
EDNA B.FOA
THERESE K.KILLEEN
K AT H E R I N E L . M I L L S
MAREE TEESSON
BONNIE DANSK Y COT TON
K AT H L E E N M . C A R R O L L
K AT H L E E N T. B R A D Y
1
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To Steve and Liam for all the ways they love, support, and inspire me.
Sudie E.Back
To my husband Charles, who has always been supportive of my work
even when it takes me away from him, with much love.
Edna B.Foa
To my husband, Timothy, who has given me so many years of love,
support, and encouragement.
Therese K.Killeen
To Andrew, Lily, and Kate, who remind me all the time that life is a
wonderful dance.
Maree Teesson
To my husband Don and daughters Eliana and Rebecca, who have
provided more love and joyful adventures than Icould have imagined.
Bonnie Dansky Cotton
To Bruce, who still teaches us everyday, and who is loved more than
he could ever know.
Kathleen M.Carroll
To Bruce, whose love and acceptance has helped many.
Kathleen T.Brady
About
T R E AT M E N T S
T H AT W O R K
viii
References
Barlow, D.H. (2004). Psychological treatments. American Psychologist, 59,
869878.
Barlow, D. H. (2010). Negative effects from psychological treatments:
Aperspective. American Psychologist, 65(2), 1320.
Institute of Medicine. (2001). Crossing the quality chasm: A new health
system for the 21st century. Washington, DC:National Academy Press.
McHugh, R.K., & Barlow, D.H. (2010). Dissemination and implementation of evidence-based psychological interventions: A review of current
efforts. American Psychologist, 65(2), 7384.
ix
Contents
Acknowledgments xiii
Chapter1
Chapter2
Chapter3
Chapter4
Chapter5
Chapter6
Chapter7
Chapter8
Chapter9
Chapter10
Chapter11
Chapter12
xi
Chapter13
Chapter14
Appendix A
Appendix B
Appendix C
Appendix D
References 221
About the Authors 231
xii
Acknowledgments
xiii
xiv
Concurrent Treatment
of PTSD and Substance
Use Disorders Using
Prolonged Exposure
(COPE)
CHAPTER1
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.
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
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 etal.,
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 etal., 1998; Brunello etal., 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 2days after exposure
to the traumatic event and can last up to 1month. 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 soldiers 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
Self-Report Assessments
Recommended self-report assessment include:
Post Traumatic Stress Disorder Symptom ScaleSelf Report (PSS-SR;
Foa, Riggs, Dancu, Constance,& Rothbaum, 1993);
Impact of Events Scale-Revised (Creamer etal., 2003);
Posttraumatic Stress Diagnostic Scale (PDS; Foa, Cashman,
Jaycox& Perry, 1997).
Combat-Related Trauma
For combat-related trauma, we recommend:
PTSD Checklist-Military (PCL-M; Weathers etal., 1991);
Combat Exposure Scale (CES; Keane etal., 1989).
assessment of SUD. Share the results of both the initial and ongoing
symptom SUD assessments with the patient as part of the treatment.
Agood time to do this is mid-treatment (i.e., session 6)when you can
present, for example, a line graph of the patients substance use. Using
the Time Line Follow Back (TLFB) or other weekly assessment of substance use, therapists can chart the patients 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.
Interview-Rated Assessments
In order to diagnose SUD, we recommend:
Structured Clinical Interview for DSM-IV (SCID; First etal., 2002);
MINI International Neuropsychiatric Interview PTSD Module
(Sheehan etal., 1998).
Self-Report Assessments
For self-report assessments we recommend:
Alcohol Use Disorders Identification Test (AUDIT; Babor et al.,
2001);
Drug Abuse Screening Test (DAST-10; Yudko, Lozhkina & Fouts
2007);
Time Line Follow Back (TLFB; Sobell& Sobell, 1992)to assess frequency and intensity of use.
Biopsychosocial Assessments
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 etal., 2007).
10
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.
11
12
Prolonged Exposure
Prolonged exposure (PE) is a treatment program that has been shown to
be highly effective for the treatment of PTSD (Powers etal., 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.
13
14
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).
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.
16
18
19
21
Figure1.1
NIAAA Guidelines for Low-Risk Drinking.
Reprinted from National Institutes of Health, Rethinking Drinking:Alcohol and Your Health (2010).
22
23
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.
24
CHAPTER2
26
Session Structure
Each session consists of the following elements:
Review Homework
Homework is a powerful part of this treatment, because real-life situations can be utilized for practice, enhancing the likelihood that these
behaviors will be repeated in similar situations (generalization). Apreplanned homework exercise has been designed for each session of this
program. If necessary, however, homework exercises can be modified to
fit the specific details of individual situations more closely.
27
for recovery from the SUD. On rare occasions, the therapist may find
it necessary to begin the session with the SUD material, for example
when a lapse has occurred.
28
Assign Homework
Compliance with homework is often a problem in therapy in general,
and the therapist will need to be unrelenting in the pursuit to encourage patients to complete the homework and help them understand why
it is so important. Anumber of steps are taken to foster compliance:
While some patients are fine with the term homework, others
do not respond well to this term. Therefore, refer to the homework
using the patients preferred label, for example, assignment, task,
exercise, and so on.
When giving each assignment, provide a clear rationale and description of the assignment. Ask the patient what problems can be foreseen in completing the assignment, and discuss ways to overcome
these obstacles. Often having the patient designate a specific time
and place to work on the assignment will be helpful. Do not simply
give the patient the checklist and wish him well.
29
30
provide a sense of progress and accomplishment. You can also refer the
patient to the workbook that accompanies this therapist manual.
31
PTSD from the US Food and Drug Administration are two SSRIs:sertraline (Zoloft) and paroxetine (Paxil). Anumber of randomized controlled trials have found SSRIs to be superior to placebo, and most
studies of SSRIs have generally found a significant reduction in all
symptom clusters of PTSD (see Jeffreys etal., 2012). SSRIs are also considered useful agents because of their efficacy in improving comorbid
disorders such as depression, panic disorder, and obsessive-compulsive
disorder, and because of their relatively low side-effect profile.
Some patients may also present to treatment taking a psychotherapeutic medication for SUD. Medications such as naltrexone and acamprosate can be beneficial in reducing cravings. Such medications can
help stabilize the SUD and can be an important adjunct to the COPE
therapy. However, some medications such as anxiolytics or sedatives,
which are often used in detoxification, may impair the patients ability
to process trauma experiences. Adjunctive pharmacotherapy should be
discussed with a treatment team and managed on a case-by-case basis.
32
33
34
Address Avoidance
Avoidance is a hallmark of both PTSD and it is a huge part of SUD.
Expect that patients will struggle with urges to avoid coming to or
engaging in therapy. Address this issue with patients from the onset.
Normalize avoidance and encourage patients to be watchful for signs of
avoidant thoughts or behaviors that might hinder their success. It may
be necessary to revisit this issue during therapy if avoidance struggles
become obstacles to successful treatment (e.g., they no-show or arrive
late for sessions, continue to use alcohol and/or drugs to self-medicate
PTSD symptoms, are non-compliant with the homework, refuse to do
imaginal exposures).
in having made it through the trauma and for his courage in seeking
treatment at this time. When referring to the trauma, use the actual
trauma term (e.g., attack, bombing, IED, explosion, rape) instead of
the word trauma.
The therapist should also display a comfortable attitude when the
patients share detailed information about their substance use. Let them
know they can share openly and honestly throughout the treatment
and that you will not be shocked by their substance use or judge them.
Do not refer to such behavior as bad. Use the specific terms they use
to refer to their substance use (e.g., weed, dope, crack) as opposed to
generic substance use.
Preventing Attrition
For many reasons, attrition rates among PTSD/SUD patient populations are high. In the first session, it is important to anticipate potential
obstacles to successful treatment, especially factors that may lead to
early attrition. Explore any instances in which the patient previously
dropped out of treatment and advise her to discuss any thoughts of
quitting treatment with you before doing so. Such thoughts are not
uncommon, and open discussion can resolve problems before patients
drop out. Progress in treatment is not steady; ups and downs and
typical.
Some patients may want to quit treatment after their first lapse. Patients
should be warned that, even with efforts to maintain recovery, some of
them may lapse and begin using. At the first session, they should be
told not to come to treatment intoxicated, but they should be strongly
encouraged to continue to attend after a lapse so that they can receive
37
38
Ask patients to talk about any drug use that occurs and about any cravings or fears of relapse that they experience. Tell patients that it is common to have some ambivalent feelings about accepting abstinence as
a goal, and encourage patients to discuss these feelings as well as any
actual slips that might occur. Ask patients not to come to session under
the influence of alcohol or drugs because they would not be able to
concentrate on or recall the topics covered. Clearly explain the consequences of attending a session under the influence: In this program,
anyone found to be under the influence of alcohol and/or other drugs
is asked to leave the session. They are not allowed to drive themselves
home. Do so in such a way that patients do not view it as a punishment,
but rather as care for their safety. Anyone who is asked to leave should
be rescheduled and asked to return to the next session clean and sober.
Call the patient later that day or the next day to check in and to reassure him that you are looking forward to seeing him at the next session,
which will hopefully be within only a few days of the rescheduled session in order to prevent attrition.
39
Summary
Do:
Display confidence in the treatment and the patients ability to
dowell.
40
Alternative Treatments
At present, there are several integrated treatments available for patients
with PTSD and SUD. For a review, please refer to McCauley et al.
(2012), van Dam etal. (2012), and Torchalla etal. (2012).
41
will bring the workbook with them to each session. Patients will find
it extremely helpful to use the workbook to help review the rationale
for treatment and the rationale for exposure therapy, and to reinforce
the coping skills they have learned in session. In addition, the patient
workbook contains instructions and forms to help patients complete
the weekly homework assignments. You may photocopy forms from the
workbooks or download copies from the Treatments ThatWork website.
42
CHAPTER3
Session 1: Introduction
toCOPE
(Corresponds to Chapter3 of the Patient Workbook)
MATERIALS NEEDED
COPE Program Treatment Contract (Form 1 at the end of the
Patient Workbook)
Breathing Retraining (Form 2 at the end of the Patient Workbook)
Information for Significant Others (Forms 3, 4, and 5 at the end of
the Patient Workbook)
SESSION OUTLINE
1. Treatment overview
2. Information gathering
3. Development of treatment goals
4. Introduce Treatment Contract
5. Teach and model breathing retraining
6. Assign homework
1. Treatment Overview
Give the patient an overview of the structure of the treatment, cover
confidentiality issues, and review the PTSD and SUD treatment
components.
43
Therapist Note
Turn off your cell phone and ask the patient to do the same before you
begin each session, especially the sessions in which imaginal exposure is
conducted (sessions 411).
I am really glad that you have chosen to come to treatment. Today is our
first session together, and Iwould like to spend most of the session getting to
know you and asking you some questions about your experiences. I d like
to start by telling you about this treatment and seeing what questions you
might have. Does that sound okay to you? This treatment, called COPE,
is designed for people who have been through a traumatic event(s), have
posttraumatic stress disorder, or PTSD, and who are also struggling with
an alcohol or drug use problem. The main goal of this treatment is to help
you significantly reduce your PTSD symptoms and your alcohol or drug use
severity and thereby regain control over your life.
The treatment consists of 12 sessions. Each session lasts about 90 minutes.
We ll meet once a week, so the therapy will be completed in about 3months.
We will be talking about sensitive information, and Iwant you to know
that we can go at your pace, and that what you share with me will remain
confidential. The only two exceptions would be (1)if you were a harm to
yourself or someone else or (2)if there was any suspected child abuse. In
these situations, Imay have to breach confidentiality to make sure everyone
is safe.
I will be recording the therapy sessions so that you can listen to them at home
between our appointments. [If part of a research protocol, explain that your
supervisors may also review the recordings to assure that the therapy is being
delivered per protocol.]
If during the course of the treatment you have any thoughts about not wanting to finish the treatment, please talk with me first. We can work together
as a team to resolve any issues so that you can have the chance to finish
the entire treatment and get the full benefit of this program. The research
shows that the majority of individuals who complete this treatment have
significant improvements in both their PTSD symptoms and substance use
severity.
44
45
and digest what happened. We have found that repeated and prolonged
(3045 minutes) imaginal exposure, followed by brief discussion about the
experience, is very effective in reducing PTSD symptoms and helping you
get a new perspective about what happened before, during, and after the
traumatic event.
The second type of exposure is called in vivo exposure, which just means
approaching situations in real life that you avoid. Iwill work with you
so that you can gradually approach situations that you have been avoiding because they remind you of the trauma (e.g., driving a car, being in a
crowd, walking alone in a safe place, lighting a fire in the fireplace, leaving
your house at night). In vivo exercises have been found to be very effective in reducing excessive fears and avoidance after a trauma. If you avoid
trauma-related situations that are objectively safe, you do not give yourself
the opportunity to conquer your fear of these situations. This is because until
you approach these situations, you will continue to believe that they are
dangerous, or that you will not be able to handle them, or that your anxiety
in these situations will remain indefinitely.
However, if you approach these situations in a gradual, systematic way, you
will find that they are not actually dangerous, that you can handle them,
and that your anxiety will diminish with repeated, prolonged exposures.
This is the way that we naturally conquer our fearsby approaching them
and practicing them over and over again. Iwant to assure you that Iwill
not be asking you to approach any dangerous situationsonly those that
are safe.
Does the idea of exposure make sense to you?
In addition to avoidance, a second factor that maintains your PTSD
symptoms is the presence of unhelpful thoughts and beliefs. These beliefs
may be about the world in general, other people, yourself, or your reaction
to the trauma. As a result of trauma, many people adopt the belief that
the entire world is extremely dangerous. Therefore, even safe situations
are viewed as dangerous. Veterans who return home after a war can have
a difficult time adjusting and may feel unsafe in their own homes, their
neighborhoods, or their workplaces. While they were in the war zone,
their hyper-vigiliance and being on guard all the time kept them alive.
But on returning home, being on guard all the time when they are in
46
objectively safe situations does not protect them and only makes their lives
more difficult.
Also, after experiencing a trauma many people feel incompetent and unable
to cope, even with normal daily stresses. Trauma survivors may also blame
themselves for the trauma and put themselves down for having difficulty
coping.
Do you ever feel this way?
How do these thoughts and beliefs about the world and about yourself
maintain your PTSD? If you believe that the world is dangerous, you will
continue to avoid even safe situations. Resuming daily activities and not
avoiding trauma reminders will help you realize that most of the time the
world is safe and that most of the time you are competent.
This treatment will give you the opportunity to gain a more realistic perspective about what happened and what it means to you now, and will help you
recover from your PTSD. This doesnt mean you will forget about what
happened to you. Rather, you will be able to remember the trauma
without it causing you so much distress and interfering with your life.
47
What happens to your substance use when your PTSD symptoms get better? (e.g., do you use more, use less, or use about the same amount)?
Therapist Note
Acknowledge that the patient has been trying to cope by using whatever
means he knows how, and that while substance use may help reduce
PTSD symptoms in the short term, it actually serves to maintain the
PTSD and causes additional problems in the long term.
Up until now, youve been trying your best to cope in the ways that you
know how, but the symptoms are still there. Although it might have felt
like your PTSD symptoms were better when you used alcohol or drugs,
youve discovered that its only a short-term gain. In the end, using alcohol
or drugs only makes it worse by masking, not resolving, the issues or PTSD
symptoms. Once you are clean and sober, the memories, dreams, irritability, anxiety, and other PTSD symptoms are still there. In fact, they may
have even gotten worse, as we know that chronic substance use disrupts your
bodys natural stress response system (the hypothalamic-pituitary-adrenal
axis) and sleep cycles.
The treatment were using has been shown in numerous research studies in the United States, Sweden, and Australia to be very helpful in
improving substance use disorders and PTSD. This treatment uses the
most effective therapies to teach you how to manage memories about the
trauma without using alcohol or drugs. Instead of your substance use
and your PTSD symptoms controlling you, you will learn how to control
them. This will help you remember the trauma without it causing you so
much distress and interfering with your life. Importantly, you wont feel
that you need to use alcohol or drugs to cope. You will learn new, healthy
ways of coping.
We are going to work very hard together during these sessions to help you
move forward with your life. Its only 12 sessions, but it could mean a significant difference in the quality of the rest of your life.
How does that sound to you?
Do you have any questions or concerns?
48
2. Information Gathering
Therapist Note
If you have not done so already, it is important to formally assess PTSD
and substance use disorders. This may require spreading the material in
session 1 across two visits. Recommendations for assessment instruments
are found in Chapter1.
Expect that for some patients it will be difficult to talk about the
trauma, as well as the substance use. These issues are often associated
with shame and embarrassment for patients, and they may have a tendency to want to avoid discussing either topic, or minimize the substance use (amount, frequency, or severity of negative consequences).
Advise the patient that he may share as much or as little detail about the
trauma(s) as he feels comfortable with at this time. Adopt a nonjudgmental, nonconfrontational attitude, and display a comfortable attitude when the patient describes his trauma history and substance use.
It is also important to know the following about the patient:
1. Overall level of functioning (e.g., employment, any major medical
problems, current medications, current housing situation, relationship status, social support);
2. Substance abuse history (e.g., when did the patient first start using
alcohol or drugs, what is her substance of choice, what problems
has she experienced as a result of substance use, previous treatments
and detoxifications, how often and what substances does she use,
previous substance abuse treatment and the outcome(s), family history of drug or alcohol use disorders, does the patients significant
other use alcohol or drugs); and
3. Trauma/PTSD history (e.g., age of trauma(s), type of trauma(s), whether
or not the patient disclosed the trauma to anyone previously and what
the response was, previous treatment for trauma/PTSD). Substitute a
specific term (e.g., car accident, rape, bombing, shooting, explosion)
instead of the word trauma when possible.
49
Therapist Note
Expect that most PTSD/SUD patients will present to treatment with a
history of multiple traumas. In our experience, single traumas among
this patient population are rare. For example, data from a recent
randomized controlled trial examining the COPE treatment among
103 PTSD/SUD patients in Sydney, Australia, showed that all of the
patients reported exposure to multiple traumas. The median number
of different types of traumas experienced (e.g., physical assault, sexual
assault) was 6 (range 210), with the first trauma occurring at approximately 8years of age (Mills etal., 2012).
For patients with multiple traumas, determine which event is the
index trauma, that is, the traumatic event that is causing most of
the patients avoidance and re-experiencing symptoms, and interfering
the most with her life. The index trauma should be the primary focus
of treatment. Research demonstrates that targeting the worst trauma
results in generalization of symptom reduction related to other traumatic events the patient has experienced. In some rare cases, up to two
different traumatic events can be addressed during the treatment. It
is very important, however, to work through the worst trauma first
and see significant reductions in PTSD symptoms related to the first
trauma, before moving on to a second trauma. Better to obtain full
resolution to the index trauma than to obtain only marginal resolution
to two different traumas.
Therapist Note
During this first visit, assess the need for medically supervised detoxification from substances. If detoxification is required, have the patient
obtain detoxification before beginning the COPE treatment.
See Appendix Aat the end of this Therapist Guide for the Information
Gathering Form to help organize the patient information.
What I would like to do for the rest of the session, if its all right, is
talk with you about some of your experiences related to the trauma that
is most distressing, but also about other traumas that you experienced.
Iwould also like to find out more about your substance use history so that
we can tailor the treatment to best meet your needs. Iwill be asking you
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some sensitive questions and Iunderstand that it may be difficult for you
to talk about some things. We can go at your pace and you can tell me as
much or as little as you feel comfortable with today. We will also identify
the beginning of the traumatic event and the end, when you either did
not feel in danger anymore or that there was a temporary relief. If there
is anything that Ican do to make it easier for you, please let me know.
Iam here to help you through this. At the end of todays session, we ll
develop your specific treatment goals and I will teach you a breathing
relaxation exercise.
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Specific
Measurable
Attainable
Realistic
Timely (i.e., have a time frame).
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Attendance
Cancellations must be made in advance, and the patient must have
a good reason to cancel. If a patient does not come for a scheduled
therapy session, the therapist should immediately attempt to contact
him to ascertain why the session was missed and to reschedule.
Consistent attendance should be emphasized as it predicts better outcomeshe will have better results and will achieve them more quickly
the more adherent he is with therapy. You can use the analogy of working out at the gym; the more he goes and trains his muscles, the faster
he will get in shape and the stronger he will be. The same holds true for
training the mind during therapy.
Promptness
Therapists should convey the attitude that time in sessions is too important to waste by being late. Therapists must assure that enough time
(e.g., 45 minutes) is allowed to complete essential components of each
session (e.g., the imaginal exposures). Otherwise, the therapist should
reschedule within the next few days.
Completion of Homework
One of the ways in which this treatment works is through the homework exercises. The exercises give the patient the chance to practice and
master specific skills necessary for her to reduce PTSD and substance
abuse severity. The patient, therefore, must agree to complete practice
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abdomen and the other hand on your upper chest. If you are doing the exercise correctly, the hand on your chest will not move much; only the hand on
your abdomen will as you inhale and exhale.
When doing this exercise, some people like to also say a word to themselves,
such as c-a-a-a-a-a-a-l-m or r-e-e-e-e-e-e-l-a-x.
An important benefit of this technique is that you can do it anywhere, anytime. When in public, you can simply focus mentally on the rise and fall of
your abdomen without placing your hand there; people will not know that
you are doing the exercise but you will know because you will feel calmer
and more in control.
Therapist Note
See Form 2 at the end of the Patient Workbook, which covers breathing
retraining.
6. Assign Homework
PTSD/SUD patients often have chaotic lives. Help patients organize
their treatment by referring them to the Patient Workbook, which
contains all of the handouts, worksheets, and homework checklists for
patients to use. Ask patients to bring the Workbook with them to each
session. If a patient is unable to obtain a copy of the Patient Workbook,
consider obtaining one for your practice or clinic and then make copies of the relevant homework checklists and handouts for each session. Provide the patient with a folder in which she can organize these
materials.
Explain to patients that homework is a key part of treatment. The exercises are designed to help them master the techniques discussed and to
help them transfer what they learn in the therapy room to the world
outside the therapy room.
Research shows us that patients who do more homework see more
improvements. Emphasize that you would not assign the homework
exercises if they werent a critical part of the patients recovery.
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Therapist Note
Emphasize the importance of completing the homework exercises without being under the influence of any substances (e.g., alcohol, marijuana,
prescription opiates).
Acknowledge that the patient may think about or want to use alcohol
or drugs before, during, or right after the exercises (especially once the
in vivo and imaginal exposure exercises start in sessions 3 and 4)and
that these feelings are normal, but encourage the patient to complete
the exercises sober, noting that the benefits of the exercises will be lost
if he is under the influence of alcohol or drugs. If patients have questions or need help problem-solving obstacles that are getting in the way
of completing their homework, encourage them to call you between
sessions.
Direct the patient to Forms 1, 2, 6, and 7 at the end of the Patient
Workbook. Assess the need to use Forms 3, 4, and 5those directed
to significant others.
Sometimes people have significant others or loved ones who do not have a
good understanding of PTSD or substance use disorders. If that is the case
for you, we have some materials that may help.
You may also offer to include the patients significant other in part of
a therapy session if the patient thinks it would be helpful. This will be
more beneficial if done early on during the course of treatment. The
focus would be on helping the significant otherto:
1. Understand what PTSD and SUD are;
2. Understand what he or she can do to help the patient successfully complete the treatment (e.g., helping him find the time and
a private space to listen to the recordings each week, not having any substances in the house, not using substances in front of
the patient, providing transportation, taking care of the children
while the patient is at therapy appointments, exercising with the
patient); and
3. Understand what she can do for her own self-care (e.g., time with
friends, good nutrition, talking with a therapist).
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Therapist Note
Note that we do not recommend having patients watch video recordings
of the sessions. We recommend audio recordings. Video recordings would
likely be distracting and patients would avoid hearing and processing
the content of the session by focusing on what they looked like, their
behavioral mannerisms, what they were wearing, and so on.
Refer the patient to the homework checklist at the end of Chapter3
in the Patient Workbook, and make sure the patient understands
how to complete the homework. If he has questions or needs help
problem-solving obstacles to completing the homework, encourage him
to call you during the week.
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CHAPTER4
Session 2: Common
Reactions to Trauma
andCraving Awareness
(Corresponds to Chapter4 of the Patient Workbook)
MATERIALS NEEDED
10 Common Reactions to Trauma (Form 8 at the end of the Patient
Workbook)
Daily Record of Cravings (Form 9 at the end of the Patient Workbook)
Facts about Cravings (Form 10 at the end of the Patient Workbook)
Guidelines for Better Sleep (Form 11 at the end of the Patient
Workbook)
SESSION OUTLINE
1. Review PTSD symptoms and any substance use since last session
2. Review homework
3. Overview of common reactions to trauma
4. Craving awareness
5. Assign homework
Therapist Note
Remember to turn off your cell phone and ask the patient to do the same,
and remember to start the audio recording device to record the session.
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1. Review PTSD Symptoms and Any Substance Use Since Last Session
Before beginning each session, have the patient complete an assessment
of his PTSD symptoms and substance use in order to monitor treatment progress (see Chapter 1 for recommended instruments). Each
week you will want toknow:
Whether the patients PTSD symptoms are getting worse or better,
and what specific symptoms he is endorsing, and
Whether the patients substance use is increasing, decreasing or staying the same.
We recommend a urine drug screen (UDS) and breathalyzer test before
each session. If used, frame the UDS and breathalyzer as a way to help
motivate the patient and to help him get the most out of the program,
and as a way to provide objective data on his progress, but not as a way
of punishing or distrusting him.
Therapist Note
If any substance use did occur since the last session, praise the patient
for sharing it with you and then help him learn from it so it can be
prevented in the future.
What were the specific triggers (e.g., did he run into a former using
buddy, was he feeling angry, did he have an argument with his partner,
did he get fired from his job)? Identify the thoughts, feelings, behaviors,
and circumstances that led up to the patient using. How did the patient
try to cope with the situation? Explain to the patient that lapses are
common in the recovery process and discuss the difference between a
lapse and a relapse. If the patient uses on one occasion but then gets right
back on the wagon, this is a lapse. However, if the patient returns to
his previous level/frequency of uncontrolled use, this is a relapse. The
distinction is useful because there is often more shame and feelings
of personal failure attached to a relapse than a lapse. If the amount
of shame or failure is viewed as being the same for having one drink
as it is for going on a week-long binge, why not go for the full binge?
The notion of a lapse helps protect against the abstinence violation
effect (i.e., the patient has one drink, which was in violation of his goal
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2. Review Homework
Find out if the patient practiced the breathing retraining, if it was
useful, and if there were any problems implementing the technique.
Discuss the patients reaction to listening to the recording of the session. If the patient did not complete the homework, inquire about the
obstacles and help the patient problem-solve.
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situation. You may experience changes in your body, feelings, and thoughts
because your view of the world and perceptions about your safety have
changed as a result of the trauma.
Sometimes anxiety may be a result of being reminded of the trauma. These
triggers may be, for example, certain times of the day, certain places, situations, activities, strangers approaching you, movies you watch, a certain
smell or a noise.
What specific triggers have you noticed that remind you of [name of specific incident]?
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make you more vulnerable to using substances to try and relax, or to try to
stay vigilant.
What kinds of situations make you feel on guard (e.g., being in crowded
stores, sitting in the middle of a restaurant, driving a car)?
Do you have trouble sleeping?
Do you use alcohol or drugs to try to help you sleep?
If the patient reports sleep problems, refer her to the Guidelines for
Better Sleep (Form 10 at the end of the Workbook). You may also want
to refer the patient to a sleep specialist for more in-depth evaluation
and management. Sleep is a salient trigger for substance use and needs
to be adequately addressed and treated. Chronic alcohol and drug use
serves to disrupt healthy sleep cycles. If necessary, encourage the patient
to pursue a medication evaluation with her doctor for a non-addictive
sleep medication.
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Suicide Assessment
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natural human tendency, these feelings of guilt can lead to other negative
feelings or depression, and negative thoughts about yourself, all of which
can limit your ability to recover from PTSD and addiction. Blame can
come from society, friends, family, and acquaintances because, unfortunately, many times people place responsibility on the person who has been
hurt and victimized.
Have you been experiencing feelings of guilt or shame?
Do you believe that if you had or had not done something, the traumatic
experience could have been avoided?
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Therapist Note
Anger may be particularly relevant for military personnel and Veterans.
Some military personnel and Veterans may believe that the only emotion
that is acceptable to feel or express is anger. Thus, anger may be used to
mask other less acceptable feelings, such as fear, guilt, or shame.
Military personnel and Veterans may be angry, for example, because
of actions they committed during combat that were necessary in order
to protect themselves or their comrades; as a result of how the leadership responded or failed to respond to certain situations; at themselves
for being weak or not being able to protect their family, friends, or
fellow soldiers; and at themselves for not being able to control their
substanceuse.
Have you had strong feelings of anger or irritability?
Are those feelings related to [name of specific incident]?
Do you sometimes use alcohol or drugs when you get angry, or to try to
stay calm and not get angry?
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the trauma may serve to confirm the belief that the world is in fact a dangerous place and no one can be trusted.
Have you had negative thoughts about others or the world in general?
4. Craving Awareness
Review with the patient what a craving is and how long cravings typically last. Elicit the patients definition of a craving.
Therapist Note
Normalize cravings so that the patient is neither caught off guard when
they occur nor feels like treatment is not working because he or she experiences a craving.
Emphasize that cravings, like anxiety, are time-limited and behave like
a wave. They rise, peak, and then come down. Although it may feel like
it, cravings do not last forever. They will come down over time naturally, without the use of alcohol or drugs.
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I d like to spend the rest of our time today talking about cravings since
they are a key part of substance use disorders and recovery.
What Is a Craving?
Youve heard the word craving before. How do you define a craving?
How often do you experience cravings?
How often do your cravings typically last?
A craving can be defined as a strong desire or urge to use alcohol or drugs.
Cravings are a key feature of substance use disorders and something that
everyone in recovery experiences. Cravings may be uncomfortable, but they
are a normal part of recovery. You should expect cravings to occur from
time to time and be prepared to manage them. Cravings are most often
experienced early in treatment, but its quite normal for episodes of craving to occur weeks, months, and sometimes even years after a person stops
using.
When you have a craving, its very important to remember that cravings,
like anxiety, are time-limited. They do not last forever. They usually
last less than 15 minutes. Cravings are like a wave in the ocean; they
increase steadily, peak, and then die down. Although in the moment
it may seem like a craving will never go away and that it will only get
stronger and stronger unless you use, this thought is not true. Cravings do
pass. The goal will be to find healthy ways to ride out the wave.
Cravings will become less frequent and less intense as you learn how to
effectively manage them. Each time you do something other than use alcohol
or drugs in response to a craving, the craving will lose its power and you
will regain yours. Using occasionally will only serve to strengthen cravings
and keep them alive. You can think of cravings like a stray catif you keep
feeding it, it will keep coming back. If you ignore the stray cat and never
feed it, it will indeed go away and will come around less and less often in
the future. If you feed it every now and then, it will keep coming back and,
in fact, it will make it even harder to get rid of that stray cat. Does that
make sense?
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Therapist Note
Sometimes a patient will deny experiencing any cravings. She will simply say, I dont have cravings. In this case, you want to review
the definition of a craving. Emphasize that cravings are related to
thoughts (e.g., That cold beer sure does look good) and that having a thought about wanting to use could be considered a craving.
Some patients react negatively to the word craving. If this is the
case, find another agreeable term (e.g., thoughts about using, wanting to use, desire). Finally, try to relate craving to something other
than alcohol or drugs (e.g., ever had a craving to eat chocolate, or a
craving for french fries)? You can also ask her to think about the last
time she used, slow down the thoughts, and help her to analyze what
led up to her use. Generally, you will be able to identify some level
of craving, or desire, to use.
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The easiest way to deal with triggers for substance use is to stay away from
them whenever possible (e.g., getting rid of all drugs and alcohol in your
house, not going to bars or restaurants that serve alcohol, reducing contact
with people who use).
What places do you need to stay away from?
What people do you need to stay away from?
Do you have alcohol or drugs in your house? If so, when and how could
you dispose of it?
5. Assign Homework
Refer the patient to the homework checklist at the end of Chapter4
in the Patient Workbook, and make sure the patient understands
how to complete the homework. If he has questions or needs help
problem-solving obstacles to completing the homework, encourage him
to call you during the week.
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CHAPTER5
Session 3: Developing
the In vivo Hierarchy
andCraving Management
(Corresponds to Chapter5 of the Patient Workbook)
MATERIALS NEEDED
SUDS Distress Thermometer (Form 12 at the end of the Patient
Workbook)
In vivo Hierarchy (Form 13 at the end of the Patient Workbook)
Pleasant Activities Checklist (Form 14 at the end of the Patient
Workbook)
Craving Thermometer (Form 15 at the end of the Patient Workbook)
Coping with Cravings Plan (Form 16 at the end of the Patient
Workbook)
Patient In vivo Exposure Data Form (Form 17 at the end of the
Patient Workbook)
SESSION OUTLINE
1. Review PTSD symptoms and any substance use since last session
2. Review homework
3. Discuss prolonged exposure procedures and construct the in vivo
hierarchy
4. Managing cravings
5. Assign homework
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1. Review PTSD Symptoms and Any Substance Use Since Last Session
Review the patients weekly PTSD and SUD assessments. If any alcohol or drug use has occurred since the last session, praise the patient
for discussing it, and then help the patient learn from it by identifying
triggers associated with the use (see session 2)and alternative, healthier
ways to respond in the future.
2. Review Homework
Did the patient complete his homework? If not, explore obstacles
and problem-solve ways to overcome those obstacles in the following
week. You may want to help the patient get started on the homework in session in order to ensure that he understands how to complete the homework, and to emphasize the importance of doing the
homework.
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Anxiety
Time
Figure5.1
This figure demonstrates what typically happens when the patient leaves a safe, but
anxiogenic situation, and how it prevents the patient from learning that the anxiety
will decrease naturally over time if she or he remains in the situation.
Anxiety
Over time,
anxiety becomes
less intense and
lasts for shorter
periods of time
Time
Figure5.2
This figure demonstrates how anxiety will become less intense over time and will last
for a shorter period of time as the patient repeatedly approaches these situations.
Use an example to help the patient understand the rationale. You
can use one of these examples or another that is more relevant to the
patients trauma.
Awoman developed a fear of driving over [insert the name of a local
bridge] after having an accident there. This fear began to cause many
problems, since she became unable to drive to work. Each time she
approached the bridge she began to breathe heavily and started to
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think about the bridge collapsing and ending up in the river. With
the help of a supportive therapist, the woman practiced driving over
other bridges every day. Within 2 weeks, she was able to cross the
bridge she feared with a friend following behind her in a different
car. By the end of 4 weeks, she was able to drive over the bridge
herself.
A soldier returned from a deployment in Iraq. While on a scouting
mission in Iraq, a roadside bomb exploded and killed his comrades
who were in the vehicle just ahead of him. Upon returning home he
subsequently avoided driving on highways or walking near building
sites because he thought there might be bombs there. He also avoided
crowded places. Instead he usually stayed home and smoked marijuana
and drank alcohol to help calm his nerves. With the help of a therapist,
they developed a list of situations for him to approach. First he would
sit on his front porch with his wife and watch people and cars pass in
front of the house. Then he sat on the porch by himself and watched the
traffic go by. Following this, he and his wife drove around the perimeter
of the neighborhood. Next they went to a small local supermarket and
walked around. Finally, he was able to drive to the store by himself and
walk around. He learned to do all of this without using alcohol or drugs
to calm his nerves.
We will begin with easier situations and progress toward more difficult situations. The goal is to stop avoiding situations that are realistically safe. We
are going to work together to make a list of situations that you have been
avoiding since the trauma.
Therapist Note
For patients who report that they have been approaching feared situations already in an unsystematic manner and their anxiety does not
decrease, it may be useful to clarify the distinction between occasional,
brief exposures (which may be under the influence of substances at times)
and therapeutic exposures:deliberate, repeated, sober, prolonged exposure to the feared situation. Explain that only the latter is effective in
ameliorating phobia or excessive fear, and that together you and your
patient will take a look at how he has been trying to face fears, with the
aim of figuring out what is interfering with habituation.
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That said, there may be times when a safe in vivo situation triggers a
craving simply because it is a stressful situation, not because it was associated with substance use in the past. For example, a patient who avoids
crowded areas could be walking through a crowded shopping mall and
become distressed, which is a normal and expected part of in vivo exposures, and start thinking about how a drink would help to calm her
nerves. If the patient is in a stressful, but safe situation and she experiences a craving, encourage her to stay in the situation long enough
to experience the decrease in both anxiety and craving. Remind the
patient that anxiety and cravings are like waves. They increase, peak,
and then decrease over time. If concerned about a particular situation
when constructing the in vivo hierarchy, ask the patient how she thinks
the in vivo situation would affect her craving or urge to use.
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Therapist Note
Patients should experience sufficient reduction in anxiety during the in
vivo situation before advancing to a more anxiety-provoking situation
on their hierarchy list. For example, if the patient approaches a situation
with a SUDS rating of 60 but does not experience a 50% or greater
reduction in anxiety, she should stay with this exposure until the SUDS
goes below 30 before advancing to a situation that evokes a SUDS rating of 70.
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On the other hand, if you stay in the situation and you realize that you are
not really in danger, your anxiety will naturally decrease and eventually
you will be able to enter the situation without fear. It is important not
to use any alcohol or drugs while you are doing the in vivo exercises.
Otherwise, you will not have the chance to learn that you can do this. You
will attribute any success to the alcohol or drugs, not to yourself. The more
frequently you practice each situation on your list, the faster you will reach
the point at which you will stop being anxious in those situations. As a
result, you will feel less of an urge to avoid situations that are distressing for
you. You should do each assigned in vivo situation 2 to 3 times a week.
Changing other factors such as the time of day or the location of the
exposure may also decrease the distress associated with the exercise to a
manageable degree. When the patient has mastered the modified, and
relatively easier, exposure situations, she can move on to the one that
she could not approach originally, and then can move on to more difficult exposures.
Occasionally, as treatment progresses, a patient may not experience
the expected fear reduction despite what appears to be systematic
and repeated exposure. In these cases, it is helpful to look closely at
what the patient is actually doing during the in vivo exposure exercises. Ask the patient exactly how he is carrying out the exposure,
how long it lasts, and when he ends it. Is the exposure of sufficient
duration? Or is the patient escaping the situation while still highly
anxious? Also look for subtle avoidance and safety behaviors, such
as shopping only when the stores are not crowded, always choosing
a female clerk or cashier to deal with, carrying a weapon for protection, having a drink before the exposure exercise, or scanning the
environment constantly.
To help identify these possible avoidance behaviors, you can ask the
patient What do you do to make yourself feel safe? These behaviors
interfere with fear reduction by maintaining the patients perception
that he was not harmed only because of the protective measures
taken, or that he was able to complete the in vivo exposures only
because he had a drink first. This perception, in turn, prevents the
patient from learning that the situations are actually not dangerous
and that he is competent enough to handle them. If safety behaviors
are identified, explain to the patient how these avoidance behaviors actually serve to maintain fear and trauma-related, unrealistic
beliefs.
4. Managing Cravings
Review the patients triggers and discuss skills for managing cravings.
You will be introducing the Craving Thermometer (Form 15 at the end
of the Patient Workbook) and the Coping with Cravings Plan (Form 16
at the end of the Patient Workbook) during this discussion.
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Figure5.3
Sample Chain of Events.
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just a want? (You need air, water, and food). Whats the evidence that
you will die if you do not smoke a joint? (Has anyone ever died from not
smoking a joint?) Will using really make you feel better? (Perhaps for a
few hours, but then what?) Can you really use just one? (When youve
tried that in the past, how did it work out?)
i. Urge surfing. Many people try to cope with their urges by gritting their
teeth and toughing it out. Some urges, however, are just too strong to
ignore and you cannot be distracted. When this happens, it can be useful
to try a different approach, and step back and observe the urge or craving until it passes. This technique is called urge surfing. It is a more
mindful coping skill and focuses less on running from the craving and
more on sitting with and tolerating it. It can help teach you to tolerate
the sensations and feelings associated with cravings, without reacting to
them. The purpose of this technique is not to make the craving go away,
but to help you learn a new way of experiencing and relating to your
cravings. If you practice urge surfing regularly, you will learn how to
ride them out until they go away naturally.
1. Urges are a lot like ocean waves. They are small when they start,
grow in size, peak, and then disappear.
2. You can imagine yourself as a surfer who will ride out the wave, staying on top of it until it crests, breaks, and turns into less powerful,
foamy surf.
3. The idea behind urge surfing is similar to the idea behind martial
arts. In judo, one overpowers an opponent by first going with the
force or the attack. This technique of gaining control by first going
with the opponent also allows one to take control while expending
minimal energy. Urge surfing is similar. You can initially sit with an
urge (as opposed to meeting it with a strong opposing force) as a way
of taking control of it.
4. To practice urge surfing, you want to step back and observe the
craving. Take an inventory of how you experience the craving.
Notice the sensations and that changes that occur in your body.
Pay attention to and notice how the urge comes and goes. Cravings
change and do not last forever. They will pass. Many people, when
they urge surf, notice that the craving has passed after only a few
minutes.
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Therapist Note
Practice this technique with your patient in session first before he tries it
alone. After patients have practiced urge surfing several times and have
become familiar with it, they may find it a useful technique when having a particularly strong urge to use.
Note that urge surfing is a technique that can also be used when dealing
with anxiety, PTSD symptoms, and/or during the in vivo homework
exercises. Just like cravings, anxiety behaves like a wave, increasing
steadily and then decreasing and disappearing over time. Encourage
the patient to see this link between anxiety and craving, and ride out
the wave of both cravings and anxiety using this technique. By doing
so, patients can increase their level of tolerance for anxiety.
After the craving has passed, congratulate yourself for successfully managing the craving. Know that it will get easier with time as you continue to
practice these healthy coping strategies. After a while, sobriety will feel less
unnatural, and cravings will occur less often and will be less intense when
they do occur.
5. Assign Homework
Refer the patient to the homework checklist at the end of Chapter5
in the Patient Workbook, and make sure the patient understands
how to complete the homework. If he has questions or needs help
problem-solving obstacles to completing the homework, encourage him
to call you during the week.
Show the patient how to record SUDS and craving during in vivo
exercises on the Patient In vivo Exposure Data Form, which can be
found as Form 17 at the end of the Patient Workbook. Emphasize to
the patient the importance of undertaking in vivo exposure exercises
between sessions. Completing in vivo exposures between sessions will
maximize the opportunities for habituation and will disconfirm cognitions about feared outcomes. Patients who complete the in vivo exercises will see greater benefits from therapy and will start feeling better
faster. Emphasize that the homework would not be included if it were
not such a critical part of treatment.
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CHAPTER6
MATERIALS
In vivo Hierarchy Form started in session 3
Patient In vivo Exposure Data Form (Form 17 at the end of the
Patient Workbook)
Patient Imaginal Exposure Data Form (Form 18 at the end of the
Patient Workbook)
Therapist Imaginal Exposure Recording Form (Appendix C at the
end of this Therapist Guide)
SESSION OUTLINE
1. Review PTSD symptoms and any substance use since last session
2. Review homework
3. Discuss imaginal exposure rationale
4. Conduct the first imaginal exposure
5. Process the imaginal exposure
6. Assign homework
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1. Review PTSD Symptoms and Any Substance Use Since Last Session
Review the patients weekly PTSD and SUD assessments. If any alcohol
or drug use has occurred since the last session, discuss this as described
in session 2.
2. Review Homework
Did the patient complete his homework? Review each homework form
with the patient. If homework was not completed, explore obstacles and
problem-solve with the patient.
Review the Patient In vivo Exposure Data Form with the patient
and scan for patterns of change in distress ratings (SUDS) or evidence of habituation. Ask the patient what he learned from doing
the invivo exposures and how helpful the exposures were. Pay attention to any safety behaviors that the patient may be using in the
in vivo exercises (e.g., alcohol or drug use before or during the exposure, distracting himself during the exposure, carrying an object or
weapon that he feels will protect him). Congratulate the patient for
his effort to face difficult situations and give him ample praise. Help
the patient plan the next in vivo exposures without using any safety
behaviors. Pay particular attention to any substance use before, during, or immediately after exposures. Assign the next in vivo exercises
at this time.
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understand why Iam asking you to do this and how this technique is going
to help you recover from your PTSD, so please feel free to ask me questions
or ask me to repeat something if you dont understand, okay?
a. Organizing the Memory. First, revisiting the memory repeatedly helps
organize the memory and get a new perspective about what happened during and after the trauma. By staying with the memory, you will begin to
make sense of the trauma so that it wont feel as confusing and dangerous. Revisiting the memory also helps you to fully digest the trauma.
For example, suppose you have eaten a very large and heavy meal and
now you have symptoms such as stomachache, nausea, and indigestion.
These symptoms will stay with you until you have digested and processed the
meal. Nightmares, flashbacks, and troublesome thoughts continue to occur
because the traumatic memory has not been fully digested. Today you are
going to start to digest and process your painful memory. The way to digest
and process a traumatic memory is to invite the memory and talk about it.
b. Discrimination. Revisiting the memory over and over again will help
you discriminate between the trauma itself and the memory of the trauma.
It will help emphasize the difference between then and now. It will help
you realize that the trauma happened in the past, and that now is not the
past, even if you think about the trauma today. While real danger did exist
during the trauma and there was a reason to be anxious and scared, the
memory of the trauma is not dangerous. Being raped or being in combat is
dangerous; but talking about rape or combat is not. By revisiting the memory you will learn that the memory cannot harm you. It is only a memory.
c. Getting Used to the Memory (Habituation). Continuous revisiting of
the trauma will reduce your anxiety and will teach you that anxiety does
not last forever and that you do not need to run away from the memory
in order to reduce your fear and anxiety. We call this habituation. The
more you revisit the full trauma memory, the better this process will work.
Repetition is necessary to get used to the memory and to decrease anxiety.
For example, you can think of it like watching a very scary movie. The first
time you watch the scary movie, it is very upsetting; you are frightened and
you may try to turn it off, cover your eyes during the most horrific parts, and
so on. However, if you watch the entire movie over and over again, at some
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point its no longer as scary. If fact, it may even become boring. You can
think about it and watch the movie without it causing so much distress. The
memory of the trauma will never be pleasant, but by repeatedly revisiting it
over and over again you will learn to tolerate and manage it, without alcohol or drugs, and the memory will no longer disrupt your life as it has been.
d. You Do Not Go Crazy. You may worry that revisiting the trauma
memory will make you fall to pieces or go crazy. The fear of losing control
is understandable and natural, but one of the things you will learn when
you revisi the memory is that, despite the temporary increase in the level of
anxiety, you will not fall to pieces and you will not go crazy. You will learn
that you are stronger than you think.
e. Increasing Mastery and Sense of Control. The more you practice
revisiting the trauma memory, the more your sense of control and confidence will increase. You will discover that you have the power to overcome
anxiety, as well as other obstacles in your life, and you will feel progressively better about yourself as you stop avoiding your fears and begin to
master them. You will be able to remember the trauma when you want
to and to put it aside when you do not want to think about it. You
will be in control of the traumatic memory instead of it controlling you.
Finally, you will learn that you do not need alcohol or drugs to cope with
the memory; as you have discovered, it does not really help. As you stop
self-medicating with substances and start managing the memory using
healthier coping skills, you will gain a greater sense of control in your life
and more confidence.
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event in the present tense with eyes closed will increase the vividness
of the imagery, and thereby increasing emotional engagement with the
memory. In our experience, we believe it is more beneficial to focus on
the level of detail that the patient brings out when revisiting the trauma
memory, as opposed to the number of times the patient repeats the
memory (e.g., quality over quantity of repetitions). However, tell the
patient that if the memory is short you will ask him to repeat the memory until the time allotted for the exposure is over. If a patient refuses
to close his eyes, do the imaginal exposure with eyes open, but ask the
patient to look down so that eye contact with you will not interfere or
distract him from the memory.
SUDS ratings of distress should be taken immediately prior to, every
5 minutes during, and immediately following the imaginal exposure. Record the SUDS ratings on the Therapist Imaginal Exposure
Recording Form (Appendix C at the end of this Guide). These ratings
will enable you to identify changes in distress levels associated with specific parts of the memory and to monitor the patients level of emotional
engagement with the memory. When the patient does not engage emotionally at all, this means that the memory has not been fully evoked
and the patient will not benefit enough from the imaginal exposure.
When arousal is too high, the experience can be overwhelming. SUDS
levels of 90 or even 100 are not uncommon. These levels are acceptable
as long as the patient does not show signs of loss of control or dissociative experience.
Record the patients craving immediately before and after the imaginal exposure (also on a scale of 0100; 0=no craving to 100=extreme
craving; see the Craving Thermometer, which is Form 15 at the end of
the Patient Workbook). Recording craving can help demonstrate how
the trauma memory and the craving for alcohol or drugs are related,
and how these cravings decrease during and between sessions over
time. Furthermore, recording craving at the end of the exposure helps
the therapist monitor risk for any potential increase in thoughts or
desire to use that may need to be addressed before the patient leaves
the office.
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During this initial exposure session, take note of hot spots (i.e., the most
distressing parts of the memory). Evidence of hot spots includes increased
SUDS ratings or overt signs of increased distress (e.g., crying), hesitation,
the use of patchy speech patterns, or obvious attempts to skip over parts of
the memory. These hot spots will be addressed in future sessions.
Use the SUDS ratings to guide the use of such probes:If they are too
low, probe for more detail; if they are too high, stick to reassuring
comments.
Therapist Note
Note that if the patient spontaneously includes this information, it is not
necessary to ask these questions. Be careful not to overuse probes or to
interrupt the patient too much during the imaginal exposure.
If the patient is not fully engaged, ask him to keep his eyes closed
(unless he finds this unbearable). Guide the patient immediately back
to the present tense if he reverts to the past tense. Continuing the exposure with his eyes open or recounting the memory in the past tense may
be a form of avoidance.
Therapist Note
After approximately three sessions of imaginal exposure and after some
reduction of anxiety has occurred, focus on the hot spots or those parts
of the trauma that are most distressing. The patient may identify the
distressing parts of the trauma, or the therapist may have taken note of
the hot spots in previous sessions. These will be revisited in a repetitive
fashion (as many as 612 times) during a single session. We describe how
to do that in session6.
It is also not uncommon that a patient remembers other distressing
traumatic events during the course of the imaginal exposure sessions.
The therapist can move on to a second traumatic event only when the
patient has sufficiently processed the presenting event. Err on the side
of caution and stay with a single trauma long enough to ensure that the
patient has truly processed it and has habituated to the memory before
moving on to another trauma memory. Remember that avoidance
among PTSD/SUD patients is strong, and some patients (and therapists) may wish to proceed to the next trauma because of the distress
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that the memory generates. Typically, therapy will focus on one trauma
memory, but a maximum of two is recommended.
Therapist Note
During the last sessions, most patients should evidence SUDS ratings
during imaginal exposures to range from 1020. Other patients may
continue to rate their SUDS as moderately high throughout treatment.
In such cases, pay more attention to other indicators of improvement
(i.e., a decrease in PTSD and depression symptoms, reduced or no substance use). If appropriate, discuss the discrepancy between the high
SUDS and the other indicators of distress and recalibrate the SUDS
ratings if needed.
Therapist Note
In the last few imaginal sessions (i.e., sessions 10 and 11), when the hot
spot work is completed, have the patient bring it all together by revisiting
the entire trauma memory again, from beginning to end.
Therapist Note
Here is a guide for the focus of imaginal exposures in sessions 411:
Session 4:Initial imaginal exposure. Revisit entire trauma memory.
Session 5:Revisit entire trauma memory and provide more details.
Session 6: Revisit entire trauma memory and provide even more
details.
Session 7: Revisit entire trauma memory and provide even more
details OR begin to focus on a hot spot.
Session 8:Focus on a hot spot.
Session 9:Focus on a hot spot.
Session 10:Revisit entire trauma memory again.
Session 11:Final revisiting of entire trauma memory.
Do:
Create a supportive atmosphere.
Provide clear instructions for the imaginal exposure.
Encourage the patient with brief, supportive remarks as needed.
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Answer any questions the patient has, but begin the imaginal exposure as soon as possible, since the patient may be increasingly anxious
until it begins. Have the patient recount the traumatic memory for
at least 30 minutes without interruption. When the patient ends one
recounting, tell her, Youre doing great. Now I want you to go back
to the beginning. So youre walking down the street...Tell me whats
happening now, and let the patient begin to go through the memory again. Do not engage in discussion with the patient between the
revisitings; have the patient repeat the full memory over and over
again without stopping to talk about it until at least 30 minutes have
passed.
Therapist Note
Just before beginning the imaginal exposure, switch from the audio
recording to a new audio recording, in order for the patient to have
the imaginal exposure on a separate audio for homework. When the
imaginal exposure and processing ends, switch back again to the session
recording. Thus, for sessions with imaginal exposure components, two
audios will be recorded in each session:(1)the beginning of the session
and the end of the session, and (2)the patients revisiting of the traumatic memory and the processing.
Use the Therapist Imaginal Exposure Recording Form (Appendix C
at the end of this Guide) to record the patients SUDS ratings every
5minutes and to make notes about things the patient says or does that
seem important to discuss later. After about 3045 minutes of imaginal
exposure, terminate the exercise by asking the patient to open his eyes
and end the imaginal experience:OK, lets stop here. Great job. Now
lets talk about how this was for you.
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Therapist Note
For later imaginal exposures, processing will focus less on the actual
exposure and more on helping the patient articulate her thoughts about
the meaning of the trauma, and highlighting important information
that can help the patient change negative erroneous cognitions about the
trauma. The processing is the part of the session where you focus on guilt,
shame, and anger in addition to fear and anxiety.
If the patients distress level did, in fact, decrease during the imaginal
exposure, offer comments such as:
As you remained in the memory, your distress level did go down.
I want you to notice that you are much less anxious than you were in the
beginning of the session How do you think that happened?
In subsequent sessions: I can see that you had much less anxiety today
than the last time you revisited this distressing memory. So, the more you
confront this memory, the less anxious and distressed you are going to feel.
Does it feel as bad as it used to feel?
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If the patients distress level did not decrease during the imaginal exposure, as is often the case in the first few sessions, normalize the lack of
habituation and give positive feedback:
You were feeling quite anxious today throughout the imaginal exposure.
But despite this, you hung in there, stayed in touch with your feelings,
and did a great job revisiting the memory. You were not sure you would
be able to do this, but you got through it. Good for you!
Many times anxiety does not go down during the imaginals in the first
few sessions. But we know from numerous research studies and experience that habituation within the sessions does not predict how much the
treatment will help you. So there is nothing to worry about, and we just
need to keep working on it.
Great job! Iknow that you did not feel less distressed at the end of the
exposure this time, and your SUDS level stayed high. But you accomplished an important aspect of our work together:You fully accessed this
memory and were really engaged with the feelings and thoughts that are
a part of the memory. That is a crucial step in processing the memory and
overcoming your PTSD.
This was tough for you and you were successful in getting through it.
Great job! This will get easier the more you do it.
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processing, and in vivo exposure exercises. These help the patient realize
that the world is not always dangerous and that he is capable of coping
successfully with the distressing memories and situations. During processing, the therapist should facilitate the patients verbal elaboration of
these realizations.
For example, a patient who was raped by her boyfriend and his
friends said:If only Ihad let them know how much Idid not want
to have sex with them, they would have stopped. The accuracy of
this statement needs to be explored with the patient with questions
like, What makes you think that they didnt know you did not
want to be raped? Alternatively, the patient might make a statement that reflects an emerging shift in perspective that seems more
realistic and appropriate. For example, after listening to her narrative of the rape several times in the sessions and at home, the above
patient said:I didnt realize how much Ifought them. Of course
they knew that Idid not want to have sex with them. Follow up
on such a statement by encouraging the patient to talk more about
the new insight:Tell me more about that, or That seems really
important. What do you think now about your behavior during the
rape? Always help the patient elaborate on these important shifts
in perspective by asking questions; refrain from telling a patient how
she should think or feel.
Another example involves a military veteran who witnessed the fatal
shooting of a close comrade while on a reconnaissance mission. The
veteran believed that he should have seen the enemy sniper and
been able to prevent his comrades death. This statement needs to be
explored with questions like, What did you do differently than what
you were trained to do? or Did any of your other comrades who
were with you that day see the enemy sniper? During the course of
treatment, the patient was able to realize that he did everything he
was trained to do as a Marine and yet neither he nor any of his other
comrades were able to prevent the shooting. As a result of these cognitive shifts in perspective, the patient was better able to accept the
outcome as an unfair circumstance of war.
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and thoughts about using alcohol or drugs, and help the patient plan
the rest of his day so he is in safe situations and with supportive people
(e.g., going to an AA meeting, working out at the gym, spending time
with his children).
Therapist Note
Some patients say that their baseline SUDSthe level of anxiety that
they walk around withis as high as 5060. They may also say that
they walk around with a baseline craving level of 2030. Baseline distress and craving levels should be used to determine a manageable rating
at the end of the session.
Explain to the patient that she may feel an increase in anxiety and
PTSD symptoms after exposure sessions, especially the first few. This
increase is completely normal and is a sign that she is processing the
trauma. This anxiety will change over time as she continues to do more
exposures. Use the analogy of getting in better physical shape:when
someone goes to the gym for the first time in a really long time and
does a tough workout, his muscles may be sore the next day. But with
each successive workout it gets easier and easier and he is less sore as his
muscles get stronger.
Consider setting up a time before the next session to check in briefly
by phone. During this brief check-in, remind the patient of coping
techniques to use, assess his compliance with homework, and encourage him to complete all assigned practice exercises, assess cravings and
any substance use, remind him about the rationale for exposure therapy and let him know that his anxiety will decrease the more he does
it. Offer the patient ample praise for his work during sessions and for
sticking with the program.
Let your patients know that they may contact you between sessions if
necessary. If PTSD symptoms have increased, normalize this for the
patients, reassure them that any exacerbation is temporary, and encourage them to think of and use the coping skills they have learned in
treatment. Remind your patients about coping skills (listed below) to
minimize and manage cravings for alcohol or drugs. Praise them for
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6. Assign Homework
Refer the patient to the homework checklist at the end of Chapter6
in the Patient Workbook, and make sure the patient understands
how to complete the homework. If he has questions or needs help
problem-solving obstacles to completing the homework, encourage him
to call you before the next session.
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Session 4 Appendix
Problems the Therapist May Encounter
During Imaginal Exposure and Ways
toManage Them
1. Under-Engagement
This is the most frequent problem with emotional engagement during
imaginal exposure. The term under-engagement refers to difficulty
accessing the emotional components of the fear structure or trauma
memory.
The tendency to suppress feelings while thinking about ones trauma
is common among individuals with PTSD and substance use disorders. An under-engaged patient may describe the trauma, even in great
detail, yet feel disconnected from it emotionally or not be able to visualize what happened. The patient may report feeling numb or detached.
Distress or SUDS levels during the exposure are typically low when the
patient is under-engaged. Alternatively, the under-engaged patient may
report high distress levels, yet his nonverbal behaviors such as facial
expression, tone of voice, and bodily gestures do not reflect high distress. Sometimes the language used by the under-engaged patient seems
stilted or distant, as if he is reading a police report rather than giving a
first-person account of a traumatic event he experienced. For example,
the patient may refer to an attacker as the assailant or perpetrator
or use other terminology that seems unlikely to have been in his mind
at the time of the trauma.
Because under-engagement is the most common problem with emotional engagement during imaginal exposures, the standard procedures
for imaginals are designed to promote emotional engagement by asking
the patient to (a)keep his eyes closed, (b)vividly imagine and visualize
the traumatic memory as if it were happening now, (c)use the present
tense, and (d)include in the revisiting of the trauma the thoughts, emotions, physical sensations, and behaviors experienced during the event.
The therapist prompts for details that are missing (e.g., How does it
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feel? or What is he doing now? or How does it smell?) and monitors the patients distress level throughout the revisiting of the trauma
memory. Always direct these brief questions at whatever the patient
is describing or visualizing at the moment so that you do not pull the
patient out of the imagery by redirecting his attention. The probes are
meant to enhance, not detract from, the patients ability to get into
the memory. Thus, it is important with under-engaged patients that
you not ask too many prompting questions. Doing so may lead to being
too directive or getting into conversations with the patient during imaginal exposure that, in turn, reduce rather than promote his connection
with the image and his emotional engagement with the memory. Your
job is to facilitate the patients access of his emotions during the revisiting of the trauma memory but at the same time not to direct it and
thereby interfere with the processing of the memory.
If under-engagement is persistent across sessions, revisit the rationale for the exposure with the patient. Discuss the reasons that you
are asking him to emotionally connect to this painful memory, and
explain why emotional engagement will promote his recovery from
PTSD. It can also be useful to show the patient (or assign for homework) a Dateline video that was created on prolonged exposure
therapy:http://www.youtube.com/watch?v=9aTDIiTr99Y. The video
demonstrates a rape victim engaging in the imaginal exposure therapy sessions and includes input from Dr. Edna Foa and colleagues
on the techniques. Watching this video can help the patient better
understand more clearly what you are asking him to do and why, as
well as how it will benefit him and help him overcome PTSD. There
are several other videos that may be obtained online (e.g., from the
Association for Behavioral and Cognitive Therapies or the VA) which
demonstrate imaginal exposure therapy.
In addition, you can remind the patient that memories are not dangerous, even though they feel upsetting, and that revisiting and visualizing
the memory are not the same as re-encountering the trauma. If it seems
relevant, ask what the patient fears will happen if he lets himself feel
the emotions associated with this trauma (e.g., Ill lose control; Ill fall
apart; Ill cry; Ill never stop feeling anxious). Validate the patients
feelings, but help him realize that being distressed is not dangerous. It
may help to share with the patient the research findings that indicate
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2. Over-Engagement
Rarely, a patient manifests the opposite pattern from under-engagement,
namely, being overwhelmed with emotions during the revisiting of the
trauma memory and feeling loss of control. We term this experience
over-engagement. Therapists tend to be most concerned about how to
handle over-engagement; however, over-engagement is much less common than under-engagement.
Imaginal confrontation with frightening memories is often distressing
and can elicit tears and emotional distress, especially in the early stage
of therapy. Thus, it can be difficult to tell when a patient has passed from
being emotionally upset to being over-engaged. One way that we identify
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horrible, move the memory forward to foster the realization that this
moment is in the past by asking, And then what happened after that?
For some patients, the revisiting of the trauma may remain conversational throughout treatment. But if possible, as the patients ability to
engage with the traumatic memory grows and her distress decreases, you
should encourage the patient to revisit the trauma memory with your
support and encouragement while reducing the conversation with her.
An alternative procedure is writing the trauma narrative instead of revisiting it aloud. This can be done during the session and also as an at-home
exercise between sessions. Ask the patient to write down what happened
and to include thoughts, feelings, actions, and sensations as well as details
about the event (e.g., Its dark outside and Im walking on the sidewalk.
Ifeel scared and so Im starting to walk faster). We suggest that patients
hand-write the narrative, as opposed to typing it out on a computer. Either
way, ask the patient to refrain from editing the content or worrying about
correct grammar, spelling, or punctuation. Once she has finished a first
draft, have the patient read the story to you during a session, adding any
additional material as needed. SUDS ratings should be recorded every
5minutes and the patient should read the written narrative aloud during
session for at least 20 minutes. Then, be sure to process the experience
with the patient and offer her a lot of praise.
You may also ask the patient if there are other things that can be done
to facilitate the feeling of being supported and grounded in the present. When patients are especially agitated or physically restless during
the revisiting of the trauma memory, we may offer them something to
manipulate, such as a stress ball or towel. On occasion, a patient may
be able to maintain engagement and also remain grounded in the present by describing the trauma while walking outside with the therapist.
For more details, see Prolonged Exposure Therapy for PTSD:Emotional
Processing of Traumatic Experiences Therapist Guide (Foa, Hembree,&
Rothbaum, 2007).
3. Wanting to Stop
Some patients may want to stop in the middle of exposure. Exposures
should not be terminated at their peak, as the belief that the anxiety will
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last forever may be confirmed and the level of anxiety associated with
the memory may increase. Find out why the patient wants to stop (e.g., is
he too emotionally overwhelmed, can he not handle the vividness of the
images). If necessary, work with the patient in a collaborative fashion to
determine ways that the exposure can be modified to allow the patient to
stay in it for at least 20 minutes (see sections above on over-engagement
for more details). For example, starting out by allowing the patient to
keep his eyes open (focusing attention on the floor, wall, or an object),
revisit the trauma memory in the past tense, and so on.
It may help to review the analogies presented in the rationale for imaginal exposure. You should assure the patient that you would not ask
him to do this if it did not work. Remind him that he is in a safe place.
Remind the patient of the effectiveness of prolonged exposure techniques. Provide the patient with lots of reinforcement, such as You
are doing really well, Keep going, you are doing great. If the patient
is adamant that he wishes to discontinue exposure, offer a brief break
before returning as soon as possible to complete the procedure.
Finally, it may be helpful to review the reasons that the patient sought
treatment in the first place (i.e., the ways in which the PTSD symptoms
interfere with life satisfaction). Reviewing these important issues, while
also validating the patients fear and concerns that exposure can be difficult, may help the patient stick with it.
4. Avoidance
Confrontation with feared situations and memories often triggers urges
to escape or avoid (including using alcohol or drugs), so avoidance is the
most commonly encountered impediment to effective exposure both in
and out of the therapists office. Some patients experience an increase
in their urges to avoid after the introduction of in vivo and imaginal
exposure, several sessions into treatment. For these patients, this stage
of therapy can be seen as feeling worse before feeling better, and their
symptoms may directly reflect this. With extremely avoidant patients, it
can be helpful to predict early on that this pattern may happen and to
let them know that increases in PTSD symptoms during treatment are
temporary, that they are not indicative or a poor treatment outcome,
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and that they actually mean that work is being done and the trauma
memory is being activated and processed.
When struggles with avoidance are evident, acknowledge the patients
distress and urges to avoid, and label them as a symptom of PTSD. At
the same time, remind the patient that while avoidance reduces anxiety
in the short term, in the long run it maintains fear and prevents the
patient from learning that the avoided situations (or thoughts, memories, impulses, images) are not harmful or dangerous.
In some cases of repeated avoidant behavior, reiterating the exposure
rationale, while important, may not be enough. In addition, metaphors or analogies can be useful tools in helping the patient to overcome avoidance. For example, we sometimes describe this struggle as
sitting on a fence between exposure and avoidance. We acknowledge
the difficulty of getting off the fence but stress that sitting on it prolongs the fear and slows progress. We sometimes encourage the patient
to invite the feeling of anxiety in the service of mastery and recovery, rather than only having it triggered against ones will. One of the
primary aims of prolonged exposure is to help the patient learn that
while anxiety is uncomfortable, it is not dangerous. Treatment involves
learning to tolerate the anxiety induced by facing rather than avoiding
trauma-related feared situations and memories.
For highly avoidant patients, the memory can be hand-written in session (see section 4 for more details).
5. Multiple Traumas
The vast majority of patients with PTSD and a substance use disorder
will have experienced multiple traumas in their lifetime, many with
childhood traumas. The trauma to be targeted in imaginal exposure
(i.e., the index trauma) may not always be clear. Select the trauma that
is the hardest for the client to put out of his mind and that is driving most of the avoidance and re-experiencing symptoms. It will be
important to identify the index trauma during the baseline assessment
(e.g., during the CAPS) and/or during the first session. Once you identify the trauma that you and your patient will use in imaginal exposure,
you and your patient should determine the beginning and end points of
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the trauma. Try not to wait until session 4 to determine the index trauma
and the beginning and end points.
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CHAPTER7
Session 5: Imaginal
Exposure Continued and
Planning for Emergencies
(Corresponds to Chapter7 of the Patient Workbook)
MATERIALS
In vivo Hierarchy Form started in session 3
Patient Imaginal Exposure Data Form (Form 18 at the end of the
Patient Workbook)
Therapist Imaginal Exposure Recording Form (Appendix C at the
end of this Therapist Guide)
Personal Emergency Plan handout
SESSION OUTLINE
1. Review PTSD symptoms and any substance use since last session
2. Review homework
3. Discuss imaginal exposure rationale
4. Conduct and process the imaginal exposure
5. Planning for emergencies
6. Assign homework
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1. Review PTSD Symptoms and Any Substance Use Since Last Session
Review the patients weekly PTSD and SUD assessments. If any alcohol
or drug use has occurred since the last session, discuss this as described
in session 2.
2. Review Homework
Did the patient complete her homework? Review each homework
form with the patient. Congratulate the patient for her efforts to
confront difficult situations, and give lots of positive feedback. If
homework was not completed, explore obstacles and problem-solve
with the patient.
Review the in vivo and imaginal homework. Go over the patients
invivo rating form and imaginal exposure practice exercise sheet. Ask
the patient what she learned from doing the exposures. Pay attention to
whether she is staying in the situation long enough, documenting her
SUDS ratings, and so on. Pay attention to any safety behaviors that
the patient may be using during the in vivo and imaginal exercises (e.g.,
alcohol or other drug use, distracting herself during the exposure, carrying an object she feels will protect her). Help the patient to plan the
next in vivo exercises without using any safety behaviors. Pay particular
attention to any substance use before, during, or after exposures. Assign
the next in vivo exercises at this time.
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Iwant to remind you that you are safe here and that an important part of
revisiting trauma memories is the connection to the feelings that are associated
with them. Is there anything that Ican do to help you with this process? Do
you have any ideas about why it is difficult for you to fully express your feelings
in here?
Therapist Note
Patients who have difficulty accessing or expressing trauma-related feelings are sometimes under-engaged. See the end of session 4 (Chapter6)
for ways to help these patients increase emotional engagement through
modification of the imaginal exposure procedures.
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Therapist Note
If the patient chooses to list relatives/friends on his support list, remind
him that it is a good idea to talk to these people ahead of time to explain
what type of support he is hoping to receive from them (e.g., distraction,
general chat, reminders that he is strong and can resist using alcohol or
drugs).
immediately to get help, not that the patient has arrived at a dead
end. Thus, a lapse is an error that can be corrected before serious
consequences ensue.
Before we end today, Iwant to discuss ways that you can cope with a
lapse should one occur. Iwant to be very clear that this is not in any way
giving you permission to lapse or suggesting that a lapse is not a very
serious and dangerous event in your recovery process. Lapses do not happen to everyone in recovery but they are common, so Iwant to make sure
that you are prepared and know how to minimize any harm that could
be done should a lapse occur. Does that make sense?
Lets think about what you could do immediately after a lapse (allow the
patient to generate suggestions first):
Remove yourself from the situation/setting immediately. How could
you do this?
Call someone for help immediately. Whom could you call?
Get rid of any alcohol or drugs immediately. How could you do this?
Therapist Note
Some patients will view substance use in a very all-or-nothing way. They
will state adamantly that any use is a relapse. In these cases, you can
acknowledge that it can be a controversial topic and explain why some
people think it is important to distinguish between a lapse and a relapse
(e.g., protecting against the abstinence violation effect, reducing guilt
and shame, which can be triggers for continued use). However, if the
patient firmly believes that any use is a relapse, join with him and try to
understand his perspective. Be collaborative, not confrontational.
Therapist Note
The patient may want to discard drug paraphernalia by throwing it in
the trash can or woods near his home; discourage this so that the patient
will not be tempted to go searching for it when having a craving and so
that others will not find it. Suggest that the patient permanently disable
the device (e.g., crush the pipe) and get rid of alcohol (e.g., pour it down
the drain).
138
139
6. Assign Homework
Refer the patient to the homework checklist at the end of Chapter7
in the Patient Workbook, and make sure the patient understands
how to complete the homework. If he has questions or needs help
problem-solving obstacles to completing the homework, encourage him
to call you before the next session.
140
CHAPTER8
Session 6: Imaginal
Exposure Continued
andAwareness
of High-Risk Thoughts
(Corresponds to Chapter8 of the Patient Workbook)
MATERIALS
In vivo Hierarchy Form started in session 3
Patient Imaginal Exposure Data Form (Form 18 at the end of the
Patient Workbook)
Therapist Imaginal Exposure Recording Form (Appendix C at the
end of this Therapist Guide)
In vivo Exposure Data Form (Form 17 at the end of the Patient
Workbook)
Awareness of High-Risk Thoughts (Form 20 at the end of the Patient
Workbook)
SESSION OUTLINE
1. Review PTSD symptoms and any substance use since last session
2. Review homework
3. Substance abuse specific check-in
4. Conduct and process imaginal exposure
5. Awareness of high-risk thoughts
6. Assign homework
141
1. Review PTSD Symptoms and Any Substance Use Since Last Session
Review the patients weekly PTSD and SUD assessments. If any alcohol
or drug use has occurred since the last session, discuss this as described
in session 2.
2. Review Homework
Did the patient complete his homework? Review each homework
form with the patient. Congratulate the patient for his efforts to
confront difficult situations, and give lots of positive feedback. If
homework was not completed, explore obstacles and problem-solve
with the patient.
Review the in vivo and imaginal homework. Go over the patients
in vivo rating form and imaginal exposure practice exercise sheet. Ask
the patient what he learned from doing the exposures. Pay attention to
whether he is staying in the situation long enough, documenting his
SUDS ratings, and so on. Pay attention to any safety behaviors that
the patient may be using in the in vivo and imaginal exercises (e.g.,
alcohol or other drug use, distracting himself during the exposure, carrying an object he feels will protect him). Help the patient to plan the
next in vivo exercises without using any safety behaviors. Pay particular
attention to any substance use before and after exposures. Assign the
next in vivo exercises at this time.
142
143
144
145
Focus on the patients hot spots during the imaginal exposure until
each has been sufficiently processed, as reflected by diminished SUDS
levels and the patients behavior (e.g., body movement, facial expression). This may take more than one session per hot spot, depending on
the patients pace and the amount of time she spends listening to the
recordings between sessions. Sometimes a patient gives a low SUDS
rating and/or appears minimally distressed even when discussing a
very distressing part of the memory; this is usually because of being
under-engaged in the trauma memory. In these cases, focusing on the
hot spot may cause increased engagement and a corresponding increase
in SUDS before habituation occurs.
Therapist Note
Note on multiple traumas:Most of our patients have experienced multiple traumas, during childhood and adulthood. For some patients
with histories of multiple traumas or repeated incidents of a particular trauma (e.g., childhood sexual abuse, combat experience), it may
be necessary to focus the imaginal exposures on more than one trauma.
However, do not move on to a second trauma until sufficient reduction
of anxiety and distress is evident with the first trauma. Because we focus
the initial revisiting on the worst trauma memory, or the one that is
causing the most re-experiencing and avoidance symptoms, the benefits
of working through this memory most of the time will generalize to the
other trauma memories. But if another memory remains significantly
distressing, devote some sessions to working on the second trauma as well.
Most of the time, therapy will only focus on one trauma.
146
Feelings
Behaviors
Figure8.1
147
you will have fewer thoughts about using, and they will be less intense when
they do happen.
Escape
Individuals may wish to avoid the discomfort caused by unpleasant situations, conflicts, or memories. Failure, rejection, disappointment, hurt,
humiliation, embarrassment, and sadness all tend to demand relief.
People may be tired of feeling hassled, lousy, and upset. They just want
to get away from it all and, more to the point, from themselves. It is not
necessarily the high that is sought; rather, it is numbness, the absence of
emotional pain, problems, and feelings. People with PTSD in particular
may wish to block out their trauma memories and try and forget what
happened. Wanting to escape from the stresses of daily life or from negative
emotions for a bit is normal, and everyone needs to have healthy ways to
do that from time to time.
What are some healthy ways you can escape for a while when you need
to? (e.g., watch a movie, read a good book, go for a run, go to a place of
worship, pray or meditate, cook a meal)
148
Relaxation
Thoughts of wanting to unwind are perfectly normal, but they lead to problems when the person has expectations of this happening immediately, and
without having to do something relaxing. Rather than engage in an enjoyable and relaxing activity, the individual may choose alcohol or drugs for
a quick fix. People with PTSD, in particular, often feel physically and
mentally on edge and jumpy or irritable, and turn to alcohol or drugs in
an attempt to relax or sleep.
Everyone needs to be able to relax. The problem with using alcohol or
drugs to relax is that although you may feel that it relaxes you for a
short period of time, it does not help you relax in the long term because
it creates so many other problems, which only add more stress. In addition, alcohol and drugs impair your bodys natural stress response system
(the hypothalamic-pituitary-adrenal axis). Research clearly shows that
chronic use of alcohol or drugs makes your bodys natural stress response
system less effective at adapting to stress. So while you may be trying your
best to relax, alcohol and drugs only make it harder for you to relax in
the long run.
What are some healthy ways you can relax when you need to? (e.g., exercise, practice the breathing retraining exercise, take a nap, go for a walk,
go fishing, read a book, meditate)
Socialization
Many individuals who are shy or uncomfortable in social settings may feel
a need for a social lubricant to feel more at ease and decrease the awkwardness and inhibitions that they feel around others. People with PTSD
who have withdrawn from others or who feel disconnected and cut off from
others may feel particularly uncomfortable and lonely in social situations.
They may use alcohol or drugs to try to cope with these negative feelings and
make it through social situations.
What are some healthy ways you can handle social situations? (e.g., exercise before the social event to help you relax; take a friend or sponsor with
you; practice the breathing retraining exercise; accept your shyness for
149
what it is and know that most people dont notice, or if they do they will
not think negatively of you because of your shyness).
Nostalgia
Some people in recovery think about using alcohol or drugs as if it were their
long-lost friend. For example, I remember the good old days when I d have
a few drinks and hang out. This can lead to other dangerous thoughts like,
I wonder what it would be like to have just one, for old times sake? These
thoughts are one-sided and do not take into account all the negative aspects
of using (e.g., how that one drink led to six drinks; which then led to one
gram; which then lead to getting arrested; then their family and children
were upset with them; then they felt shame, guilt, and became depressed).
Its important to play out the image or, as some say, play it out.
What are some ways you can manage nostalgic thoughts? (e.g., make a
list of all the negative consequences you experienced from using, call your
sponsor, go to a meeting).
Testing Control
Sometimes after a period of successful abstinence, people in recovery
become overconfident and want to test their control over substances. For
example, I wonder if I am strong enough to leave some alcohol in the
house, just for friends who come over? or I bet Ican have just one drink;
no one will ever know. Testing control is never a good idea. If you have
thoughts of wanting to test your control over drugs or alcohol, recognize it
as a sign that you are headed toward relapse and take action to prevent it.
While you want to have some level of confidence in your ability to combat addiction, you do not want to be overconfident. Addiction is a very
powerful disease, and most people who have tried to test themselves end up
failing. It is not simply a matter of will power. Patients with PTSD may be
particularly susceptible to this, as both PTSD and substance use disorders
are characterized by loss of control. The patient was helpless and unable to
control what was happening during the trauma, has been unable to control the PTSD symptoms since the trauma, and has been unable to control
his or her substance use.
150
What are some ways you can manage thoughts about testing control?
(e.g., remember the times that you have tried to test control in the past
and how it turned out, call a sponsor, go to a meeting).
Therapist Note
Another issue is related to overconfidence:Sometimes when people experience a significant reduction in their PTSD symptoms they start to feel
better and think it means that they can now drink or use drugs socially
or recreationally. For the vast majority of our patients, however, their
addiction has taken on a life of its own, and their use is triggered by
other things in addition to trauma-related triggers or PTSD symptoms
(e.g., holidays and celebrations, sporting events, bars where they used in
the past, seeing other people use). Just because their PTSD symptoms are
improving and they feel better does not necessarily mean that they will be
able to control their substance use and drink like everyone else.
Crisis
During stressful situations or crises, people in recovery may say, I need
a drink to get through this or I cant handle this or I went through so
much, Ideserve a line or Once this is all over, I ll be able to stop using
again but not right now. They do not feel that they have other options to
effectively cope with stress, and they underestimate the harm and additional stress that using will bring. People with PTSD may also use to help
self-medicate stress and symptoms associated with their trauma.
What are some healthy ways you can manage crises in the future? (e.g.,
engage in daily wellness activitieslike eating well, getting rest, exercise,
pleasant activitiesto keep your baseline stress level low; realize that
one of the best things you can do to help the situation is to stay clean and
sober; talk with a friend or sponsor).
Improved Self-Image
When individuals become unhappy with themselves, feel inferior to others,
or feel unattractive or deficient, they may begin to think of alcohol or drugs
151
again. In the past, they experienced immediate and temporary relief from
these negative feelings with alcohol or drugs. People with PTSD may be
particularly susceptible to this if the traumatic experience has left them feeling inadequate, weak, damaged, like a bad person or a failure, responsible for what happened, or irreparably flawed in some way.
What are some healthy ways you can manage thoughts about self-image?
(e.g., make a list of some of the positive attributes you have, ask a friend
or your sponsor to share with you what they think are some of your most
positive attributes, remember some of the good things you have done in
the past such as helping out a friend or family member, realize that
everyone has strengths and weakness, and give yourself permission to be a
human being).
Romance
When bored or unhappy with their lives, some people yearn for excitement,
romance, the joy of flirtation, and the thrill of being in love. These are
usually the kind of thoughts that, when engaged in too seriously, require
a drug to keep them going and to make the thoughts more vivid and real.
In addition, some people, especially those who have suffered sexual abuse,
may have a hard time engaging in physical intimacy with another person.
152
They may use alcohol or drugs because they believe it is the only way to get
through it, to zone out during intimacy or, alternatively, to feel emotions
and feel for the other person.
What are some healthy ways you can manage thoughts about romance?
(e.g., talk to a close friend or sponsor, talk with your partner about ways
to enhance intimacy without using alcohol or drugs).
To-Hell-With-It
At times, people may think that nothing matters to them or they simply
dont care. It is important to realize, however, that even though they may
not care in that moment, at some point they will care.
What are some healthy ways you can manage to-hell-with-it thoughts?
(e.g., although you may not care right now, list out the reasons why you
will probably care in a month or a year from now; look at pictures of
loved ones or your children; reflect on your future goals for work or education; remember how far you have come and dont let this situation get
the best of you).
Therapist Note
Help your patients identify their common high-risk ways of thinking.
Keep in mind that although it may appear that the entirety of a patients
alcohol or drug use is in direct response to the trauma and PTSD symptoms, it is important to include all situations that trigger thoughts about
using, both those that are trauma-related and those that are not related
to trauma. Patients may get the false message that if they have developed
good coping skills to deal with their PTSD symptoms or if they no longer meet criteria for PTSD, they can drink socially or use now without
concern. While substance abuse may begin in response to trauma/PTSD
for many patients, or may be exacerbated by the PTSD symptoms, it
has often taken on a life of its own by the time patients seek treatment
(which can be 10years after the traumatic event for some patients).
Which of these high-risk thoughts do you relate to?
Which thoughts seem to be the most frequent or strongest for you?
What thoughts preceded your last relapse after a period of abstinence?
153
6. Assign Homework
Refer the patient to the homework checklist at the end of Chapter8
in the Patient Workbook, and make sure the patient understands
how to complete the homework. If he has questions or needs help
problem-solving obstacles to completing the homework, encourage him
to call you before the next session.
154
CHAPTER9
Session 7: Imaginal
Exposure Continued
andManaging High-Risk
Thoughts
(Corresponds to Chapter9 of the Patient Workbook)
MATERIALS
In vivo Hierarchy Form that patient started in session 3
In vivo Exposure Data Form (Form 17 at the end of the Patient
Workbook)
Patient Imaginal Exposure Data Form (Form 18 at the end of the
Patient Workbook)
Therapist Imaginal Exposure Recording Form (Appendix C at the
end of this Therapist Guide)
The ABC Model (Form 21 at the end of the Patient Workbook)
Managing Thoughts About Using (Form 22 at the end of the Patient
Workbook)
SESSION OUTLINE
1. Review PTSD symptoms and any substance use since last session
2. Review homework
3. Conduct and process imaginal exposure
4. Managing high-risk thoughts
5. Assign homework
155
1. Review PTSD Symptoms and Any Substance Use Since Last Session
Review the patients weekly PTSD and SUD assessments. If any alcohol
or drug use has occurred since the last session, discuss this as described
in session 2.
2. Review Homework
Did the patient complete her homework? Review each homework form
with the patient. Congratulate the patient for her efforts to confront
difficult situations, and give lots of positive feedback. If homework was
not completed, explore obstacles and problem-solve with the patient.
Review the in vivo and imaginal homework. Go over the patients
in vivo rating form and imaginal exposure practice exercise sheet. Ask
the patient what she learned from doing the exposures. Pay attention
to whether she is staying in the situation long enough, documenting
her SUDS ratings, and so on. Pay attention to any safety behaviors
that the patient may be using in the in vivo and imaginal exercises (e.g.,
alcohol or other drug use, distracting herself during the exposure, carrying an object she feels will protect her). Help the patient to plan the
next in vivo exercises without using any safety behaviors. Pay particular
attention to any substance use before and after exposures. Assign the
next in vivo exercises at this time.
156
Activating Event
Belief
Consequences
(Something
happens)
(Your thoughts;
What you say to
yourself)
Figure9.1
The ABC Model.
Feeling an intense
craving and going to
use.
Figure9.2
157
PERSON #1
A
C
Feeling an intense
craving and going
to use.
Figure9.3
These beliefs and thoughts occur very quickly and are automatic, but with
practice you can train your mind to interrupt the automatic thought process, identify unhelpful thoughts, and replace them with more positive,
helpful thoughts. This process is called cognitive restructuring, because
you are restructuring your thoughts.
Lets take a look at how this works, using the example we just discussed (see
Figure 9.3).
While another person might be thinking differently, as in Figure 9.4.
What are some other helpful thoughts that the person in this example
could say to himself to help decrease the chance of using? (e.g., Ive come
too far to give it all up now. It doesnt matter if Ihurt his feelings or
he gets mad at me for not using; Ineed to focus on me and my recovery.
Its not worth it.)
PERSON #2
A
Figure9.4
158
I know that I
cannot have just
one. I have tried
that before and it
doesn't work. I
don't want to use.
It's not worth it.
To really change ones thinking is a slow process, because our thoughts are so
automatic. But if you practice, this new way of thinking will become easier
and you will feel much more in control.
Here are ways to help patients challenge unhelpful thoughts:
a. Question Your Thoughts
We have a lot of thoughts that are not actually true. Its a fact that you
have thoughts, but not all thoughts are facts. So, question your thoughts.
If you are having a thought about wanting to use ask yourself, What is
the evidence for this thought? Is it REALLY true?
Some examples of challenging thoughts include:
Thought: I can have just one.
Question:Whats the evidence for that thought? What data do
Ihave that tells me that Ican have just one?
Thought: A drink sure would help me relax.
Question: Is that really true? Would a drink really help me relax, or
would it only end up leading to more stress in my life from all the
problems it would cause?
Thought: No one will ever know.
Question: Is that true? Even if it were, Iwill know; and thats what
matters. Iam doing this for me.
Thought: I want to be part of the group.
Question: Do Ireally want to be a part of this group? Ive been a
part of this group for a while and look where its gotten me. Ican
meet new people.
b. Alternative Way of Thinking
Ask yourself, Is there a more helpful way of thinking about this? (e.g.,
I can handle this. Imay feel stressed out, but its not the end of the
world. This too shall pass.)
c. Putting It Into Perspective
Ask yourself, Is it as bad as Im making it out to be? (e.g., cravings
are uncomfortable but they dont last forever, Having an argument
with my husband is stressful but we will be okay. Its annoying that
this person cut in front of me in the line, but its not worth me getting
upset about it.). Be sure not to catastrophize or make the situation
any bigger than it needs to be.
159
d. Goal-Directed Thinking
Ask yourself, Are my thoughts helping me achieve my goals? What can
Ido to change the situation? And if Icant do anything to change the
situation, what can I do to change the way I am thinking about the
situation?
In addition to using these techniques to help challenge and change your
thoughts, you can use these additional coping skills as needed, such as:
5. Assign Homework
Refer the patient to the homework checklist at the end of Chapter9
in the Patient Workbook, and make sure the patient understands
how to complete the homework. If she has questions or needs help
problem-solving obstacles to completing the homework, encourage her
to call you before the next session.
160
161
CHAPTER10
Session 8: Imaginal
Exposure Continued
andRefusal Skills
(Corresponds to Chapter10 of the Patient Workbook)
MATERIALS
In vivo Hierarchy Form started in session 3
In vivo Exposure Data Form (Form 17 at the end of the Patient
Workbook).
Patient Imaginal Exposure Data Form (Form 18 at the end of the
Patient Workbook)
Therapist Imaginal Exposure Recording Form (Appendix C at the
end of this Therapist Guide)
Alcohol and Drug Refusal Skills (Form 23 at the end of the Patient
Workbook)
SESSION OUTLINE
1. Review PTSD symptoms and any substance use since last session
2. Review homework
3. Conduct and process imaginal exposure
4. Drug and drink refusal skills
5. Assign homework
163
1. Review PTSD Symptoms and Any Substance Use Since Last Session
Review the patients weekly PTSD and SUD assessments. If any alcohol
or drug use has occurred since the last session, discuss this as described
in session 2.
2. Review Homework
Did the patient complete his homework? Review each homework form
with the patient. Congratulate the patient for his efforts to confront
difficult situations, and give lots of positive feedback. If homework was
not completed, explore obstacles and problem-solve with the patient.
Review the in vivo and imaginal homework. Go over the patients
in vivo rating form and imaginal exposure practice exercise sheet. Ask
the patient what he learned from doing the exposures. Pay attention to
whether or not he is staying in the situation long enough, documenting
his SUDS ratings, and so on. Pay attention to any safety behaviors
that the patient may be using in the in vivo and imaginal exercises (e.g.,
alcohol or other drug use, distracting himself during the exposure, carrying an object he feels will protect him). Help the patient to plan the
next in vivo exercises without using any safety behaviors. Pay particular
attention to any substance use before and after exposures. Assign the
next in vivo exercises at this time.
164
165
may or may not know about your substance abuse history. An offer may
take the form of a single, casual offer or may involve repeated pestering and
harassment (often by former dealers).
In what situations have you received offers or pressure to drink or use
drugs?
If youre unable to stay out of a high-risk situation, you need to be able
to effectively refuse offers to use. Refusal skills are critical to recovery, and
sometimes people become overconfident and think they are more skilled at
refusing than they actually are. Effective refusal skills will help you respond
more quickly and successfully when these kinds of situations arise.
The precise nature of a refusal to an invitation to drink or use will vary,
depending on who is offering the substance and how the offer is made.
Sometimes a simple No, thank you will be sufficient. Other times, additional strategies will be necessary. In some cases, telling the other person
about your substance abuse problem will be useful in eliciting his or her
help and support. You may need to say, Im in a program. I dont use
anymore.
Here are some important points to remember when refusing a drink or
drugs:
Nonverbal behaviors
1. Make direct eye contact with the other person to increase the effectiveness
of your message.
2. Do not feel guilty. You wont hurt anyone by not using (in fact, you can
only hurt others by using), so dont feel guilty. You have a right not to
use. Stand up for your rights and praise yourself for your assertiveness
and for sticking to the program.
Verbal behaviors
1. Speak in a clear, firm, and unhesitating voice. Otherwise, you invite
questioning about whether or not you really mean what you say.
2. No should be the first word out of your mouth. When you hesitate to
say no, people wonder whether or not you really mean it and if they
can get you to take the bait. The more rapidly a person is able to say
166
no, the less likely she is to relapse. Why is this so? It is the old notion
of she who hesitates is lost; that is, being unsure and hesitant allows
you to begin rationalizing (e.g., well, Iguess just this time it would be
okay). The goal is to learn to say no in a convincing manner and to
have your response at the ready.
3. After saying no, change the subject to something else. Do not get drawn
into a long discussion or debate about using alcohol or drugs. For example, you could say, No thanks, Idont drink. You know Im glad Icame
to this family reunion. I havent seen a lot of these people in quite a
while, including you. In fact, Ive been wondering what youve been up
to lately? How are the kids?
4. Do not use excuses (e.g., Im on a medication right now or Im the
designated driver) or vague answers (e.g., Not right now). These
imply that at some later point and time you will accept an offer to use.
This means the other person will likely be offering you alcohol or drugs
again in the near futurea scenario you want to avoid if at all possible.
5. Suggest an alternative to using alcohol or drugs. For example, suggest
something else to do (e.g., go to the movies instead of going drinking on
Saturday night) or something else to drink or eat (e.g., coffee, ginger ale,
orange juice, dessert, a sandwich, etc.) and go to a place that does not
serve alcohol.
6. Request a behavior change. If the person is repeatedly pressuring you,
ask him not to offer you a drink or drugs any more. For example, if
the person is saying, Oh come on, just have one drink for old times
sake. You used to drink with me all the time. What, you think youre
too good for me now? an effective response might be, Its important
for me to stay clean. If you want to be my friend, then dont offer me
a drink.
Within-Session Role-Play
After reviewing the basic refusal skills, use role-play to help your patient
practice so that any problems in assertive refusals can be identified and
discussed.
a. Pick a concrete situation that occurred recently for the patient, and
ask him to provide some background on the target person.
167
b. For the first role-play, have the patient play the target individual
so that he can convey a clear picture of the style of the person who
offers alcohol or drugs and you can model effective refusal skills.
c. Then reverse the roles for subsequent role-plays, with you being the
target person who offers the substance and the patient modeling
how to effectively refuse the offers.
5. Assign Homework
Refer the patient to the homework checklist at the end of Chapter10
in the Patient Workbook, and make sure the patient understands
how to complete the homework. If he has questions or needs help
problem-solving obstacles to completing the homework, encourage him
to call you before the next session.
168
CHAPTER11
Session 9: Imaginal
Exposure Continued
andSeemingly Irrelevant
Decisions (SIDs)
(Corresponds to Chapter11 of the Patient Workbook)
MATERIALS
In vivo Hierarchy Form started in session 3
In vivo Exposure Data Form (Form 17 at the end of the Patient
Workbook)
Patient Imaginal Exposure Data Form (Form 18 at the end of the
Patient Workbook)
Therapist Imaginal Exposure Recording Form (Appendix C at the
end of this Therapist Guide)
Seemingly Irrelevant Decisions (SIDs) (Form 24 at the end of the
Patient Workbook)
Making Safe Decisions (Form 25 at the end of the Patient Workbook)
SESSION OUTLINE
1. Review PTSD symptoms and any substance use since last session
2. Review homework
3. Conduct and process imaginal exposure
4. Seemingly irrelevant decisions
5. Assign homework
169
1. Review PTSD Symptoms and Any Substance Use Since Last Session
Review the patients weekly PTSD and SUD assessments. If any alcohol
or drug use has occurred since the last session, discuss this as described
in session 2.
2. Review Homework
Did the patient complete her homework? Review each homework form
with the patient. Congratulate the patient for her efforts to confront
difficult situations, and give lots of positive feedback. If homework was
not completed, explore obstacles and problem-solve with the patient.
Review the in vivo and imaginal homework. Go over the patients
invivo rating form and imaginal exposure practice exercise sheet. Ask
the patient what she learned from doing the exposures. Pay attention to
whether or not she is staying in the situation long enough, documenting
her SUDS ratings, and so on. Pay attention to any safety behaviors
that the patient may be using in the in vivo and imaginal exercises (e.g.,
alcohol or other drug use, distracting herself during the exposure, carrying an object she feels will protect her). Help the patient to plan the
next in vivo exercises without using any safety behaviors. Pay particular
attention to any substance use before and after exposures. Assign the
next in vivo exercises at this time.
170
171
and look for a store where she could buy cigarettes. Along this route,
she drove past a bar she had frequented in the past and where she often
partied with friends. Kim decided to stop in momentarily and get a pack
of cigarettes from the vending machine. She pulled into the parking lot
and sat there in her car for a moment. She didnt recognize any of the
other cars so she figured it would probably be fine. Kim entered the bar
and went to the cigarette vending machine. Reaching into her purse,
she realized that she had left her credit card and money at home, She
looked around the bar to see if she knew anyone from whom she could
borrow some money for cigarettes. Amid the clacking of billiard balls,
she heard her name, Kim! Turning toward the sound, she recognized
an old drinking buddy. Her friend instantly turned to the bartender
and said, Give my friend a drink, Ihavent seen her in so long! Kim
decided that since she had been clean for 30days, it would probably be
fine to have just one beer. Debating only a second, Kim sipped her first
taste of foaming beer. One beer led to another, which led to another, and
Kim ended up in a full-blown relapse.
When do you think Kim first got into trouble?
What were the decisions that Kim made that may have seemed irrelevant
at the time (e.g., to take a scenic route, to go searching for a place to buy
cigarettes, to stop at the bar)?
Clearly explain to your patients that each and every choice that they
make takes them down one of two pathsthe path toward health and
recovery, or the path toward alcohol or drug use and relapse:
You may be able to see that Kim took a series of steps, which led up to her
final decision to drink. At each one of these decision points, Kim could have
made a different decision that would have taken her away from a dangerous situation. For example, did she really have to have a cigarette? Could
she have said no to the offer of a drink?
One of the things about these chains of decisions that lead to substance use
is that they are far easier to change in the early part of the chain. It is much
easier to stop the decision-making process the further away you are from the
alcohol or drugs. For example, it would have been much easier for Kim to
decide to wait until she got home to get more cigarettes than it was for her
to refuse the free and foaming cold beer sitting in front of her.
172
You can often catch seemingly irrelevant decisions because they contain
thoughts like I have to do this or I am in a hurry and Ireally need to take
a shortcut home or I need to see so-and-so because... These thoughts are
rationalizations, or ways of talking oneself into alcohol or drug use without
seeming to do so. Sometimes individuals talk themselves into high-risk situations by telling themselves that a situation is safe or that they can handle it.
Here is another example of a man named Joe that you can share with
your patient:
Joe had been clean for several weeks. He was riding the bus home from work
one Friday afternoon and had planned to use the money that he was paid
that week to pay for rent. He got off the bus and headed for his landlords
house. His landlord was not home and Joe thought that while he was out
this way, he would stop and see an old friend, Mike, whom he had not seen
in a while. Seeing Mike brought back memories of good times, partying
and having fun. They began to reminisce about the last time they partied
together. Mike was excited to see Joe and asked if he wanted to crash at
Mikes place that night because he was going to have some other mutual
friends over and they would enjoy seeing Joe and catching up. Joe thought
about it momentarily and decided that he had worked hard this week and
deserved some fun. Later, as his old friends gathered and had a few drinks,
someone took a crack pipe out of her pocket, set it on the table, and asked if
anyone wanted to have some more fun. Joe decided that he could probably
work extra next week and his landlord would not mind if the rent was paid
a day or 2 late. Mike passed the pipe and a lighter to Joe, who did not resist.
When do you think Joe first got into trouble?
What were some of the early warning signs? (e.g., Joe was only a few
weeks clean, it was Friday, and he had money in his pockets)
What could Joe have done differently? (called ahead of time to make sure
the landlord was home, mailed the landlord a check instead)
173
and usingI couldnt help it.) They dont recognize that many of their
little decisions gradually brought them closer and closer to using. Its easy
to play Monday morning quarterback with these decisions and see how
you set yourself up for relapse, but its much harder to recognize them when
you are actually in the midst of the decision-making process. That is because
so many choices dont actually seem relevant to using at the time. Each
choice you make may only take you just a little bit closer to having to make
that big choice. But when alcohol or drugs are not on your mind, its hard
to make the connection between using and a minor decision that seems very
far removed from using.
The best solution is to think about and be mindful of every choice you make,
no matter how seemingly irrelevant it is to using alcohol or drugs. By thinking ahead about each possible option you have and where each of them may
lead, you can anticipate dangers that may jeopardize your goals. It may
feel awkward at first to have to consider every decision so carefully, but
after a while it becomes second nature and happens automatically, without
much effort. Its well worth the initial effort you will have to make for the
increased control you will gain over your recovery and your life.
By paying more attention to the decision-making process, you ll have
a greater chance to interrupt the chain of decisions that could lead to a
relapse. This is important because its much easier to stop the process early
on, before you are actually in the high-risk situation, than it is later on,
when youre deep in the high-risk situation and may be exposed to a number of triggers and pressures to use.
174
5. Assign Homework
Refer the patient to the homework checklist at the end of Chapter11
in the Patient Workbook, and make sure the patient understands
how to complete the homework. If he has questions or needs help
problem-solving obstacles to completing the homework, encourage him
to call you before the next session.
175
176
to use alcohol or drugs when doing so. Record your SUDS levels on
the In vivo Exposure Data Form (Form 17 at the end of the Patient
Workbook).
Review the Seemingly Irrelevant Decisions form (Form 24 at the
end of the Patient Workbook)
Review and complete the Making Safe Decisions form (Form 25
at the end of the Patient Workbook).
CHAPTER12
MATERIALS
In vivo Hierarchy Form started in session 3
In vivo Exposure Data Form (Form 17 at the end of the Patient
Workbook)
Patient Imaginal Exposure Data Form (Form 18 at the end of the
Patient Workbook)
Therapist Imaginal Exposure Recording Form (Appendix C at the
end of this Therapist Guide)
Anger Awareness (Form 26 at the end of the Patient Workbook)
Daily Wellness Strategies (Form 27 at the end of the Patient
Workbook)
SESSION OUTLINE
1. Review PTSD symptoms and any substance use since last session
2. Review homework
3. Conduct and process imaginal exposure
4. Anger awareness
5. Assign homework
177
Therapist Note
During these last few sessions of the treatment program, you should begin
to increasingly fade out of the therapeutic role. Doing so will help your
patient gain confidence in her own abilities, facilitate termination, and
enhance the likelihood of generalization and maintenance of the skills
acquired during treatment.
1. Review PTSD Symptoms and Any Substance Use Since Last Session
Review the patients weekly PTSD and SUD assessments. If any alcohol
or drug use has occurred since the last session, discuss this as described
in session 2.
2. Review Homework
Did the patient complete his homework? Review each homework
form with the patient. Congratulate the patient for his efforts to
confront difficult situations, and give lots of positive feedback. If
homework was not completed, explore obstacles and problem-solve
with the patient.
Review the in vivo and imaginal homework. Go over the patients
in vivo rating form and imaginal exposure practice exercise sheet. Ask
the patient what he learned from doing the exposures. Pay attention to
whether he is staying in the situation long enough, documenting his
SUDS ratings, and so on. Pay attention to any safety behaviors that
the patient may be using in the in vivo and imaginal exercises (e.g.,
alcohol or other drug use, distracting himself during the exposure, carrying an object he feels will protect him). Help the patient to plan the
next in vivo exercises without using any safety behaviors. Pay particular
attention to any substance use before and after exposures. Assign the
next in vivo exercises at this time.
178
4. Anger Awareness
Rationale
Anger is often a trigger for relapse. Many people report that they
abused substances when they felt angry or upset at another person. In
addition, many people report that following treatment, they took their
first drink, hit, or smoke when they were angry.
Anger is common among individuals with PTSD. Patients may feel
anger for a variety of reasons (e.g., anger toward their perpetrator or
toward themselves for what happened, anger toward society or the
world in general, anger for the part of themselves that they lost after
the trauma, anger at loved ones for their reactions, or anger at their
inability to get over it and move on with life). Thus, PTSD/SUD
patients need to know how to deal with anger in a healthy way, as
opposed to using alcohol or drugs to cope.
Anger may also be particularly relevant for military personnel and
Veterans. Some military personnel may believe that the only feeling
or emotion that is really acceptable for them to feel or express is
anger. Therefore, the feeling of anger may be quite salient and intense
for them, and/or anger may be used to mask other less acceptable
179
180
181
helpless or depressed, reduces self-esteem, and makes one feel like no one
cares. It can also elicit resentment in others.
d. Passive-aggressive reactions (e.g., where you act out by, for example,
slamming the door or giving someone the silent treatment, but you
never clearly communicate with words that you are angry and why you
are angry) can leave you feeling frustrated, victimized, and depressed.
It can also leave others feeling frustrated, confused, and resentful.
182
Behaviors:You may find yourself getting quiet, or the opposite (you may
find yourself talking loudly). You may fidget or pace back and forth.
Pay close attention to these early signs and catch them as soon as possible.
Look for signs that you are about a 3 or 4 on the anger scale. The higher a
person gets on the scale, the harder it is to cool down. Its much easier if you
can catch it early on and take action to prevent it from escalating.
Therapist Note
Many individuals with PTSD/SUD have difficulty managing and
expressing anger. They may be particularly uncomfortable with anger
expression because of previous situations when they used alcohol or drugs
in which an extreme expression of anger occurred. They may have overreacted or managed to get others very angry at them. In other cases, a
family history of substance abuse, violence, or child neglect or abuse may
be relevant. Clinicians may have to draw out individuals to help them
feel comfortable discussing the topic. In addition, some patients have a
very hard time recognizing the early signs of anger and say they simply
go from 0 to 10. Help them to slow down the action and slow down
the thoughts so that they can better learn to identify these early signs.
183
Refer to the Daily Wellness Strategies (listed on Form 27 at the end of the
Patient Workbook). Learn and practice the strategies that will help you
cope with stress and will help prevent you from getting too high (e.g., stay
belowa5)on the Anger Thermometer scale. These daily activities include:
5. Assign Homework
Refer the patient to the homework checklist at the end of Chapter12
in the Patient Workbook, and make sure the patient understands
how to complete the homework. If she has questions or needs help
problem-solving obstacles to completing the homework, encourage her
to call you before the next session.
184
185
CHAPTER13
MATERIALS
In vivo Hierarchy Form that patient started in Session 3
In vivo Exposure Data Form (Form 17 at the end of the Patient
Workbook)
Patient Imaginal Exposure Data Form (Form 18 at the end of the
Patient Workbook)
Therapist Imaginal Exposure Recording Form (Appendix C at the
end of this Therapist Guide)
Coping with Anger (Form 28 at the end of the Patient Workbook)
SESSION OUTLINE
1. Review PTSD symptoms and any substance use since last session
2. Review homework
3. Conduct and process final imaginal exposure
4. Anger management strategies
5. Assign homework
187
Therapist Note
During these last few sessions of the treatment program, you should begin
to increasingly fade out of the therapeutic role. Doing so will help your
patients gain confidence in their own abilities, facilitate termination,
and enhance the likelihood of generalization and maintenance of the
skills acquired during treatment.
1. Review PTSD Symptoms and Any Substance Use Since Last Session
Review the patients weekly PTSD and SUD assessments. If any alcohol
or drug use has occurred since the last session, discuss this as described
in Session 2.
2. Review Homework
Did the patient complete his homework? Review each homework form
with the patient. Congratulate the patient for his efforts to confront
difficult situations, and give lots of positive feedback. If homework was
not completed, explore obstacles and problem-solve with the patient.
Review the in vivo and imaginal homework. Go over the patients
in vivo rating form and imaginal exposure practice exercise sheet. Ask
the patient what he learned from doing the exposures. Pay attention to
whether the patient is staying in the situation long enough, documenting his SUDS ratings, and so on. Pay attention to any safety behaviors
that the patient may be using in the in vivo and imaginal exercises (e.g.,
alcohol or other drug use, distracting himself during the exposure, carrying an object he feels will protect him). Help the patient to plan the
next in vivo exercises without using any safety behaviors. Pay particular
attention to any substance use before and after exposures. Assign the
final in vivo exercises at this time.
3. Conduct and Process Final Imaginal Exposure
Conduct the final imaginal exposure and processing. In this last
imaginal exposure, have the patient revisit the entire trauma memory
188
from beginning to end, not just the hot spots. Doing so will allow for
organization and closure of the trauma memory. See Session 4 for
instructions.
189
190
191
Activating
Event
Belief
Consequences
(Something
happens)
(Your thoughts;
What you say to
yourself)
Figure13.1
If you did actually resolve the problem, congratulate yourself:I handled that one pretty well. Im doing better at this all the time.
192
5. Assign Homework
Refer the patient to the homework checklist at the end of Chapter13
in the Patient Workbook, and make sure the patient understands
how to complete the homework. If she has questions or needs help
problem-solving obstacles to completing the homework, encourage her
to call you before the next session.
193
CHAPTER14
MATERIALS
In vivo Hierarchy Form that patient started in session 3
COPE Program Treatment Contract (Form 1 at the end of the Patient
Workbook) signed at the beginning of therapy with initial goals
Early Warning Signs (Form 29 at the end of the Patient Workbook)
My Next Steps (Form 30 at the end of the Patient Workbook)
Certificate of Completion (Appendix D at the end of this Therapist
Guide)
AGENDA
1. Review PTSD symptoms and any substance use since last session
2. Review homework
3. Termination
4. Feedback
5. Saying goodbye
In this final session with the patient, you will want to take time to
review the patients success and highlight specific areas of improvement
(e.g., no substance use in 10 weeks, 85% negative urine drug screens,
improved relationship with family members, obtained a job, able to talk
about the trauma without being overwhelmed, significant decreases in
PTSD symptoms, able to go to the movie theater again, able to date
195
1. Review PTSD Symptoms and Any Substance Use Since Last Session
Review the patients weekly PTSD and SUD assessments, urine drug
screen, and breathalyzer. If any alcohol or drug use has occurred since
the last session, discuss this as described in session 2.
2. Review Homework
Did the patient complete her homework? Review each homework
form with the patient. Congratulate the patient for her efforts to confront difficult situations, and give lots of positive feedback. If homework was not completed, explore obstacles and problem-solve with
the patient.
3. Termination
Evaluate and discuss the patients progress. Review the skills the patient
has learned, provide positive feedback for all the accomplishments
made during the program, and make recommendations for further
treatment if indicated.
196
197
Substance Abuse
Review the substance abuse goals that were generated in session 1 and
written down on the Treatment Contract. Show the patient a graph of
his substance use over the course of therapy (e.g., percentage of days he
used alcohol or drugs each week, dollar amount spent on drugs each
week, number of standard drinks consumed each week) to illustrate his
198
level of progress. As with the PTSD symptoms, you will want to make
a graph of the changes in substance use over time by drawing them out
on paper or entering the data into Excel or other type of spreadsheet.
Ask the patient questions to help her increase awareness regarding cravings and triggers, and to articulate skills that she has learned to help
reduce/stop substanceuse.
What have you noticed about the frequency or intensity of your cravings?
Do they happen less often now?
What have you learned about your ability to manage cravings?
What have you learned about your triggers for substance use?
What helped you the most to be able to quit using?
What made it the hardest for you to quit using?
You will also want to ask questions related to the interrelationship of
substance use and PTSD symptoms.
What have you learned about the connection between your PTSD and
substance use?
How do you think the changes (or lack thereof) in your substance use
affected the changes in your PTSD symptoms?
What did you notice about your PTSD symptoms as your substance use
decreased?
199
200
4. Feedback
Patients should be encouraged to provide comments, both positive and
negative, regarding their reactions to the therapy experience as a whole
and to the therapist in particular. This feedback should include recommendations to improve the treatment protocol as well as comments on
the therapists style. Since they are less accustomed to this role, patients
may require some prompting to carry on this aspect of the discussion.
You should ask about experiences that may have been especially helpful
201
5. Saying Goodbye
Working with individuals to process their trauma and increase control over their substance abuse can be emotionally intense for both
the patients and the therapist. Not surprisingly, terminating therapy
can be hard. Indeed, for many patients, reminding them throughout
therapy of the relatively short-term nature of the work you are doing
together can be useful. Take time to offer the patient feedback and to
say goodbye.
You did a great job with this challenging treatment. Ihave really enjoyed
working with you.
You had some difficult weeks there, but you persisted with courage and
patience, and it is obvious that your efforts have paid off.
You mentioned that you were disappointed that you had not made more
progress in the program. I d like to tell you that it is not unusual for
patients to express the same feelings and then discover that they feel much
better as time goes on.
202
It can take time to digest and process what you have learned in treatment. You may continue to feel better as time goes on, especially if you
continue to use the skills and techniques that you have learned.
I know this program was difficult for you to complete. In fact, there
were a few days (weeks) when you wanted to just drop out of treatment.
But you had the courage to stick with the program and have made some
important progress.
I really admired your courage in doing this work, and Iam thankful for
having had the opportunity to work with you.
Some patients will have a particularly hard time saying goodbye to the
therapist. In rare cases, the anxiety generated by the final therapy session can increase the patients thoughts about using or cravings to use.
Encourage these patients to continue to use the skills learned in therapy
over the next several months and to call you if they run into difficulties. As stated earlier, you can always set up a booster session for 46
weeks after the COPE treatment has been completed. Indicate to the
patient that she does not have to be doing poorly or struggling to come
in for the booster session. The booster session is a check-in appointment to catch up and review coping skills, even for patients who continue to do well with regard to both PTSD and SUD symptoms.
Provide ample praise for the patients courage in seeking and staying in
treatment. Focus on the gains and highlight the patients courage and
areas of strength and resiliency.
Present the patient with a Certificate of Completion (Appendix D
in this Therapist Guide) to take with him or her, as well as the My
Next Steps form (Form 30 at the end of the Patient Workbook) and
the Early Warning Signs form (Form 29 at the end of the Patient
Workbook) that might indicate the need to seek additional professional
help for substance use or other problems.
203
Appendices
205
Appendix A
Information Gathering Form
(for Therapist use in Session1)
Note: This form is to be used as a means of outlining and summarizing important information about the patient.
Name:
Date:
Age:
Race:
Gender:
207
Employment status:
208
Relationship status:
Living arrangements (e.g., with whom does the patient live, how long has the patient lived
there? Is it safe? Do others in the home use substances?):
Legal problems:
209
Substance of choice:
210
Problems experienced as a result of substance use (e.g., legal, family/social, physical health,
mental health, employment, education, financial):
211
IV. Trauma/PTSD
Type of trauma(s) experienced during lifetime:
Brief description of index trauma (i.e., the trauma that is causing the most re-experiencing
and avoidance symtpoms now):
212
Problems experienced as a result of PTSD (e.g., physical health, mental health, employment,
education, relationships with friends, family or loved ones):
213
Appendix B
Safety Agreement
I,
, agree that Iwill not attempt to harm myself. Ipromise
that Iwill not attempt to commit suicide. Ipromise that Iwill not participate in any activity
that could result in my intentionally causing harm or death to myself.
If Ihave thoughts of suicide or feel like Iwant to hurt or kill myself, Ipromiseto:
A. Call 911 if Iam in immediate danger of harming myself.
B. Call the following support people or agencies if Iam feeling suicidal, but do not feel that
Iwill cause harm to myself immediately:
Support Persons Name:
Phone Number:
Phone Number:
My Therapists Name:
Phone Number:
Patient Signature
Date
Therapist Signature
Date
Patient should be given a copy of the signed agreement to take with him or her.
215
Appendix C
Therapist Imaginal Exposure
RecordingForm
Date:
Subject #:
Session #:
Exposure #:
Trauma #:
Brief description of the incident being recounted during the imaginal exposure:
Start time:
End time:
SUDS
Craving
Beginning
5 min.
10 min.
15 min.
20 min.
25 min.
30 min.
35 min.
40 min.
45 min.
Notes
Processing Notes:
217
Appendix D
Certification of Completion
219
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