Simultaneous Treatment of Substance Abuse and Post-Traumatic Stress Disorder-A Case Study

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Simultaneous Treatment of Substance Abuse and Post-Traumatic Stress Disorder : A Case Study
Joanne L. Davis, Stephenie Davies, David C. Wright, Sherry Falsetti and John C. Roitzsch Clinical Case Studies 2005 4: 347 DOI: 10.1177/1534650103259745 The online version of this article can be found at: http://ccs.sagepub.com/content/4/4/347
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CLINICAL 10.1177/1534650103259745 Davis et al. /CASE PTSDSTUDIES AND SUBSTANCE / October 2005 ABUSE TREATMENT
Simultaneous Treatment of Substance Abuse and Post-Traumatic Stress Disorder

A Case Study
JOANNE L. DAVIS
University of Tulsa
STEPHENIE DAVIES
Private Practice, Ottawa University of Tulsa
DAVID C. WRIGHT SHERRY FALSETTI JOHN C. ROITZSCH
Medical University of South Carolina
Abstract: The type and timing of treatment for comorbid substance abuse and victimization has been debated in the past decade. Arguments have been made for simultaneous treatment and consecutive treatment of each difficulty. Current issues and a case study in which both problems are treated simultaneously are presented. The patient received inpatient detoxification, inpatient and outpatient group counseling following the 12-step program, and a cognitive-behavioral-oriented outpatient group in the substance treatment component. Multiple Channel Exposure Therapy (MCET), a 12-week manualized treatment developed to treat individuals suffering from both post-traumatic stress disorder and panic disorder, was implemented in the victimization component. At postassessment and at follow-up, the patient no longer met criteria for any pretreatment diagnoses, and her alcohol dependence was in remission. Clinical implications and recommendations for the treatment of substance abuse and victimization are discussed. Keywords: substance abuse; Post-Traumatic Stress Disorder; PTSD; Multiple Channel Exposure Therapy; MCET
THEORETICAL AND RESEARCH BASIS
Research has indicated that trauma victims report greater past involvement and higher expected future involvement for engaging in substance use than nonvictims
CLINICAL CASE STUDIES, Vol. 4 No. 4, October 2005 347-362 DOI: 10.1177/1534650103259745 2005 Sage Publications
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(Heffernan et al., 2000; Reifman & Windle, 1996; Resnick, Acierno, & Kilpatrick, 1997; Smith, Davis, & Fricker, 2002; Stewart, Conrod, Pihl, & Dongier, 1999). This finding is consistent across different types of violence (e.g., sexual abuse, physical abuse) and is particularly salient for victims who have experienced multiple incidents (Davis, CombsLane, & Jackson, 2002). Treatment efforts targeting this population have encountered difficulties, and debates have ensued as to the best way to approach treatment. This article will briefly outline the current issues related to treating individuals with comorbid substance abuse and victimization and will describe a case study in which both problems are treated simultaneously. The relationship among trauma, post-traumatic stress disorder (PTSD), and substance use is quite complex, and investigators have recently begun to examine this relationship in an effort to better inform treatment planning. One question that has been explored is the order of onset of PTSD and substance abuse. Brady, Dansky, Sonne, and Saladin (1998) examined the order of onset of traumatic events, PTSD, and cocaine dependence in a treatment-seeking sample. They found fairly even the number of individuals who developed cocaine dependence prior to PTSD and those who developed PTSD prior to cocaine dependence. The groups differed in several ways, however. The primary PTSD group (i.e., PTSD developed first) included more women, suggesting that developmental pathways may differ by gender. The primary PTSD group was also more likely to have experienced a sexual assault, whereas the primary cocaine group was more likely to have witnessed a trauma or to have experienced a physical assault. In fact, the investigators noted that most of the trauma in the primary cocaine group was related to obtaining and using the drug, whereas the primary PTSD groups traumatic events were mostly assaults in childhood. It remains unclear how treatment planning may depend on the order of onset of the disorders or on other, related characteristics. Another question with implications for treatment is whether the relationship between victimization and substance abuse is direct or mediated by other long-term correlates, such as psychological problems. A number of factors may influence development of PTSD and/or substance abuse, including social support before and after the trauma, substance use in the peer group or family, the nature of the trauma itself, and the individuals coping mechanisms (Kofoed, Friedman, & Peck, 1993). For example, Polusny and Follette (1995) suggest that victims may engage in alcohol use as a strategy to avoid or palliate negative, abuse-related internal experiences, such as depression or anxiety (see also Briere, 1992). Perhaps specifically related to PTSD, some literature suggests that individuals may use substances to forget disturbing memories or intrusive thoughts and images. If use of substances results in escaping the negative internal experiences, it may become a strong negative reinforcer (Wulfert, Greenway, & Dougher, 1996).
AUTHORS NOTE: The treatment described herein was conducted by the first author while an NIMH-funded postdoctoral fellow at the National Crime Victims Research and Treatment Center, Charleston, SC. Correspondence concerning this article should be addressed to Joanne L. Davis, 600 South College Avenue, 308C Lorton Hall, University of Tulsa, Tulsa, OK 74104; e-mail: joanne-davis@utulsa.edu.
Davis et al. / PTSD AND SUBSTANCE ABUSE TREATMENT
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The type of substance used may also reflect the pattern of symptoms experienced (Brown & Wolfe, 1994). For example, Saladin, Brady, Dansky, and Kilpatrick (1995) found that alcohol-dependent individuals reported more arousal symptoms than did cocainedependent individuals, suggesting the use of a specific drug (i.e., alcohol) to assist coping with specific symptoms (i.e., arousal). Bremner, Davis, Southwick, Krystal, and Charney (1994) have suggested that drug abusers with a history of trauma may use specific drugs to mitigate the symptoms associated with the trauma exposure, specifically the use of opiates for their analgesic properties of hyperarousal symptoms. It is likely that individuals who find that they are able to escape or reduce the negative stimuli related to the abuse through substance use will begin to use this strategy in other difficult situations. Another contributing factor to substance use among victimized individuals may be related to the perception of risk involved with substance use. A study sampled 340 college women and examined the perceived risks, benefits, and self-reported previous involvement in six categories of risky behaviors, including drug use and heavy drinking (Smith et al., 2002; Smith, Fricker, & Davis, 1997). Although PTSD was not assessed, results indicated that those reporting child sexual abuse (CSA) perceived greater benefit and less risk associated with illicit drug use and risky sexual behaviors. The CSA group also reported greater frequency of past involvement in risky sexual behaviors, illicit drug use, and aggressive/illegal behaviors. Although more research is needed in this area, the investigators suggest that the manner in which victims perceive various risky behaviors may partially explain their more frequent involvement in such behaviors. It appears that victimized individuals may develop substance problems for different reasons and through different routes than nonvictim substance users. Thus, traditional forms of treatment that are successful with nonvictim substance users may not be as effective with victim users. Although there is much to learn about the mechanisms involved in the relationship between victimization and substance use, it seems logical that unless issues related to the abuse and negative correlates of the abuse (e.g., PTSD) are also treated, the efficacy of treating substance use may be compromised (Moran, Davies, & Toray, 1994). In fact, in an examination of records from a substance abuse rehabilitation facility, Chiavaroli (1992) found that those individuals who also worked on issues related to childhood abuse experiences showed a higher rate of success than those who did not work on such issues. Several different approaches to addressing the issue of the comorbidity of PTSD and substance abuse have been discussed. Arguments have been made for treating the disorders separately and consecutively, whereas others advocate for concurrent and simultaneous treatment. Those who advocate concurrent and simultaneous treatment argue that if trauma-related issues and PTSD symptoms are not addressed early on in treatment, negative affect will continue, lessening the likelihood that substance use will decrease and increasing the chance of dropout and relapse. In addition, if the motivation for substance use is in part to reduce negative affect and trauma-related memories, addressing the PTSD symptoms early on may decrease the perceived need for substance
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use. Kofoed et al. (1993) suggest that alcohol and drug issues have to be treated early on in the intervention along with treatment for PTSD symptoms, so as to make the substance abuse treatment components acceptable and psychologically accessible. Sullivan and Evans (1996) outline a five-stage model for synergistic treatment of traumabased psychiatric syndromes (i.e., PTSD) and substance abuse/dependency. The authors state that the combination of focus on both the trauma and substance abuse components may increase efficacy of treatment. The simultaneous treatment of PTSD and substance abuse has recently received more attention, in that several manualized treatments have been published (Back, Dansky, Caroll, Foa, & Brady, 2001; Najavits, Weiss, Shaw, & Muenz, 1998; Triffleman, Carroll, & Kellogg, 1999). Triffleman and associates (1999) have indicated that initial pilot data using the Substance Dependence PTSD Therapy (SDPT) is effective in reducing PTSD severity. Najavits et al. (1998) have manualized a treatment protocol for concurrent treatment of PTSD and substance abuse in women (Seeking Safety) and included outcome data for their treatment. Although no control group was included in their study, the women who completed treatment (63%) evidenced not only reduced substance use but also PTSD symptoms at postassessment (Najavits et al., 1998). Not all researchers and practitioners agree with simultaneous treatment approaches. In a comprehensive review of the treatment of PTSD and substance use, Ruzek, Polusny, and Abueg (1998) argue against the simultaneous treatment of PTSD and substance abuse. The authors postulate that substance abuse issues need to be addressed before treatment of PTSD symptoms. The authors theorize that the individuals seeking treatmentwhen not treated for their substance abuse issues firstare limited in their ability to use healthy coping strategies to gain support from their social network, to engage in trauma-focused treatment, and to have an increased vulnerability to experiencing other trauma or victimization because of their intoxication. Zaslav (1994) discussed ways in which substance abuse may interfere with PTSD treatment, in that substance abusers may have difficulty sustaining a commitment to psychotherapy and maintaining the therapeutic alliance. The author states that when active substance abusers are in simultaneous treatment regimes, a majority of their time may be spent on efforts to obtain, use, and recover from the substance of abuse, thereby causing less effort in improvement as well as increased problems and crises. Thus, arguments have been made for treating the disorders separately and concurrently and treating the disorders simultaneously. However, little empirical support is available to suggest one method may be more effective than another. In fact, although much has been written about the comorbidity of these disorders, there is a limited amount of outcome data in the literature. The aim of this article is to present outcome data from a case study of trauma-focused therapy conducted simultaneously with substance abuse treatment. PTSD symptoms were treated with a modified version of Cogni-
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tive Processing Therapy (Resick & Schnicke, 1993) and MCET (Falsetti, 1997). Substance abuse was treated initially on an inpatient substance abuse unit and subsequently in outpatient group therapy. The trauma-focused therapy was conducted on an individual basis, although the therapist involved was part of the treatment team for the substance abuse component. The patient also attended additional types of treatment, which are described in detail below. The therapist (JD) was a predoctoral clinical psychology intern supervised by a Ph.D. level clinical psychologist (JR) and trained in MCET by one of the authors (SF) of the treatment.
CASE INTRODUCTION
The patient, referred to by the pseudonym Jackie, was a 33-year-old Caucasian woman admitted to an inpatient substance abuse unit of a Southern university hospital following a suicide attempt. She presented with chief complaints of depression and anxiety. At the time of intake, the patient met the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV) (American Psychiatric Association, 1994) criteria for Post-Traumatic Stress Disorder, Major Depressive Episode, recurrent, Alcohol Dependence, and Borderline Personality Disorder. Jackie reported numerous previous admissions to various psychiatric hospitals for both psychological problems and substance use, and had attempted suicide more than 20 times since her early teens. At the time of admission to the inpatient unit, Jackie was single, employed full-time, and had completed a bachelors degree.
PRESENTING COMPLAINTS
Following approximately 2 weeks of inpatient treatment, the clinical team referred Jackie to JD for treatment of PTSD symptomatology. While on the inpatient unit, several treatment planning sessions were held by JD and Jackie during which different treatment options were discussed. Trauma-focused treatment began while she was an inpatient, and outpatient treatment began immediately following Jackies discharge, approximately 1 month after her admission to the hospital. During her weekly traumafocused treatment with JD, Jackie was also involved in several other treatment modalities. She attended weekly outpatient substance abuse group therapy, bimonthly individual therapy sessions at a local mental health center, and a weekly group Dialectical Behavior Therapy session for individuals with Borderline Personality Disorder. She had been attending therapy at the mental health center for approximately 2 years, with treatment focusing primarily on stabilizing her depression.
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HISTORY
SUBSTANCE USE HISTORY
Jackies alcohol use began at age 12. In the past year, Jackie consumed alcohol approximately 3 to 4 days per week. On those occasions, she would typically drink a 12pack of beer or a pint of liquor. She also binged approximately every other week. Jackie also reported almost daily marijuana use from age 13 to age 17, experimenting with amphetamines on one occasion, and using sedatives during several of her suicide attempts. Jackie responded affirmatively to four questions assessing problems associated with substance use, including feeling the need to cut down on drinking, being annoyed by others criticizing her drinking, feeling bad or guilty about drinking, and having a drink first thing in the morning.
TRAUMA HISTORY
An assessment of previous traumatic events was conducted using the Trauma Assessment for Adults (Resnick, Best, Kilpatrick, Freedy, & Falsetti, 1993). Jackie reported an extensive trauma history including childhood sexual and physical abuse, beginning when she was approximately 8 years old. Her childhood sexual abuse experiences involved several incidents with different perpetrators and ranged from molestation to rape. She also experienced two rapes in adulthood and was physically assaulted by a partner.
ASSESSMENT
The initial part of the assessment involved a clinical interview in which demographic and background information were gathered and Jackie described the trauma and her responses. A structured clinical interview and several self-report measures were used to determine Jackies diagnosis. She was administered the PTSD and mood disorders portions of the Structured Clinical Interview for DSM-IV (First, Spitzer, Gibbon, & Williams, 1997). Results from the interview indicated that she met criteria for PTSD, chronic, and Major Depressive Disorder, recurrent, moderate. She was diagnosed with alcohol dependence by the intake assessor on the substance abuse unit. Jackie also completed several self-report measures at pretreatment, posttreatment, and follow-up. For the pretreatment assessment, Jackie was administered the Symptom Checklist 90Revised (SCL90-R) (Derogatis, 1983), the Impact of Events Scale (IES) (Horowitz, Wilner, & Alvarez, 1979), the Trauma Symptom Inventory (TSI) (Briere, 1995), the Risk in Intimacy Inventory (Pilkington & Richardson, 1988), and the Beck Depression Inventory (BDI) (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). The
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posttreatment and follow-up assessment materials were the same with the addition of the Modified PTSD Symptom Checklist (Resick, Falsetti, Resnick, & Kilpatrick, 1991). Jackie attained clinically elevated scores on numerous indices at pretreatment (see Table 1).
CASE CONCEPTUALIZATION
An individuals style of coping is an amalgamation of numerous factors, including genetics, temperament, modeling, life events, and culture. Determining the contribution of each of these factors is often difficult. In Jackies case, it was important for the therapist to understand how the substance abuse and trauma contributed to each other and to her current level of functioning. Jackies father was an alcoholic, as were several other extended family members on both sides of her family, resulting in a predisposition for Jackie to abuse alcohol as well as providing models for her to learn that alcohol is often used to reduce stress. Her mother was diagnosed with recurrent depressive episodes. Not only did this render her unavailable emotionally to and seemingly unsupportive of Jackie, it also provided another poor model for how to cope with life stressors. Jackie reported being involved with a peer group throughout her adolescence, who encouraged substance use in its members. As her initial trauma occurred at an early age (8 years old), it is difficult to determine to what extent the trauma influenced her initial substance use. Jackie reported, however, that she was soon using alcohol and other substances to cope with the negative effects of the trauma, including depression, low selfesteem, and flashbacks. Her continued use and her growing reliance on substances to regulate affect appear to have significantly increased her risk of becoming dependent on alcohol. Jackie had experienced multiple traumas by young adulthood, including several rapes. Acierno, Resnick, Kilpatrick, Saunders, and Best (1999) have suggested some factors that put women at risk of being raped are past victimization, young age, and/or a diagnosis of active PTSD. Other studies suggested that some risk factors for child abuse, including sexual abuse, are living in poverty, having a single parent, or having parental psychopathology. Many of these risk factors tend to coexist (Hecht & Hansen, 2001). Another risk factor that emanates from sexual abuse is revictimization. Children who have experienced sexual abuse have a higher chance of being revictimized, dependent on the personal history of the child (traumatic sexualization) or the relationship with the perpetrator (if from authority figure, he or she may experience a decreased ability to resist unwanted sexual advances). Also, the community of the victim (lack of support system) and the culture at large (blaming-victim attitudes) may put the victim at greater risk of being abused again (Grauerholz, 2000). Other research also supports the contribution of substance use to victimization. Victims may be exposed to more potential perpetrators because of particular lifestyle factors associated with substance use, and the sub-
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Preassessment and Postassessment Scores for Case 1

Pretreatment Symptom Checklist 90Ra Somatization Obsessive-Compulsive Interpersonal Sensitivity Depression Anxiety Hostility Phobic Anxiety Paranoid Ideation Psychoticism Global Severity Index Impact of Events Scale Intrusion Avoidance Beck Depression Inventory Risk in Intimacy Inventory NOTE: Numbers in italic are means. a. T scores more than 65 are clinically elevated. Posttreatment 3-Month Follow-Up
TABLE 1
91 88.2 103.6 122.3 120 100.7 105.8 65 108.4 116.5 4.14 4.00 44 43
55.2 45.8 48.2 48.9 50 46.7 50.3 42.3 44.4 49.4 0.14 0.00 0 20
40 <27 <27 31 <27 <32 <38 <33 <30 25 0.00 0.00 5 34
stances may impair decision-making abilities and risk assessment. Jackie had a number of these risk factors that likely contributed to her revictimization. By the time the therapist met Jackie, she had been stuck for many years in a vicious cycle of substance use, victimization, depression, and PTSD. She was demoralized and stated that she was tired of it all. She had been hospitalized so many times that she lacked hope she would ever be well. She did not believe she had the power to change her circumstances or the energy to try. In the past, when she had tried to quit drinking, she found the emotional distress (e.g., PTSD and depression) to be too great and would return to using. She was not close to her family and had few supports outside the therapeutic community. Although she had been in therapy for quite some time and had been hospitalized many times, she had not previously received trauma-focused treatment. She reported that her therapists did not want to focus on her trauma until she had quit abusing substances and her depression was stabilized.
COURSE OF TREATMENT AND ASSESSMENT OF PROGRESS
As stated above, Jackie was involved in several types of treatment. This article focuses on the treatment of the PTSD symptoms concurrently with the alcohol dependence. (Please see Table 1 and Figure 2 for a summary of the pre-, post-, and follow-up assessments.)
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SUBSTANCE TREATMENT
Substance treatment consisted of inpatient detoxification, inpatient and outpatient groups following the 12-step program, and a cognitive-behavioral-oriented outpatient group focusing on identifying cognitive and behavioral cues for drinking and implementing strategies to cope with these cues.
MCET
MCET (Falsetti, 1997) is a 12-week manualized treatment developed to treat individuals suffering from both PTSD and Panic Disorder. MCET combines aspects of cognitive processing therapy (Resick & Schnicke, 1993) and panic control treatment (Barlow & Craske, 1989). This treatment includes psychoeducation about traumatic events and correlates of trauma (including substance use), psychoeducation about panic attacks and PTSD, breathing retraining, cognitive exposure, in vivo exposure, and cognitive restructuring to address distorted thinking related to the trauma or panic attacks (Falsetti, 1997). The manualized treatment was followed as described with the exception of the exclusion of the chapter on interoceptive exposure to panic symptoms and psychoeducation about panic attacks, as Jackie did not meet criteria for panic disorder. Jackie attended 17 individual therapy sessions. During this time, she completed weekly homework assignments. Each week she was asked to complete a PTSD symptom checklist from which her average number of symptoms per week was determined (see Figure 1). Other homework was assigned based on the particular chapter that was covered in the MCET protocol. Jackie was taught and practiced methods of coping with anxiety, including breathing retraining. She completed assignments in and out of session identifying and challenging distorted cognitions related to her traumatic experiences. She engaged in cognitive exposure through writing about several of the traumatic events and reading them to herself in between sessions and to the therapist within session. It was during the written exposure component of the treatment (Sessions 5 and 6 of the protocol) that Jackie reported the most distress (see Figure 1). Jackie was able to continue to work through her distress to the next component of treatment, in vivo exposure. She engaged in in vivo exposure targeting her fear of being in close proximity to unfamiliar men and seeking medical assistance from a gynecologist. These activities included developing separate fear hierarchies for three target fears, including riding in an elevator with an unfamiliar man, sitting in the therapists office with an unfamiliar male therapist, and scheduling and attending an appointment with her gynecologist. Each target fear was broken down into small steps and Jackies homework involved engaging in each step until her anxiety had significantly decreased. Finally, she learned and talked about how traumatic events can disrupt belief systems related to intimacy, esteem, trust, safety, and power/competence.
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Figure 1. Average Number of PTSD Symptoms Per Week

NOTE: PTSD = Post-Traumatic Stress Disorder.
On completion of trauma-focused therapy, Jackie had also completed the outpatient substance abuse program and the Dialectical Behavior Therapy group. She planned to continue seeing her counselor at the local mental health center.
IMMEDIATE POSTASSESSMENT
One week following the completion of the MCET treatment, Jackie returned to the clinic to complete the postassessment. At the posttreatment assessment, Jackie no longer met criteria for PTSD, depression, and the alcohol dependence was in remission. She reported that she had not engaged in substance use in more than 1 month and had not been drunk in more than 5 months. In addition, she reported significantly decreased trauma symptomatology (see Figure 2).
COMPLICATING FACTORS
Jackie reported relapsing on two separate occasions during treatment. She stated that on each occasion she consumed several beers but did not binge. These incidents were discussed in session and framed as Jackie returning to familiar methods of coping. Her new coping skills were reviewed and she was encouraged to continue practicing them. Also during treatment, Jackie experienced several events that significantly increased her stress level. These included fears related to having physical problems and not wanting to seek medical treatment, becoming involved in a new relationship, ending
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Pre-treatment 100 90 80 70 60 50 40 30 20 10 0
Anxious Arousal Depression Anger Irritability Intrusive Experiences
Post-treatment
Follow-up
Defensive Avoidance
Dissociation
Sexual Concerns
Dysfunctional Impaired SelfSexual Reference Behavior
Tension Reduction Behavior
Figure 2. Trauma Symptoms at Pretreatment, Posttreatment, and Follow-Up
the relationship on recognizing potentially abusive behavior on the part of her partner, and learning that she was pregnant. In spite of these difficulties, Jackie continued in treatment and progressed very well. She stated that had these events occurred 6 months earlier, she would likely have been drinking heavily and attempted suicide.
MANAGED CARE CONSIDERATIONS
Jackie had private insurance through her employer. The clinic works on a sliding scale and she received a 40% discount for the amount that her insurance company would not pay. Managed care directives are becoming increasingly relevant to psychologists. Initially, the primary outcome of managed care involvement in psychological services was to reduce the quantity of treatment sessions offered. Ironically, this had the effect of forcing therapists and personnel directors to increasingly adopt the most effective, efficient, and empirically supported interventions. Therefore, while limiting the overall quantity of services patients can obtain, managed care has indirectly increased the quality of services delivered. Although there is good evidence for efficacious treatments for PTSD and substance abuse alone, the research regarding when and how to treat individuals suffering from both PTSD and substance abuse is in its infancy. Several studies have shown promising results for simultaneous treatment or combined treatment packages; however, more research is needed.
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FOLLOW-UP
Jackie again returned to the clinic to complete a 3-month follow-up assessment and booster session. At this time, she again did not meet criteria for any pretreatment diagnoses. Furthermore, she reported not having had a drink in 4 months and not being intoxicated in more than 8 months. Several issues were discussed in the booster session to help Jackie maintain treatment gains and plan for potential future obstacles. Various potential risk factors were identified that might lead to a resurgence of Jackies symptoms, including revictimization, life stressors, and becoming involved in relationships. She was encouraged to expand her support system, particularly with the impending birth of her child. The unique stressors and risk factors related to child rearing were also discussed. During the session, Jackie engaged in appropriate problem solving related to these potential difficulties. She reported continuing to attend all prenatal appointments and was involved in a Lamaze class with a friend as her support. She was also in touch with one of her sisters, who was providing significant support. She denied being in a relationship and stated no intentions of becoming involved with anyone for quite some time. She expressed the desire to continue her focus on herself and her baby.
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TREATMENT IMPLICATIONS
Research findings indicate a significant association between substance abuse and PTSD (Dansky, Saladin, Brady, Kilpatrick, & Resnick, 1995; Najavits, Weiss, & Shaw, 1997). The combination of the two disorders is marked by a higher level of social impairment, poorer treatment outcome, more severe symptoms, and higher rates of other pathology than either disorder alone (Brady, Dansky, Back, Foa, & Carroll, 2001; Najavits et al., 1998). These problems have led to significant concern regarding the most appropriate approach to treatment. Traditional forms of treatment for either disorder alone may be ineffective and even contraindicated for individuals suffering from both problems (Najavits et al., 1997). For example, PTSD symptoms have been found to increase with abstinence, whereas other comorbid Axis I disorders tend to remit with abstinence. Several different approaches to addressing the issue of the comorbidity of PTSD and substance abuse have been discussed. Arguments have been made for treating the disorders separately and consecutively, whereas others advocate for concurrent and simultaneous treatment. The findings from this case study suggest that simultaneous treatment of PTSD symptoms and drug abuse behaviors was effective in the reduction of both. The authors of this study do not wish to claim that this treatment is appropriate for all or that the results can be generalized. However, this study supports previous research suggesting that substance use and PTSD treatments do not have to be conducted contiguously. More information about the treatment of these comorbid disorders is surely needed. In recent years, several manualized treatments have been developed that incorporate
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addiction treatment and PTSD treatment in the same package. It will be important to continue to assess the efficacy of such treatments, as well as test these treatments against separate, but simultaneous, treatment and either form of treatment alone.
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RECOMMENDATIONS TO CLINICIANS AND STUDENTS
It is rare to encounter any client with just one difficulty or issue. Victims of trauma often report numerous mental and physical health problems. Clinicians often report feeling overwhelmed by the number of issues and magnitude of distress reported by victims. Prioritizing targets of treatment in these cases is challenging. Particularly when faced with comorbid, debilitating disorders, such as PTSD and substance use, clinicians may question whether it is necessary to target specific psychological symptoms first in an attempt to decrease the related negative affect, avoidance behaviors, and maladaptive cognitions associated with the trauma. Or is it appropriate to focus on the substance use initially in an effort to reduce the patients risk for revictimization and negative health consequences? Which approach is likely to be better tolerated by the client? Furthermore, with respect to interventions for substance use, what are the best treatment approaches with victims of trauma (e.g., 12-step approach or cognitive-behavioral intervention)? Do these differ from standard approaches with nonvictims? First, the clinician needs to recognize and understand the implications of working with clients who engage in health risk behaviors such as substance use. Second, the nature and course of treatment needs to be adapted to meet the unique needs of victims who are struggling with both trauma and substance use. Third, it is important for clinicians to understand that both trauma symptoms and substance use are well-established patterns for the patient and treatment may take several attempts. Fourth, clinicians working with trauma victims who are not familiar with treatment of addictions may want to seek additional training and supervision, particularly focusing on evidence-based treatments for trauma and substance issues. If research demonstrates continued support for separate, concurrent treatment of these issues, clinicians may want to focus on establishing a good working relationship with a colleague who specializes in treating the substance use and work together to meet the needs of the patient. REFERENCES
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Joanne L. Davis is an assistant professor at the University of Tulsa, Tulsa, OK. She received her doctorate from the University of Arkansas, completed a National Institute of Mental Health (NIMH)funded internship at the Medical University of South Carolina and completed a 2-year NIMH-funded postdoctoral fellowship at the National Crime Victims Research and Treatment Center in Charleston, SC. Her research interests include the assessment, treatment, and prevention of interpersonal violence. Stephenie Davies received her doctorate degree from the University of Georgia and completed her internship at the Medical University of South Carolina. She currently works at a childrens mental health center providing residential treatment to conduct-disordered adolescents and has a private practice in Ottawa, ON, Canada. David C. Wright is a graduate student in the Clinical Psychology Ph.D. program at the University of Tulsa, Tulsa, OK. He is currently the lab manager for the Trauma Research, Assessment, Prevention, and Treatment Center (TRAPT Center) at the University of Tulsa. His research interests include PTSD, interpersonal violence, and the MMPI-2.
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Dr. Sherry Falsetti is Associate Professor and Director of Behavioral Sciences in the Department of Family and Community Medicine at the University of Illinois. Prior to this she was the Director of Clinical Operations and an associate professor at the National Crime Victims Research and Treatment Center (NCVC) in the Department of Psychiatry and Behavioral Sciences at the Medical University of South Carolina. Dr. Falsettis research interests include treatment of post-traumatic stress disorder (PTSD) and comorbid psychiatric disorders as well as health problems associated with trauma. Dr. Falsetti also maintains an active clinical practice for the treatment of PTSD and other anxiety disorders. She is on the review board of Cognitive and Behavioral Practice and both presents and publishes regularly in the area of traumatic stress and anxiety disorders. John C. Roitzsch is a clinical associate professor at the Medical University of South Carolina. He is currently president of the South Carolina Psychological Association. He received his doctorate from Louisiana State University. He has previously served on the faculty of the LSU Medical School and the University of Georgia. Research interests have included stress management behavioral change and substance abuse.

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