Concurrent Treatment
Concurrent Treatment
Concurrent Treatment
Editor-In-Chief
Jack M. Gorman, MD
Concurrent Treatment
of PTSD and
Substance Use
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
1
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Printed in the United States of America
on acid-free paper
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 I could 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
vii
The manuals and workbooks in this series contain step-by-step
detailed procedures for assessing and treating specific problems
and diagnoses. But this series also goes beyond the books and
manuals by providing ancillary materials that will approximate
the supervisory process in assisting practitioners in the imple-
mentation of these procedures in their practice.
viii
all four clusters of PTSD symptoms and reducing the severity
of alcohol and drug use, thus minimizing the negative impact
that PTSD and SUD have on the lives of individuals who
suffer from both.
References
ix
Contents
Acknowledgments xiii
xi
Chapter 13 Session 11: Final Imaginal Exposure
and Anger Management 187
Chapter 14 Session 12: Review and Termination 195
Appendix A Information Gathering Form 207
Appendix B Safety Agreement 215
Appendix C Therapist Imaginal Exposure Recording
Form 217
Appendix D Certificate of Completion 219
References 221
About the Authors 231
xii
Acknowledgments
xiii
PI: Hien) (R01 DA07761; PI: Brady), the J. William Fulbright
U.S. Scholars Program (Project ID 3834; PI: Back), and the
Australian National Health and Medical Research Council
(455209, 630504; PI: Mills) (510274, 1041756; PI: Teesson).
xiv
Concurrent Treatment
of PTSD and Substance
Use Disorders Using
Prolonged Exposure
(COPE)
Introductory Information
CHAPTER 1
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.
What Is COPE?
1
• Techniques to help patients manage cravings and thoughts about
using alcohol or drugs, and to identify both PTSD-related as well as
substance-related triggers for use;
• Coping skills to help prevent relapse to substances, for example,
awareness and management of anger, and drink/drug refusal skills;
• Breathing retraining relaxation exercise that teaches the patient how
to breathe in a calming way;
• Repeated in vivo (i.e., real life) exposure to safe situations, places, peo-
ple, or activities that the patient is avoiding because of trauma-related
distress or anxiety;
• Repeated imaginal exposure to the trauma memories (i.e., revisiting
the trauma memory in imagination);
• Review of treatment progress and anticipation of future challenges to
enhance relapse prevention for both PTSD and SUD symptoms.
2
Concerns that PTSD/SUD patients who receive trauma-focused care
will experience an increase in substance use, relapse rates, and/or attri-
tion rates have not been borne out by the data. Insofar as substance use
represents self-medication of PTSD symptoms, addressing the trauma
and PTSD symptoms early in treatment and providing some concur-
rent relief from PTSD symptoms will likely improve SUD outcomes
(Back, 2010; Brady et al., 2001; Hien et al., 2010; Ouimette et al., 1997).
Furthermore, a substantial proportion of PTSD/SUD patients indicate
that they would prefer to receive integrated treatment delivered by the
same clinician (Back et al., 2014; Back et al., 2006c; Brown, Stout &
Gannon-Rowley, 1998; Najavits, 2004).
The main goal of COPE is to treat PTSD in a way that is effective for
individuals who also have an SUD. COPE is designed for use with
3
men and women exposed to a variety of different types of civilian and
combat-related traumas. The COPE treatment seeks to help patients
reduce both the severity of PTSD symptoms and the severity of alco-
hol and drug use, and to minimize the negative impact that PTSD and
SUD have on the patient’s life. COPE does not attempt to produce
personality changes or solve problems not directly related to PTSD
or SUD.
4
sexual and physical abuse. Exposure through electronic media, televi-
sion, 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).
The symptoms of PTSD must last more than one month; they must
cause clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning; and they must not
be attributable to substances or another medical condition. For more
5
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 expe-
rience at least one traumatic event in their life (Breslau, 2009; Elklit,
2002; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Mills et al.,
2011). In the United States, the lifetime prevalence rate of PTSD is
estimated to be 7%–8% (Kessler, Berlung, Demler, Jin, Merikangas, &
Walters, 2005). As a testimony to the human capacity for resilience and
recovery, the large majority of individuals who experience a traumatic
event do not develop PTSD. Only about 8%–20% will go on to meet
criteria for PTSD (Breslau et al., 1998; Brunello et al., 2001). Exposure
to a traumatic event can also lead to a condition known as acute stress
disorder (ASD). The primary distinction between PTSD and ASD is
the duration of symptoms. ASD can occur from 2 days after exposure
to the traumatic event and can last up to 1 month. In order to meet
criteria for PTSD, symptoms must have lasted 1 month or longer in
duration.
PTSD was first added to the Diagnostic and Statistical Manual of Mental
Disorders (DSM) nomenclature in 1980 with the third edition of the
DSM. Before that time, the diagnostic condition presently known as
PTSD was recognized primarily in combat survivors and was known
by various names, including soldier’s heart, irritable heart, shell shock,
and combat neurosis (Sadock & Sadock, 2003).
Assessment of PTSD
6
withdrawal. See Wilson & Keane (2004) or McCauley et al. (2012) for
more information regarding assessment of trauma and PTSD.
Therapist Note
Once a PTSD diagnosis has been established, be sure to assess the patient’s
PTSD symptoms regularly throughout treatment (e.g., weekly self-report
measurements). This is critical for monitoring progress and guiding
treatment decisions. Share the results of both the initial and ongoing
symptom assessments with the patient as part of the treatment. A good
time to present the weekly scores to the patient is mid-treatment
(i.e., session 6). It can be helpful to present the scores in a line graph
or other visual form.
Interview-Rated Assessments
Interviewer-rated assessments (based on DSM-IV diagnostic criteria)
that we recommend include:
7
Self-Report Assessments
Combat-Related Trauma
Like PTSD, substance use disorders (SUD) are often chronic and
relapsing conditions. Substances of abuse include alcohol, licit drugs
(e.g., cocaine, marijuana, heroin, methamphetamine), and prescription
drugs (e.g., opioid analgesics, benzodiazepines). The DSM-5 (American
Psychiatric Association, 2013) defines SUD as a maladaptive pattern of
use that leads to significant impairment in important areas of life (e.g.,
work, social) or significant distress.
8
exhibiting tolerance, which is defined as a need for markedly increased
amounts of the substance in order to achieve the desired effect, or
markedly diminished effect with continued use of the same amount of
the substance; and experiencing withdrawal as manifested by the char-
acteristic withdrawal syndrome for that particular substance, or if the
person takes the same (or closely related) substance in order to relieve
or avoid withdrawal symptoms.
Substance use disorders are among the most prevalent of all psychiatric
disorders (Merikangas et al., 1998). The National Comorbidity Survey
Replication (NCS-R), which assessed a nationally representative sample
of 9,282 adults in the United States, found that the lifetime prevalence
rate for any SUD was 14.6% and the past 12-month prevalence rate was
3.8% (Kessler, Berglund, Demler, Jin, Merikangas, & Walters, 2005).
Among military personnel and Veterans, rates of SUD are significantly
higher (Brady et al., 2009; McKenzie et al., 2006; SAMHSA, 2005).
Data from the National Survey on Drug Use and Health (NSDUH)
estimates that approximately 7.1% of Veterans meet criteria for a past
12-month SUD (SAMHSA, 2007). This rate is almost twice as high
as data in the general population (Kessler et al., 2005). Furthermore,
examination of Veterans 18–53 years of age reveals a 12-month SUD
prevalence rate of 18.2%, which is almost five times as high as the gen-
eral population (SAMHSA, 2007).
9
assessment of SUD. Share the results of both the initial and ongoing
symptom SUD assessments with the patient as part of the treatment.
A good time to do this is mid-treatment (i.e., session 6) when you can
present, for example, a line graph of the patient’s substance use. Using
the Time Line Follow Back (TLFB) or other weekly assessment of sub-
stance use, therapists can chart the patient’s changes in the percent
of days using substances (e.g., from 6/7 days or 86% to 3/7 days or
43%), amount of money spent on drugs, number of standard drinks
consumed, or the number of joints smoked or pills taken.
Interview-Rated Assessments
Self-Report Assessments
Biopsychosocial Assessments
10
Therapist Note
11
Negative Impact of PTSD and SUD Comorbidity
12
as compared to Veterans without dual diagnosis PTSD/SUD (Young
et al., 2005).
Prolonged Exposure
13
According to Foa and Kozak (1986), a fear structure becomes
pathological when
Foa and Kozak (1985) suggested that the anxiety disorders, such as
PTSD, reflect specific pathological fear structures and that treatment
reduces anxiety disorder symptoms via modifying the pathological
elements in the fear structure. These modifications are the essence of
emotional processing, which is the mechanism underlying successful
treatment, including exposure therapy.
According to Foa and Kozak, two conditions are necessary for success-
ful modification of a pathological fear structure, and thereby ameliora-
tion of the anxiety symptoms.
14
erroneous cognitions about anxiety itself that are disconfirmed dur-
ing 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 reduc-
tion. 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 behav-
ioral 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).
15
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 orga-
nization was associated with reduced depression.
16
How Prolonged Exposure Reduces PTSD Symptoms
17
How Is COPE Different From Existing Integrated Therapies?
18
incorporate both key elements of PE: (1) imaginal exposure followed
by emotional processing, and (2) in vivo exposure techniques.
Not every person with PTSD and a co-occurring SUD needs or will
be appropriate for the COPE treatment. On the basis of treating and
studying hundreds of individuals with PTSD and SUD, we recom-
mend that COPE be considered for use with:
19
intervention, and COPE should not be implemented until after such
intervention has occurred and the condition is stabilized:
Therapist Note
20
treatment. Safety is paramount. COPE should be delayed until the
person is away from the ongoing violent living situation.
• Lack of memory of a traumatic event(s). COPE should not be employed
as a means of helping the patient “recover” his traumatic memo-
ries. While patients do sometimes recall more details of the trauma
through the course of the treatment, we strongly discourage using
this treatment with patients who present with only a “sense” or a
vague feeling that they have experienced a trauma.
• Lack of desire to significantly reduce or cease alcohol or drug use. Most
PTSD/SUD patients present with ambivalence about whether or
not, and to what extent, they want to reduce their substance use.
However, if a patient is adamant about not wanting to stop or sig-
nificantly reduce alcohol or drug use, COPE should be deferred.
A motivational enhancement therapy approach may be more useful
to facilitate resolution of this ambivalence before beginning COPE.
In fact, being able to work on trauma symptoms could serve as a
source of motivation for patients unwilling or uninterested in reduc-
ing substance use. Patients should be expected to demonstrate some
level of clinically significant improvement in frequency and/or inten-
sity in substance use over the course of the first 3 sessions, before
the exposures begin. If during the first 3 sessions no improvement
in substance use is observed or an increase in substance use (relative
to baseline) occurs, therapy should focus on the substance use until
significant reductions in frequency and intensity are evidenced.
The recommended levels are different for men and women because
research shows that women develop more severe alcohol-related prob-
lems at lower drinking levels and at a faster rate than men. This is due to
physiological differences in men and women, such as women generally
weighing less than men and having less total body water as compared
to men. Alcohol disperses in body water, so after a man and woman of
the same weight drink the same amount of alcohol, the woman’s blood
21
Figure 1.1
NIAAA Guidelines for Low-Risk Drinking.
Reprinted from National Institutes of Health, Rethinking Drinking: Alcohol and Your Health (2010).
Note that the NIAAA guidelines are for low-risk, not no-risk, drink-
ing. Even if drinking within these limits, patients can still experience
problems. Clearly, it is best for patients to stay within these low-risk
limits in order to minimize harm and maximize the benefits of the
integrated treatment. For many patients, achieving low-risk drinking
levels will be very challenging, and abstinence will be the ideal option
(e.g., if they have a medical condition made worse by alcohol use, a
positive family history of addiction, or previous unsuccessful attempts
at cutting down).
22
symptoms when trying to cut down or stop using substances (e.g.,
nausea, vomiting, headaches, tremors, sweating). You can also use
measures such as the Clinical Institute Withdrawal Assessment
Scale for Alcohol - Revised (CIWA-AR) to help assess the need for
detoxification from alcohol. Generally, a score of 10 or above on the
CIWA-AR indicates the need for medication.
23
Therapist Note
24
Outline of This Treatment
CHAPTER 2
Program
All of the material in each session does not necessarily have to be dis-
cussed. Rushing to cover everything may send the message that the
therapist’s agenda of adhering strictly to the manual is more impor-
tant than the issues and concerns that constitute the patient’s personal
agenda. Indeed, if patients are not routinely involved and encouraged
25
to provide their own material as examples, treatment becomes boring
and the energy level for learning drops off dramatically.
Therapist Note
While the chapters are in a particular order therapists should use their
clinical judgment and apply the content of the treatment in a flexible
fashion. Prioritize the information and tailor the order of the session
material (in particular, the SUD session material) based on the patient’s
presenting PTSD and SUD symptoms. For example, if a patient is strug-
gling with anger-related problems, move the content on anger from ses-
sions 10 and 11 so that it is covered sooner during the course of therapy.
26
Session Structure
Review Homework
Generally, therapists prefer to start the session with the PTSD material
(a) in order to emphasize the importance of not avoiding, and (b) to
ensure that there is enough time to conduct the imaginal exposure exer-
cises. Furthermore, ending the session with the SUD material will nat-
urally assist with a decrease in distress level before the patient leaves the
office, and allow the session to end with a focus on positive coping skills
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
and emphasize the importance of being “smart” versus being “strong.”
In order to be successful with recovery from SUD, it’s more about
increasing awareness and knowledge of what triggers cravings and the
desire to use, and learning skills to effectively cope with these triggers,
than it is about relying on the strength of one’s will power. While the
patient may have made important gains in substance use, it’s important
to continue to discuss issues related to SUD every session in order to
help protect the patient against cravings or thoughts about using that
will occur in the future.
Therapist Note
Assign Homework
• While some patients are fine with the term “homework,” others
do not respond well to this term. Therefore, refer to the homework
using the patient’s preferred label, for example, “assignment,” “task,”
“exercise,” and so on.
• When giving each assignment, provide a clear rationale and descrip-
tion of the assignment. Ask the patient what problems can be fore-
seen 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
• With regard to the exposure homework, finding a private place in
which patients can listen to the recording of the imaginal exposure is
very important. If doing so is a persistent problem, consider having
the patient come into the clinic prior to or between sessions to lis-
ten to the recordings. Also remind patients to keep their homework,
including session recordings, in a secure place so that others in the
household do not listen to them. Providing a binder of folder can be
helpful.
• Be sure to instruct the patient not to use any alcohol or drugs while
completing the homework exercises. The patient should get the
maximum potential benefit from each exercise; having substances on
board would only serve to prevent growth, mastery, and new learn-
ing. We’re trying to break the cycle of using substances to cope with
anxiety and distress.
Therapist Note
At the first session, give the patient a binder or folder to help him keep
the handouts and homework forms organized. So much of a PTSD/
SUD patient’s life is disorganized (internally and externally)—hav-
ing the treatment handouts and assignments kept in a binder that he
can carry with him reinforces the importance of homework and can
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: ser-
traline (Zoloft) and paroxetine (Paxil). A number of randomized con-
trolled 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 et al., 2012). SSRIs are also con-
sidered 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.
First, let the model guide you. As you are helping your patient learn
that anxiety cannot hurt her, and that the feelings of fear and anxiety
do pass with time, you will be able to experience and appreciate this
fact as well. Developing tolerance for patient distress requires that you
accept the rationale for treatment, and especially the idea that memories
cannot hurt the patient. Therapists typically habituate to the trauma
memory along with the patient over the course of treatment.
32
The internal dialogue of the novice therapist is full of questions: “Do
I stop the imaginal exposure now because the patient is upset? What
if this makes my patient more depressed? Should I not do the ima-
ginal exposure this session because the patient had a lapse and con-
sumed a few drinks? What if she keeps feeling this way after she
leaves my office? Is this a realistically safe situation my patient is
avoiding? Is this really the index trauma, or should we be focusing on
another trauma memory during the imaginal exposures?” Allowing
the treatment model to guide these decisions both assists in making
the decisions and leads to decisions that are well grounded in the
available research. Keep in mind that even though emotional pro-
cessing can be distressing in the first few sessions, for most patients
it is quite beneficial. Remind yourself of this as often as you do the
patient.
The following are some guidelines for enhancing the therapeutic rela-
tionship with patients seeking treatment for comorbid PTSD and
SUD. These guidelines should be applied when implementing COPE.
33
Express Confidence in the Treatment and the Patient
The confidence of the therapist and the patient’s capacity for change
will go a long way in helping the patient remain in treatment, despite
the fact that it will be difficult at times and the patient may feel like giv-
ing up and dropping out. A therapist’s confidence in both the program
and the patient will provide a sense of hope, which many patients are in
dire need of, and which will give them a source of motivation to engage
fully in the therapy. They will look to you for these feelings. If you are
optimistic about their recovery, they will be more likely to be optimistic
as well. Before providing this treatment, be sure to review the empirical
literature on integrated psychotherapies for PTSD and comorbid SUD,
as well as the empirical literature on PE techniques. See the Reference
section for suggested readings.
It is highly likely that the patients you will see have been subjected to
judgmental attitudes with regard to their trauma history and their sub-
stance use, particularly those who use illicit drugs. Patients need to know
that the therapist does you do not view them or their behavior as “bad”
or “immoral” or “weak.” It is also important that the therapist is care-
ful not to judge how patients reacted during or after the trauma (e.g.,
whether or not they were intoxicated when the trauma occurred, how
long they waited to tell anyone about it, whether or not it was reported
to the police). Even if a patient did make a mistake in judgment, he did
not deserve to suffer, nor is he to blame for what happened to him.
Patients with PTSD and SUD often feel that they have very little
control over their lives. Many feel unable to adequately control their
thoughts, feelings, dreams, or substance-related behaviors. It is impor-
tant to convey from the very beginning that the therapist you and the
patient will be working on this treatment together as a team in order to
help the patient establish a greater sense of control in life.
34
Address Avoidance
Patients may feel discomfort when discussing their trauma history for
a number of reasons. This discomfort may be associated with distrust
of others in general (or of clinicians), a history of having their boundar-
ies violated, or fear that the information could be used against them.
Some patients will have had the experience in which other people did
not want to hear about the trauma(s), or they could not handle listen-
ing to it, especially the gruesome or horrific details. Military person-
nel or Veterans, in particular, may also want to help “protect” others
by keeping the trauma to themselves. Patients need to know that the
therapist can be told anything and everything about what happened
and can handle it well. They need to know that you want them to share
with you the details of what happened. When listening to the trauma
history, demonstrate respect and admiration for the patient’s strength
35
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.”
Many individuals with PTSD feel that they are going crazy, and merely
hearing from a mental health professional that the reactions they are expe-
riencing are common helps to normalize their reactions. Letting patients
know that their reactions make sense can help alleviate some of the shame
and guilt that they have been feeling about not recovering sooner.
Inform all patients of what to expect and avoid surprises. Patients with
prominent hyperarousal PTSD symptoms and those who have been
physically or sexually assaulted, in particular, can feel physically and
mentally “on guard.” With such patients, be careful not to make sud-
den movements or to invade their physical space. Slow, calm move-
ments are best. The more spacious the therapy room, the better. This
will help patients feel less confined and help them to relax more.
36
content. Although the focus of the sessions should be on the structured
program, ignoring patients’ real-life problems entails the risk that they
will view treatment as peripheral or irrelevant to their current needs. As
a compromise between the demands of the therapy and the patients’
perceived needs, spend 5–10 minutes at the end of the session to dis-
cuss these problems when they arise. These discussions should be struc-
tured to keep them consistent with the approach of the therapy. Ask
patients what they have learned in the therapy that they can apply to
each problem.
Preventing Attrition
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
help in regaining their recovery program, coping with their reaction to
the lapse, and avoiding future lapses.
Therapist Note
There is a delicate balance between setting the stage for patients feeling
that it is encouraged to return to treatment after a lapse, and actually
giving them permission to use. Therapists should take care that patients
clearly understand this distinction.
Therapist Note
Tell patients from the onset that the safest goal regarding substance use
is abstinence.
Ask if the patient would consider trying abstinence for a few weeks
to see what it is like. Emphasize that it does not have to be forever, as
the thought of never having a drink or smoke again in their lives can
be overwhelming for some patients, especially younger patients. Frame
abstinence as an opportunity for the patient to test it out for a brief
period to see how he feels when clean and sober. Let the patient know
that the treatment will be most effective if he is not using. However,
if patients are unwilling to participate in the therapy with the goal
of abstinence in mind, they may instead strive toward a substantial
reduction in substance use. In this case, it is important to revisit goals
throughout treatment, as patients may start to realize that the use of
substances is more of a problem than they initially thought, and that
abstinence would be a healthier goal.
38
Ask patients to talk about any drug use that occurs and about any crav-
ings or fears of relapse that they experience. Tell patients that it is com-
mon 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 conse-
quences 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 reas-
sure 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 ses-
sion in order to prevent attrition.
39
Involving Significant Others
Summary
Do:
40
Display a comfortable attitude when the patient describes the trauma
and substance use.
Give each patient undivided attention, empathy, and unconditional
positive regard.
Normalize the patient’s response to the trauma and validate his
feelings.
Praise the patient for having the courage to work on PTSD and sub-
stance use problems.
Work with the patient to minimize attrition.
Maximize opportunities for patient choice and control over treat-
ment processes.
Monitor the patient’s PTSD and SUD symptoms at every visit.
Monitor homework compliance at every visit.
Don’t:
Alternative Treatments
The patient workbook will assist you in effectively delivering this treat-
ment, will aid in transferring knowledge from the therapy room to the
patient’s daily life, and will help to monitor progress. Ideally, patients
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
Session 1: Introduction
CHAPTER 3
to COPE
(Corresponds to Chapter 3 of the Patient Workbook)
MATERIALS NEEDED
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
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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 4–11).
I am really glad that you have chosen to come to treatment. Today is our
first session together, and I would 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.
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 want-
ing 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.
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Sometimes after getting about halfway through the treatment, patients
start to feel better and decide they don’t need to keep coming to sessions.
However, I want you to think of this treatment as being similar to a regi-
men of antibiotics. You know how your doctor always tells you to make sure
to take the entire course of antibiotics, even if you start to feel better at, for
example, day 5, but it’s a 10-day course of antibiotics? That’s because the
benefits of the antibiotics, just like the benefits of this treatment, will be
more effective and will last longer if you complete the full course of treat-
ment. Thus, I hope you’ ll stick with it for the 12 sessions. I am here to work
with you and help you through this in any way that I can.
• Do you have any questions? Feel free to ask me questions at any time.
Many people experience traumatic events in their lives. Shortly after the
trauma, most people will have some PTSD symptoms. However, for most
people, the symptoms decrease over time and they recover, although they
may have minor symptoms occasionally. However, for some people, the
symptoms persist and they develop PTSD. Understanding what maintains
these PTSD symptoms is helpful to understand how this treatment works.
• Can you think of things that you have avoided since the trauma?
Because avoiding thoughts and situations that remind you of the trauma
maintains your PTSD, this treatment aims to help you stop avoiding and
instead approach trauma-related thoughts and situations in a safe and sys-
tematic way. The treatment includes two types of exposures. The first one is
called imaginal exposure, in which I will ask you to revisit the memory of
the trauma during your therapy sessions with me. This will help you process
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and digest what happened. We have found that repeated and prolonged
(30–45 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. I will work with you
so that you can gradually approach situations that you have been avoid-
ing 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 effec-
tive 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.
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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.
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 perspec-
tive about what happened and what it means to you now, and will help you
recover from your PTSD. This doesn’t 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.
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• What happens to your substance use when your PTSD symptoms get bet-
ter? (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, you’ve 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,
you’ve discovered that it’s 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, irritabil-
ity, 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
body’s natural stress response system (the hypothalamic-pituitary-adrenal
axis) and sleep cycles.
The treatment we’re using has been shown in numerous research stud-
ies 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 won’t 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. It’s only 12 sessions, but it could mean a sig-
nificant difference in the quality of the rest of your life.
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2. Information Gathering
Therapist Note
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 ten-
dency to want to avoid discussing either topic, or minimize the sub-
stance 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 nonjudg-
mental, nonconfrontational attitude, and display a comfortable atti-
tude when the patient describes his trauma history and substance use.
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Therapist Note
Therapist Note
During this first visit, assess the need for medically supervised detoxi-
fication from substances. If detoxification is required, have the patient
obtain detoxification before beginning the COPE treatment.
See Appendix A at 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 it’s 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.
I would also like to find out more about your substance use history so that
we can tailor the treatment to best meet your needs. I will be asking you
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some sensitive questions and I understand 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 I can do to make it easier for you, please let me know.
I am here to help you through this. At the end of today’s session, we’ ll
develop your specific treatment goals and I will teach you a breathing
relaxation exercise.
Find out which PTSD symptoms are causing the most distress or
impairment. Aim for a reduction in the frequency or intensity of these
symptoms. Complete absence of PTSD symptoms is possible but should
not be the goal. Forgetting about what happened is not the goal of this
treatment. The goal is that the patient can remember the trauma with-
out as much distress and limitations on her life, and without needing
drugs or alcohol to deal with the memories. Questions to jump-start
this part of the session include:
• What do you want to get out of treatment with regard to your PTSD?
• How would you like to see yourself at the end of treatment?
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(session 3) and listening to the imaginal exposures (session 4) each day.
You do not want the patient to have alcohol or drugs in his system
when doing these exercises, so having entire days when he does not use
substances is optimal for new learning to take place.
With regard to alcohol use, follow the guidelines set forth by the
National Institute on Alcohol Abuse and Alcoholism (NIAAA),
which define low-risk drinking as no more than 7 standard drinks
per week for women (and no more than 3 drinks in one day) or no
more than 14 standard drinks per week for men (and no more than
4 drinks per day). See Chapter 1 for more information about the
NIAAA guidelines.
Sometimes patients are hesitant to set a specific goal or are not amend-
able to reducing their use. This hesitance typically happens when they
are using multiple substances (e.g., alcohol and marijuana) and they
want to reduce one but not the other (e.g., they want to cut down/stop
using alcohol, but want to continue smoking marijuana on a regular
basis). In this case, it may be helpful to explore ahead by asking the
patient, “What would need to happen (or not happen) for you to take a
closer look at your use?” You could also review with the patient the pros
and cons of reducing versus abstinence.
Therapist Note
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failures may be able to do well with a goal of significant reduction of
use. On the other hand, if someone has a positive family history of
substance use problems, has tried more than once in the past to signifi-
cantly reduce or stop using alcohol/drugs but has been unable to do so,
or if substance use is causing or worsening a medical condition, absti-
nence is strongly recommended. Discuss these issues with the patient in
a collaborative, caring manner.
Talk through the characteristics of good, realistic goals with the patient.
Goals need to be SMART:
• Specific
• Measurable
• Attainable
• Realistic
• Timely (i.e., have a time frame).
• What do you want to get out of treatment with regard to your substance
abuse?
• What would you like to change, and why is it important to you?
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Attendance
Promptness
Therapists should convey the attitude that time in sessions is too impor-
tant 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.
Patients should refrain from any alcohol or drug use on the day of a
therapy session and when completing the homework assignments (e.g.,
listening to imaginal exposure recordings, doing the in vivo exposure
assignments). If the patient shows up intoxicated to a session, the ses-
sion will be rescheduled.
Completion of Homework
One of the ways in which this treatment works is through the home-
work 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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exercises between each session. Again, the analogy of working out at
the gym can be useful. If the patient were trying to get into better
physical shape, she would need to do more than just meet you once a
week for a single workout at the gym. The training done between ses-
sions is critical.
Unless we are preparing to fight or flee from real danger (e.g., combat, rob-
bery), we often don’t need as much air as we are taking in. When people
become upset, they sometimes feel like they need more air, and may begin to
breathe faster, or hyperventilate. Hyperventilation, however, is not calm-
ing and can lead to an increase in anxiety. In safe but stressful situations,
learning to breathe slowly and calmly provides a useful tool for reducing
stress and tension.
Breathing in through your nose helps to humidify, clean, and warm the
incoming flow of air. Along those lines, it allows you to take in clean oxygen
into your lungs, blood, and brain, helping you to think more clearly and
rationally. Exhaling out through your mouth allows for a greater volume of
air to be released at once and will help your jaw to relax.
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abdomen and the other hand on your upper chest. If you are doing the exer-
cise 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.”
Therapist Note
See Form 2 at the end of the Patient Workbook, which covers breathing
retraining.
6. Assign Homework
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Therapist Note
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 ques-
tions or need help problem-solving obstacles that are getting in the way
of completing their homework, encourage them to call you between
sessions.
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 patient’s 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 other to:
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Therapist Note
Chapter 1.
If applicable, share this material with family or loved ones:
Workbook).
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Session 2: Common
CHAPTER 4 Reactions to Trauma
and Craving Awareness
(Corresponds to Chapter 4 of the Patient Workbook)
MATERIALS NEEDED
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
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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of abstinence, thus, he figures he might as well go ahead and have 12
drinks because it doesn’t matter since he has “broken the rule”).
Be aware that there may be times when the patient’s UDS is positive
for drugs, but the patient says that no drug use has occurred. This dis-
crepancy is likely to happen early on in treatment, but it may happen
at any point during the therapy. You can acknowledge the discrepancy
with the patient, but you should refrain from getting into a lengthy dis-
cussion about it or being confrontational with the patient. The patient
will likely be embarrassed by his behavior and disappointed in himself,
wanting to avoid a discussion about it (note that there is substantial
avoidance associated with both SUD and PTSD).
Therapist Note
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2. Review Homework
Today I’ d like for us to talk about some common reactions to trauma and
specific PTSD symptoms, and to learn more about which ones you experi-
ence. This will help us guide your treatment plan. Does that sound okay
with you?
Of all these common reactions to trauma, fear and anxiety are the most
common and debilitating. The feelings of anxiety that you are experienc-
ing can be understood as reactions to a dangerous and life-threatening
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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.
• What specific triggers have you noticed that remind you of [name of spe-
cific incident]?
A common strategy that people use to alleviate the anxiety and fear associ-
ated with a trauma is to avoid places, people, or other reminders of what
happened. Sometimes this avoidance also includes using alcohol or drugs to
try to block out memories and thoughts, or to reduce emotional or physical
sensations of anxiety.
You may find that you are having flashbacks in which visual pictures of
some aspect of the incident suddenly pop into your mind. Sometimes the
flashback may be so vivid that you might feel as if the trauma is actu-
ally occurring again. These experiences are distressing and you probably feel
that you don’t have any control over what you are feeling, thinking, and
experiencing sometimes. You may also find that you are re-experiencing the
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trauma through nightmares or dreams. Finally, you may re-experience the
trauma by having distressing thoughts and feelings about what happened
to you.
These changes in your body are the natural result of fear. Animals and
people have three potential reactions to being traumatized or threat-
ened: (1) freeze, (2) flee, or (3) fight. The fleeing or fighting responses require
a burst of adrenaline to mobilize your body and to help it respond to a
dangerous situation. As a result of the trauma, you may want to be ready
for danger at any time, so your body is in a constant state of preparedness
and being “on guard,” even at times when there is no real need to be. This
constant state of being on guard can be physically exhausting and can leave
you feeling very fatigued. It can also make your nerves feel “ frazzled” and
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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.
You may have feelings of hopelessness and despair, cry more easily, and
sometimes even have thoughts of hurting yourself and suicide. People with
PTSD often feel a sense of grief for what they have lost or for who they were
before the trauma occurred. A loss of interest in people and activities you
once found pleasurable is often associated with trauma. Nothing may seem
fun to you anymore. You may also feel that life is not worth living and that
plans you had made for the future no longer matter.
Therapist Note
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Suicide Assessment
During the trauma, you may have felt as though you had no control over
your feelings, body or mind. Sometimes the feelings of loss of control may be
so intense that you feel as if you truly are “ losing it.” For people who are also
struggling to control their alcohol or drug use, this sense of loss of control can
be very strong; they may even feel like they have lost themselves.
• Do you ever feel like you are “ losing it” or “going crazy”?
Guilt and shame can be a part of both PTSD and SUD. You may feel
guilt or shame because of something you did or did not do in order to sur-
vive the trauma. It is common to second-guess your reactions and blame
yourself. For example, victims of sexual assault sometimes believe that if
they had fought off their assailants, their trauma would not have hap-
pened. While trying to make sense of a very distressing situation is a
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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, unfortu-
nately, many times people place responsibility on the person who has been
hurt and victimized.
Many people also direct the anger toward themselves for something that they
did or did not do during the trauma. These self-directed feelings of anger
may lead to feelings of guilt, hopelessness, depression, or alcohol/drug use.
In fact, anger is one of the most common reasons that people relapse. People
with substance use problems may also feel anger toward themselves for not
being able to control their substance use, or for the problems that substance
use has caused them or their loved ones.
Many people also find that they are experiencing anger and irritability
toward the people whom they love the most: family, friends, and their chil-
dren. Sometimes you might lose your temper with the people who are dear-
est to you, or be snappy or short with them. This may be confusing since
you may not understand why you are angry and irritable with those you
care about most. While closeness with others may feel good, it also increases
the opportunity for feelings of intimacy, dependency, and vulnerability.
Having those feelings may make you feel angry and irritable because they
remind you of the trauma.
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Therapist Note
You may tell yourself “I am a bad person so bad things happen to me,” or “If
I had not been so weak or stupid, this would not have happened to me,” or
“I should have been able to protect my fellow soldier,” or “I should be over
this by now.”
• What negative thoughts about yourself have you been having since the
trauma?
For many people, the safe and rewarding world with which they have been
familiar suddenly becomes a very dangerous and dissatisfying place. You
may feel that you have a hard time trusting anyone. If people have had
previous negative experiences and thoughts about the world to begin with,
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the trauma may serve to confirm the belief that “the world is in fact a dan-
gerous place” and “no one can be trusted.”
• Have you had negative thoughts about others or the world in general?
This disruption is, in part, a result of feeling sad, distressed, and angry. In
order to cope with these negative feelings, you may withdraw from others and
isolate yourself. You may stop participating in the activities that you once did
(e.g., dating, going to movies with friends, being on sports teams, exercising or
working out with friends). You may use alcohol or drugs to try to be social. You
may also find that the people whom you love the most and expect to be the most
supportive are not. Friends and family may have difficulty hearing about your
trauma and may have strong reactions to it. In an effort to “protect” friends
and family, you may intentionally not discuss the trauma or how you are suf-
fering. It is important that you get support for what you are going through.
The loss of interest can stem from various causes. For example, it is very
common for people who are depressed to experience a loss of interest in
their sexual drive. Also, disinterest in or fear of physical or sexual relations
is extremely common in those who have been sexually traumatized. You
may feel uncomfortable being emotionally intimate with someone because
this experience may bring back your feelings of vulnerability during the
trauma. In fact, you may use alcohol or drugs to be able to cope with close
physical contact and intimacy.
• Have you felt a loss of interest in physical affection since [name of specific
incident]?
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n. As a Result of This Trauma, You May be Reminded
of Other Traumas
This can make it difficult for you to think of any other situations or experi-
ences that are not negative. In fact, it may be very difficult to believe that
you will ever feel happy again or have pleasant experiences again. But you
will. You will find that it is possible to put these negative experiences behind
you and you will start to remember more positive memories. These positive
memories will trigger other positive recollections, and eventually you will
gain a more balanced view of life.
4. Craving Awareness
Review with the patient what a craving is and how long cravings typi-
cally last. Elicit the patient’s 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 expe-
riences 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 natu-
rally, 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?
• You’ve heard the word “craving” before. How do you define a craving?
• How often do you experience cravings?
• How often do your cravings typically last?
When you have a craving, it’s 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 cat—if 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 sim-
ply say, “I don’t 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 hav-
ing 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, want-
ing 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.
The first step in learning to conquer your cravings is to identify what brings
them on for you. Some “triggers” are hard to recognize, especially at first.
Quite often, this whole process happens so quickly that people may not even
realize what has happened—almost as though you have gone into auto-
matic pilot and just want to use for no reason. By becoming more aware
of your triggers, you put yourself in a much better position of being able to
manage them. You gain control over your cravings instead of them control-
ling you.
• People, places, and things (e.g., being around alcohol or drugs, seeing
other people using alcohol or drugs, bars, former using friends, certain
neighborhoods, cash, advertisements for alcohol). Note that trauma cues
in the environment can also trigger cravings (e.g., the location where the
trauma occurred, seeing someone who looks similar to the perpetrator).
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• Negative emotions (e.g., anger, depression, loneliness, boredom,
stress). Note that negative emotions associated with PTSD (e.g., anx-
iety, anger, shame) may also trigger cravings to use.
• Thoughts (e.g., “stinking thinking” or the “addictive voice” as they
refer to it in Alcoholics Anonymous (AA), reminiscing about getting
high in the past, planning how to get alcohol or drugs, rationaliz-
ing why just one time would be okay and that no one would know,
focusing on the pleasurable aspects of using without “playing out the
tape” and considering the negative consequences of using). Intrusive
thoughts about the trauma, flashbacks, or trauma-related dreams
can also trigger cravings.
• Physical symptoms (e.g., feeling on edge or restless, muscle tension,
fatigue, physical pain, withdrawal symptoms).
Therapist Note
Help the patient identify triggers for use that can be avoided. It can be
helpful to directly address and explain the distinction between asking
patients to avoid substance-related triggers and asking them not to avoid
trauma-related triggers.
Explain that you are encouraging the patient to stay away from
substance-related triggers (e.g., people, places, things) because these
are in fact dangerous in the sense that they put the patient at risk of
relapsing and jeopardize recovery. During the treatment program, you
will be asking the patient not to avoid, but rather to approach safe,
trauma-related triggers (e.g., places, memories). The reason for this is
because the trauma-related triggers are in fact safe and because avoiding
the trauma-related triggers only serves to keep the patient “stuck” and
maintains PTSD symptoms. Emphasize that you will only be asking
him to approach safe trauma-related triggers.
73
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).
Review with the patient several basic ways that she can handle a trig-
ger. Note that you will discuss managing cravings in more depth in
session 3.
In our next session, we will focus in depth on specific techniques that you
can use to cope with triggers and manage cravings or urges to use. Some
quick tips, however, include (1) as we talked about, doing your best to stay
away from triggers (e.g., not going to visit friends you previously used with,
staying away from parts of town where you used to buy drugs), and (2) if
you do come into contact with a trigger, leave the situation immediately
and call someone (e.g., a supportive friend, your AA/NA sponsor). You can
also use the breathing relaxation exercise that we discussed last session to
“ride out” a craving. Finally, distract yourself by getting involved in a posi-
tive, healthy activity (e.g., go to the gym, exercise, watch a movie, read a
good book, cook). We’ ll spend some time next session going over other ways
you can effectively cope with cravings.
5. Assign Homework
74
Homework for Session 2
75
Session 3: Developing
CHAPTER 5 the In vivo Hierarchy
and Craving Management
(Corresponds to Chapter 5 of the Patient Workbook)
MATERIALS NEEDED
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
77
1. Review PTSD Symptoms and Any Substance Use Since Last Session
Review the patient’s weekly PTSD and SUD assessments. If any alco-
hol 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
In our first session we talked about imaginal exposure and in vivo exposures
and how they are very effective in helping people overcome PTSD. Today
we will review the rationale for the in vivo exposures and talk about why
approaching trauma-related situations that you avoid will help. We will
then create a list of situations that you have been avoiding for the in vivo
exposures. We will also talk about ways to cope with cravings or triggers to
use alcohol/drugs.
78
Readiness to Begin Prolonged Exposure Assessment
Our bodies have a built-in alarm system—kind of like a car alarm system.
When it is working properly, this alarm is very useful and alerts us when
we are in danger, and it helps us mobilize and mount a “fight or flight”
response. With PTSD, however, the alarm system gets off kilter and the
alarm goes off without discrimination. For example, instead of just going
off when someone is trying to break into the car, the alarm goes off every
time someone parks next to the car in the parking lot. This is not a very
helpful alarm system. Because the alarm system is off kilter in this way,
you may feel like you are on constant alert, and it may be very hard for you
to differentiate between safe situations and dangerous ones. A goal of this
treatment is to help you recalibrate your body’s alarm system so that it alerts
you to dangerous situations, but is not keeping you from approaching (and
staying in) safe situations.
It is for this reason that part of the program involves helping you to face
the trauma-related situations that you are avoiding now. There are sev-
eral ways in which in vivo exposures will help you overcome your PTSD.
You have developed a habit of reducing anxiety or distress through either
79
avoiding situations that cause you to feel anxious or scared, or escaping
them. For example, you are at home and you discover that you ran out of
milk. You say to yourself “I’ ll drive to the supermarket and pick some up.”
As you contemplate this thought, you begin to feel very anxious. Then you
say to yourself: “I can just wait for my wife to get it tomorrow; I’ ll stay here.”
Immediately after you make the decision not to go to the store, your anxiety
decreases and you feel better. Each time you reduce your anxiety by avoid-
ance, your habit of avoiding gets stronger and stronger. In vivo exposure,
that is, systematically approaching feared, but safe situations that you now
avoid, will help you overcome this.
When you repeatedly approach situations that you have avoided because
you think that they are dangerous and you find out that nothing bad hap-
pens, you learn that these situations are actually safe and that you do not
need to avoid them. However, if you continue to avoid, you will continue
to believe that these situations are dangerous. Thus, in vivo exposure helps
you disconfirm your idea that the safe situation is dangerous. If you felt OK
going to the grocery store alone before the trauma occurred, then it is prob-
ably OK to do so now.
In addition, many people with PTSD believe that if they stay in the situa-
tion that makes them anxious, their anxiety will remain indefinitely or will
even get worse. However, if you stay in the situation long enough, you will
find that your anxiety will diminish. This process is called habituation. As
a result of this process, your symptoms will decline. Similar to cravings or
urges to use, anxiety is like a wave; it is time-limited and will pass.
Therapist Note
You can show the patient this process visually, as shown in Figures 5.1
and 5.2.
Finally, facing feared situations and overcoming your fears will enhance
your self-esteem and make you feel more competent, because you will know
that you can cope successfully with your problems. You will start doing
things again that you used to enjoy but that you stopped doing because
of your PTSD, and you will begin to enjoy life again and expand your
activities.
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The point when
you leave the
situation or you
decide to avoid it
Anxiety
Time
Figure 5.1
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.
Over time,
anxiety becomes
less intense and
lasts for shorter
periods of time
Anxiety
Time
Figure 5.2
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.
81
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 situ-
ations. 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 situ-
ations 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 expo-
sure 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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Introduction to Subjective Units of Distress Scale (SUDS)
In order to find out how much distress or anxiety certain situations cause
you, we will use a scale that we call the SUDS, which stands for Subjective
Units of Distress Scale. It’s a 0 to 100 scale. A rating of 0 indicates no
discomfort at all—complete relaxation. A rating of 100 indicates that you
are extremely distressed—the most you have ever been in your life. Usually
when people say they have a rating of 100, they are experiencing physi-
cal reactions, such as sweaty palms, rapid heartbeats, trembling, difficulty
breathing, feelings of dizziness, and so on. So 100 indicates the highest level
of distress you’ve ever felt. People are different, so what makes one person
feel 100 may not be troublesome at all for someone else. This is why we call
it a subjective scale. For example, imagine that you and I are standing near
a deep pool and someone pushes us both in the water. If I cannot swim well,
I may feel a SUDS level of 90. But if you can swim, or are not afraid of
deep water, you may be at a 10. Does this idea make sense?
We are going to be using this subjective distress scale to monitor your progress
during the imaginal and in vivo exercises. Remember this is not a scale only
of situations you avoid because of your trauma, but it is a general scale of
distress. Many times for people who suffer from PTSD, the 100 is the worst
moment in their trauma. But it is important that you will also use the scale
in everyday life to rate things you fear that are unrelated to the trauma.
Work with the patient to identify anchor points at 0, 50, and 100 by
asking the following questions:
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In vivo Hierarchy Situations
During this discussion, you will be referring the patient to the In vivo
Hierarchy (Form 13 at the end of the Patient Workbook). Begin by
eliciting specific examples about situations, people, and places that the
patient avoids because of the trauma. The situations need to be easily
accessible for repeated practice. Situations that require a 3–hour drive
each way are unrealistic for repeated practice. Patients need situations
that they can practice two to three times each week (or until habitu-
ation is achieved).
For some patients, constructing a hierarchy is easily done, and you will
have 15–20 situations fairly quickly. For others, especially those who
are not accustomed to thinking of their behavior in terms of avoidance,
constructing the list will be more challenging. For these patients, it
may be best to concentrate on identifying 3–5 situations so they can
be assigned as homework. Part of the patient’s assignment will be to
add more avoided situations to the list, so that eventually the list will
include 15–20 situations.
Therapist Note
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Three types of situations are commonly avoided by patients with PTSD,
and may be considered for the in vivo hierarchy:
• First are safe situations that patients perceive as dangerous because they
are similar in some way to the traumatic situation (e.g., walking
alone in safe areas after dark, going to crowded places, going to a
restaurant and sitting in the middle of the room). This type of situ-
ation is avoided because patients believe they will be harmed or that
something bad will happen.
• Second are situations that are reminders of the traumatic event, such
as wearing the same or similar clothing, going on a date, driving a
car, hearing music that was present during the trauma, or watching
the news on TV for fear they will hear about a trauma similar to
their trauma. This type of situation is avoided not because patients
perceive them as dangerous but because they trigger memories of
the traumatic event and cause distress, shame, anger, or helplessness.
These situations are often objectively quite safe as exposures despite
the level of distress they generate.
• The third type is particularly helpful for patients who are depressed
and avoid situations and activities that they have lost interest in. These
include things like re-engaging in sports, exercise, clubs, hobbies,
and friendships; going to a place of worship; visiting friends or invit-
ing people to one’s home for a meal; traveling; and generally doing
other activities that patients used to enjoy but have stopped doing.
This type of behavioral activation should be added to the in vivo
exposure list for patients who are depressed, socially isolated, and/or
inactive in an effort to help them reconnect to other people and to
the world, even if it does not trigger significant anxiety. See Form 14,
“Pleasant Activities Checklist,” at the end of the Patient Workbook
for examples.
85
helpful to assign in vivo exercises in which they act “as if” they did
feel the emotion. For example, a patient who wanted to feel love
toward his grandchild but felt nothing could be assigned an in vivo
exercise that would involve having him engage in loving behaviors.
Ask the patient what he would do if he felt love toward his grand-
child (e.g., hold the child’s hand, give him a hug, go for a walk
with him). Doing so takes the pressure off the patient to feel, which
is largely outside the patient’s control, and instead focuses on the
behavior, which is something the patient will have much more control
over. By engaging in the loving behaviors repeatedly, the patient will
be showing his grandchild love and may eventually feel the loving feel-
ings again as he recovers from PTSD and SUD (Dr. Matthew Yoder,
personal communication).
Therapist Note
Keep a copy of the in vivo list in order to keep track of and add/
modify the items on the list. Give the patient a copy to take home
and continue to add items to the list. If the patient has difficulties
generating avoided situations, use the information already gathered
to start the conversation. Explore common areas of avoidance for
specific trauma types; for example, riding in cars for motor vehicle
accident survivors or military Veterans who have experienced impro-
vised explosive devices (IEDs). Use information from the initial
assessment or examples from Table 5.1 if the patient has difficulty
identifying situations.
Table 5.1 List of Typically Avoided Situations for Trauma Survivors
87
Safety Considerations for the In vivo Hierarchy
It is important that the situations chosen for in vivo exposure are objec-
tively safe, which means that there is extremely low probability of harm
while being in the situation. The in vivo exposure exercises are selected
by the patient and the therapist with consideration of safety and rele-
vance of the situations to the patient’s daily functioning. If the therapist
is unfamiliar with the places, activities, or situations that the patient
avoids, it is important to ask about normative behavior for the patient’s
peer group in that situation. For example, if the therapist is consider-
ing whether or not it is safe for a woman to walk outside alone in her
neighborhood, ask: “Do other women you know do this? Do women in
your neighborhood walk outside alone, and how late do they do this?”
“Would this be safe for your sister, mother, or grandmother to do?” “Is
this something that you did without any concerns before the trauma?”
Situations that trigger craving for substances and that may put the
patient at risk of exposure to substances should not be listed on the
in vivo hierarchy. For example, if the trauma occurred in a bar where
the patient commonly went to drink, visiting the bar would not be a
safe in vivo exposure to assign. A patient who has been avoiding hang-
ing out with friends with whom he previously used drugs should not be
encouraged to do so now. It is best to pick situations and activities that
are physically safe and that help keep the patient safe from increased
risk of alcohol/drug use.
88
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 asso-
ciated 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 expo-
sures, 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 experi-
ences 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.
89
Therapist Note
Review the in vivo exposure hierarchy list with the patient and decide
together which two situations to assign for homework. Start with situ-
ations with SUDS ratings between 40 and 50. For a patient who is
particularly avoidant and very anxious about in vivo exposure practice
exercises, the therapist may need to start even lower (e.g., 25–30 SUDS
range) in order to maximize the chance of successful exposure. By the
end of treatment, the patient should have repeatedly practiced all of the
situations listed on the hierarchy.
Once the in vivo situations have been determined, explain the proce-
dure to the patient:
90
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.
PTSD patients usually struggle with their tendency to avoid feared situ-
ations during treatment. Most patients will benefit from ample support
and encouragement from the therapist to hang in there and keep work-
ing on their in vivo assignments. The urges to avoid are common and
understandable but, as you have already explained to the patient, avoid-
ance maintains the trauma-related fear and anxiety. When a patient has
difficulty completing in vivo exposure assignments, it is often useful to
modify the hierarchy by breaking the target situation(s) into smaller,
incremental steps. If it becomes evident that an in vivo exposure situa-
tion is too difficult to approach at the present time, find ways to make
it less difficult.
91
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 dif-
ficult exposures.
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 patient’s 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 behav-
iors actually serve to maintain fear and trauma-related, unrealistic
beliefs.
4. Managing Cravings
Review the patient’s 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.
92
As we talked about last session, cravings are a normal part of recovery, so it
is important that you know how to manage them. Some strategies work well
for some people, and others do not. You will want to pick a few coping strat-
egies that work well for you and use those whenever you experience a crav-
ing. And the earlier in the process the better—it is a lot easier to manage a
craving that is a 30 on a scale of 0–100 (0 = no craving to 100 = extreme
craving) than it is to manage a craving that is a 90. Take a look at the
Craving Thermometer, which is Form 15 at the end of your Workbook.
a. Stay away from triggers for cravings. Cravings, or the desire to use
substances are most often “triggered” by people, places, and things that
remind the person of using (e.g., former using friends, bars where you
frequently drank, seeing someone else use, keeping alcohol in your refrig-
erator). The easiest way to deal with these triggers is to stay as far away
from them as you can (for example, refrain from going to bars, stay
away from certain parts of town where you used to get high, delete your
dealer’s number from your phone and do not answer the phone when he
calls, don’t keep any alcohol or drugs in your home). If you find yourself
in a high-risk situation (that is, a situation that puts you at risk of want-
ing to use), the best thing to do is leave the situation immediately and
call a friend/sponsor.
b. Distraction. When having a craving, there are a number of behavioral
strategies that you can use to help distract yourself and help you ride out
the craving wave, such as:
– Exercise (e.g., lifting weights, jogging, yoga, sit-ups, push-ups, go
for a bike ride)
– Watch a movie
– Call a friend or sponsor
– Go to an AA or NA meeting
– Engage in a hobby (e.g., cooking, reading a good book, fishing)
– Go for a walk
– Listen to relaxing music
– Meditate
– Pray or go to a place of worship
– Spend time with a pet (e.g., give your dog a bath, take him for a
walk)
– Take a nap
– Look at pictures of family or children. Let their pictures remind
you of reasons why you do not want to use.
93
– Do something to help others (e.g., offer to help an elderly person
with yard work, volunteer at a shelter)
– Eat a good meal or dessert
– Write in a diary or notebook.
c. Plan ahead. Not all triggers can be avoided. If you know of a high-risk
situation that you cannot stay away from (e.g., grocery store), plan ahead
ways that you can make the situation less risky. For example, when you
have to go to the grocery store, make out a list and get only those items on
your list, limit your time in the store, have a safe friend accompany you,
and don’t go down the beer aisle. If it is a family gathering where you
know there will be alcohol or drugs, think through whether you want
to go at all, or if you can instead catch up with family at another time.
If you decide to go, plan to go early (before people get too intoxicated),
have a safe friend/sponsor go with you, limit the amount of time you
stay, let your family know that you are in recovery and do not keep it a
secret, stay clear of family members who you know will try to offer you
substances, and bring your own nonalcoholic drinks.
d. Decision delay. Cravings are time-limited. So, when a craving hits,
delay the decision to use for 15 minutes. During this time, say to
yourself: “I will not act on this craving now. I will delay my decision
to act on this craving for 15 minutes.” This will help you to break
the habit of immediately reaching for alcohol or drugs when a crav-
ing hits. After 15 minutes, you will likely find that the strength of
your craving has substantially decreased or perhaps even has passed.
Remember that cravings are like ocean waves; they rise and fall natu-
rally with time.
e. Breathing retraining. Breathing retraining, which you learned dur-
ing the first session, can be used for coping with anxiety related to your
trauma as well as cravings. Try it for 5–10 minutes when you have a
craving.
f. List and recall the negative consequences of using, and the positive
benefits of not using. When experiencing a craving, many people have
a tendency to remember only the positive effects of using alcohol or drugs
and often forget the negative consequences of using. Therefore, when
experiencing a craving, remind yourself of the negative consequences
of using (e.g., poor self-esteem, incarceration, family upset, financial
loss), and the benefits of not using (e.g., improved self-esteem, good
physical health, more money, able to keep a job, better relationships,
94
clear-headed, more energy, improved appearance, less arguments with
family and friends).
Have the patient write these out on the Coping with Cravings Plan,
which can be found as Form 16 at the end of the Patient Workbook.
g. Play it out. When having a craving, many people focus on the drug/
drink and how it will make them feel. They stop there, and do not play
out the image of what happens next. If you are having a craving,“play
out the tape” and see where it realistically will lead you.
Figure 5.3 is an example of a chain of events that you can share with
your patient. Write it out on a sheet of paper or on a dry erase board.
h. Challenge your thoughts. It iss a fact that you have thoughts, but not
all thoughts are facts. So when you have thoughts about using, be sure
to question those thoughts. For example, do you really need a hit, or is it
A line of cocaine
More cocaine
Jail
All of this as a result
of just one beer!
Not showing up for work
Being broke
Figure 5.3
Sample Chain of Events.
95
just a want? (You need air, water, and food). What’s 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 you’ve
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 crav-
ing 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, stay-
ing 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.
96
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 hav-
ing 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 manag-
ing 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
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 cogni-
tions about feared outcomes. Patients who complete the in vivo exer-
cises 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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Homework for Session 3
98
Session 4: Initial Imaginal
CHAPTER 6
Exposure
(Corresponds to Chapter 6 of the Patient Workbook)
MATERIALS
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
99
1. Review PTSD Symptoms and Any Substance Use Since Last Session
Review the patient’s 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 evi-
dence of habituation. Ask the patient what he learned from doing
the in vivo exposures and how helpful the exposures were. Pay atten-
tion 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 expo-
sure, 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, dur-
ing, or immediately after exposures. Assign the next in vivo exercises
at this time.
Therapist Note
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Rationale for Imaginal Exposure
The rationale for imaginal exposure is key. It is critical that the patient
understand why you are asking her to do something that she has been
avoiding for so long, sometimes for many years. Using analogies can be
helpful. Also, repeating the rationale at different times to make sure the
patient understands and is fully on board may be necessary. Present the
patient with the rationale for prolonged imaginal exposure:
Today we are going to spend some time helping you revisit the memory of
[name the actual trauma or use the patient’s language for the traumatic
incident, e.g., the car accident, rape, IED explosion]. Traumatic events are
difficult to understand and make sense of. As we have talked about before,
it is natural that you would want to push away or avoid the painful memo-
ries about the trauma. You may tell yourself, “Just don’t think about it;
time heals all wounds,” or “I just have to forget about it and move on.”
Your friends, family, or loved ones may advise you to use these same tactics.
They may feel uncomfortable hearing about the trauma, which may influ-
ence you not to talk about it. Or they may want so badly for you to feel
better, but they lack a full understanding of what PTSD is and how it is
treated, and so they say things like “ just let it go.” As you have discovered,
no matter how hard you try to push away thoughts about the trauma, the
memory keeps coming back in the form of distressing thoughts and feelings,
nightmares, and flashbacks. These are signs that there is “unfinished busi-
ness” that needs attention. You have probably tried and have found that
you can’t “ just forget about it.” Nor is forgetting about what happened a
healthy or realistic goal. The goal of this treatment is not for you to forget
what happened, but rather to help you come to terms with what hap-
pened and to process it so that the trauma memory no longer causes so
much distress in your life. You will remember what happened, but it
will not have the same impact on you as it does now.
Let’s discuss how repeatedly revisiting the memory of what happened will
help you process it and overcome your PTSD. It is very important that you
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understand why I am 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 don’t understand, okay?
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 mem-
ory you will learn that the memory cannot harm you. It is only a memory.
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 it’s 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 alco-
hol 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.
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The ultimate goal of imaginal exposure is to enable you to experience
thoughts about the trauma, talk about it, or see reminders of it without
experiencing the intense anxiety that now disrupts your life. This part of the
program involves having you revisit trauma-related memories that generate
both anxiety and an urge to avoid. For it to work, we’ ll do it repeatedly for
an extended period each time. We will be doing this gradually, together, at
your own pace, and in a safe environment.
I want to make sure you know that prolonged exposure therapy that
includes the exposure techniques we are using in this program has been
researched extensively and is the gold standard—or the most effective—
treatment for PTSD. Sometimes it takes a number of sessions to start
seeing the benefits, but if you stick with it, most people find they start to
feel better.
General Instructions
As noted earlier, be sure to turn your cell phone off and ask the patient
to do the same so that the imaginal exposure will not be interrupted by
the phone ringing.
Therapist Note
Ask the patient to close his eyes and repeat the trauma over and over, in
the present tense without any pause for 30–45 minutes. Describing the
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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 mem-
ory 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.
Record the patient’s craving immediately before and after the imagi-
nal exposure (also on a scale of 0–100; 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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The First Imaginal Exposure Session
Therapist Note
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.
During future sessions ensure that the memory becomes more detailed
with each account (through additional prompts when appropriate).
Probe for more detail: ask questions that elicit emotions (e.g., fear,
guilt), and help your patient engage in the memory more vividly (e.g.,
with sights, sounds, smells), and through meanings derived from the
experience (e.g., “It was my fault,” or “I should have been the one to die,
not him”). Examples of probes include
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• What are you thinking?
• What do you smell?
• What do you hear?
• What does it look like?
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
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 expo-
sure with his eyes open or recounting the memory in the past tense may
be a form of avoidance.
Therapist Note
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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 10–20. 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 sub-
stance 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
Do:
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Keep probes to a minimum; ask short questions with only a few
words.
Help the patient return to present tense; however, if the patient is
emotionally engaged and uses past tense, do not interfere by correct-
ing him.
Ask for level of distress (SUDS ratings) every 5 minutes.
Assess level craving before and after.
Write down possible worst moments (hot spots) according to the
patient’s reaction and level of distress.
Don’t:
For this part of the session, you will be using the Therapist Imaginal
Exposure Recording Form (Appendix C at the end of this Guide).
Present the following directions to your patient concerning how to do
the imaginal exposure:
Before we start the imaginal exposure, I would just like to get an idea of
your current level of distress and craving. Let’s review what we discussed
last session:
• Using the SUDS scale of 0 to 100, with 0 being no distress and 100
being the most distressed you have ever been, what is your SUDS rating
right now?
• Using the Craving Thermometer on a scale of 0 to 100, with 0 being
no craving and 100 being the strongest craving you have ever had, how
much are you craving [insert patient’s substance of choice] right now?
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Explain the imaginal exposure procedure to the patient. It is typical for
patients to express trepidation and hesitation (i.e., to want to continue
to avoid the memory). Reassure the patient and then continue to pres-
ent the following explanation:
For the next 30–45 minutes, I am going to ask you to revisit the memory
of the trauma. It’s best to start at a point in the memory that is a little bit
before the trauma actually occurred, so that you have a chance to enter the
memory and get connected to it. So you may want to start at least several
minutes before the situation got bad or frightening. You will then go through
the memory up until the point at which the immediate danger is over.
Therapist Note
You should previously have selected specific beginning and ending points
with the patient during session 1 when you identified the index trauma.
In this current session (session 4), check with the patient if those are still
the correct points.
It is best for you to close your eyes while you do this so you won’t be dis-
tracted. I will ask you to revisit the memory as vividly as possible and to
picture it in your mind’s eye. I would like you to describe the experience in
the present tense, as if it were happening right now. I’ d like you to recount
aloud what happened during the trauma in as much detail as you can. We
will work on this together. If you start to feel uncomfortable and want to
run away or avoid it by leaving the image, I will help you to stay with it.
It’s important that you not avoid or stop in the middle. From time to time
while you are revisiting the memory, I will ask you for your distress level
on the 0 to 100 SUDS scale. Please just try to answer quickly with the first
number that comes to mind and don’t leave the image. Because it is impor-
tant that we stay in the imaginal exposure for a lengthy period of time,
when you finish revisiting the full memory of the trauma, I’ ll ask you to
start over again, without pause. We may do this several times within today’s
session, depending on the length of the memory. It’s important that you not
push the memories away, even if they are painful. Remember, memories are
not dangerous, even if they feel bad. I will not say much during the imagi-
nal exposure, but we’ ll have time afterward to talk about your experiences
with it. Do you have any questions before we start?
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Answer any questions the patient has, but begin the imaginal expo-
sure 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, “You’re doing great. Now I want you to go back
to the beginning. So you’re walking down the street . . . Tell me what’s
happening now,” and let the patient begin to go through the mem-
ory 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 patient’s revisiting of the trau-
matic memory and the processing.
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and by offering positive comments or praise for what was accomplished.
For example:
• You hung in there really well, even though it was pretty distressing to do
this; that took a lot of courage.
• You did a great job with that; I know it is really hard to do.
• You included a lot more details this time, such as [note specific details].
That’s good.
For the first few imaginal exposures, processing will focus more on the
exposure itself. Ask the patient open-ended questions, such as
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 patient’s distress level did, in fact, decrease during the imaginal
exposure, offer comments such as:
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If the patient’s distress level did not decrease during the imaginal expo-
sure, 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 experi-
ence 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! I know that you did not feel less distressed at the end of the
exposure this time, and your SUDS level stayed high. But you accom-
plished 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 pro-
cessing, the therapist should facilitate the patient’s verbal elaboration of
these realizations.
• For example, a patient who was raped by her boyfriend and his
friends said: “If only I had let them know how much I did 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 didn’t know you did not
want to be raped?” Alternatively, the patient might make a state-
ment that reflects an emerging shift in perspective that seems more
realistic and appropriate. For example, after listening to her narra-
tive of the rape several times in the sessions and at home, the above
patient said: “I didn’t realize how much I fought them. Of course
they knew that I did 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 comrade’s 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 cog-
nitive shifts in perspective, the patient was better able to accept the
outcome as an unfair “circumstance of war.”
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To summarize, during the processing of the imaginal exposure the
therapist should:
Much of the distress of patients with chronic PTSD comes from per-
spectives on the trauma that they developed after the trauma occurred,
rather than from the particular thoughts that went through their minds
at the time the event was happening. Questions that may be useful to
help patients identify these post-trauma thoughts during processing,
especially in later treatment sessions, include
115
• What would you tell your son/daughter/sister/friend if they were thinking
this way?
• What does it mean to you that this happened?
• For military Veterans: What did you do differently than you were trained
to do?
Similar questions can also be asked about the patient’s appraisal of his
PTSD symptoms:
• Why do you think you currently have these symptoms related to the
trauma?
• What do you think the symptoms say about you or mean to you?
• How does it make you feel to think of yourself in this manner?
• How does that fit with what you’ve learned about common reactions to
trauma?
Therapist Note
See the Appendix at the end of this chapter discussing problems that you
as the therapist may encounter during imaginal exposure and ways to
handle them.
For patients who end the first imaginal exposure feeling very distressed,
help them calm down and return to a less distressed state before leaving
the office. In doing so, it may be helpful to guide these patients in a few
minutes of breathing retraining. If the patient is still very distressed at
the end of the session, have her wait in the waiting room, continuing to
practice the breathing retraining, and perhaps read a magazine. Check
on her every 5 minutes. When her SUDS level decreases to 50 or less,
then she is permitted to leave.
Assess craving level as well and ensure it is relatively low. Use the 0–100
scale for this, too. As with the SUDS, aim for a craving of 50 or less
before the patient leaves. It may be helpful to guide the patient through
the urge surfing technique. Breathing retraining can also be useful.
Review cognitive and behavioral coping skills for managing cravings
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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 SUDS—the level of anxiety that
they walk around with—is as high as 50–60. They may also say that
they walk around with a baseline craving level of 20–30. Baseline dis-
tress 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 encour-
age him to complete all assigned practice exercises, assess cravings and
any substance use, remind him about the rationale for exposure ther-
apy 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 encour-
age 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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their hard work and accomplishments to date and express confidence
in both patient and treatment.
6. Assign Homework
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Imaginal Exposure Data Form (Form 18 at the end of the Patient
Workbook).
Complete the in vivo exposure assignments (pick two from the
hierarchy list). Practice each in vivo assignment two to three times
before the next session. Be sure not to use alcohol or drugs when
doing so.
Practice copings skills for managing cravings and substance abuse.
119
Session 4 Appendix
Problems the Therapist May Encounter
During Imaginal Exposure and Ways
to Manage Them
1. Under-Engagement
120
feel?” or “What is he doing now?” or “How does it smell?”) and moni-
tors the patient’s 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 patient’s 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 ima-
ginal 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 patient’s access of his emotions during the revis-
iting of the trauma memory but at the same time not to direct it and
thereby interfere with the processing of the memory.
In addition, you can remind the patient that memories are not danger-
ous, 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., “I’ll lose control; I’ll fall
apart; I’ll cry; I’ll never stop feeling anxious”). Validate the patient’s
feelings, but help him realize that being distressed is not dangerous. It
may help to share with the patient the research findings that indicate
121
that emotional engagement facilitates recovery. Metaphors may help;
for example, ask the patient what we can do to help him get around this
wall he has built to protect himself from his emotions.
Finally, patients who may not understand what is being asked of them
can greatly benefit from having the therapist model for the patient
how to revisit a memory during imaginal exposure. Tell the patient
that you are going to role-play for him and demonstrate how to do the
imaginal revisiting. You could go through what you had for breakfast
that morning in great detail (including sights, smells, taste, touch), and
demonstrate the vividness, present tense, and richness of detail that
is being strived for in an imaginal exposure. For example, “I hear the
toaster oven ‘ding’ and I’m walking over to get the toast out. My feet
are bare and the tile floor feels really cold on them. I’m wearing my long
gray robe and I pull it up closer around my neck and tighten the belt a
little more to help me warm up. With my right hand, I reach out and
pull the piece of toast out of the toaster oven. My stomach is rumbling
and my mouth is starting to water a little. I put the toast on a small,
red plate and begin to spread some butter over it. The butter is melting
quickly around the edges. The outside edges of the toast are a little burnt.
As I bite into the toast, I notice how it’s crispier on the outside and then
softer on the inside . . .” For more details see Prolonged Exposure Therapy
for PTSD: Emotional Processing of Traumatic Experiences Therapist Guide
(Foa, Hembree, & Rothbaum, 2007).
2. Over-Engagement
122
excessive engagement or distress is by asking ourselves whether or not
the patient’s experience in this moment is conducive to learning. Is the
patient able to learn from this experience that memories are not danger-
ous, even if they are painful; that she is not losing her mind; and that
anxiety does not last indefinitely? If not, the patient is likely over-engaged.
In our experience and those of other researchers in the field, very few
patients will be over-engaged. The few who are can be divided into
two types: “dissociative” and “emotionally overwhelmed.” Dissociative
over-engaged patients have difficulty maintaining a sense of being
grounded and safe in the present moment. Revisiting the trauma mem-
ory feels to them like actually re-encountering the trauma. They may
have body memories or flashbacks during imaginal exposure. They
may be less responsive to the therapist’s questions or directions. Their
physical movements during exposure may mirror actual actions that
took place during the trauma. Distress or SUDS levels are typically
extremely high, and habituation does not occur over successive repeti-
tions of exposure. Sometimes the patient may feel or appear detached
or dissociated from present experience.
123
• Will the patient learn anything useful from repeatedly listening to
(as part of homework) an audio recording of this imaginal exposure?
124
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 conversa-
tional throughout treatment. But if possible, as the patient’s 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.
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 pres-
ent. 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 pres-
ent 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
125
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 ima-
ginal 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 tech-
niques. 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 patient’s fear and concerns that exposure can be dif-
ficult, may help the patient stick with it.
4. Avoidance
126
and that they actually mean that work is being done and the trauma
memory is being activated and processed.
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 driv-
ing 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 iden-
tify the trauma that you and your patient will use in imaginal exposure,
you and your patient should determine the beginning and end points of
127
the trauma. Try not to wait until session 4 to determine the index trauma
and the beginning and end points.
128
emotional processing and recovery. If needed, we encourage the patient
to direct the energy of his anger toward getting better and to move it
aside in order to focus on other equally important elements of his expe-
rience. Repeated conversations during the processing phase over the
course of treatment may be needed when engagement with the memory
and other trauma reminders triggers intense anger. However, Cahill
et al. (2003) found that anger does not interfere with the patient’s abil-
ity to improve with prolonged exposure. In fact, prolonged exposure
was found to reduce anger, shame, guilt, depression, and general anxi-
ety. Patients will likely experience a reduction in anger even though the
treatment is focused on reduction of fear (Cahill, Rauch, Hembree, and
Foa, 2003).
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If the patient’s mood or behavior causes imminent concern about her
personal safety or the safety of others, the need to attend to this promi-
nent risk may require postponing prolonged exposure. However, if a
crisis arises without imminent risk, we explain to the patient that adher-
ing to the treatment plan, and thereby decreasing PTSD symptoms, is
the best help we can offer. In maintaining this focus, the therapist must
clearly express support for the patient’s desire to recover from PTSD
and addiction. Communicate a strong belief that the patient wants to
get better, and applaud every step in the direction of healthy coping
and adherence to the treatment program. If appropriate, you may pre-
dict that these situations will improve as the patient’s skills improve
and the PTSD and substance use symptoms decline. However, keep in
mind that some psychosocial problems may persist and may need to be
addressed beyond the scope of this therapy. The aim is to provide emo-
tional support throughout the crises and at the same time keep PTSD
and addiction the major foci of treatment.
130
Session 5: Imaginal
CHAPTER 7 Exposure Continued and
Planning for Emergencies
(Corresponds to Chapter 7 of the Patient Workbook)
MATERIALS
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
131
1. Review PTSD Symptoms and Any Substance Use Since Last Session
Review the patient’s 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
132
4. Conduct and Process the Imaginal Exposure
For the second imaginal exposure, which you will conduct in today’s
session, encourage your patient to slow down and include even more
details.
Today we will again spend some time again, about 30–45 minutes, revis-
iting the memory of [index trauma]. I would like to ask you to slow down
during the revisiting of the memory, and add in as many details as you can
about what is happening, and what you are seeing, hearing, and think-
ing. Just like last time, I will ask you to give me your SUDS ratings on the
0–100 scale every 5 minutes. When I ask for your SUDS level, just give
me your rating as quickly as possible and try not to leave the image. Just
like last time, I’ d like you to close your eyes and use the present tense, as if
it were happening right now. Include everything you can remember about
what happened, and what you were feeling and thinking as you went
through this experience. The more you can include, the better.
The last two sessions that you revisited the memory of your trauma, I noticed
that you seemed to have difficulty really letting yourself feel your feelings.
133
I want 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 I can 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
Discuss ways to help your patient plan for and cope with stressful,
high-risk situations. For this section of the session, you will be referring
134
to the Personal Emergency Plan (which is Form 19 at the end of the
Patient Workbook).
You did a great job with the imaginal exposure today. That was challeng-
ing but you made it through it. I want us to spend the rest of the session
reviewing how to cope with stressful, high-risk situations. A high-risk
situation is one that increases your likelihood of wanting to use or puts
you at risk for using alcohol or drugs. Generally, these are situations in
which alcohol or drugs are present, other people are using in front of you,
or you are susceptible to wanting to self-medicate negative emotions (such
as fear, sadness, loneliness, or anger). We already talked about some of
your high-risk situations in session 2 (name a few of the patient’s specific
triggers).
Stress is often a trigger for using. There will always be “surprises” in life that
require you to immediately cope with a stressful situation. Some common
situations that people find stressful and that can make them more vulner-
able to wanting to use are:
a. Major life events and big changes in your life. These events could be
negative or positive, such as
– Getting a new job
– Losing a job
– Social separations (e.g., divorce, death of family/friend, child
leaving home)
– Medical problems
– Invitations to family gatherings (birthdays, holidays)
– Getting married
– Having a baby
– Legal problems
– Financial changes
Are there other major events or changes in your life that you can add to
this list?
b. Major events happening to people to whom you feel close can also be
stressful.
135
c. Dealing with your trauma and substance abuse is a very positive
thing, and is stressful at times. It takes courage and persistence to make
the kind of positive life changes you are working toward.
Have a plan for coping with high-risk situations so that you are not
caught off-guard. Let’s spend a few minutes talking about what your
plan will be.
Ask your patient to write down at least one or two names. Identifying
people to call when in trouble may be difficult for some people. The
patient may feel embarrassed or weak, or may think that he can do it on
his own. Help him understand that having a support system in place is
critical for recovery. This is not something to try to do alone.
• Whom to call for support (and whom not to call, e.g. former using
friends/associates)
• When to call for support (as soon as he knows that “something is up”)
• When not to enter a potentially risky situation (e.g., there will be
alcohol, there will be certain people there who cause the patient stress)
• How to leave a risky situation (e.g., to say goodbye to the host or to
just leave and call him later)
Play devil’s advocate and challenge your patient with “And what if that
does not work?” to encourage her to think of numerous options in an
emergency situation.
136
Therapist Note
Therapist Note
Review with the patient the difference between a lapse and a relapse.
For example, if the patient drinks one beer, but then leaves the situ-
ation and calls someone and does not continue to drink, this would
be a lapse. However, if the patient has one beer but then continues to
drink and returns to previous level/frequency of use, this is a relapse.
Although 12-step models consider any use of alcohol or drugs a
relapse, other models including COPE make a distinction between
a lapse and a full-fledged relapse. The distinction is useful because
more shame and feelings of self-defeat are often attached to a relapse
than to 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 also helps protect against the negative con-
sequences of the “abstinence violation effect” (i.e., the patient has
one drink, thus violating the goal of abstinence, so he figures that
he might as well go ahead and have 12 drinks because it doesn’t
matter since he has “broken the rule”). A lapse is a warning sign
that the patient is heading in the wrong direction and needs to act
137
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, I want to discuss ways that you can cope with a
lapse should one occur. I want 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 hap-
pen to everyone in recovery but they are common, so I want 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?
Let’s think about what you could do immediately after a lapse (allow the
patient to generate suggestions first):
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
138
If a lapse does occur, it is likely to be accompanied by feelings of guilt
and shame, and thoughts such as “I’ve failed” and “This will never
work.” Some patients will “catastrophize” and see a lapse as the end
of the world and as an end to their attempt to become abstinent. Help
your patient to generate a less catastrophic and more realistic, helpful
way of viewing the situation. Help your patient to see it as a mistake
rather than a complete failure in order to prevent reoccurrence in the
future.
For example:
If a lapse happens, learn from the events that led up to the lapse, in order to
decrease the chances that it will happen again:
• Examine the slip with your therapist; do not sweep it under the rug.
• Analyze possible triggers: who, what, when, where?
• Analyze anticipatory thoughts/feelings/expectations (e.g., Were you trying
to test yourself to see if you could handle it? Did you try to refuse an offer
from a friend, but not know how to effectively turn down the offer? Were
you thinking “I can have just one”?).
• Guard against negative thoughts (e.g., “I guess I’ ll never change,” “I’ve
blown it now,” “They were right, I’ ll never be able to stop”).
• Guard against poor judgment and rationalization (e.g., “I’ ll quit again
after this bag”).
• Recognize the difference between a lapse and a relapse.
139
6. Assign Homework
140
Session 6: Imaginal
Exposure Continued
CHAPTER 8
and Awareness
of High-Risk Thoughts
(Corresponds to Chapter 8 of the Patient Workbook)
MATERIALS
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 patient’s 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
142
If the Patient’s Substance Use Is Improving
143
now. Follow up with statements and questions about what he thinks
will help him get closer to these important values and goals, and what
is he willing to do now. Remind him that now is the most opportune
time to act since he is getting support from this treatment.
• For patients who are not yet seeing strong improvements in PTSD
symptoms, link this lack of improvement in substance use to the
lack of PTSD improvement. Remind the patient that substance use
is a type of avoidance behavior that can serve to maintain PTSD
symptoms. Continued substance use could reduce the amount
of improvement seen in PTSD symptoms, and/or could make the
PTSD symptoms take longer to improve. Encourage the patient to
test it out these last six sessions to see what happens to their PTSD
symptoms if they stop using substances.
In sessions 4–11 you will conduct the imaginal exposure procedure and
process it with your patient. You will want to spend at least 30 minutes
conducting the imaginal exposure and have about 10–15 minutes after-
ward for processing. The remaining 30–45 minutes of the session will
be dedicated to the substance abuse treatment component. Be sure to
prepare ahead of time for these sessions so that you will stay on track.
During this session you will be conducting the third session of imagi-
nal exposure with the patient. Beginning at this session or the next ses-
sion, emotional processing of the trauma memories can be made more
efficient by having your patient focus primarily or exclusively on the
most distressing parts of the trauma, which are called the “hot spots.”
When should you start working on hot spots? The hot spots procedure
should be introduced after three to four sessions of imaginal exposure
have been conducted and habituation (especially between-session habit-
uation) to the relatively less-distressing parts of the memory has begun
to occur. In the session in which the hot spots procedure is introduced
144
(typically session 6 or session 7), prior to beginning to recount the
trauma memory, explain to the patient:
Up to this point, each time you have revisited the trauma memory, you
have described the entire memory of [name trauma]. And you have been
making great progress and have been experiencing the decrease in anxiety
that we expect to see. Today we are going to do the imaginal exposure a
little differently.
When someone starts getting the benefit that you are having, we begin using
a different procedure that helps to emotionally process the most difficult
moments. We call these moments “ hot spots.” This is where people sometimes
get stuck, and so it’s important to focus directly on the hot spots. In a minute
I will ask you to tell me, based on your last imaginal exposure in session and
on your listening to the imaginal exposure recording last week, what the
most distressing or upsetting parts of this memory are for you now. And then
today, rather than going through the entire memory from beginning to end,
I will ask you to focus the revisiting on one “ hot spot.” If there is more than
one hot spot, we want to start with the most distressing one today. Then
once we have worked through the most distressing hot spot (which may take
more than one session), we can move on to another hot spot. We will work
on hot spots one at a time. Today, we will pick one to begin with, and you
will repeat that one part of the memory over and over. You will want to
describe what happened in as much detail as possible, as if in slow motion,
including every little detail about what you felt, saw, heard, smelled, and
thought. We will repeat the hot spot as many times as necessary to “wear it
out” or bring about a decrease in your SUDS level. Does that make sense
to you? Any questions?
Identify the hot spot(s) on the basis of the patient’s self-report of the
currently most distressing moment of the traumatic event and record
this on the Therapist Imaginal Exposure Recording Form (Appendix
C at the end of this Therapist Guide). If the patient does not identify a
part of the memory that you perceive as a hot spot (e.g., the part where
the patient always gives high SUDS ratings or avoids that part some-
what during the imaginals), ask him whether that part is a hot spot
as well. Help the patient select a hot spot to begin the exposure. This
should be one of the most distressing parts, if not the most distressing
part, of the trauma.
145
Focus on the patient’s hot spots during the imaginal exposure until
each has been sufficiently processed, as reflected by diminished SUDS
levels and the patient’s behavior (e.g., body movement, facial expres-
sion). This may take more than one session per hot spot, depending on
the patient’s 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
Patients may initially be unaware of the thoughts that precede the deci-
sion to have a drink or use drugs. Patients may simply state that they
“just wanted to drink.” This lack of awareness makes it difficult for
patients to identify the actual antecedents and then apply appropriate
coping skills.
146
film sequence) is useful. The primary goal is to gradually make patients
more aware of their high-risk thought processes that set the stage for
alcohol or drug use, and to replace those high-risk thoughts with more
adaptive, helpful thoughts. Once patients feel comfortable examining
the chain of thoughts that might have led to previous use, the notion
of self-awareness and of modifying one’s thoughts can then be more
readily introduced.
The way we think and what we say to ourselves is very powerful. How
we think determines, in large part, how we feel and behave. As shown in
Figure 8.1, our thoughts, feelings, and behaviors are closely connected.
Everyone in recovery will have thoughts about using; these thoughts are
normal and should be expected. You may feel guilty about the thoughts
(even though you have not acted on them), and you may try to deny or
ignore them. The problem is not so much thinking about using, but whether
or not you act on those thoughts.
Sometimes the thoughts are obvious, but other times they can creep up on
you almost without being noticed. People in recovery need to be aware of
a state of mind (sometimes referred to as “stinking thinking”) that can put
them at risk for a relapse—a state of mind characterized by certain danger-
ous patterns of thinking.
With practice you can train your mind to dismiss high-risk thinking when-
ever it occurs, to recognize it for what it is, and to realize that it’s only a
thought, and then you can learn to replace unhelpful thoughts with more
helpful, positive thoughts that keep you on the path of recovery. Over time,
Thoughts
Feelings Behaviors
Figure 8.1
147
you will have fewer thoughts about using, and they will be less intense when
they do happen.
Let’s talk about “ high-risk thoughts”—these are types of thoughts that make
people more vulnerable to using. Here are some common types of high-risk
thoughts that people in recovery experience. Tell me if you can relate to any
of these:
Escape
• 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 prob-
lems when the person has expectations of this happening immediately, and
without having to do something relaxing. Rather than engage in an enjoy-
able 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.
• What are some healthy ways you can relax when you need to? (e.g., exer-
cise, 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 awk-
wardness 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., exer-
cise 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 don’t 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).
It’s 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
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
Crisis
• What are some healthy ways you can manage crises in the future? (e.g.,
engage in daily wellness activities—like eating well, getting rest, exercise,
pleasant activities—to 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
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 feel-
ing inadequate, weak, damaged, like a “bad person” or a failure, respon-
sible 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).
Some people find that new problems arise after they become clean, and they
think it would help to resume using alcohol or drugs in order to end those
new problems. For example: “I’m being very short-tempered and irritable
around my family—maybe it’s more important for me to be a good-natured
parent and spouse than it is for me to stop using drugs right now,” or “I’m
no fun to be around when I’m not high. I don’t think I should stop using
drugs because if I do, people won’t enjoy or like me as much.”
• What are some healthy ways you can manage thoughts about feeling
uncomfortable when clean and sober? (e.g., remind yourself that you will
feel more comfortable with time; remind yourself that although you may
feel uncomfortable it is not the end of the world).
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
don’t 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 edu-
cation; remember how far you have come and don’t let this situation get
the best of you).
Therapist Note
153
6. Assign Homework
154
Session 7: Imaginal
Exposure Continued
CHAPTER 9
and Managing High-Risk
Thoughts
(Corresponds to Chapter 9 of the Patient Workbook)
MATERIALS
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 patient’s 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.
156
4. Managing High-Risk Thoughts
For this section, you will be referring to the “ABC Model” (Form 21 at
the end of the Patient Workbook).
Often people think that A causes C. For example, they run into a former
using buddy (A) and they think that’s what “caused” them to have a drink
(C) (see Figure 9.2).
Or maybe someone got into an argument with his spouse (A) and that is
what “made” him angry and wanting to use (C).
But it’s actually B, a person’s beliefs or thoughts, that lead to C. Two differ-
ent people can experience the exact same event but will react very differently.
The situation is the same, but their beliefs (B) and the way they interpret
the situation are different. You can’t get to C without going through B.
A B C
Activating Event Belief Consequences
(Your thoughts;
(Something What you say to (How you feel and
happens) yourself) behave)
Figure 9.1
The ABC Model.
A C
Figure 9.2
157
PERSON #1
A B C
Figure 9.3
These beliefs and thoughts occur very quickly and are automatic, but with
practice you can train your mind to interrupt the automatic thought pro-
cess, identify unhelpful thoughts, and replace them with more positive,
helpful thoughts. This process is called “cognitive restructuring,” because
you are restructuring your thoughts.
Let’s take a look at how this works, using the example we just discussed (see
Figure 9.3).
• 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., “I’ve come
too far to give it all up now.” “It doesn’t matter if I hurt his feelings or
he gets mad at me for not using; I need to focus on me and my recovery.”
“It’s not worth it.”)
PERSON #2
A B C
“I know that I
cannot have just Less craving, leaving
You run into an old one. I have tried the situation
using buddy. that before and it immediately, and
doesn't work. I going to call a friend
don't want to use. or sponsor. No use.
It's not worth it”.
Figure 9.4
158
To really change one’s 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.
159
d. Goal-Directed Thinking
Ask yourself, “Are my thoughts helping me achieve my goals? What can
I do to change the situation? And if I can’t do anything to change the
situation, what can I do to change the way I am thinking about the
situation?”
5. Assign Homework
160
Complete the in vivo exposure assignments. Practice each in vivo
assignment two to three times before the next session. Be sure not
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 “ABC Model” and “Managing Thoughts About Using”
(Forms 21 and 22 at the end of the Patient Workbook).
161
Session 8: Imaginal
CHAPTER 10 Exposure Continued
and Refusal Skills
(Corresponds to Chapter 10 of the Patient Workbook)
MATERIALS
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 patient’s 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.
In sessions 4–11 you will conduct the imaginal exposure procedure and
process it with your patient. You will want to spend at least 30 minutes
conducting the imaginal exposure and have about 10 minutes after-
ward for processing. The remaining 30–45 minutes of the session will
be dedicated to the substance abuse treatment component. Be sure to
prepare ahead of time for these sessions so that you will stay on track.
164
4. Drug and Drink Refusal Skills
As you may have found, as alcohol or drug use increases in severity over
time, there can be a “ funneling” effect, or a narrowing of social relation-
ships. People begin to eliminate non-using friends, and their peer group
becomes populated with people who support and reinforce continued alco-
hol or drug use. They don’t know anyone who doesn’t use. Being with these
ndividuals and former using buddies increases the risk of relapse through:
Given the increased risk for relapse associated with social pressure, the first
action that should be considered is to stay away from those situations and
people. However, this is not always possible or practical. Because alcohol
and drugs are so common in our society, even the person who never goes to a
bar will still find himself in situations where others are using or are making
plans to go use. Examples include at weddings, funerals, family reunions,
office parties, and restaurants where alcohol is served. A variety of different
people could offer you a drink, such as relatives, new acquaintances, dates,
your boss, and restaurant waiters. The person offering you a drink or drug
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).
Nonverbal behaviors
1. Make direct eye contact with the other person to increase the effectiveness
of your message.
2. Do not feel guilty. You won’t hurt anyone by not using (in fact, you can
only hurt others by using), so don’t 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, I guess 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 exam-
ple, you could say, “No thanks, I don’t drink. You know I’m glad I came
to this family reunion. I haven’t seen a lot of these people in quite a
while, including you. In fact, I’ve been wondering what you’ve been up
to lately? How are the kids?”
4. Do not use excuses (e.g., “I’m on a medication right now” or “I’m 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 future—a 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 time’s
sake. You used to drink with me all the time. What, you think you’re
too good for me now?” an effective response might be, “It’s important
for me to stay clean. If you want to be my friend, then don’t 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.
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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
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Session 9: Imaginal
Exposure Continued
CHAPTER 11
and Seemingly Irrelevant
Decisions (SIDs)
(Corresponds to Chapter 11 of the Patient Workbook)
MATERIALS
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
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1. Review PTSD Symptoms and Any Substance Use Since Last Session
Review the patient’s 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.
In sessions 4–11 you will conduct the imaginal exposure procedure and
process it with your patient. You will want to spend at least 30 minutes
conducting the imaginal exposure and have about 10 minutes after-
ward for processing. The remaining 30–45 minutes of the session will
be dedicated to the substance abuse treatment component. Be sure to
prepare ahead of time for these sessions so that you will stay on track.
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4. Seemingly Irrelevant Decisions
Patients who struggle with substance abuse make decisions every day
that lead them closer and closer toward either recovery or relapse. While
many of the mundane and ordinary decisions that are made each day
may not seem relevant to recovery, they move the patient, one step at a
time, closer and closer toward relapsing.
In today’s session, you will help the patient identify different kinds of
seemingly irrelevant decisions (SIDs) that may culminate in a high-risk
situation or relapse (e.g., whether or not to tell a friend that you have
quit drinking or keep it a secret, whether or not to keep alcohol in the
house or get rid of it, whether or not to ride by an old neighborhood or
take another route home, whether or not to make plans for the weekend
or “just see what happens”). You want to encourage the patient to think
through every decision, no matter how small, in order to avoid ratio-
nalizations or minimizations of risk (e.g., “I need to keep a few beers in
the refrigerator in case my neighbor comes over; just because I stopped
drinking doesn’t mean that he has to”). Introduce the concept of SIDs
to your patient:
Many of the ordinary, mundane choices that are made every day seem to
have nothing at all to do with using alcohol or drugs. Although they may
not involve making a direct choice of whether or not to use, they can move
you, one small step at a time, closer and closer to using. These seemingly
unimportant or innocent decisions that may, in fact, put you on the road to
relapse are called “seemingly irrelevant decisions” (SIDs).
Kim had been clean for 30 days. She was driving home after work one
afternoon and instead of taking her usual route home, she chose to take
a longer more “scenic” route. While driving, she reached into her purse
and found that she was out of cigarettes. She decided to drive around
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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 didn’t 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, I haven’t seen her in so long!” Kim
decided that since she had been clean for 30 days, 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.
Clearly explain to your patients that each and every choice that they
make takes them down one of two paths—the 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 danger-
ous 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.
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You can often catch seemingly irrelevant decisions because they contain
thoughts like “I have to do this” or “I am in a hurry and I really 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 situ-
ations 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 landlord’s
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
Mike’s 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.
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and using—I couldn’t help it.”) They don’t recognize that many of their
“ little” decisions gradually brought them closer and closer to using. It’s easy
to play “Monday morning quarterback” with these decisions and see how
you set yourself up for relapse, but it’s much harder to recognize them when
you are actually in the midst of the decision-making process. That is because
so many choices don’t 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, it’s 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 think-
ing 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. It’s well worth the initial effort you will have to make for the
increased control you will gain over your recovery and your life.
Review common SIDs with your patient and find out which ones he or
she may be vulnerable to. Solicit the patient’s input for each of these and
ask about other patient-specific SIDs.
Here are some common SIDs. Let’s go through and discuss each of these
together.
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• Whether or not to go to a bar or party to see old using friends
• Whether or not to tell a friend that you have quit using or keep it a secret
• Whether or not to make plans for the weekend (sometimes not planning
means planning to use. What plans could you make for this weekend that
would reduce the risk of winding up in a risky situation?).
Finally, discuss the “Making Safe Decisions” (Form 25 at the end of the
Patient Workbook) with your patient. When making decisions, encour-
age your patient to think through potential negative consequences of
each option. When in doubt, choose the safest option. If there is time
in session, you can have the patient think through a recent or pending
decision and write out the safe and unsafe options on the “Making
Safe Decisions” form. If there is not time left in session, assign this for
homework.
5. Assign Homework
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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).
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Session 10: Imaginal
CHAPTER 12 Exposure Continued
and Anger Awareness
(Corresponds to Chapter 12 of the Patient Workbook)
MATERIALS
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
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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 patient’s 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
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3. Conduct and Process Imaginal Exposure
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.
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feelings, such as guilt or shame. Military personnel and Veterans may
be angry because of actions they committed during combat that were
necessary in order to protect themselves or their comrades, or as a result
of how the leadership responded or failed to respond to certain situa-
tions, or at themselves for being “weak” and having PTSD symptoms
that they cannot control.
For the rest of today’s session, I’ d like to talk about anger. For many
people with substance abuse, anger is a trigger for using. Research studies
show that one of the main reasons that people relapse after they complete
a substance abuse treatment program is because they were angry. For a
lot of people with alcohol or drug abuse problems, they never learned
how to effectively manage anger in a healthy way, without alcohol or
drugs. They sometimes report using substances to “self-medicate” feelings
of anger. In addition, people with PTSD often report feeling angry and
irritable (e.g., about what happened to them, about other people’s reac-
tions to the trauma, about the fact that they have PTSD). Because anger
is a normal human emotion, it’s important to learn new, healthy ways
of coping with anger.
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Constructive Effects of Anger
a. Feelings of anger can help motivate you to change for the better. Some
examples might include getting clean from alcohol and drugs, quitting
smoking, deciding to get in shape, or deciding to go back to school. Think
about some of our historical leaders who have been angry about situa-
tions that were not right, and how they used that anger in a positive way
to make important changes in our country.
b. An assertive response to anger (i.e., where you approach the problem
directly, respectfully, and in a thoughtful and controlled manner)
increases your self-confidence and self-respect.
c. An assertive response allows you to communicate your negative feelings
in a healthy way, and can help to improve your relationships. It leads to
resolving problems and bringing people closer.
d. An assertive response teaches you that you can manage your anger with-
out exploding at others, losing your cool, or saying or doing things that
you will later regret.
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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.
Spend a few minutes helping your patient identify his primary triggers
for anger:
The first step to managing your anger is to become aware of what triggers
your anger. Once you know what is setting you off, you can develop a plan
for how to cope with it.
The next step is to become aware of your signs that you’re starting to get
angry. Common signs include:
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• 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. It’s much easier if you
can catch it early on and take action to prevent it from escalating.
Therapist Note
Review with the patient several basic ways he or she can help reduce
anger. Note that you will discuss managing anger in more depth in
session 11.
In our next session, we’ ll focus in depth on specific techniques that you can
use to cope with anger. For now, though, I want to review the importance
of practicing “ daily wellness” activities and establishing an anger policy.
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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
below a 5) on the Anger Thermometer scale. These daily activities include:
Make a commitment that no matter what happens, you will not act on your
anger. The bottom line is that no matter what someone else does or says, it is
NOT okay to act out anger. The only exception is when your physical safety
is at risk and you truly need to defend yourself against harm.
5. Assign Homework
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going to bed at night. Do not use alcohol or drugs when listening to
the recordings, and do not let other people listen to the recordings.
Close your eyes and try to visualize what is being said. Record your
SUDS levels while listening to the audio using the Patient Imaginal
Exposure Data Form (Form 18 at the end of the Patient Workbook).
Complete the in vivo exposure assignments. Practice each in vivo
assignment two to three times before the next session. Be sure not
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 “Anger Awareness” form (Form 26 at the end of the
Patient Workbook).
Review the “Daily Wellness Strategies” (Form 27 at the end of the
Patient Workbook).
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Session 11: Final Imaginal
CHAPTER 13 Exposure and Anger
Management
(Corresponds to Chapter 13 of the Patient Workbook)
MATERIALS
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
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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 patient’s 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.
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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.
For this part of the session, you will be referring to the Coping with
Anger form (Form 28 at the end of the Patient Workbook).
In our last session we talked about anger, and how it’s a normal human
emotion and it isn’t necessarily bad. However, anger can be a powerful
emotion and it can be a trigger for relapse. Therefore, it’s important to
know how to manage anger in a healthy way. We discussed anger aware-
ness, which focused on increasing your awareness of (1) anger triggers and
(2) internal and external warning signs that you’re starting to get angry.
Now that we have a better understanding of what triggers or sets off your
anger, we will spend some focused time today talking about techniques that
you can use to manage anger. In addition to engaging in daily wellness
activities that we discussed last session (e.g., rest, eating well, medication
compliance, exercise), which will help keep your baseline level low and
make you less vulnerable to anger, here are a few techniques you can use
when you get angry.
Review with the patient the following four steps for what to do when
he or she gets angry.
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• Use these cool-down phrases to help you calm down:
Easy does it
Relax
I can handle this
Chill out
Slow down
No big deal
• Use the breathing retraining exercise to help your body and mind settle
down.
• Engage in calming activities
Listen to soothing music
Read a good book
Take a shower or bath
Meditate or pray
Exercise
Practice yoga
Call a supportive friend or AA/NA sponsor
Watch a movie
• Engage in activities you can control. If you are feeling out of control
of the situation or your emotions, engage in activities that you can
control, such as cleaning your room, washing clothes, making a “to do”
list, searching the Web for job listings, and so on. This will make you
feel more in control and will help you refocus and calm down.
2. After you’ve cooled down, step back and think about the situation.
Depending on the situation, it may take 30 minutes to cool down or it
may take a few hours. In some instances you may need to wait a day or
two before you can really get some clarity on the situation. When you are
ready, ask yourself the following questions:
• What exactly is getting me angry?
• Am I angry because I’m expecting too much of myself or someone else?
• What are the positives in this situation?
A frequent source of anger is our own expectations of others. For
example, sometimes we expect other people to do something, but they
do not and then we get angry. Other times, we expect them not to do
something, and then they do it and we are upset. Remember that the
only person you can really control is yourself. You cannot control others.
While it would be nice if others were always kind, polite, told the truth,
showed respect, and so on, those expectations are unrealistic. So, lower
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your expectations of other people, and relax your judgments of others,
too. Focus on yourself and your recovery and worry less about what oth-
ers are, or are not, doing.
3. After assessing what really made you angry, think about your options:
• What is in my best interest here?
• What can I do?
• Is it really worth it, or should I let it go?
Often, people get angry over situations that are, in the grand
scheme of things, simply not that important (e.g., someone cuts
you off in traffic, a friend forgets to return your phone call, some-
one cuts in line in front of you at the grocery store, your room-
mate doesn’t want to share the remote control). During recovery,
people are more likely to feel irritable or annoyed and get upset
by things that may not have normally upset them. They may be
experiencing withdrawal symptoms, including irritability or anxi-
ety, or they may be having to face situations, issues, or feelings
that they have not had to deal with in a very long time because
alcohol and/or drugs were used to mask them. Encourage your
patient to be forbearing with himself, and others, during this
time. Encourage him to ask these questions: Is it worth it? Is it
really worth getting upset over this and spending the rest of the
day upset? Am I really going to remember this or care about it in
a month, a year, 5 years from now? The vast majority of times, the
answer is going to be no. Encourage your patient to practice let-
ting go in these situations.
4. After trying to resolve the problem:
• You may find that you cannot resolve the conflict and you still feel
angry. Remember that you can’t fix everything. There will be some
situations in which you will have to accept the outcome. In those situ-
ations, do the best you can to move on to more positive activities and
thoughts. Be proud of yourself for having tried to resolve the situation.
The real measure of success in these difficult situations is not neces-
sarily the outcome—it’s that you used a healthy way of coping (not
alcohol or drugs, not being aggressive or threatening) to try to resolve
the problem. You may not always get what you want, but if you can
walk away from the situation feeling good about yourself and how you
managed your emotions, that’s success.
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A B C
Activating
Belief Consequences
Event
(Your thoughts;
(Something (How you feel and
What you say to
happens) behave)
yourself)
Figure 13.1
You can also use cognitive restructuring techniques to help you manage
anger. Earlier in the program we talked about how events lead to cer-
tain beliefs or thoughts, which then lead to feelings and behaviors. Recall
the ABC model (from Form 21 at the end of the Patient Workbook; see
Figure 13.1).
Remember it is not the event (A) that leads to anger (C), but rather it’s
the beliefs or thoughts (B), the interpretation of the event, that leads to
anger (C).
For example:
(A) Activating event: Your spouse is acting quiet and withdrawn when
you arrive home.
(B) Beliefs: I must have done something wrong. She is mad at me again
and we’re in for a fight.
(C) Consequences: Feeling defensive, muscle tension, headache, wanting
to pick a fight.
• What are examples of more positive or helpful thoughts that would
be less likely to lead to angry feelings?
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5. Assign Homework
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Session 12: Review
CHAPTER 14
and Termination
(Corresponds to Chapter 14 of the Patient Workbook)
MATERIALS
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 patient’s 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
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again). Compare the baseline scores on PTSD and SUD measurements
with the scores from today and point out to the patient where posi-
tive changes have occurred. Congratulate her for all her hard work and
effort, and for sticking with it!
You also want to take time during this session to discuss areas that may
still need work and focused attention. Much can be accomplished in
12 sessions, but it is also likely, given the clinical severity and complex-
ity of patients with PTSD/SUD, that additional areas of concern will
need to be addressed following COPE treatment. Help your patient
plan the next step (e.g., making an appointment with a vocational reha-
bilitation office, getting a sponsor in AA or NA, continuing to work on
avoidance symptoms related to the trauma).
1. Review PTSD Symptoms and Any Substance Use Since Last Session
Review the patient’s 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
3. Termination
Evaluate and discuss the patient’s 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.
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We have been working together on your PTSD symptoms and substance
abuse for [insert number of weeks or sessions]. Today, in our last session,
I’ d like to review your progress in the program and the skills that you’ve
learned. I’ d also like to take a few minutes to thank you for the opportu-
nity to work together and to say goodbye. We’ve been working together to
help you process what happened during the trauma, to stop/reduce your
substance use, and to develop healthy coping skills. You’ve worked really
hard during the program, and I’m very proud of you. I’ d like to talk with
you about how you are feeling now, what you found helpful or not helpful
during treatment, what additional skills you need to learn, and your treat-
ment aftercare plans.
Next, take out the In vivo Hierarchy Form started in session 3. Without
showing it to the patient, read each of the situations on the list and ask
the patient to imagine doing each of the things on the hierarchy now.
Ask the patient to provide anticipated SUDS levels for each situation if
he or she were to engage in that situation today. Record these ratings in
the column labeled “Final Session.” When completed, show the patient
the sheet with the two columns of ratings, the first one from session 3
and the one from today. For nearly all patients, there will be significant
decreases in SUDS levels for most items on the list. Ask the patient,
“What do you think of the two sets of ratings? How did you accomplish this
remarkable change?”
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Note improvements in those situations that changed significantly.
Discuss the situations for which the patient’s SUDS did not decrease
as much. Ask, “What do you think happened with this situation? Why
has it remained relatively high?” Usually, these are the situations that
the patient has not confronted sufficiently. Help the patient make
a schedule to practice these situations over the next few weeks.
Encourage the patient to face the feared situations and memories as
they come up.
Next, review what the patient has learned over the course of therapy by
asking additional questions. The aim of this discussion is to help the
patient articulate what he has learned, and what caused his symptoms
to decline and his satisfaction in life to increase. For example:
• How are you feeling now compared with when you began the
program?
• Are you now able to do certain things/activities that you didn’t do before
the program?
• What have you noticed about your level of anxiety or discomfort in cer-
tain situations?
• How did you accomplish all of these changes?
• What did you do in this therapy that brought about this difference?
• What helped you the most to be able to face the trauma?
• How do you feel about the changes you made?
Also ask the patient about improvements she has noticed with regard
to other PTSD symptoms (e.g., reexperiencing, hyperarousal). Is she
sleeping better? Is she less irritable or jumpy? Explore changes in nega-
tive cognitions about herself and the world.
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
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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 crav-
ings and triggers, and to articulate skills that she has learned to help
reduce/stop substance use.
• 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?
• 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?
Discuss the gains made in various areas of the patient’s life (e.g., socially,
interpersonally, at work, physical health, assertiveness). Ask the patient
to describe the skills she used to overcome or cope with these problems.
The patient needs to be reassured that she has the skills to solve life’s
problems without having to rely on you for support.
199
Considering the Need for More Treatment
Normalize for the patient that change takes time, especially big changes
like what he has been working on, and that there may be additional
areas (e.g., depression, anger, vocational functioning) that the patient
would benefit from working on now that the COPE treatment program
has been completed. Emphasize that the patient has already made great
strides toward improving these other areas of life by working on the
PTSD and substance abuse issues. Patients need to be reassured that
they have the skills to solve life’s problems without having to rely on the
therapist for support.
Using the My Next Steps form (Form 30 at the end of the Patient
Workbook), have the patient write down the areas they want to con-
tinue working on. Those goals may be PTSD or SUD related, or they
may pertain to other areas of life (e.g., get in shape, get a job).
200
Explaining That PTSD and Cravings May Temporarily
Increase During Stressful Times
It’s fairly common for people with PTSD and substance abuse, even those
who have recovered significantly from them as you have, to find that in
times of high stress, even positive life stress (e.g., getting married, having a
baby, getting a new job), symptoms can creep up again. It’s important to
then put this in perspective and begin using the tools you’ve learned in this
program.
• What will you do if 2 months from now you suddenly start experiencing
intrusive thoughts and nightmares about the trauma again?
• What will you do if you find yourself in a situation that reminds you
strongly of your trauma and it causes you to begin feeling afraid of going
out again?
• What will you do when you go through a stressful period of life and you
find yourself craving and wanting to use again?
4. Feedback
201
or meaningful or particular sessions that stand out as valuable. What
motivated the patient to complete the homework between sessions,
and what factors stood in the way? Solicit suggestions for improving
future offerings of this treatment. Did you do anything that rubbed
the patient the wrong way, or in what way could you have been more
helpful? Did the patient perceive you as being open to comments and
suggestions?
Therapist Note
5. Saying Goodbye
• You did a great job with this challenging treatment. I have 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 treat-
ment. 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 I am 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 ses-
sion can increase the patient’s 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 difficul-
ties. As stated earlier, you can always set up a “booster session” for 4–6
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” appoint-
ment to catch up and review coping skills, even for patients who con-
tinue to do well with regard to both PTSD and SUD symptoms.
Provide ample praise for the patient’s courage in seeking and staying in
treatment. Focus on the gains and highlight the patient’s courage and
areas of strength and resiliency.
203
Appendices
205
Appendix A
Note: This form is to be used as a means of outlining and summarizing important informa-
tion about the patient.
Name:
Date:
207
II. Overall Level of Functioning
Education level:
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
Any other current treatments:
Current substance use (e.g., which substance(s) using, frequency and amount of use, date of
last use):
Substance of choice:
210
Family history of substance use disorders:
Problems experienced as a result of substance use (e.g., legal, family/social, physical health,
mental health, employment, education, financial):
211
IV. Trauma/PTSD
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 I will not attempt to harm myself. I promise
that I will not attempt to commit suicide. I promise that I will not participate in any activity
that could result in my intentionally causing harm or death to myself.
If I have thoughts of suicide or feel like I want to hurt or kill myself, I promise to:
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
Brief description of the incident being recounted during the imaginal exposure:
Beginning
5 min.
10 min.
15 min.
20 min.
25 min.
30 min.
35 min.
40 min.
45 min.
Processing Notes:
217
Appendix D
Certification of Completion
219
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About the Authors
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Lifetime Achievement Award presented by the International Society
for Traumatic Stress Studies; Lifetime Achievement Award presented
by the Association for Behavior and Cognitive Therapies; TIME 100
most influential people of the world; 2011 Lifetime Achievement in the
Field of Trauma Psychology Award from the American Psychological
Association; and the Inaugural International Obsessive Compulsive
Disorder Foundation Outstanding Career Achievement Award.
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mental health and substance use disorders, and improving treatment
delivery. Professor Teesson has a strong track record of competitive sci-
entific grant funding and has published extensively in these areas. She
maintains strong links with treatment services and is a founding mem-
ber (since 1990) of The Mental Health Services Conference (TheMHS),
the largest mental health services conference in Australia.
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