Past-/trauma-focused therapies are typically delivered individually and involve various exposure-based techniques in which the client revisits, and seeks to make meaning of, the traumatic events they have experienced and their consequences. Of these, prolonged exposure (PE) has received the most empirical attention. Alongside other past-/trauma-focused therapies, including cognitive processing therapy (CPT), and EMDR, PE is considered a first-line treatment for PTSD in the absence of AOD use [1303, 1308].
Prolonged exposure (PE)
Similar to exposure for phobias, PE for PTSD involves exposure to the feared object or situation; in this case, traumatic memories (imaginal exposure) and physical reminders of the trauma (in vivo exposure). Traditionally, PE for PTSD was considered inappropriate for use with people experiencing AOD use disorders based on concerns that the emotions experienced may be overwhelming and could lead to relapse or further deterioration [1314]. However, the evidence suggests that this is not the case; PE does not lead to an exacerbation of AOD use, cravings, or increase the severity of the AOD use disorder [741, 1314]; in fact, it may be protective against relapse [1315]. Trials examining the efficacy of PE (in its original form, as well as modified or enhanced versions) delivered alongside treatment-as-usual for AOD use report positive outcomes including significant reductions in PTSD symptoms [741, 1316, 1317]. Contingency management has also been shown to be an effective adjunct to PE among people with opioid use disorders, leading to greater treatment retention and greater reductions in PTSD symptoms [1318]. One RCT has also examined the efficacy of PE and concurrent naltrexone in treating PTSD and alcohol use disorders. Exposure therapy was not found to be superior to supportive counselling in reducing PTSD symptoms; however, it was associated with reduced risk of relapse to alcohol use at 6-month follow-up [1315].
A number of clinical researchers have investigated the efficacy of integrated exposure-based programs that address PTSD and AOD use simultaneously. Typically these programs involve psychoeducation regarding each disorder and their interrelatedness, coping skills training, relapse prevention, and exposure to traumatic memories and/or reminders; and they are sometimes delivered in combination with other therapeutic techniques [739]. Support for these programs is growing, with an increasing number of studies providing evidence for their safety and efficacy, including two Australian trials [1300, 1301]. Participants in these studies did not demonstrate a worsening of symptoms or high rates of relapse; on the contrary, they demonstrated improvements in relation to both AOD use and PTSD outcomes [739, 1296, 1307].
The majority of research in this area has focused on the efficacy of an integrated treatment called Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) [442]. Since the first RCT of this intervention was completed in Australia [1300], a further three have been undertaken in the United States [772, 1319, 1320]. Collectively, these studies have found that, while decreases in substance use are comparable to control conditions, with respect to PTSD symptom reduction, COPE outperforms treatment-as-usual for AOD use, relapse prevention, and a present-/non-trauma focused therapy (Seeking Safety). A modified version of the COPE program is currently being examined among Australian adolescents [1321, 1322]. Another integrated exposure-based program for adolescents that has shown promise in reducing PTSD symptoms, AOD use and risk behaviours is Risk Reduction Through Family Therapy (RRFT), which combines trauma-focused CBT and multisystemic therapy [1323, 1324].
Cognitive processing therapy (CPT)
CPT focuses on challenging and modifying unhelpful trauma-related beliefs (e.g., beliefs surrounding safety, trust, power, control, esteem, and intimacy) that are having a negative impact on a person’s life via written exposure and cognitive restructuring. Despite CPT being a first line treatment for PTSD, few studies have examined its effectiveness for people with co-occurring AOD use disorders. CPT, and CPT integrated with CBT for substance use, have shown promise among people with AOD use disorders; however, the predominance of this research has been conducted on veteran samples. Studies comparing outcomes of CPT for veterans with and without co-occurring AOD use disorders have found no significant differences between groups [1325, 1326]. Subsequent open label trials of CPT combined with CBT for substance use have also reported reduced PTSD symptoms, depressive symptoms, and AOD-related outcomes [1327–1329].
Eye movement desensitisation and reprocessing (EMDR)
In EMDR, a person focuses on the imagery of a trauma, negative thoughts, emotions and body sensations whilst following guided eye movements led by a therapist. Although EMDR is a first line treatment for PTSD only a small number of studies have examined its effectiveness for people with co-occurring AOD use disorders. Two small pilot trials have found that EMDR, alongside treatment-as-usual for AOD use, produces significantly greater reductions in PTSD symptoms compared to treatment-as-usual for AOD use alone [1330, 1331]. Although case series have described benefits in relation to AOD use as well [1332], these trials did not find any between-group differences [1330, 1331]. There is some very preliminary evidence to suggest that EMDR combined with schema therapy for PTSD and AOD use disorders may be effective in reducing both PTSD and AOD use [1333]. Two additional studies of EMDR for people with either PTSD or a history of trauma and co-occurring AOD use are currently underway [1334, 1335].