The Dual Diagnosis

Trauma is an epidemic, with most Americans at some point in their lives surviving one or more incidents – violence, child abuse, domestic violence, military combat, rape, car accidents, natural disasters, life-threatening illness, and industrial accidents. For most people, the impact of trauma fades relatively soon, typically within one to three months. But for others, trauma problems can persist for years and even decades. This type of lingering trauma is typically diagnosed as Post-Traumatic Stress Disorder, or PTSD. Among those who seek treatment for substance abuse, a dual diagnosis PTSD and substance abuse disorder is surprisingly common. For most, the traumatic event or events occur first, and then the addiction develops. Substance abuse has been often viewed as “self-medication” to cope with the overwhelming pain that trauma has caused in an individual’s daily living.

However, addiction can also lead to trauma, as individuals become more vulnerable while under the influence of substances. The rate of a diagnosable level of PTSD among those receiving substance abuse treatment is 12%-34%, and the rates are even higher among women (30%-59%). Most women with this dual diagnosis have experienced childhood physical or sexual abuse, and men have typically experienced war trauma or crime victimization. Various subgroups have higher rates of this dual diagnosis than others, such as combat veterans, victims of domestic violence, teenagers, prisoners, and the homeless. Overall, incidences of PTSD and substance abuse have consistently been found to co-occur, regardless of the nature of trauma or the type of substances that were abused.

As a result, those with PTSD and substance abuse have a more severe clinical profile than those with just one of those disorders. Not only are they seeking treatment for their substance abuse, but they are facing recovery while also dealing with the lingering effects of intense trauma. Furthermore, those with PTSD and substance abuse disorder are particularly vulnerable to repeated traumas, far more so than those with substance abuse or PTSD alone. Typically, there are also a wide variety of life problems that may present themselves as complicating factors in successful treatment. These may include, but are not limited to, other diagnoses and disorders, interpersonal and medical problems, child maltreatment and neglect, homelessness, HIV risk, custody battles, financial hardships, job insecurity, and domestic violence. Due to these issues, those with a dual diagnosis are at risk of falling into a “downward spiral.” Researchers describe this as one triggering event after another, burying the individual deeper and deeper into substance abuse and PTSD. For example, the increased vulnerability to new trauma can lead to increased substance abuse, and vice versa. In a nutshell, PTSD symptoms can be common triggers of substance abuse, which in turn can intensify PTSD symptoms.

The Presenting Problem

Because of the possibility of this “downward spiral,” many clinicians have chosen to avoid trauma therapy in their modalities for substance abuse treatment, arguing that it may be too distressing a topic to discuss in the midst of recovery. While there is some validity among these concerns, becoming abstinent does not resolve PTSD and, in some cases, may even cause the symptoms to worsen if they are not addressed. On the other hand, traditional trauma based interventions involve delving into a detailed narrative of the traumatic events, which can leave a client who is struggling with substance abuse more vulnerable as well.

However, it is important for clinicians to recognize that trauma and substance abuse are intrinsically intertwined. Research has shown that an integrated model of treating both PTSD and substance abuse disorder at the same time is recommended as more likely to produce successful results. Unfortunately, clinical programs have historically been known to treat PTSD or substance abuse, but rarely both. As a result, the majority of patients with PTSD and substance abuse never receive trauma-focused therapy, and many patients who are in addiction recovery are never even assessed for PTSD. Treatments that are usually effective for treating each diagnosis individually may not be advisable when the two disorders occur together, hence the need for an integrated modality.

The Treatment

Currently, there is only one evidence-based model that is endorsed by professionals for treating the dual diagnosis of substance abuse and PTSD. This model used to address both addiction and trauma together is known as Seeking Safety. Seeking Safety is an evidence-based therapy model that can be used in group or individual counseling, and can be conducted with the broadest range of clients – including the highly complex, chronic, and multiply burdened clients who often cycle in and out of treatment. It was specifically developed to help survivors with trauma and substance abuse disorder in a way that does not ask them to delve into emotionally distressing trauma narratives. This significantly minimizes the risk of instigating the “downward spiral” that other forms of trauma-based therapies often present. Thus, “safety” is a deep concept with varied layers of meaning throughout the modality: the safety of the client as they do the work, helping clients envision what safety would look and feel like in their lives, and helping them learn specific new ways of coping.

How it Works

Seeking Safety stays in the present, teaching a broad array of safe coping skills that patients may never have learned if they grew up in dysfunctional families or may have lost along the way as their addiction and trauma spiraled downward. All of the Seeking Safety coping skills apply to both trauma and addiction at the same time – providing integrated treatment that can help boost motivation and guide clients to see the connections between their trauma and addiction issues. Seeking Safety provides various options for recovery, in keeping with current research and understanding about substance abuse. It can be done as part of an abstinence-based approach (with clients giving up all substances of abuse), harm reduction (decreasing use, perhaps with an ultimate goal of abstinence), or controlled use (decreasing use to a safe level).

Helping to meet the both patient’s trauma and substance abuse needs at the same time and in safe fashion can build hope in new ways.

The 25 Seeking Safety Topics

There are 25 topics that clients are exposed to during therapy, each a safe coping skill. Each topic is independent of the others so they can be used in any order and for as long or short as the client’s time in treatment. The topics address cognitive, behavioral, and interpersonal skills, plus there is a focus on engaging clients in community resources.

  1. Introduction/Case Management: Introduction to the treatment, getting to know the patient, and assessment of case management needs.
  2. Safety: Patients explore what safety means to them, and are provided with a list of over 80 “Safe Coping Skills”
  3. PTSD – Taking Back Your Power: Clients are provided information regarding “What is PTSD?”; “The Link between PTSD and Substance Abuse”; “Using Compassion to Take Back Your Power”; and “Long-Term PTSD Problems.”
  4. Detaching From Emotional Pain (Grounding): Three types of grounding are presented, along with an experiential exercise to help clients detach from emotional pain.
  5. When Substances Control You: Eight handouts are provided regarding various substance abuse topics.
  6. Asking for Help: Encourages patients to become aware of their needs and learn how to seek assistance.
  7. Taking Good Care of Yourself: Tips for Self-Care and a commitment to improvement and immediate action.
  8. Compassion: Patients are taught that a loving perspective towards oneself can produce lasting change.
  9. Red and Green Flags: A safety plan is developed to identify signs of both danger and safety.
  10. Honesty: Exploring the role of honesty and dishonesty in the journey to recovery.
  11. Recovery Thinking: The power of rethinking is demonstrated through various exercises.
  12. Integrating the Split Self: Patients are trained to notice splits as a defense mechanism and strive for self integration.
  13. Commitment: Creative strategies for keep commitments are described.
  14. Creating Meaning: Meanings that are harmful versus those that bring healing are discussed.
  15. Community Resources: A lengthy list of national non-profit resources is offered to aid patients’ recovery. Also, guidelines are offered to help patients take a consumer approach in evaluating treatments.
  16. Setting Boundaries in Relationships: Ways to set healthy boundaries are explored, and domestic violence information is provided.
  17. Discovery: Discovery is offered as a tool to reduce the cognitive rigidity common to PTSD and substance abuse.
  18. Getting Others to Support Your Recovery: Patients are encouraged to identify which people in their lives are supportive, neutral, or destructive toward their recovery.
  19. Coping with Triggers: A simple three-step model is offered to actively fight triggers of PTSD and substance abuse.
  20. Respecting Your Time: Balancing structure versus spontaneity, work versus play, and time alone versus in relationships are addressed.
  21. Healthy Relationships: Healthy and unhealthy relationship beliefs are contrasted. Patients are guided to notice how PTSD and substance abuse can lead to unhealthy relationships.
  22. Self-Nurturing: Safe self-nurturing is distinguished from unsafe self-nurturing.
  23. Healing from Anger: Guidelines for working with both constructive and destructive types of anger are offered.
  24. Life Choices: As part of termination, patients are invited to play a game as a way to review the material covered in the treatment.  Patients pull from a box slips of paper that list challenging life events (e.g., “You find out your partner is having an affair”).  They respond with how they would cope, using game rules that focus on constructive coping.
  25. Termination: Patients express their feelings about the ending of treatment, discuss what they liked and disliked about it, and finalize aftercare plans.

Benefits of this Approach

The concept of safety is designed to protect the clinician as well as the client. By helping clients move toward safety, clinicians are protecting themselves from treatment that could move too fast without a solid foundation. Increased substance use and harm to self or others are of particular concern with this vulnerable population. Thus, seeking safety is both the clients’ and clinicians’ goal. Over many years, feedback on the model indicates that its structured approach and compassionate tone make it practical and user-friendly for both the clinician and client.

The approach has been successfully implemented with a wide range of populations including both males and females; adolescents; military and veterans; homeless people; survivors of domestic violence; criminal justice and racially/ethnically diverse populations; clients with cognitive or reading impairments (including mild traumatic brain injury); those who are seriously and persistently mentally ill; individuals with behavioral addictions such as pathological gambling; active substance users; and clients in all levels of care (outpatient, residential, inpatient, community care, and private practice).

Seeking Safety is one of the lowest-cost trauma models available as only the book is needed to conduct it. No degree or licensure is required to conduct Seeking Safety. It has been used successfully in peer-led format, by case managers, and by domestic violence advocates.

Seeking Safety was developed over a ten-year period beginning in the early 1990’s under a grant from the National Institute on Drug Abuse. Clinical experience and research studies informed revisions of the manual, resulting in the final published version in 2002. Altogether, more than 20 studies have been conducted including pilots, controlled trials, multisite trials, and dissemination studies. While most studies on PTSD exclude people with complex problems, Seeking Safety research has been conducted with such populations.
It is currently classified as the only model for co-occurring PTSD and substance abuse disorder “strongly supported by research” and the only one that has evidenced significant improvements on both disorders by the end of treatment.

Our Mission at APEX Recovery

Overall, our mission at Apex Recovery Rehab is to use this research and other treatments to provide the best possible evidence – based individual recovery in the world. We are committed to treating every person and family in recovery with dignity, respect, love, personal care and attention. We choose to follow the best scientific, medical, holistic and smart ways to deal with one’s addiction and offer a comfortable setting and memorable experience to last a lifetime for every client and their family. We achieve our mission by having very strong convictions, a set of beliefs and solid core values, family-centered, comprehensive, individualized, treatment that takes place in a safe, substance-free environment.