Staff Perspective: Finally, An Integrated Treatment for Patients with PTSD and SUD

Staff Perspective: Finally, An Integrated Treatment for Patients with PTSD and SUD

Have you heard about Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE)? This session-by-session therapist guide, written by Dr. Sudie Back and colleagues, was published in 2015. However, when I mention it at Prolonged Exposure Therapy (PE) workshops, few therapists in the audience have heard about it.

COPE is an integrated cognitive behavioral psychotherapy developed for patients struggling with both PTSD and an alcohol or drug problem. To address both PTSD and substance use disorders (SUD) concurrently, the approach combines two manualized evidence-based treatments: PE, developed by Dr. Edna Foa, and a cognitive behavioral therapy to treat SUD, developed by Dr. Kathleen Carroll.

We all know how common it is for patients with PTSD to have an accompanying substance use problem. Yet, I’m wondering if you’ve felt frustrated or even hopeless, as I have, when trying to help these individuals. I’ve struggled with the chicken or the egg, i.e., which should I target first: the trauma or the substance? Historically, the standard approach has been to treat SUD and PTSD sequentially. Typically, you start with SUD treatment, then transition the patient to PTSD treatment, often with a handoff from the SUD provider to a new PTSD therapist. That’s if the patient makes it that far in their treatment journey.

Underlying justification for the sequential model is the concern that, if patients don’t fully address their SUD prior to PTSD treatment, the intensity of processing the trauma will worsen their alcohol or drug problem or lead to relapse. In other words, patients will turn to drinking or abusing substances to cope with the emotionally overwhelming traumatic material. This sequential model persisted for years, although there was not much evidence to suggest it actually worked.

Fortunately, research conducted over the past several years has debunked that model and is now focused on a more promising and effective approach. An integrated model delivered by the same therapist who actively works with the patient to tackle both PTSD and SUDS simultaneously appears to have better outcomes with significant reductions in both PTSD and SUD symptoms. Data has not supported the fear that rates of substance use, relapse, or attrition will increase if these dual-diagnosed patients engage in a trauma-focused treatment like PE while addressing their substance abuse.

The COPE therapist guide reviews which patients are appropriate to consider for this treatment. Obviously, it’s for individuals with current PTSD and SUD. They also need a sufficient memory of the traumatic event(s) for the PE components of the treatment. Patients with other comorbidities (e.g., depression, shame) can benefit from COPE, but the symptoms from those other conditions should not be their primary concern or diagnosis. COPE is not recommended for individuals with imminent threat of suicidal or homicidal ideation, serious self-injurious behavior, ongoing domestic violence, lack of memory of the traumatic event(s), or the lack of desire to significantly reduce or stop alcohol or drug use.

Several months ago, I attempted to use COPE with a patient I diagnosed with PTSD and alcohol use disorder, but he was unable to commit to reducing his drinking (four to six drinks per night) or to engaging in the in vivo and imaginal exposures, so we stopped the therapy early in the program. In hindsight, if I had done more motivational interviewing at the beginning, I would have realized he was not committed to the goals of the program and thus he was not appropriate for COPE at that time. Nonetheless, I found the COPE therapist guide easy to follow with many great tools, techniques, explanations, and tips for each session. I’m excited to try COPE again with a patient who is motivated to engage in the process and to share the basics about COPE with you in this blog to spark your interest.

Goal: To arm clinicians with an intervention they can independently use to successfully treat PTSD in individuals who also wrestle with a SUD without having to refer them. The treatment aims to reduce the severity of patient’s PTSD and SUD symptoms and lessen the negative toll that PTSD and SUD have on their life and well-being.

Structure & Number of Sessions: COPE consists of 12 weekly 90-minute sessions that follow the agenda below for each appointment:

  • Review current PTSD symptoms and any substance use since last session
  • Review homework
  • Focus on trauma and PTSD
  • Focus on substance abuse
  • Assign homework
  • All sessions are audio-recorded so the patient can listen to them in between sessions for homework. Starting with imaginal exposure in session four, two audio-recordings are made: one for the imaginal portion; the other is for the other parts of the session before and after imaginal exposure.

Session Topics & Techniques:

Session 1: Introduction to COPE
Session 2: Common reactions to trauma and craving awareness
Session 3: Developing the in vivo hierarchy and craving management
Session 4: Initial imaginal exposure
Session 5: Imaginal exposure continued and planning for emergencies
Session 6: Imaginal exposure continued and awareness of high-risk thoughts
Session 7: Imaginal exposure continued and managing high-risk thoughts
Session 8: Imaginal Exposure continued and refusal skills
Session 9: Imaginal Exposure continued and seemingly irrelevant decisions
Session 10: Imaginal exposure continued and anger awareness
Session 11: Final imaginal exposure and anger management
Session 12: Review and termination

Additional Information:

COPE should be used by individuals with graduate training in psychology, social work, psychiatry, etc., formal training in the delivery of Cognitive Behavioral Therapy and PE, and adequate ongoing support or supervision.

In some circumstances, therapists can change the order of the content to tailor it to a patient’s unique needs. This should be done thoughtfully and with good clinical judgment. For example, if a patient is struggling with anger problems, moving the content on anger from sessions 10 & 11 to earlier in course of treatment could be done.

There is a companion patient workbook called, Concurrent Treatment of PTSD and Substance Use Disorder using Prolonged Exposure Therapy (COPE): Patient Workbook, that includes the homework forms, treatment techniques, etc. See the link below.

To monitor progress, therapists are encouraged to assess the patient’s PTSD and SUD symptoms through weekly self-report measures such as the PCL-5 (for PTSD) and AUDIT, DAST-10 or Time Line Follow Back (for SUD).

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Paula Domenici, Ph.D. is Director of Training Education at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. She oversees the development of courses and training programs for providers on evidence-based treatments for Service members and Veterans.

The links below are provided for informational use only and CDP does not endorse any specific vendor.

COPE: Therapist Guide:

COPE: Patient Workbook: