Concurrent Treatment

Concurrent Treatment
of PTSD and Substance

Use Disorders Using
Prolonged Exposure
(COPE)
T R E AT M E N T S T H AT W O R K
Editor-In-Chief
David H.Barlow, PhD
Scientific Advisory Board

Anne Marie Albano, PhD
Gillian Butler, PhD
David M.Clark, PhD
Edna B.Foa, PhD
Paul J.Frick, PhD
Jack M.Gorman,MD
Kirk Heilbrun, PhD
Robert J.McMahon, PhD
Peter E.Nathan, PhD
Christine Maguth Nezu, PhD
Matthew K.Nock, PhD
Paul Salkovskis, PhD
Bonnie Spring, PhD
Gail Steketee, PhD
John R.Weisz, PhD
G. Terence Wilson, PhD
T R E AT M E N T S T H AT W O R K
of PTSD and
SubstanceUse
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
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Library of Congress Cataloging-in-Publication Data
Back, Sudie E., author.
Concurrent treatment of PTSD and substance use disorders using prolonged exposure (COPE) : therapist guide /
Sudie E. Back [and seven others].
pages cm
Includes bibliographical references.
ISBN 9780199334537 (paperback)
1. Post-traumatic stress disorderTreatment. 2. Substance abuseTreatment. 3. Cognitive therapy. I. Title.
RC552.P67B323 2015
616.8521dc23
2014030749
987654321
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 Icould 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
Stunning developments in healthcare have taken place over the

last several years, but many of our widely accepted interventions and strategies in mental health and behavioral medicine
have been brought into question by research evidence as not
only lacking benefit, but perhaps, inducing harm (Barlow,
2010). Other strategies have been proven effective using the
best current standards of evidence, resulting in broad-based
recommendations to make these practices more available to
the public (McHugh & Barlow, 2010). Several recent developments are behind this revolution. First, we have arrived at a
much deeper understanding of pathology, both psychological
and physical, which has led to the development of new, more
precisely targeted interventions. Second, our research methodologies have improved substantially, such that we have reduced
threats to internal and external validity, making the outcomes
more directly applicable to clinical situations. Third, governments around the world and healthcare systems and policymakers have decided that the quality of care should improve,
that it should be evidence based, and that it is in the publics
interest to ensure that this happens (Barlow, 2004; Institute of
Medicine, 2001; McHugh & Barlow, 2010).
Of course, the major stumbling block for clinicians everywhere
is the accessibility of newly developed evidence-based psychological interventions. Workshops and books can go only so far
in acquainting responsible and conscientious practitioners with
the latest behavioral healthcare practices and their applicability
to individual patients. This new series, TreatmentsThatWork, is
devoted to communicating these exciting new interventions to
clinicians on the frontlines of practice.
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 implementation of these procedures in their practice.
In our emerging healthcare system, the growing consensus is
that evidence-based practice offers the most responsible course
of action for the mental health professional. All behavioral
healthcare clinicians deeply desire to provide the best possible
care for their patients. In this series, our aim is to close the dissemination and information gap and make that possible.
This therapist guide and the companion workbook for patients
address the treatment of posttraumatic stress disorder (PTSD)
and a co-occurring substance use disorder (SUD) using cognitive-behavioral therapy. The program, COPE, represents
an integration of two evidence-based treatments: Prolonged
Exposure (PE) therapy for PTSD and Relapse Prevention for
SUD. COPE was developed by the authors in response to the
increased recognition that individuals with PTSD and an SUD
have unique needs and tend to have poorer outcomes in standard treatment. Historically, the standard of care has been to
treat the SUD first and then treat the PTSD; but with COPE,
patients can experience substantial reductions in both PTSD
and substance use severity at the same time.
Comprised of 12 individual, 6090 minute therapy sessions,
the program includes several components: education about the
relationship between PTSD and substance use disorders; education about common reactions to trauma; cognitive-behavioral techniques to help patients manage cravings and high-risk
thoughts about using alcohol or drugs; coping skills to help
prevent relapse to substances; breathing retraining relaxation
exercise; in vivo (real life) exposures; and imaginal exposures.
COPE is designed to treat patients by reducing the severity of
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.
David H.Barlow, Editor-in-Chief,
Treatments ThatWork
Boston,MA
References
Barlow, D.H. (2004). Psychological treatments. American Psychologist, 59,
869878.
Barlow, D. H. (2010). Negative effects from psychological treatments:
Aperspective. American Psychologist, 65(2), 1320.
Institute of Medicine. (2001). Crossing the quality chasm: A new health
system for the 21st century. Washington, DC:National Academy Press.
McHugh, R.K., & Barlow, D.H. (2010). Dissemination and implementation of evidence-based psychological interventions: A review of current
efforts. American Psychologist, 65(2), 7384.
ix
Contents
Acknowledgments xiii
Chapter1
Introductory Information for Therapists 1
Chapter2
Outline of This Treatment Program 25
Chapter3
Session 1:Introduction to COPE 43
Chapter4
Session 2:Common Reactions to Trauma

andCraving Awareness 59
Chapter5
Session 3:Developing the In vivo Hierarchy

and Craving Management 77
Chapter6
Session 4:Initial Imaginal Exposure 99
Chapter7
Session 5:Imaginal Exposure Continued

andPlanning for Emergencies 131
Chapter8

andAwareness of High-Risk Thoughts 141
Chapter9

andManaging High-Risk Thoughts 155
Chapter10

andRefusal Skills 163
Chapter11

andSeemingly Irrelevant Decisions
(SIDs) 169
Chapter12

andAnger Awareness 177
xi
Chapter13
Session 11:Final Imaginal Exposure

andAnger Management 187
Chapter14
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
We would like to give a very special thanks to the therapists who

have delivered COPE over the years. These individuals have
helped enormously with the revisions and improvements to the
manual and training. We are grateful to Dr.Elizabeth Santa
Ana, Dr.Matt Yoder, Dr.Scott Coffey, Dr.Patricia Halligan,
Dr.Brian Lozano, Dr.Kristy Center, Dr.Julianne Flanagan,
Dr.Sabine Merz, Dr.Julia Rosenfeld, Dr.Adriana Rodriguez,
Dr. Joanna Fava, Dr. Amber Kraft Nemeth, Dr. Tina Saha,
Ms. Mai Elkhoury, Dr. Teresa Lopez-Castro, Ms. McBee
Zimmerman, Ms. Sharon Becker, and Ms. Laurie Storm. In
addition, we wish to thank Drs. Denise Hien, Lisa Litt, Lisa
Cohen, Lesia Ruglass, and other colleagues at the City College
of NewYork who helped to advance this therapy.
Numerous project coordinators, research assistants, independent assessors, consultants, and colleagues have contributed to
this work. Our thanks go to Mr. Frank Beylotte, Mr. Andrew
Teer, Dr. Ron Acierno, Ms. Amanda Federline, Ms. Mary
Ashley Mercer, Dr. Jenna McCauley, Dr. Peter Tuerk and
Ms.Wendy Muzzy. We are also thankful to the following individuals for their input and collaboration:Drs. Sonya Norman
and Brittany Davis at the University of California, San Diego;
Dr.Markus Heilig at the National Institutes of Health; Dr.sa
Magnusson and Ms. Anna Persson in Stockholm, Sweden; and
Drs. Jennifer Potter and John D.Roache at the University of
Texas Health Science Center at San Antonio.
This work was funded by grants from the National Institute
on Drug Abuse (R01 DA030143; PI:Back) (R01 DA023187;
xiii
PI:Hien) (R01DA07761; 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
of PTSD and Substance
Use Disorders Using
Prolonged Exposure
(COPE)
CHAPTER1
Introductory Information
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.
Background Information and Purpose of This Program

What Is COPE?
COPE is a cognitive behavioral psychotherapy designed for use with
patients who have PTSD and a co-occurring alcohol and/or drug
use disorder. COPE represents an integration of two empirically supported, manual-based treatments. One of these treatments, developed
by Dr. Edna B. Foa, is a cognitive behavioral therapy for posttraumatic stress disorder (PTSD) called prolonged exposure (PE) (Foa,
Hembree, & Rothbaum, 2007). The other treatment, developed by
Dr.Kathleen Carroll, is a cognitive behavioral approach to treat substance use disorders (SUD) (Carroll, 1998; Kadden et al., 1992). COPE
is an integrated psychotherapy, which means that both PTSD and SUD
are addressed simultaneously in therapy by the same clinician. COPE
includes the following procedures:
Education about the relationship between PTSD and SUD;
Education about common reactions to trauma;
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, people, 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.
Why Was COPE Developed?

COPE was developed in response to the increased recognition that
individuals with PTSD/SUD comorbidity have unique needs and
demonstrate poorer treatment outcome in standard treatment (Back,
2010). Historically, the standard of care has been to treat the SUD
first and then treat the PTSD; this approach is known as the sequential model. If the patient follows up on PTSD treatment, a different clinician usually provides the treatment at a separate clinic, with
little provider cross-communication. Although the exact numbers
are unknown, many PTSD/SUD patients are likely lost in this process. Proponents of the sequential model state that continued substance use during therapy will impede therapeutic efforts and/or
that PTSD treatment may induce relapse (Nace, 1988; Pitman et al.,
1991). However, little empirical data exist to support these concerns.
On the contrary, accumulating research now shows that therapies based
on the integrated model, such as COPE, which address both PTSD
and SUD together in treatment, may also lead to significant improvements in PTSD symptoms, SUD severity, and associated problems (e.g.,
depression, physical health) (Back, 2010; Back et al., 2012; Brady etal.,
2001; Hien etal., 2010; Mills etal., 2012; Najavits etal., 1998, 2005;
Triffleman, 2000; van Dam, Vedel, Ehring, & Emmelkamp, 2012).
Concerns that PTSD/SUD patients who receive trauma-focused care

will experience an increase in substance use, relapse rates, and/or attrition 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 concurrent relief from PTSD symptoms will likely improve SUD outcomes
(Back, 2010; Brady etal., 2001; Hien etal., 2010; Ouimette etal., 1997).
Furthermore, a substantial proportion of PTSD/SUD patients indicate
that they would prefer to receive integrated treatment delivered by the
same clinician (Back etal., 2014; Back etal., 2006c; Brown, Stout&
Gannon-Rowley, 1998; Najavits, 2004).
Two studies highlight the centrality of PTSD improvement in the treatment of PTSD/SUD patients. Among 353 PTSD/SUD patients, Hien
etal. (2010) found that subjects who demonstrated improvements in
PTSD were significantly more likely to show subsequent improvements
in SUD symptoms, but the reciprocal relationship was not observed.
Only minimal evidence indicated that improvement in SUD symptoms results in improvement in PTSD. Rather, for every unit of PTSD
improvement made (as evidenced by the Clinician Administered PTSD
Scale), the odds of being a heavy substance user at follow-up decreased
by 4.6%. These findings show that if a PTSD/SUD patient can achieve
PTSD symptom reduction, he will likely also experience a reduction in
SUD symptoms. However, if only SUD symptom reduction is attained,
PTSD symptoms will likely remain. These findings are similar to those
reported in an earlier study examining temporal changes in improvement among 94 outpatients with PTSD and alcohol dependence (Back
etal., 2006a). Several other smaller studies have also observed this relationship (Back etal., 2006b; Brown, Stout,& Gannon-Rowley 1998;
c.f. Read, Brown,& Kahler, 2004). Taken together, the findings from
these studies show that co-occurring PTSD symptoms have a strong
impact on substance-related outcomes and that integrated interventions
that include critical elements of evidence-based treatment for PTSD
may be important in optimizing treatment for PTSD/SUD patients.
What Is the Main Goal of COPE?
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 alcohol and drug use, and to minimize the negative impact that PTSD and
SUD have on the patients life. COPE does not attempt to produce
personality changes or solve problems not directly related to PTSD
orSUD.
The substance use treatment component of COPE is designed to help
patients (1) recognize and effectively manage triggers for cravings,
including environmental, physical, cognitive, and emotional triggers;
(2)recognize and modify high-risk thoughts about using alcohol and
drugs; and (3)learn effective coping skills (e.g., drug refusal skills).
The PTSD treatment is designed to help patients understand the
interrelationship between PTSD and substance use and follows the
prolonged exposure (PE) manual, which includes education about
common reactions to trauma, and two exposure techniques:(1)imaginal exposure to the most upsetting traumatic memory, followed by
processing of the experience, and (2)in vivo exposure.
What Is Posttraumatic Stress Disorder?

Posttraumatic stress disorder (PTSD) is a chronic, debilitating psychiatric disorder that may develop after direct or indirect exposure
to a Criterion A event (Criterion A refers to the Diagnostic and
Statistical Manual of Mental Disorders [5th ed.; DSM-5] diagnostic
criteria; American Psychiatric Association, 2013). Criterion A events
involve exposure to actual or threatened death, serious injury, or sexual
violence. Such exposure may occur through directly experiencing an
event, witnessing an event, or through learning that a traumatic event
occurred to someone close, such as a family member. PTSD may result
from exposure to a single traumatic event (e.g., a single serious car accident or exposure to a single terrorist attack), or it may involve repeated
exposure (e.g., repeated child sexual abuse incidents, multiple combat
exposure over the course of deployment). Certain professionals may be
repeatedly exposed to aversive details of traumatic event(s) over their
course of their profession, such as first responders who collect human
remains, or police officers who are repeatedly exposed to details of child
4
sexual and physical abuse. Exposure through electronic media, television, 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).
PTSD is characterized by four symptom clusters:(1)intrusion, (2)avoidance, (3)negative cognitions and mood, and (4)alterations in arousal and
reactivity. Examples of intrusion symptoms include recurrent and distressing memories of the traumatic event, distressing dreams, and flashbacks in which the individual feels or acts as if the event is happening
again. When exposed to internal or external cues that resemble the traumatic event(s), the person may experience physiologic reactivity such as
increased heart rate and sweating. Avoidance symptoms include, for example, persistently avoiding thoughts about the trauma, conversations and
about the trauma, feelings associated with the trauma (e.g., fear), and
people, places, or activities that remind them of the trauma. Negative
alterations in cognitions and mood may include an inability to remember
important aspects of the traumatic event(s). This is typically due to dissociative amnesia and is not due to other factors such as substance use or
head injury. In addition, symptoms may involve persistent and exaggerated negative beliefs and expectations about oneself, others, or the world
(e.g., I am bad, No one can be trusted, The world is completely dangerous, My whole nervous system is permanently ruined). The person
may experience persistent negative emotional states (e.g., fear, horror,
anger, guilt, or shame) and may feel detached or estranged from others.
Finally, marked alterations in arousal and reactivity may involve irritable
behavior, angry outbursts (with little or no provocation), verbal or physical aggression toward people or objects, and reckless or self-destructive
behavior, including excessive substance use. The person may be hypervigilant and, for example, may constantly scan the environment for signs
of danger and only sit with his back toward the wall. Other examples of
marked alterations in arousal and reactivity include problems with concentration and trouble sleeping (e.g., difficulty falling or staying asleep or
restless sleep), as well as an exaggerated startle response.
The symptoms of PTSD must last more than one month; they must
cause clinically significant distress or impairment in social, occupational, or other important areas of functioning; and they must not
be attributable to substances or another medical condition. For more
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 experience at least one traumatic event in their life (Breslau, 2009; Elklit,
2002; Kessler, Sonnega, Bromet, Hughes,& Nelson, 1995; Mills etal.,
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 etal., 1998; Brunello etal., 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 2days after exposure
to the traumatic event and can last up to 1month. 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 soldiers heart, irritable heart, shell shock,
and combat neurosis (Sadock& Sadock, 2003).
Assessment of PTSD
Accurate assessment of PTSD is a critical first step in treatment planning. As part of the baseline or initial assessment, it is necessary to identify the index trauma (i.e., the trauma that causes the most distress and
is the primary focus of attention in treatment) and to find out additional
details about the index trauma to help plan the exposure sessions. It is
important to survey the types of traumas the patient has experienced in
addition to the index trauma. PTSD assessment should be conducted
after a patient has emerged from acute alcohol or drug intoxication and
withdrawal. See Wilson& Keane (2004) or McCauley etal. (2012) for

more information regarding assessment of trauma and PTSD.
We recommend using both interview and self-report instruments in the
assessment process.
Therapist Note
Once a PTSD diagnosis has been established, be sure to assess the patients
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. Agood
time to present the weekly scores to the patient is mid-treatment
(i.e., session6). 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:
PTSD Symptom Scale-Interview (PSS-I; Foa, Riggs, Dancu, &
Rothbaum, 1993; Foa& Tolin, 2000; Powers, Gillihan, Rosenfield,
Jerud,Foa, 2012);
Trauma Interview Form (Foa, Hembree,& Rothbaum, 2007), which
assesses trauma exposure and identifies the index trauma, patients
support system, suicide risk, and substance use;
Clinician-Administered PTSD Scale (CAPS; Blake et al., 1995),
which includes a Life Events Checklist of potentially traumatic
events to assess lifetime trauma exposure, and assesses frequency and
intensity of diagnostic PTSD symptoms related to traumatic events;
Structured Clinical Interview for DSM-IV (SCID; First et al.,
2002), a semi-structured interview designed to diagnose most Axis
Idisorders;
MINI International Neuropsychiatric Interview PTSD Module
(Sheehan etal., 1998), which also evaluates most major Axis Ipsychiatric disorders.
Self-Report Assessments
Recommended self-report assessment include:
Post Traumatic Stress Disorder Symptom ScaleSelf Report (PSS-SR;
Foa, Riggs, Dancu, Constance,& Rothbaum, 1993);
Impact of Events Scale-Revised (Creamer etal., 2003);
Posttraumatic Stress Diagnostic Scale (PDS; Foa, Cashman,
Jaycox& Perry, 1997).
Combat-Related Trauma
For combat-related trauma, we recommend:
PTSD Checklist-Military (PCL-M; Weathers etal., 1991);
Combat Exposure Scale (CES; Keane etal., 1989).
What Is a Substance Use Disorder?

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.
SUD are characterized by a loss of control over the substance use.
Symptoms include, for example, taking more of the substance than
intended; a persistent desire or unsuccessful efforts to cut down or control substance use; spending a lot of time obtaining, using, or recovering from the effects of a substance; experiencing a craving, strong desire,
or urge to use the substance; failure to fulfill major role obligations at
work, school, or home; continued use despite having problems caused
or exacerbated by using (e.g., arguments with spouse, legal problems,
medical or psychological problems); giving up important social, occupational, or recreational activities because of the substance use; recurrent use of substances in situations in which it is physically hazardous;
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 characteristic 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.
The severity of the SUD is rated as mild (23 symptoms), moderate
(45 symptoms), or severe (6 or more symptoms). Patients may be classified as being in early remission (312months during which none of
the SUD criteria other than cravings has been met) or sustained remission (12months or longer during which none of the SUD criteria other
than cravings has been met. For more information and for a complete
list of the diagnostic criteria for SUD, please refer to the Diagnostic
and Statistical Manual of Mental Disorders (5th ed., DSM-5) (American
Psychiatric Association, 2013).
Substance use disorders are among the most prevalent of all psychiatric
disorders (Merikangas etal., 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 etal., 2009; McKenzie etal., 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 etal., 2005). Furthermore,
examination of Veterans 1853years of age reveals a 12-month SUD
prevalence rate of 18.2%, which is almost five times as high as the general population (SAMHSA, 2007).
Assessment of Substance Use Disorders

As with PTSD, both interviewer and self-report forms (based on
DSM-IV diagnostic criteria) are recommended for a thorough
assessment of SUD. Share the results of both the initial and ongoing
symptom SUD assessments with the patient as part of the treatment.
Agood time to do this is mid-treatment (i.e., session 6)when you can
present, for example, a line graph of the patients substance use. Using
the Time Line Follow Back (TLFB) or other weekly assessment of substance use, therapists can chart the patients 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
In order to diagnose SUD, we recommend:
Structured Clinical Interview for DSM-IV (SCID; First etal., 2002);
MINI International Neuropsychiatric Interview PTSD Module
(Sheehan etal., 1998).
Self-Report Assessments
For self-report assessments we recommend:
Alcohol Use Disorders Identification Test (AUDIT; Babor et al.,
2001);
Drug Abuse Screening Test (DAST-10; Yudko, Lozhkina & Fouts
2007);
Time Line Follow Back (TLFB; Sobell& Sobell, 1992)to assess frequency and intensity of use.
Biopsychosocial Assessments
To assess the impact of SUD on a variety of biopsychosocial areas (e.g.,
medical, legal, psychiatric, social) we use the Addiction Severity Index
(ASI-Lite; Cacciola etal., 2007).
10
Therapist Note
During the course of the initial assessment:
Get additional information about substance use.
Find out when the patient first started using alcohol or drugs, what
his substance of choice is, how often and what substances he uses,
what type of substance abuse treatment he has received in the past and
what the outcome was, any family history of drug or alcohol abuse,
what his relationship status is and if any significant use of alcohol or
other drugs, and if he attends NA or AA meetings or has any other
additional supports in the community.
As with PTSD symptoms, it is critical to assess substance use periodically throughout the treatment (e.g., weekly self-report measure or the
TLFB) in order to monitor progress and guide treatment decisions.
How Often Do PTSD and Substances Use Disorders Co-occur?

Over the last 20years, evidence of the frequent co-occurrence of PTSD
and SUD, and the negative impact of this comorbidity on treatment
outcomes, has increased (Back & Brady, 2008, 2010; Brady et al.,
2001, 2009; Breslau etal., 2003:Hien etal., 2004; Mills, 2005a, 2007,
2009). Kessler and colleagues found that adults with PTSD were 2 to
4times more likely than those without PTSD to have a comorbid SUD
(Kessler etal., 1995). Similarly, data from the Australian National Survey
of Mental Health and Well-Being (N > 10,000) found that 34.4% of
respondents with PTSD had at least one SUD, with alcohol use disorders
being the most common (Mills etal., 2006). Among treatment-seeking
substance abusers, the prevalence of lifetime PTSD has been reported as
high as 50% or greater (Dansky, Brady,& Roberts, 1994; Dore etal.,
2012; Mills etal., 2005a; Triffleman, Marmar, Delucchi,& Ronfeldt,
1995; Torchalla etal., 2012). In the majority of cases, the development of
PTSD precedes the development of the SUD (Back etal., 2005, 2006b;
Breslau, Davis,& Schultz, 2003; Jacobsen, Southwick,& Kosten, 2001;
Stewart& Conrod, 2003), thereby lending support to the notion that
alcohol or drugs are used by patients to help diminish PTSD symptoms
(i.e., self-medication hypothesis; Khantzian, 1985).
11
Negative Impact of PTSD and SUD Comorbidity

In both civilian and veteran populations, research demonstrates a more
complicated clinical course and worse treatment outcomes in persons
with comorbid PTSD and SUD, as compared to persons with either
disorder alone (Back etal., 2000; Brady etal., 1998; Cottler etal., 1992;
Mills etal., 2007; Ouimette& Brown, 2003; Ruzek, 2003). Aseries
of associated problems are common, including medical issues, family
dysfunction, homelessness, HIV risk behaviors, and intimate partner
violence (Brady etal., 1998; Hien, 2009; Ouimette etal., 2006). Mills
and colleagues (2005) conducted the largest study to date of comorbid PTSD and SUD in a clinical setting (N = 615) and found that
individuals with, as compared to without, PTSD had more extensive
polydrug use histories, poorer physical and mental health, higher rates
of attempted suicide (48% lifetime), and more extensive health service
utilization.
PTSD/SUD Comorbidity Among Military Populations

In comparison to the general population, military personnel and
Veterans are at increased risk of developing both PTSD and SUD
(Hoge etal., 2004, 2006; Vasterling etal., 2008). Initial reports among
military personnel focused on Vietnam Veterans with PTSD, in which
64%84% met lifetime criteria for an alcohol use disorder (Keane&
Kaloupek, 1998). Amore recent study (Smith et al., 2008) of a large
military cohort (N = 50,184) found that personnel with problem
drinking had significantly higher odds of new onset PTSD following
deployment, as compared with personnel without problem drinking
(odds ratio 1.73). If left untreated, military personnel with SUD and/or
PTSD are at risk for other psychiatric problems (e.g., depression, sleep
disturbances), neuropsychological impairment, suicidal ideation and
attempts, physical health problems, increased mortality, reduced resiliency, unemployment, and family/couples impairment (Brady et al.,
2009; Marx etal., 2009; Pietrzak etal., 2009; Tanielian etal., 2008).
Veterans with comorbid PTSD and SUD tend to have both a longer
duration of substance use and more symptoms of substance dependence, and to undergo more episodes of substance abuse treatment
12
as compared to Veterans without dual diagnosis PTSD/SUD (Young

etal., 2005).
Prolonged Exposure
Prolonged exposure (PE) is a treatment program that has been shown to
be highly effective for the treatment of PTSD (Powers etal., 2010). To
date, there are over 30 published randomized controlled trials (RCTs)
on PE showing statistically and clinically significant improvement
in PTSD, including studies with Veterans (McNally, 2007; Schnurr
et al., 2007). PE was endorsed as the most appropriate form of psychotherapy to manage PTSD by the International Consensus group
on Depression and Anxiety (Ballenger et al., 2000). Moreover, the
Institute of Medicine (IOM) reviewed all published RCTs for PTSD
and the only modality of psychotherapy deemed by the IOM to have
sufficient empirical evidence to be considered effective in ameliorating
PTSD was exposure-based therapy (IOM, 2008). Thus, PE therapy is
the gold standard psychosocial treatment for PTSD.
Emotional Processing Theory

The conceptual backbone of PE is emotional processing theory, which
was developed by Foa and Kozak (1985, 1986) as a framework for
understanding the anxiety disorders and the mechanisms underlying
exposure therapy. The starting point of emotional processing theory
is the notion that fear is represented in memory as a cognitive structure. This fear structure includes representations of the feared stimuli
(e.g., bear), the fear responses (e.g., heart rate acceleration), the meaning associated with the stimuli (e.g., bears are dangerous), and the
responses to the stimuli (e.g., fast heartbeat means Iam afraid). When
a fear structure represents a realistic threat, we refer to it as a normal
fear that acts as a template for effective action to threat. Thus, feeling fear or terror in the presence of a bear and acting to escape are
appropriate responses and can be seen as normal and adaptive fear
reactions.
13
According to Foa and Kozak (1986), a fear structure becomes

pathologicalwhen
1. Associations among stimulus elements do not accurately represent
the world;
2. Physiological and escape/avoidance responses are evoked by harmless stimuli;
3. Excessive and easily triggered response elements interfere with adaptive behavior; and
4. Harmless stimulus and response elements are erroneously associated
with threat meaning.
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.
How Prolonged Exposure Works

According to Foa and Kozak, two conditions are necessary for successful modification of a pathological fear structure, and thereby amelioration of the anxiety symptoms.
1. The fear structure must be activated, otherwise it is not available for
modifications;
2. New information that is incompatible with the erroneous information embedded in the fear structure must be available and incorporated into the fear structure. When this occurs, information that
previously evoked fear and anxiety symptoms will no longer do so.
Deliberate, systematic confrontation with stimuli (e.g., situations,
objects) that are feared despite being safe or having low probability
of producing harm meets these two conditions. How so? Exposure to
feared stimuli results in the activation of the relevant fear structure
and at the same time provides realistic information about the likelihood and the cost of feared consequences. In addition to the fear
of external threat (e.g., being attacked again), the person may have
14
erroneous cognitions about anxiety itself that are disconfirmed during 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 reduction. 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 behavioral 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).
PTSD and Trauma

According to emotional processing theory, the fear structure underlying PTSD is characterized by a particularly large number of stimulus
elements that are erroneously associated with the meaning of danger, as
well as representations of physiological arousal and of behavioral reactions that are reflected in the symptoms of PTSD. Because of the large
number of stimuli that are perceived as dangerous, individuals with
PTSD may perceive the world as entirely dangerous. In addition, representations of how the person behaved during the trauma, her subsequent symptoms, and negative interpretation of the PTSD symptoms
are associated with the meaning of self-incompetence. These two broad
sets of negative cognitions (The world is entirely dangerous and I am
completely incompetent to cope with it) further promote the severity
of PTSD symptoms, which in turn reinforce the erroneous cognitions
(for more details, see Zalta et al., 2014).
Trauma survivors narratives of their trauma have been characterized
as being fragmented and disorganized. Foa and Riggs (1993) proposed
that the disorganization of trauma memories is the result of several
mechanisms known to interfere with the processing of information that
is encoded under conditions of intense distress. Consistent with hypotheses that PTSD would be associated with a disorganized memory for
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 organization was associated with reduced depression.
As noted earlier, high levels of PTSD symptoms are common immediately following a traumatic event, but most individuals will show a
decline in their symptoms over time. However, a significant minority
of trauma survivors fail to recover and continue to suffer from PTSD
symptoms for years. Foa and Cahill (2001) proposed that natural
recovery results from emotional processing that occurs in the course
of daily life. This process occurs through repeated activation of the
trauma memory, and engagement with trauma-related thoughts and
feelings and sharing them with others, and approaching safe situations
that serve as reminders of the trauma. In the absence of additional traumas, these natural exposures contain information that disconfirms the
common post-trauma perception that the world is a dangerous place
and that the person is incompetent. In addition, talking about the event
with supportive others and thinking about it help the survivor organize
the memory in a meaningful way.
Why, then, do some trauma victims go on to develop PTSD? Within
the framework of emotional processing theory, the development and
maintenance of PTSD is conceptualized as a failure to adequately
process the traumatic memory because of extensive avoidance of
trauma reminders. Accordingly, therapy for PTSD should promote
approaching safe trauma reminders and engaging in emotional processing. Paralleling natural recovery, PE for the treatment of PTSD is
assumed to work through (1)activation of the fear structure, by the
patients deliberately approaching trauma-related thoughts, images,
and situations via imaginal and in vivo exposure, and (2)corrective
learning that their perceptions about themselves and the world are
inaccurate.
16
How Prolonged Exposure Reduces PTSD Symptoms

How does PE lead to improvement in PTSD symptoms? Avoidance
of trauma memories and related reminders is maintained through the
process of negative reinforcement, that is, through the reduction of
anxiety in the short run. In the long run, however, avoidance maintains
trauma-related fear by impeding emotional processing. By approaching
trauma memories and reminders, PE reduces the habit of diminishing distress via cognitive and behavioral avoidance, thereby reducing
one of the primary factors that maintains PTSD. Another mechanism
involved in emotional processing is habituation of anxiety, which disconfirms erroneous beliefs that anxiety will last forever or will diminish
only upon escape. Patients also learn that they can tolerate their symptoms and that having them does not result in going crazy or losing
control, -fears commonly held by individuals with PTSD.
Imaginal exposure followed by processing (discussing) the imaginal
experience and in vivo exposure also help patients to differentiate the
traumatic event from other similar but non-dangerous events. This
allows them to see the trauma as a specific event occurring in space and
time, which helps to refute their perception that the world is entirely
dangerous and that they are completely incompetent. Importantly,
PTSD patients often report that thinking about the traumatic event
feels to them as if it is happening right now. Repeated imaginal exposure to the trauma memory promotes discrimination between the past
and present by helping patients realize that remembering the trauma
is not the same as being in the trauma again, and therefore, thinking about the event is not dangerous. Repeatedly revisiting the trauma
memory also provides the patient with the opportunity to accurately
evaluate aspects of the event that are actually contrary to their beliefs
about danger and self-incompetence that may otherwise be overshadowed by the more salient threat-related elements of the memory. For
example, individuals who feel guilty about not having done more to
resist an assailant may come to the realization that the assault likely
would have been more severe had they resisted. All of these changes
reduce PTSD symptoms and bring about an increased sense of mastery
and competence. The corrective information that is provided via imaginal and in vivo exposure is further elaborated during the processing
part of the session that follows the imaginal exposure.
17
How Is COPE Different From Existing Integrated Therapies?

Several integrated treatments for PTSD/SUD patients have been developed. The most widely researched thus far is Seeking Safety (SS;
Najavits, 2002), a 25-session psychotherapy that provides psychoeducation and coping skills training to help individuals gain more control
over their lives. SS was originally designed for women with PTSD and
to focus on healing from the effects of childhood physical and sexual
abuse (Najavits, 1998). In contrast to COPE, SS does not include imaginal or in vivo exposure therapy techniques. SS has been shown to
lead to improvements in PTSD and SUD symptoms, but the question
of whether patients evidence better outcomes after receiving SS versus
a non-integrated therapy that only targets the SUD is unclear (Hien
etal., 2004, 2009).
To date, six investigations have examined the integrated use of PE
techniques among SUD patients with civilian and combat-related
traumas (Back et al., 2012; Brady et al., 2001; Coffey, Stasiewicz,
Hughes & Brimo, 2006; Mills et al., 2012; Najavitz et al., 2005;
Triffleman et al., 1999). The findings demonstrate that addressing
PTSD among SUD patients via exposure-based techniques results
in significant improvements in substance use severity, PTSD symptomatology, and global functioning. Triffleman and colleagues
(1999, 2000) first applied in vivo exposure to civilian PTSD/SUD
patients. Substance Dependence Posttraumatic Stress Disorder
Therapy (SDPT) is a 40-session treatment that utilizes relapse prevention, coping skills, and in vivo exposure. In a pilot trial (N=19)
with methadone-maintained, cocaine-dependent subjects, SDPT was
contrasted to twelve-step facilitation therapy and was found to be
equivalent with regard to improvements in drug use and PTSD. Of
relevance, SDPT does not include imaginal exposure. In an uncontrolled pilot study (N=5), Najavits etal. (2005) examined the use of
adding imaginal exposure to SS and found that it resulted in significant reductions in PTSD and SUD symptoms. In vivo exposure was
not included in that study. In addition, Coffey et al. (2006) examined the use of adding imaginal exposure to treatment-as-usual for
SUD among 43 outpatients and found positive results. Notably, no
psychotherapy treatments other than COPE have been developed that
18
incorporate both key elements of PE:(1)imaginal exposure followed

by emotional processing, and (2)invivo exposure techniques.
Which Patients Should Be Considered for COPE?

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 recommend that COPE be considered for usewith:
Individuals with current PTSD. The COPE treatment has been
designed for use with those who meet diagnostic criteria for PTSD.
The program may also be useful, however, for individuals with subsyndromal PTSD, where the person exhibits significant symptoms
of PTSD (in particular avoidance and re-experiencing symptoms)
that are distressing and interfering with his life.
Individuals with sufficient memory of the traumatic event(s). Trauma
memories are often fragmented, and often some parts of the memory
cannot be fully remembered. The patients ability to describe the traumatic event is vital to the treatment. Ideally, the narrative would have
enough details and have a beginning, middle, and end. However, PE
has been shown to be effective with short and fragmented memories,
which often occur when the trauma was child sexual abuse.
Individuals with a substance use disorder. This treatment targets
patients who are experiencing significant misuse or have an alcohol
or drug use disorder within the past year.
A large percentage of PTSD/SUD patients present with multiple comorbid problems (e.g., major depression, other anxiety disorders, high levels of anger or shame, Axis II symptoms). We have found that these
patients can also benefit from COPE and should not be excluded. The
related symptomatology, however, should not be the primary diagnosis.
Which Patients Should Not Be Considered for COPE?

COPE is not recommended if the following comorbidities or problems
are present. Instead, these problems should take priority in the clinical
19
intervention, and COPE should not be implemented until after such

intervention has occurred and the condition is stabilized:
Imminent threat of suicidal or homicidal behavior. While current suicidal ideation and history of suicide gestures or attempts are common in PTSD/SUD patients, if the person is currently at risk for
acting on these impulses, the suicidal or homicidal behavior requires
immediate clinical attention. Asustained period of stabilization (e.g.,
6months) and a written commitment (safety contract) by the patient
not to harm himself during treatment would be necessary prior to
initiation of COPE or any other trauma-focused treatment. It is
important to gather data on previous attempts (e.g., how long ago,
lethality of attempt, treatment following attempt) and the context in
which they occurred (e.g., during times of abstinence, when trauma
symptoms were triggered), and to involve significant others when
appropriate.
Therapist Note
If a patient expresses suicidal ideation at the initial assessment, or any
other time during the course of treatment, it will be critical that you
assess intent, plan, means, and ability to contract for safety on a regular
basis (e.g., weekly, each session) in order to monitor the patients safety
and for treatment planning purposes.
Serious self-injurious behavior. If self-injurious behaviors, such as cutting or burning or otherwise deliberately injuring herself, are currently active, COPE should be deferred until the person has acquired
skills or tools to manage these impulses without acting on them.
We recommend a period of at least 3months with no self-injurious
behavior. During treatment, therapists tell patients that they may
have urges to harm themselves but that is not an option during COPE
treatment, as they need to learn that they can tolerate negative emotions without efforts to avoid, escape, or distract in unhealthy ways,
including using substances.
Ongoing domestic violence. Many of our patients have lived in dangerous environments that carry a significant risk of negative events
and were successfully treated with COPE. But if the patient is currently in a living situation in which there is ongoing abuse or domestic violence of high magnitude, this matter should be the focus of
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 memories. 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 significantly reduce alcohol or drug use, COPE should be deferred.
Amotivational 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 reducing substance use. Patients should be expected to demonstrate some
level of clinically significant improvement in frequency and/or intensity 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.
With regard to alcohol use, we encourage clinicians to use 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 Figure 1.1).
The recommended levels are different for men and women because
research shows that women develop more severe alcohol-related problems 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 womans blood
21
Figure1.1
NIAAA Guidelines for Low-Risk Drinking.
Reprinted from National Institutes of Health, Rethinking Drinking:Alcohol and Your Health (2010).
alcohol concentration will likely be higher, putting her at greater risk

for harm.
Note that the NIAAA guidelines are for low-risk, not no-risk, drinking. 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 cuttingdown).
Current psychosis. COPE has not been systematically studied with
this population and is not recommended for individuals with current
psychosis.
Medical emergencies. Depending on the patients level of substance
use, medically supervised detoxification or other medical emergencies may need to be addressed and stabilized before the patient begins
this program. Clinicians should determine this during the first session. Ask whether the patient has a history of detox, seizures, or delirium tremens. Assess whether the patient experiences physiological
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.
In addition to these exclusionary criteria, another commonly encountered issue to consider in determining whether to offer COPE therapy
is comorbid dissociative disorder. Clinicians sometimes express reservations about using exposure therapy to treat patients with severe dissociative symptoms or disorders due to concern that the exposure will
increase their dissociation. In considering whether to use COPE with
such patients, we recommend that the therapist consider the severity
of the dissociative symptoms relative to the PTSD. If the patients dissociation experiences outweigh the PTSD-related symptoms in severity and in degree of interference, effective implementation of PE may
not be possible, and the patient may not be able to benefit from the
treatment. In such cases, as when other disorders are of primary clinical importance (i.e., severe depression with suicidal risk), the more
severe or life-threatening disorder should take precedence in clinical
intervention.
In summary, individuals with PTSD presenting with all types
of trauma, who have a relatively clear memory of their traumatic
experience(s) and a desire to abstain from or significantly reduce their
use of alcohol and/or drugs, are good candidates for COPE. If medically supervised detoxification is required, patients need to first obtain
detox and be stabilized before beginning this COPE therapy.
Studies show that PE reduces depression, anxiety, guilt, and anger as
well as PTSD, so its use is warranted in patients with complex trauma
histories and complicated clinical presentations. Comorbidity of other
Axis I and Axis II disorders, as well as multiple life difficulties (e.g.,
unemployment, financial difficulties, chronic health problems, relationship and family troubles, social isolation) are extremely common
among PTSD/SUD patients, and COPE has been used successfully in
the presence of these problems.
23
Therapist Note
In general, we recommend that if another disorder or problem is present
that is life-threatening or otherwise clearly of primary clinical importance, it should be treated and stabilized prior to initiation of this
treatment.
24
CHAPTER2
Outline of This Treatment

Program
COPE is composed of 12 individual, 90-minute sessions that are

designed to be delivered once a week. Once a week, as compared to
twice a week, is optimal as it allows the patient time to practice skills
between sessions and to engage in the in vivo and imaginal exposure
exercises. This Therapist Guide is divided into chapters that provide
information about how to conduct each session and suggestions for
ways to present the material to the patient. The italicized text in the
manual is meant to serve as a guide for the therapist when presenting the
material to the patient. It is not meant to be used verbatim. Read and
study the material before each session, and then make it your own. Do
not read the material from the manual during the sessions. Practice
with a friend or colleague in order to develop mastery over the material before a session with a patient. Maintain good eye contact with the
patient when delivering the material. Use a natural, free-flowing style
and use open-ended questions to engage the patient whenever possible.
The sessions are ordered in a wayto accomplish the following:
1. Provide psychoeducation around the relationship between PTSD
and SUD;
2. Provide the patient with some SUD coping skills to manage cravings and high-risk thoughts and situations;
3. Participate in imaginal and in vivo exposures for PTSD; and
4. Address the PTSD and SUD in an integrated fashion throughout.
All of the material in each session does not necessarily have to be discussed. Rushing to cover everything may send the message that the
therapists agenda of adhering strictly to the manual is more important than the issues and concerns that constitute the patients 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 patients
presenting PTSD and SUD symptoms. For example, if a patient is struggling with anger-related problems, move the content on anger from sessions 10 and 11 so that it is covered sooner during the course of therapy.
Each session should be recorded for the patient to review as part of
the homework between sessions. Use an audio recording, as opposed to
a video recording, as the latter may be too distracting for patients who
may end up criticizing themselves for how they look on camera, their
mannerisms, and so on. Beginning in session 4, two recordings will
be needed in each session:
1. The imaginal exposure portion of the session and the processing
discussion that follows the imaginal exposure will be recorded alone
and the patient is assigned to listen to this once every day;
2. The other recording contains everything up to the onset of imaginal
exposure and everything following the processing discussion. The
patient will listen to this recording at least once between sessions.
We cannot overemphasize the importance of building a good foundation for treatment that is based on a strong therapeutic alliance and a
clear and compelling rationale for treatment. Implementing a manualized treatment like COPE while at the same time providing empathy
and support and consistent attention to the therapeutic alliance takes
practice. Following treatment manuals is sometimes misconceived as
dehumanizing the therapy process; tailoring the interventions of a treatment manual to the individual patient while simultaneously being a
therapist requires practice and skill.
26
Session Structure
Each session consists of the following elements:
Review Current PTSD Symptoms and Any Substance

Use Since Last Session
Monitoring patients progress throughout treatment is critical. This is
accomplished in part by having the patient complete assessments of
PTSD symptoms and substance use before each session. The therapist
should review these forms at the beginning of each session, allowing the
therapist to closely monitor the patients symptoms and progress.
Review Homework
Homework is a powerful part of this treatment, because real-life situations can be utilized for practice, enhancing the likelihood that these
behaviors will be repeated in similar situations (generalization). Apreplanned homework exercise has been designed for each session of this
program. If necessary, however, homework exercises can be modified to
fit the specific details of individual situations more closely.
Focus on Trauma and PTSD

Spend 4560 minutes on trauma and PTSD-related issues. Do not
spend large amounts of time lecturing to patients; instead make the
session more interactive by soliciting input and reactions from patients.
Doing so will engage their interest and prevent them from tuning out.
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 exercises. Furthermore, ending the session with the SUD material will naturally 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.
Focus on Substance Abuse

Spend about 30 minutes each session on substance abuse issues. As
mentioned earlier, do not lecture to patients, but rather engage them in
a discussion and utilize the patients own examples.
It is important that a substantial portion of every session (e.g., 30
minutes) is devoted to the patients SUD, even if the patient has
been abstinent from substances for a while. It is sometimes easier to
see improvements in SUD symptoms before improvements in PTSD.
For example, patients will often stop using substances or they will significantly decrease the frequency of substance use before significant
decreases in re-experiencing and avoidance symptoms are observed.
However, expect that the patient is still struggling internally with cravings, thoughts about using, ambivalence about quitting or reducing
use, and knowing how to effectively refuse substances. Note that early
remission (APA, 2013)is defined as at least 3months (but no more
than 12months) without meeting any SUD criteria (other than cravings). Sustained remission is defined as at least 12months without
meeting any SUD criteria (other than craving). Thus, the SUD problem requires significant attention at each session, even for patients who
have not used in several months, in order to maintain gains and/or
prevent a lapse or relapse.
Patients with SUD may, understandably, prefer to avoid talking about
their use or their thoughts about using. They may feel embarrassed
or shameful about their lack of control over the substance use. They
may try to convince themselves and the therapist that the SUD issue is
under control and not a problem. Patients may become overconfident with regard to SUD, which places them and their recovery at risk.
Patients may also deny that they have any cravings or desire to use ever
again. They may insist that their will power is strong and they have
made up their mind not to use. The therapist can normalize this, label it
as a common high-risk pattern of thinking (e.g., being overconfident),
28
and emphasize the importance of being smart versus being strong.

In order to be successful with recovery from SUD, its 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 ones will power. While the
patient may have made important gains in substance use, its 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
It is important to note that by the time most patients seek treatment,
they have been struggling with the SUD for a while, sometimes for
many years, and numerous triggers and associations with substance use
have been established during that time. Some of these triggers will be
trauma-related, but others may not be. Non-trauma-related triggers
(e.g., holidays, work-related stress, relationship stress, bars or nightclubs,
family reunions, weddings) need to be evaluated and addressed during
the treatment, as well.
Assign Homework
Compliance with homework is often a problem in therapy in general,
and the therapist will need to be unrelenting in the pursuit to encourage patients to complete the homework and help them understand why
it is so important. Anumber of steps are taken to foster compliance:
While some patients are fine with the term homework, others
do not respond well to this term. Therefore, refer to the homework
using the patients preferred label, for example, assignment, task,
exercise, and so on.
When giving each assignment, provide a clear rationale and description of the assignment. Ask the patient what problems can be foreseen 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 listen 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 learning. Were trying to break the cycle of using substances to cope with
anxiety and distress.
As the therapist, be sure to stay on top of the patients homework. Check
it at the beginning of every session. If the patient did not complete an
assignment, or the assignment was completed under the influence of
alcohol/drugs, discuss what could be done to ensure compliance with
the next assignment. Having extra copies of the homework forms available in the therapy room can also be helpful, so if a patient did not complete it or forgets to bring it, the therapist can then review the form with
the patient in session. The patient can complete it partially in session,
and the patient can assign the rest as homework for the next session. The
therapist may have to review the issue of homework non-compliance
several times during the course of therapy. Keep at it, kindly, and do not
give up on the patient. Do not assume that the patient just wont do it.
Therapist Note
If part of a research study, retain a copy of the patients completed forms.
Tell the patient in advance that the weekly practice exercise forms will be
collected, as this may reinforce the value of the assignments.
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 patients life is disorganized (internally and externally)having 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.
Who Can Deliver COPE?

The implementation of COPE requires a moderate level of clinical
skill and should only be applied by persons with graduate training in
psychology/psychiatry (e.g., MD, PhD, MA, MSW), formal training
in the delivery of CBT and PE, and adequate ongoing supervision.
Therapists must have good interpersonal skills, must be comfortable
hearing the details of traumatic events, and must be familiar with the
material so as to impart skills successfully and serve as credible models. Clinicians must fully understand the general rationale of how prolonged exposure reduces PTSD, how imaginal exposure helps organize
and process the traumatic memories, and how in vivo exposure helps
regain a more realistic view of the world. The therapist must be able
to explain the rationale in a manner that is well understood by the
patients. Patients who have confidence in the clinicians knowledge and
expertise of the therapy are more likely to do well in treatment. COPE
should not be administered by anyone who has not received specific
training in these techniques or does not have appropriate supervision
and ongoing support. Reading the manuals of PE (Foa, Hembree,&
Rothbaum, 2007)and SUD (Carroll, 1998)may be useful.
The Role of Medications

While psychotherapy is considered the first line of treatment for PTSD,
patients with PTSD and comorbid SUD often enter treatment already
taking a psychotherapeutic medication. We have no reason to think
that concurrent medication treatment hinders the process or outcome
of COPE. While it is beyond the scope of this Therapist Guide to review
pharmacotherapy for PTSD, we will mention that selective serotonin
reuptake inhibitors (SSRIs) and selective serotonin-norepinephrine
reuptake inhibitors (SNRIs) are considered first-line pharmacological
treatment for PTSD (Jeffreys, Capehart,& Friedman, 2012). Moreover,
the only medications to date to receive indications for the treatment of
31
PTSD from the US Food and Drug Administration are two SSRIs:sertraline (Zoloft) and paroxetine (Paxil). Anumber of randomized controlled 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 etal., 2012). SSRIs are also considered 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.
Some patients may also present to treatment taking a psychotherapeutic medication for SUD. Medications such as naltrexone and acamprosate can be beneficial in reducing cravings. Such medications can
help stabilize the SUD and can be an important adjunct to the COPE
therapy. However, some medications such as anxiolytics or sedatives,
which are often used in detoxification, may impair the patients ability
to process trauma experiences. Adjunctive pharmacotherapy should be
discussed with a treatment team and managed on a case-by-case basis.
Tips for the Therapist:How Do You Care for Yourself?

Our experiences as therapists, trainers, and supervisors have taught us
that even experienced therapists are at times concerned about using PE
procedures with substance abusing patients. As any therapist who has
listened to a painful and horrifying experience can attest, helping a
patient to emotionally process traumatic events can be emotionally difficult and particularly challenging with the first few patients. In order
to conduct this treatment, therapists need to develop or increase their
own tolerance for patient distress. The exposure procedures can trigger
distress in the patient for the first few sessions, as this is the purpose of
the work. How can you cope with this reaction in your patient?
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

Istop the imaginal exposure now because the patient is upset? What
if this makes my patient more depressed? Should Inot do the imaginal exposure this session because the patient had a lapse and consumed 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 processing 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.
Supervision with an expert or consultation with peers can be beneficial
and can provide ongoing technical and emotional support. Ideally, you
should have a team or supervision group that meets weekly to discuss
PTSD/SUD cases. Regular consultation provides opportunities for
input from colleagues regarding difficult decisions about how to proceed with complex and challenging cases.
Finally, as much as possible, engage in pleasant and healthy activities
each week (e.g., exercise, spending time with friends, traveling, reading
a good book) and be sure that you are taking good care of yourself (e.g.,
eating well, getting sufficient rest) so that you will be less vulnerable to
burn out and can be more fully available to help your patients complete the treatment.
Special Considerations in Treating PTSD and Substance Use Disorders

The following are some guidelines for enhancing the therapeutic relationship 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 patients 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 giving up and dropping out. Atherapists 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.
Adopt a Nonjudgmental Attitude

It is highly likely that the patients you will see have been subjected to
judgmental attitudes with regard to their trauma history and their substance 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 careful 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.
Emphasize the Collaborative Nature of the Treatment

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 important 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
Avoidance is a hallmark of both PTSD and it is a huge part of SUD.
Expect that patients will struggle with urges to avoid coming to or
engaging in therapy. Address this issue with patients from the onset.
Normalize avoidance and encourage patients to be watchful for signs of
avoidant thoughts or behaviors that might hinder their success. It may
be necessary to revisit this issue during therapy if avoidance struggles
become obstacles to successful treatment (e.g., they no-show or arrive
late for sessions, continue to use alcohol and/or drugs to self-medicate
PTSD symptoms, are non-compliant with the homework, refuse to do
imaginal exposures).
Display a Comfortable Attitude When Hearing about the

Trauma and Substance Use
Before assessing the patients trauma history, seek her permission to
ask about traumatic experiences. Advise the patient that she may share
as much or as little detail about the trauma(s) as she feels comfortable
with at this time. Clearly communicate the reasons for asking about
past trauma. It may not be readily apparent to the patient that her
current situation may be related to her past trauma exposure. Advise
the patient of any restrictions on confidentiality (e.g., mandated child
abuse reporting).
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 boundaries 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 listening to it, especially the gruesome or horrific details. Military personnel 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 patients 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.
The therapist should also display a comfortable attitude when the
patients share detailed information about their substance use. Let them
know they can share openly and honestly throughout the treatment
and that you will not be shocked by their substance use or judge them.
Do not refer to such behavior as bad. Use the specific terms they use
to refer to their substance use (e.g., weed, dope, crack) as opposed to
generic substance use.
Normalize the Patients Response to the Trauma

andValidate Their Experiences
Many individuals with PTSD feel that they are going crazy, and merely
hearing from a mental health professional that the reactions they are experiencing 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.
Create a Safe and Welcoming Environment

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 sudden movements or to invade their physical space. Slow, calm movements are best. The more spacious the therapy room, the better. This
will help patients feel less confined and help them to relax more.
Be Prepared to Handle Discussion of Patients Recent Problems

PTSD/SUD patients often experience numerous life stressors that they
want to focus on, but doing so may interfere with completion of session
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 510 minutes at the end of the session to discuss these problems when they arise. These discussions should be structured 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.
There is sometimes a conflict between the desire of patients to get
help with their immediate problems and the desire of the therapist to
get on with the session agenda. Patients must be reminded that this
time-limited therapy cannot always explore problems to the point of
complete resolution. This treatment will not solve all of the patients
problems; however, if the therapist can help patients to significantly
reduce their PTSD and substance use severity, the patients will be in
a much better place to deal with these other problems in their lives.
Discuss whether additional treatment is needed, or if participation in
the program is in the patients best interest.
Preventing Attrition
For many reasons, attrition rates among PTSD/SUD patient populations are high. In the first session, it is important to anticipate potential
obstacles to successful treatment, especially factors that may lead to
early attrition. Explore any instances in which the patient previously
dropped out of treatment and advise her to discuss any thoughts of
quitting treatment with you before doing so. Such thoughts are not
uncommon, and open discussion can resolve problems before patients
drop out. Progress in treatment is not steady; ups and downs and
typical.
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.
Alcohol and Drug Use

Praising patients for their resilience in the face of adversity is important,
even if past adaptations and ways of coping are now causing problems
(e.g., substance abuse). Understanding substance abuse as a learned
response helps reduce patients guilt and shame, and provides a framework for learning and developing new skills to better cope with symptoms (Elliot, 2005; Mills etal., 2009).
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 cravings or fears of relapse that they experience. Tell patients that it is common 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 consequences 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 reassure 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 session in order to prevent attrition.
Checking In With the Patient During Sessions

It is important that the patient summarize her understanding of critical points of this therapy (e.g., rationale for treating both PTSD and
SUD concurrently, rationale for using in vivo exposure and imaginal
exposure, how in vivo and imaginal exposure work, how avoidance
prolongs healing from PTSD, how alcohol and/or drug use prolong
healing from PTSD). The therapist may encourage this by stopping
during sessions and asking questions, such as, How does the distress
thermometer work? or Why do you actually have to practice in vivo
exercises several times? or Why do we not stop the exposure if we
see that your anxiety is increasing? Simple phrasing, in the patients
own words, is geared to ensure a deeper understanding. When asking for summaries during the sessions, be careful not to present these
summaries as quizzes but rather as checks on how the teamwork
is going. For example, the therapist might say, I want to be sure
Iclearly explained this as its very important that we are on the same
page about it. Could you please tell me your understanding of what
we just discussed?
39
Involving Significant Others

Most of our patients have disrupted interpersonal relationships and do
not have anyone they can or would like to involve in their treatment.
However, if they do, it is an opportunity to engage and bolster the
patients social support network. While it is not necessary for significant others to be included in order for the treatment program to be
beneficial, including a family member or loved one can be useful in the
followingways:
Helping the significant other understand what PTSD is;
Helping the significant other understand what an SUD is;
Increasing the significant others appreciation of how PTSD and
SUD are related, and how using substances is a way that his or her
loved one has learned to cope with distress;
Increasing the significant others understanding of what triggers or
aggravates the patients PTSD symptoms and substance use;
Helping reduce substance use cues in the environment (e.g., removing all alcohol or drug paraphernalia from the home);
Enlisting the significant others support in the patients effort to participate fully in treatment and complete the program;
Emphasizing the importance of giving the patient the space and time
needed each day to complete the homework assignments;
Providing suggestions to the significant other for ways to take good
care of him- or herself while their loved one is in treatment.
In the accompanying patient workbook, there are handouts of psychoeducational material and tips for significant others. This information is
designed to help significant others be supportive of the patients efforts
to engage in and complete the treatment. In some cases, it may be useful for the therapist to meet with significant others to discuss this information and ways they can support the patient during the program.
Summary
Do:
Display confidence in the treatment and the patients ability to
dowell.
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 patients response to the trauma and validate his
feelings.
Praise the patient for having the courage to work on PTSD and substance use problems.
Work with the patient to minimize attrition.
Maximize opportunities for patient choice and control over treatment processes.
Monitor the patients PTSD and SUD symptoms at every visit.
Monitor homework compliance at every visit.
Dont:
Judge the patient in relation to the trauma or substance use.
Encourage the patient to wait until later or another session to talk
about the trauma.
Read from the Therapist Guide or lecture to the patient during
session.
Let homework non-compliance continue. Work with the patient to
problem-solve and reinforce the importance of homework.
Engage in confrontational therapeutic techniques.
Be afraid to seek assistance.
Alternative Treatments
At present, there are several integrated treatments available for patients
with PTSD and SUD. For a review, please refer to McCauley et al.
(2012), van Dam etal. (2012), and Torchalla etal. (2012).
Use of the Patient Workbook

The patient workbook will assist you in effectively delivering this treatment, will aid in transferring knowledge from the therapy room to the
patients 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
CHAPTER3
Session 1: Introduction
toCOPE
(Corresponds to Chapter3 of the Patient Workbook)
MATERIALS NEEDED
COPE Program Treatment Contract (Form 1 at the end of the
Patient Workbook)
Breathing Retraining (Form 2 at the end of the Patient Workbook)
Information for Significant Others (Forms 3, 4, and 5 at the end of
the Patient Workbook)
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
Give the patient an overview of the structure of the treatment, cover
confidentiality issues, and review the PTSD and SUD treatment
components.
43
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 411).
I am really glad that you have chosen to come to treatment. Today is our
first session together, and Iwould 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.
The treatment consists of 12 sessions. Each session lasts about 90 minutes.
We ll meet once a week, so the therapy will be completed in about 3months.
We will be talking about sensitive information, and Iwant you to know
that we can go at your pace, and that what you share with me will remain
confidential. The only two exceptions would be (1)if you were a harm to
yourself or someone else or (2)if there was any suspected child abuse. In
these situations, Imay have to breach confidentiality to make sure everyone
is safe.
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 wanting 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.
44
Sometimes after getting about halfway through the treatment, patients

start to feel better and decide they dont need to keep coming to sessions.
However, Iwant you to think of this treatment as being similar to a regimen 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 its a 10-day course of antibiotics? Thats 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 treatment. Thus, Ihope you ll stick with it for the 12 sessions. Iam here to work
with you and help you through this in any way that Ican.
Do you have any questions? Feel free to ask me questions at any time.
PTSD Treatment Component Discussion

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.
A major factor in being stuck with PTSD symptoms is avoidance. People
with PTSD tend to avoid in two ways. The first is trying to push away
memories, thoughts, and feelings about the trauma. The second is by avoiding situations, places, people, and objects that cause distress and fear because
they remind the person of the trauma. While the strategy of avoiding might
reduce distress in the short term, it prolongs the PTSD symptoms and prevents you from moving on.
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 systematic way. The treatment includes two types of exposures. The first one is
called imaginal exposure, in which Iwill ask you to revisit the memory of
the trauma during your therapy sessions with me. This will help you process
45
and digest what happened. We have found that repeated and prolonged
(3045 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. Iwill work with you
so that you can gradually approach situations that you have been avoiding 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 effective 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.
However, if you approach these situations in a gradual, systematic way, you
will find that they are not actually dangerous, that you can handle them,
and that your anxiety will diminish with repeated, prolonged exposures.
This is the way that we naturally conquer our fearsby approaching them
and practicing them over and over again. Iwant to assure you that Iwill
not be asking you to approach any dangerous situationsonly those that
are safe.
Does the idea of exposure make sense to you?
In addition to avoidance, a second factor that maintains your PTSD
symptoms is the presence of unhelpful thoughts and beliefs. These beliefs
may be about the world in general, other people, yourself, or your reaction
to the trauma. As a result of trauma, many people adopt the belief that
the entire world is extremely dangerous. Therefore, even safe situations
are viewed as dangerous. Veterans who return home after a war can have
a difficult time adjusting and may feel unsafe in their own homes, their
neighborhoods, or their workplaces. While they were in the war zone,
their hyper-vigiliance and being on guard all the time kept them alive.
But on returning home, being on guard all the time when they are in
46
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.
Do you ever feel this way?
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 perspective about what happened and what it means to you now, and will help you
recover from your PTSD. This doesnt 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.
Substance Use Treatment Component Discussion

In addition to targeting your PTSD, we are going to work very hard
together on your substance use problems. Many people who have PTSD
also struggle with substance abuse. Substance abuse is a harmful behavior
that people learn over time. Once people start to use substances excessively,
they learn that alcohol or drugs change the way they feel. Some people use
substances because they think it helps them deal with stressful situations,
boredom, or feelings of depression. Other people use substances to make the
good times seem even better. Many people who have PTSD use substances
to try to self-medicate or block out memories or feelings related to what
happened, to sleep better, or to not remember dreams.
Can you relate to any of these?
Do you know why you use [insert name of patients drug of choice]?
What happens to your substance use when your PTSD symptoms get
worse (e.g., do you use more, use less, or use about the same amount)?
47
What happens to your substance use when your PTSD symptoms get better? (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, youve 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,
youve discovered that its 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, irritability, 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
bodys natural stress response system (the hypothalamic-pituitary-adrenal
axis) and sleep cycles.
The treatment were using has been shown in numerous research studies 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 wont 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. Its only 12 sessions, but it could mean a significant difference in the quality of the rest of your life.
How does that sound to you?
Do you have any questions or concerns?
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2. Information Gathering
Therapist Note
If you have not done so already, it is important to formally assess PTSD
and substance use disorders. This may require spreading the material in
session 1 across two visits. Recommendations for assessment instruments
are found in Chapter1.
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 tendency to want to avoid discussing either topic, or minimize the substance 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 nonjudgmental, nonconfrontational attitude, and display a comfortable attitude when the patient describes his trauma history and substance use.
It is also important to know the following about the patient:
1. Overall level of functioning (e.g., employment, any major medical
problems, current medications, current housing situation, relationship status, social support);
2. Substance abuse history (e.g., when did the patient first start using
alcohol or drugs, what is her substance of choice, what problems
has she experienced as a result of substance use, previous treatments
and detoxifications, how often and what substances does she use,
previous substance abuse treatment and the outcome(s), family history of drug or alcohol use disorders, does the patients significant
other use alcohol or drugs); and
3. Trauma/PTSD history (e.g., age of trauma(s), type of trauma(s), whether
or not the patient disclosed the trauma to anyone previously and what
the response was, previous treatment for trauma/PTSD). Substitute a
specific term (e.g., car accident, rape, bombing, shooting, explosion)
instead of the word trauma when possible.
49
Therapist Note
Expect that most PTSD/SUD patients will present to treatment with a
history of multiple traumas. In our experience, single traumas among
this patient population are rare. For example, data from a recent
randomized controlled trial examining the COPE treatment among
103 PTSD/SUD patients in Sydney, Australia, showed that all of the
patients reported exposure to multiple traumas. The median number
of different types of traumas experienced (e.g., physical assault, sexual
assault) was 6 (range 210), with the first trauma occurring at approximately 8years of age (Mills etal., 2012).
For patients with multiple traumas, determine which event is the
index trauma, that is, the traumatic event that is causing most of
the patients avoidance and re-experiencing symptoms, and interfering
the most with her life. The index trauma should be the primary focus
of treatment. Research demonstrates that targeting the worst trauma
results in generalization of symptom reduction related to other traumatic events the patient has experienced. In some rare cases, up to two
different traumatic events can be addressed during the treatment. It
is very important, however, to work through the worst trauma first
and see significant reductions in PTSD symptoms related to the first
trauma, before moving on to a second trauma. Better to obtain full
resolution to the index trauma than to obtain only marginal resolution
to two different traumas.
Therapist Note
During this first visit, assess the need for medically supervised detoxification from substances. If detoxification is required, have the patient
obtain detoxification before beginning the COPE treatment.
See Appendix Aat 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 its 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.
Iwould also like to find out more about your substance use history so that
we can tailor the treatment to best meet your needs. Iwill be asking you
50
some sensitive questions and Iunderstand 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 Ican do to make it easier for you, please let me know.
Iam here to help you through this. At the end of todays session, we ll
develop your specific treatment goals and I will teach you a breathing
relaxation exercise.
3. Development of Treatment Goals

Discuss Goals for PTSD
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 without 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?
Discuss Goals and Motivation for Substance Abuse

Although abstinence is the optimal and safest choice, patients may
decide to choose a significant reduction in use. Let the patient know
that the treatment will be most effective with the goal of abstinence. If
the patient is not interested in abstinence at the beginning of therapy,
suggest a meaningful reduction in the number of days per week the
patient uses substances (e.g., from 6 to 2days each week by session6).
Aim for having some days completely substance-free. This will be particularly helpful when the patient starts doing the in vivo exercises
51
(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 amendable 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
Be sure to revisit the goals throughout therapy (at a minimum, review
the goals and progress at session 6, midway through the treatment) to see
if the patients goals have changed.
In assisting the patient to generate goals, consider the following:
Degree of dependence (mild, moderate or severe);
Patterns of use (e.g., daily/almost daily use or infrequent binge use);
Negative consequences from use (e.g., legal problems, relationship
impairment, physical health and injuries, job losses);
Outcomes of previous attempts to control or stop substance use (e.g.,
longest time clean, detoxification history);
Family history of substance use problems.
A person with no family history of substance use problems, no legal
or medical problems from substance use, and no previous treatment
52
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 significantly reduce or stop using alcohol/drugs but has been unable to do so,
or if substance use is causing or worsening a medical condition, abstinence 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 beSMART:

Specific
Measurable
Attainable
Realistic
Timely (i.e., have a time frame).
For example drink less is too general to be effective. A better goal

would be reduce from 20 drinks a week to 7 drinks a week by session3. Check in with the patient during the course of therapy to see if
she is achieving her goal, or if the goal needs to be revised. Goals will
help whether or not they are achieved. Goals that the patient reaches
can be celebrated or rewarded, but others that are not achieved can
be used as learning experiences for future goal setting. Questions to
jump-start this part of the session include:
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?
4. Introduce Treatment Contract

Introduce the COPE Program Treatment Contract (Form 1 at the
end of the Patient Workbook) with the patient. Go over each section
together. Do not just give the patient the contract to read and sign.
After reviewing the contract together, both the patient and therapist
sign the contract and the patient retains a copy.
53
Attendance
Cancellations must be made in advance, and the patient must have
a good reason to cancel. If a patient does not come for a scheduled
therapy session, the therapist should immediately attempt to contact
him to ascertain why the session was missed and to reschedule.
Consistent attendance should be emphasized as it predicts better outcomeshe will have better results and will achieve them more quickly
the more adherent he is with therapy. You can use the analogy of working out at the gym; the more he goes and trains his muscles, the faster
he will get in shape and the stronger he will be. The same holds true for
training the mind during therapy.
Promptness
Therapists should convey the attitude that time in sessions is too important 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.
Alcohol and Drug Use

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 session will be rescheduled.
Completion of Homework
One of the ways in which this treatment works is through the homework 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
54
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 sessions is critical.
5. Teach and Model Breathing Retraining

I want to finish today by teaching you a breathing relaxation technique.
Most of us realize that our breathing affects the way we feel. For example,
when we are upset, people may tell us to take a deep breath and calm
down. However, a deep breath often does not help. Instead, in order to
calm down, you should take a normal breath and exhale all the air out as
slow as you can. It is the slow exhalation that is associated with relaxation.
Unless we are preparing to fight or flee from real danger (e.g., combat, robbery), we often dont 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 calming 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.
Lets go through three steps together, and Iwill demonstrate:
Step 1: Get in a comfortable position. Close your eyes.
Step 2: Breathe in normally through your nose and then hold it for
3seconds.
Step 3: Exhale slowly through your mouth, emptying out all the air.
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.
Concentrate on taking breaths right down to your lower abdomen. Some
people call this belly breathing. Your belly should rise and fall each time
you inhale and exhale. To help you learn this, place one hand on your lower
55
abdomen and the other hand on your upper chest. If you are doing the exercise 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.
An important benefit of this technique is that you can do it anywhere, anytime. When in public, you can simply focus mentally on the rise and fall of
your abdomen without placing your hand there; people will not know that
you are doing the exercise but you will know because you will feel calmer
and more in control.
Therapist Note
See Form 2 at the end of the Patient Workbook, which covers breathing
retraining.
6. Assign Homework
PTSD/SUD patients often have chaotic lives. Help patients organize
their treatment by referring them to the Patient Workbook, which
contains all of the handouts, worksheets, and homework checklists for
patients to use. Ask patients to bring the Workbook with them to each
session. If a patient is unable to obtain a copy of the Patient Workbook,
consider obtaining one for your practice or clinic and then make copies of the relevant homework checklists and handouts for each session. Provide the patient with a folder in which she can organize these
materials.
Explain to patients that homework is a key part of treatment. The exercises are designed to help them master the techniques discussed and to
help them transfer what they learn in the therapy room to the world
outside the therapy room.
Research shows us that patients who do more homework see more
improvements. Emphasize that you would not assign the homework
exercises if they werent a critical part of the patients recovery.
56
Therapist Note
Emphasize the importance of completing the homework exercises without being under the influence of any substances (e.g., alcohol, marijuana,
prescription opiates).
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 questions or need help problem-solving obstacles that are getting in the way
of completing their homework, encourage them to call you between
sessions.
Direct the patient to Forms 1, 2, 6, and 7 at the end of the Patient
Workbook. Assess the need to use Forms 3, 4, and 5those directed
to significant others.
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 patients 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 otherto:
1. Understand what PTSD and SUD are;
2. Understand what he or she can do to help the patient successfully complete the treatment (e.g., helping him find the time and
a private space to listen to the recordings each week, not having any substances in the house, not using substances in front of
the patient, providing transportation, taking care of the children
while the patient is at therapy appointments, exercising with the
patient); and
3. Understand what she can do for her own self-care (e.g., time with
friends, good nutrition, talking with a therapist).
57
Therapist Note
Note that we do not recommend having patients watch video recordings
of the sessions. We recommend audio recordings. Video recordings would
likely be distracting and patients would avoid hearing and processing
the content of the session by focusing on what they looked like, their
behavioral mannerisms, what they were wearing, and so on.
Refer the patient to the homework checklist at the end of Chapter3
in the Patient Workbook, and make sure the patient understands
how to complete the homework. If he has questions or needs help
problem-solving obstacles to completing the homework, encourage him
to call you during the week.
Homework for Session 1

The patientshould do the following:
Listen to the audio recording of this session at least once.
Practice breathing retraining 3 times each day. (See Form 2 at the
end of the Patient Workbook.)
Review the section What Is the COPE Treatment Program from
Chapter1.
If applicable, share this material with family or loved ones:
For Family and Loved Ones: What Is PTSD and How Is It
Treated? (Form 3 at the end of the Patient Workbook)
For Family and Loved Ones:How Can IHelp? (Form 4 at the
end of the Patient Workbook)
For Family and Loved Ones:Common Reactions to Trauma
(Form 5 at the end of the Patient Workbook).
Read Understanding Drug Abuse and Addiction (Form 6 at the
end of the Patient Workbook).
Read 10 Tips for Well-Being (Form 7 at the end of the Patient
Workbook).
58
CHAPTER4
Session 2: Common
Reactions to Trauma
andCraving Awareness
MATERIALS NEEDED
10 Common Reactions to Trauma (Form 8 at the end of the Patient
Workbook)
Daily Record of Cravings (Form 9 at the end of the Patient Workbook)
Facts about Cravings (Form 10 at the end of the Patient Workbook)
Guidelines for Better Sleep (Form 11 at the end of the Patient
Workbook)
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.
59
1. Review PTSD Symptoms and Any Substance Use Since Last Session
Before beginning each session, have the patient complete an assessment
of his PTSD symptoms and substance use in order to monitor treatment progress (see Chapter 1 for recommended instruments). Each
week you will want toknow:
Whether the patients PTSD symptoms are getting worse or better,
and what specific symptoms he is endorsing, and
Whether the patients substance use is increasing, decreasing or staying the same.
We recommend a urine drug screen (UDS) and breathalyzer test before
each session. If used, frame the UDS and breathalyzer as a way to help
motivate the patient and to help him get the most out of the program,
and as a way to provide objective data on his progress, but not as a way
of punishing or distrusting him.
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
60
of abstinence, thus, he figures he might as well go ahead and have 12

drinks because it doesnt matter since he has broken the rule).
Although a lapse can be a disappointment, it does not mean failure or
indicate an inability to change. SUD are chronic conditions and most
patients will lapse or relapse at some point during the recovery process.
Reassure the patient that this does not mean that he will not ultimately
succeed. Emphasize, however, the importance of learning from this
experience to prevent it in the future. Note that some patients do not
believe in lapses; for them, any use is considered a relapse. This can be a
controversial topic, so we recommend that you simply provide the education around what some professionals consider a lapse and a relapse,
and why that distinction is made. If the patient feels strongly that there
is no such thing as a lapse, do not debate this extensively with the
patient. Rather, help support her efforts to maintain abstinence, making sure that she has a support network in place and a plan for how to
manage cravings or urges to use substances.
Be aware that there may be times when the patients UDS is positive
for drugs, but the patient says that no drug use has occurred. This discrepancy 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 discussion 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
Avoidance is a symptom of the patients mental disorder, and neither
personal in any way nor directed at you. If a discrepancy arises between
the UDS test results and what the patient says about his use, view it as
a sign that the patient is struggling and needs compassionate professional
help. Work to ensure that a discrepancy of this nature does not interfere
with the therapeutic relationship.
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2. Review Homework
Find out if the patient practiced the breathing retraining, if it was
useful, and if there were any problems implementing the technique.
Discuss the patients reaction to listening to the recording of the session. If the patient did not complete the homework, inquire about the
obstacles and help the patient problem-solve.
3. Overview of Common Reactions to Trauma

Discuss PTSD symptoms and how the use of alcohol/drugs may be
related to these symptoms. For example, the patient may use substances
as a way to numb unpleasant emotions, to escape, or to avoid memories
or dreams about the trauma. It is not necessary to go over every single
common reaction listed, just the ones most relevant to this patient.
Most of the questions you will ask are geared to help you learn more
about what situations the patient has been avoiding, as this will be useful for planning the in vivo exposures, and also what negative thoughts
the patient has related to the trauma, which will be useful to target
during the processing of the imaginal exposures.
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 experience. This will help us guide your treatment plan. Does that sound okay
with you?
A trauma is an emotional shock. Iknow that the [name of specific incident]
has affected you greatly. Although each person responds in his or her own
unique way, you may find that you have experienced some of these common
reactions:
a. The Primary Reactions People Experience After

a Trauma are Fear and Anxiety
Of all these common reactions to trauma, fear and anxiety are the most
common and debilitating. The feelings of anxiety that you are experiencing can be understood as reactions to a dangerous and life-threatening
62
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.
Sometimes anxiety may be a result of being reminded of the trauma. These
triggers may be, for example, certain times of the day, certain places, situations, activities, strangers approaching you, movies you watch, a certain
smell or a noise.
What specific triggers have you noticed that remind you of [name of specific incident]?
b. Another Common Symptom is Avoidance

A common strategy that people use to alleviate the anxiety and fear associated 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.
Another avoidance-related experience you may have is emotional numbness. Some people with PTSD feel numb, empty, or distant and cut off
from people to whom they once felt close. They may also no longer engage
in certain social activities that they used to engage in before the trauma.

What situations or places do you avoid as a result of the trauma?

What activities do you no longer engage in since the trauma happened?
What would you like to do again that you dont do now?
What do you do to avoid thoughts or feelings associated with the trauma?
c. People With PTSD Also Re-Experience the Trauma

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 actually occurring again. These experiences are distressing and you probably feel
that you dont have any control over what you are feeling, thinking, and
experiencing sometimes. You may also find that you are re-experiencing the
63
trauma through nightmares or dreams. Finally, you may re-experience the

trauma by having distressing thoughts and feelings about what happened
to you.
Do you experience flashbacks or distressing thoughts about [name of specific incident]? What are those thoughts like?
Do you have distressing dreams or nightmares?
d. Some People Have Trouble Concentrating

Trouble concentrating is another common experience that results from a
trauma. It is frustrating and upsetting to be unable to concentrate, remember, or pay attention to what is going on around you. This experience also
leads to a feeling that you are not in control of your mind, or a feeling
that you are going crazy. Remembering that these reactions are normal is
important.
Difficulty concentrating is likely due to the intrusive and distressing feelings
and memories about the trauma. The use of alcohol and drugs also clouds
the mind and makes concentration worse.
Have you had trouble concentrating or focusing since [name of specific
incident] occurred?
e. Other Common Reactions Are Feeling on Edge,

Feeling Overly Alert or on Guard, Being Easily Startled,
and Having Trouble Sleeping
These changes in your body are the natural result of fear. Animals and
people have three potential reactions to being traumatized or threatened:(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
64
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.
f. Other Common Reactions to Trauma Are Sadness and a Sense

ofFeeling Down or Depressed
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. Aloss 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.
Have you been feeling sad, depressed, or hopeless?
Are you having any feelings or thoughts that life is not worth living or
that you would be better off dead?
Therapist Note
See the accompanying Suicide Assessment box if the patient endorses
suicidal ideation.
65
Suicide Assessment
If the patient endorses suicidal ideation, discontinue the discussion of the

common reactions to trauma and conduct a suicide assessment. Ask the
patient about the specific thoughts, urges, feelings, fantasies, means, and
plans to harm himself. Inquire if he has ever thought about or attempted
to hurt himself in the past. If he has, ask him when and what exactly he
did. Using a 010 scale (0=I would never do it to 10=I would do
it right now if Icould), assess the patients intentions of carrying out
his plans. If the patient reports a past suicide attempt, or if the patient
exhibits any current suicidal ideation, have him sign a safety agreement
(see Appendix B at the end of this Therapist Guide) to contact you, a supportive friend, or another mental health professional if he has thoughts
or plans to harm himself. If a patient presents with a high risk of suicidal
behavior, this should take precedence, and the COPE treatment can be
resumed after these symptoms have been addressed and stabilized.
g. Some People Feel as if They Are Going Crazy

orLosing it
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?
h. Feelings of Guilt and Shame May be Present

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 survive 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 happened. While trying to make sense of a very distressing situation is a
66
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, unfortunately, many times people place responsibility on the person who has been
hurt and victimized.
Have you been experiencing feelings of guilt or shame?
Do you believe that if you had or had not done something, the traumatic
experience could have been avoided?
i. Anger is Also a Very Common Reaction to Trauma

The anger is often associated with a strong sense of unfairness or injustice
that you were a victim of such a terrible experience. While anger may be
mostly directed at a specific cause of the trauma, these feelings of anger may
also be stirred up in the presence of people or situations that remind you of
the event.
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 children. Sometimes you might lose your temper with the people who are dearest 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
Anger may be particularly relevant for military personnel and Veterans.
Some military personnel and Veterans may believe that the only emotion
that is acceptable to feel or express is anger. Thus, anger may be used to
mask other less acceptable feelings, such as fear, guilt, or shame.
Military personnel and Veterans may be angry, for example, because
of actions they committed during combat that were necessary in order
to protect themselves or their comrades; as a result of how the leadership responded or failed to respond to certain situations; at themselves
for being weak or not being able to protect their family, friends, or
fellow soldiers; and at themselves for not being able to control their
substanceuse.
Have you had strong feelings of anger or irritability?
Are those feelings related to [name of specific incident]?
Do you sometimes use alcohol or drugs when you get angry, or to try to
stay calm and not get angry?
j. Self-Image Can Also Suffer as a Result of a Trauma

You may tell yourself I am a bad person so bad things happen to me, or If
Ihad 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?
k. People Can Also Develop Negative Thoughts About

Other People and the World in General
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 dangerous place and no one can be trusted.
Have you had negative thoughts about others or the world in general?
l. Disruptions in Relationships With Other People

areCommon After a Trauma
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 suffering. It is important that you get support for what you are going through.
How have your relationships (e.g., friendships, intimate relationships,
family relationships) changed since the trauma?
What kinds of social activities did you once enjoy that you no longer
engage in?
m. After a Trauma, it is not Unusual to Experience a Loss

ofInterest in Physical Affection and Sexual Relations
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

ofOtherTraumas
Once a negative experience comes to mind, it tends to bring up memories of
other negative experiences. This is the normal way in which memory works.
For this reason, after the trauma, you may recall negative memories about
a past trauma(s) that you had not thought about for a long time. These
memories may be as disturbing to you as the memories of the recent trauma.
For example, a person who was raped as an adult, might be reminded of a
time when she was sexually assaulted as a child. Or a person who experienced a bomb explosion as an adult might be reminded of a time when he
experienced a severe burn injury as a teenager.
Has [name of specific incident] brought up any memories of earlier traumas you experienced?
This can make it difficult for you to think of any other situations or experiences 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 typically last. Elicit the patients 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 experiences 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 naturally, 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?
Youve heard the word craving before. How do you define a craving?
How often do you experience cravings?
How often do your cravings typically last?
A craving can be defined as a strong desire or urge to use alcohol or drugs.
Cravings are a key feature of substance use disorders and something that
everyone in recovery experiences. Cravings may be uncomfortable, but they
are a normal part of recovery. You should expect cravings to occur from
time to time and be prepared to manage them. Cravings are most often
experienced early in treatment, but its quite normal for episodes of craving to occur weeks, months, and sometimes even years after a person stops
using.
When you have a craving, its 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 catif 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 simply say, I dont 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 having 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, wanting 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.
What Triggers Craving?

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 happenedalmost as though you have gone into automatic 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 controlling you.
Some Common Triggers for Substance Use

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., anxiety, 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 getalcohol or drugs, rationalizing 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).
A common phrase related to triggers for alcohol/drug use is
HALTif you are Hungry, Angry, Lonely, or Tired, take that
as a sign for you to halt, and to take care of your needs in a healthy
way (e.g., eat a good meal, do the breathing retraining exercise, call a
friend, take a nap).
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.
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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).
What places do you need to stay away from?
What people do you need to stay away from?
Do you have alcohol or drugs in your house? If so, when and how could
you dispose of it?
Coping With Triggers

Review with the patient several basic ways that she can handle a trigger. Note that you will discuss managing cravings in more depth in
session3.
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 positive, 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
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Practice breathing retraining 3 times each day.
Complete the Daily Record of Cravings (Form 9 at the end of the
Patient Workbook).
Read the Facts about Cravings (Form 10 at the end of the Patient
Workbook).
Optional:Read Guidelines for Better Sleep (Form 11 at the end of
the Patient Workbook).
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CHAPTER5
Session 3: Developing
the In vivo Hierarchy
andCraving Management
MATERIALS NEEDED
SUDS Distress Thermometer (Form 12 at the end of the Patient
Workbook)
In vivo Hierarchy (Form 13 at the end of the Patient Workbook)
Pleasant Activities Checklist (Form 14 at the end of the Patient
Workbook)
Craving Thermometer (Form 15 at the end of the Patient Workbook)
Coping with Cravings Plan (Form 16 at the end of the Patient
Workbook)
Patient In vivo Exposure Data Form (Form 17 at the end of the
Patient Workbook)
SESSION OUTLINE
2. Review homework
3. Discuss prolonged exposure procedures and construct the in vivo
hierarchy
4. Managing cravings
5. Assign homework
77
Review the patients weekly PTSD and SUD assessments. If any alcohol 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
Did the patient complete his homework? If not, explore obstacles
and problem-solve ways to overcome those obstacles in the following
week. You may want to help the patient get started on the homework in session in order to ensure that he understands how to complete the homework, and to emphasize the importance of doing the
homework.
3. Discuss Prolonged Exposure Procedures and Construct

theInvivo Hierarchy
Rationale for In vivo Exposures
Present a thorough rationale for in vivo exposure:
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.
People commonly want to escape or avoid memories, situations, thoughts,
and feelings that are painful and distressing. However, while this avoidance
of painful or distressing situations works in the short term, doing so keeps
you stuck and maintains the PTSD symptoms in the long run.
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Readiness to Begin Prolonged Exposure Assessment
Exposures (in vivo and imaginal) should not be commencedif:

the patient fails to demonstrate any meaningful reduction in the
frequency or intensity of substance use since the start of treatment;
the patient demonstrates an increase in substance use since the
start of treatment; or
the patient decompensates in other ways (e.g., increased
suicidality).
The patient does not have to be abstinent from all substances in
order to commence the exposures, but does need to show a clinically
significant reduction in use and be willing and able to, at a minimum,
refrain from substance use before, during, and immediately after
engaging in the in vivo and imaginal exposure exercises.
Elicit examples of the patients avoidance based on previous discussions
or assessments (e.g., the CAPS). You can also use the car alarm analogy
below.
Our bodies have a built-in alarm systemkind 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. Agoal of this
treatment is to help you recalibrate your bodys 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 several 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 avoidance, 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 happens, 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 probably OK to do so now.
In addition, many people with PTSD believe that if they stay in the situation 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 shownin Figures 5.1
and5.2.
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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Anxiety
The point when

you leave the
situation or you
decide to avoid it
Time
Figure5.1
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.
Anxiety
Over time,
anxiety becomes
less intense and
lasts for shorter
periods of time
Time
Figure5.2
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.
Use an example to help the patient understand the rationale. You
can use one of these examples or another that is more relevant to the
patients trauma.
Awoman developed a fear of driving over [insert the name of a local
bridge] after having an accident there. This fear began to cause many
problems, since she became unable to drive to work. Each time she
approached the bridge she began to breathe heavily and started to
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 situations. 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 situations 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 exposure 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)

Begin this discussion by introducing the concept of subjective distress,
and refer the patient to the Distress Thermometer (Form 12 at the end
of the Patient Workbook).
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. Its a 0 to 100 scale. A rating of 0 indicates no
discomfort at allcomplete relaxation. Arating of 100 indicates that you
are extremely distressedthe most you have ever been in your life. Usually
when people say they have a rating of 100, they are experiencing physical reactions, such as sweaty palms, rapid heartbeats, trembling, difficulty
breathing, feelings of dizziness, and so on. So 100 indicates the highest level
of distress youve 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 Iare standing near
a deep pool and someone pushes us both in the water. If Icannot swim well,
Imay 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:
In what situations have you been a 0 level of discomfortthat is,
totally relaxed?
In what situation have you been a 100that is, the most distressed,
upset, and terrified youve ever been?
Now whats a 50 for youthat is, a medium level of distress, halfway
between the way you feel when [insert the patients 0 anchor situation]
and [insert the 100 anchor situation]? For example, giving a presentation to 40 people, going for a job interview, and so on.
What is your distress level on the scale right now?
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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 3hour drive
each way are unrealistic for repeated practice. Patients need situations
that they can practice two to three times each week (or until habituation is achieved).
The situations should be specific. For example, walking down a
crowded street or going to a supermarket is not specific enough.
Ask the patient to designate a specific street or specific supermarket
at a specific time of the day, and so on. Finally, make sure that the
assigned activity allows the patient to remain engaged for the time
requirement.
For some patients, constructing a hierarchy is easily done, and you will
have 1520 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 35 situations so they can
be assigned as homework. Part of the patients assignment will be to
add more avoided situations to the list, so that eventually the list will
include 1520 situations.
Therapist Note
Think of the in vivo hierarchy list as a work in progress. Throughout the
course of treatment more situations can be added to the list.
The list should contain items representing a wide range of subjective
distress levels of 40, 50, 60, 70, 80, 90, 100 (or thereabouts), as these
will be the focus of treatment. The list does not have to be exhaustive,
including every situation the patient avoids, but merely representative
of avoided situations.
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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 situation 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 inviting people to ones 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.
It is important to consider the functionality of the situations that will
be considered for in vivo exposures. Ask your patient:
Is this an activity you enjoyed engaging in prior to the trauma?
Is this activity something that you want to be able to do again?
Some PTSD/SUD patients report feeling emotionally numb. For
patients who experience high levels of emotional numbing, it can be
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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 grandchild (e.g., hold the childs 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 patients 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 feelings again as he recovers from PTSD and SUD (Dr.Matthew Yoder,
personal communication).
In vivo Hierarchy Construction

Construct the patients in vivo hierarchy by listing the avoided situations and activities on the In vivo Exposure Hierarchy List (Form 13 at
the end of the Patient Workbook). Have the patient provide a rating for
each item and write these on the list.
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 improvised explosive devices (IEDs). Use information from the initial
assessment or examples from Table5.1 if the patient has difficulty
identifying situations.
Table5.1 List of Typically Avoided Situations for Trauma Survivors

Being in a crowded mall, store, or shopping market* (e.g., Walmart)
Driving a car or being stopped at a stop light*
Staying at home alone (day or night)
Walking down a street or being out in the open*
Going somewhere alone at night
Watching or reading the news*
Going to a restaurant and sitting in the middle of the room*
Seeing a person who resembles the perpetrator
Someone standing close or approaching suddenly
Hearing a person walking behind you
Talking to strangers
Engaging in activities similar to the trauma situation (e.g., for motor vehicle accident
survivors, driving or riding in a car)
Taking public transportation
Riding in elevators or being in small, confined spaces
Reading about a similar event in the newspaper
Talking with someone about the trauma
Watching movies that remind one of the trauma (e.g., combat films, assault scenes)*
Going to the location where the trauma took place
Hugging and kissing significant others
Sexual activity or physical contact
Listening to a song that the patient heard during the traumatic event
Wearing makeup or looking attractive
Enrolling in an exercise class or other group activity
Going to support group meetings (AA, NA, place of worship)
Barbequing*
Building a fire
*These triggers may be especially relevant for military-related traumas.
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Safety Considerations for the In vivo Hierarchy

It is important that the situations chosen for in vivo exposure are objectively 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 relevance of the situations to the patients 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 patients
peer group in that situation. For example, if the therapist is considering 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 are objectively dangerous or high risk should not be
assigned. For example, the patient should not be asked to walk alone
in areas where drugs are known to be sold or in a park where ongoing
criminal activity is known to take place. Instead, alternate exposures
should be designed that include elements that trigger trauma-related
anxiety while preserving safety. For example, the patient could walk
alone in a relatively safe area of the city. If there is doubt about the
objective safety of an activity after discussing it with the patient, forgoing that activity may be best.
Considerations Regarding Combination PTSD/

Substance Use Triggers
Situations that trigger craving for substances and that may put the
patient at risk of exposure to substances should not be listed on the
invivo 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. Apatient who has been avoiding hanging 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.
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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 associated 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 exposures, 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 experiences 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.
Selecting the First Few In vivo Exposures

In vivo exposure begins with situations that evoke moderate levels
of anxiety (SUDS = 40 or 50) and gradually progresses to more
distressing situations (SUDS=8095). Emphasize to your patient
the goal of remaining in the situation for 3045 minutes or until
SUDS decrease considerably (by 50%).
It is important to maximize the potential for a successful learning
experience early on by carefully selecting the first few in vivo exposure
assignments. Guide the patient to first select two situations that have a
high likelihood of successful completion with some reduction in anxiety. These may be situations that the patient has difficulty approaching
but can already manage if necessary. Early success increases confidence,
motivation to continue, and realization of the benefits of treatment.
Discussion of the patients previous and successful experiences with
natural exposure situations can also help instill confidence. Ask the
patient what activities he has feared doing and has successfully overcome. These activities do not have to be trauma specific (e.g., flying
in airplanes, speaking up in a group). By pointing to these examples,
the therapist helps the patient see that he has already successfully done
exposure.
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Therapist Note
Patients should experience sufficient reduction in anxiety during the in
vivo situation before advancing to a more anxiety-provoking situation
on their hierarchy list. For example, if the patient approaches a situation
with a SUDS rating of 60 but does not experience a 50% or greater
reduction in anxiety, she should stay with this exposure until the SUDS
goes below 30 before advancing to a situation that evokes a SUDS rating of 70.
Presentation of In vivo Exposure Homework

Review the in vivo exposure hierarchy list with the patient and decide
together which two situations to assign for homework. Start with situations 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., 2530 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 procedure to the patient:
When you are practicing [name of situation to be practiced], you may
initially experience anxiety symptoms, such as your heart beating rapidly,
your palms getting sweaty, feeling faint. You may feel a strong urge to
leave the situation immediately. But in order to get over the fear, it is
important to remain in the situation until your anxiety decreases and you
realize that what you were afraid could happen (e.g., being attacked or
falling apart) did not actually happen. By leaving the situation early,
you will not learn that the situation really is not dangerous. Once your
anxiety has decreased a good deal, or by at least 50%, then you can stop
the exposure. However, if you leave the situation when you are very anxious, you are again telling yourself that the situation is dangerous, that
anxiety will remain forever, or that something terrible is going to happen
to you. And the next time you go into that situation, your level of anxiety
will be high again.
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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.
Modifying In vivo Exposure

PTSD patients usually struggle with their tendency to avoid feared situations during treatment. Most patients will benefit from ample support
and encouragement from the therapist to hang in there and keep working on their in vivo assignments. The urges to avoid are common and
understandable but, as you have already explained to the patient, avoidance 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 situation is too difficult to approach at the present time, find ways to make
it less difficult.
Sometimes having a friend or family member accompany the patient
during the exposure exercise helps the patient manage the distress
associated with that situation, and then the patient can approach the
situation alone in subsequent exposure exercises. If the patient has an
accompanying support person, make sure that this persons presence
is one that helps the patient feel a reduced level of SUDS rating. The
patient should choose a kind, nonjudgmental person, not someone who
will push, guilt-trip, or cajole the patient. The support person should
not be someone who is inconvenienced by the patients avoidance (and
may therefore want him or her to get over it as quickly as possible).
The support person should also not be someone who may suggest or go
along with the patients desire to use alcohol or drugs before, during, or
after the in vivo exercises.
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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 difficult exposures.
Occasionally, as treatment progresses, a patient may not experience
the expected fear reduction despite what appears to be systematic
and repeated exposure. In these cases, it is helpful to look closely at
what the patient is actually doing during the in vivo exposure exercises. Ask the patient exactly how he is carrying out the exposure,
how long it lasts, and when he ends it. Is the exposure of sufficient
duration? Or is the patient escaping the situation while still highly
anxious? Also look for subtle avoidance and safety behaviors, such
as shopping only when the stores are not crowded, always choosing
a female clerk or cashier to deal with, carrying a weapon for protection, having a drink before the exposure exercise, or scanning the
environment constantly.
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 patients 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 behaviors actually serve to maintain fear and trauma-related, unrealistic
beliefs.
4. Managing Cravings
Review the patients 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.
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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 strategies that work well for you and use those whenever you experience a craving. And the earlier in the process the betterit is a lot easier to manage a
craving that is a 30 on a scale of 0100 (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 refrigerator). 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
dealers number from your phone and do not answer the phone when he
calls, dont 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 wanting 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.
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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 dont 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. Iwill 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 craving 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 naturally with time.
e. Breathing retraining. Breathing retraining, which you learned during the first session, can be used for coping with anxiety related to your
trauma as well as cravings. Try it for 510 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,
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clear-headed, more energy, improved appearance, less arguments with

family and friends).
What are the negative consequences of using for you?
What are the benefits of not using for you?
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 cold beer sure would taste good right now.

Six more beers
A line of cocaine
More cocaine
Jail
Not showing up for work
All of this as a result

of just one beer!
Losing your job

Being broke
Family angry and hurt
Depression, shame, guilt
Figure5.3
Sample Chain of Events.
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just a want? (You need air, water, and food). Whats 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 youve
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 craving 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, staying 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.
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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 having 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 managing 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 cognitions about feared outcomes. Patients who complete the in vivo exercises 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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98

Complete the in vivo exposure assignments (pick 2 from the hierarchy list). Practice each in vivo assignment 2 to 3 times before the
next session. Be sure not to use alcohol or drugs when doing so.
Read the Coping with Cravings Plan (Form 16 at the end of the
Patient Workbook).
CHAPTER6
Session 4: Initial Imaginal

Exposure
MATERIALS
In vivo Hierarchy Form started in session 3
Patient In vivo Exposure Data Form (Form 17 at the end of the
Patient Workbook)
Patient Imaginal Exposure Data Form (Form 18 at the end of the
Patient Workbook)
Therapist Imaginal Exposure Recording Form (Appendix C at the
end of this Therapist Guide)
SESSION OUTLINE
2. Review homework
3. Discuss imaginal exposure rationale
4. Conduct the first imaginal exposure
5. Process the imaginal exposure
6. Assign homework
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Review the patients 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 evidence of habituation. Ask the patient what he learned from doing
the invivo exposures and how helpful the exposures were. Pay attention 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 exposure, 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, during, or immediately after exposures. Assign the next in vivo exercises
at this time.
3. Discuss Imaginal Exposure Rationale

Therapist Note
In this and all subsequent sessions, it will be particularly important
to ensure that your cell phone and the patients cell phone are off or
silenced during the session so that the imaginal exposure will not be
interrupted. Check to make sure your cell phone is off and ask the
patient to do the same.
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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 patients 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 memories about the trauma. You may tell yourself, Just dont 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 influence 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 business that needs attention. You have probably tried and have found that
you cant 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 happened 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.
Present the Rationale for How Repeated Imaginal Exposure

Facilitates the Processing of This Memory
Lets 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 Iam 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 dont understand, okay?
a. Organizing the Memory. First, revisiting the memory repeatedly helps
organize the memory and get a new perspective about what happened during and after the trauma. By staying with the memory, you will begin to
make sense of the trauma so that it wont feel as confusing and dangerous. Revisiting the memory also helps you to fully digest the trauma.
For example, suppose you have eaten a very large and heavy meal and
now you have symptoms such as stomachache, nausea, and indigestion.
These symptoms will stay with you until you have digested and processed the
meal. Nightmares, flashbacks, and troublesome thoughts continue to occur
because the traumatic memory has not been fully digested. Today you are
going to start to digest and process your painful memory. The way to digest
and process a traumatic memory is to invite the memory and talk about it.
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 memory you will learn that the memory cannot harm you. It is only a memory.
c. Getting Used to the Memory (Habituation). Continuous revisiting of
the trauma will reduce your anxiety and will teach you that anxiety does
not last forever and that you do not need to run away from the memory
in order to reduce your fear and anxiety. We call this habituation. The
more you revisit the full trauma memory, the better this process will work.
Repetition is necessary to get used to the memory and to decrease anxiety.
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 its 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 alcohol 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.
e. Increasing Mastery and Sense of Control. The more you practice
revisiting the trauma memory, the more your sense of control and confidence will increase. You will discover that you have the power to overcome
anxiety, as well as other obstacles in your life, and you will feel progressively better about yourself as you stop avoiding your fears and begin to
master them. You will be able to remember the trauma when you want
to and to put it aside when you do not want to think about it. You
will be in control of the traumatic memory instead of it controlling you.
Finally, you will learn that you do not need alcohol or drugs to cope with
the memory; as you have discovered, it does not really help. As you stop
self-medicating with substances and start managing the memory using
healthier coping skills, you will gain a greater sense of control in your life
and more confidence.
In summary, the rationale for imaginal exposure includes the

following five points:
1. Organizing and digesting the memory;
2. Promoting discrimination between the actual traumatic event
and the memory of the event, between then and now, between
the past and the present;
3. Learning that anxiety does not last forever;
4. Learning that you do not go crazy;
5. Increasing your sense of control, mastery, and confidence.
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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 standardor 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.
Before we begin, do you have any questions?
4. Conduct the First Imaginal Exposure

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
Note on multiple traumas:Most patients will have experienced multiple traumas, so be sure that you have identified the index trauma to
target in the imaginal exposures. Ideally, the index trauma is identified in session 1.The index trauma may not always be clear. Select the
trauma that is the source of most of the avoidance and re-experiencing
symptoms. Improvements with the most severe trauma will likely generalize to other trauma memories.
Ask the patient to close his eyes and repeat the trauma over and over, in
the present tense without any pause for 3045 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 memory 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.
SUDS ratings of distress should be taken immediately prior to, every
5 minutes during, and immediately following the imaginal exposure. Record the SUDS ratings on the Therapist Imaginal Exposure
Recording Form (Appendix C at the end of this Guide). These ratings
will enable you to identify changes in distress levels associated with specific parts of the memory and to monitor the patients level of emotional
engagement with the memory. When the patient does not engage emotionally at all, this means that the memory has not been fully evoked
and the patient will not benefit enough from the imaginal exposure.
When arousal is too high, the experience can be overwhelming. SUDS
levels of 90 or even 100 are not uncommon. These levels are acceptable
as long as the patient does not show signs of loss of control or dissociative experience.
Record the patients craving immediately before and after the imaginal exposure (also on a scale of 0100; 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
Be flexible during this first imaginal exposure session. Allow patients
the freedom to give as few or as many details as they choose. If they open
their eyes or tell the story in the past tense, do not be too concerned with
this during the first session.
Although it is important to not engage the patient in conversation during the imaginal exposure, it is helpful to let her know that you are
there by offering brief but encouraging comments once in a while. The
comments should be kept to a minimum so as not to interrupt the
imagery. The following statements are examples of supportive comments that may be helpful to the patient during the exposure:

Youre doing fine, stay with the image.

Youre doing great, hang in there.
Great job, keep going.
Stay with the image. You are safe here.
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.
Future Imaginal Exposures

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
What is happening now?
What is he doing now?
What are you feeling?
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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
Note that if the patient spontaneously includes this information, it is not
necessary to ask these questions. Be careful not to overuse probes or to
interrupt the patient too much during the imaginal exposure.
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 exposure with his eyes open or recounting the memory in the past tense may
be a form of avoidance.
Therapist Note
After approximately three sessions of imaginal exposure and after some
reduction of anxiety has occurred, focus on the hot spots or those parts
of the trauma that are most distressing. The patient may identify the
distressing parts of the trauma, or the therapist may have taken note of
the hot spots in previous sessions. These will be revisited in a repetitive
fashion (as many as 612 times) during a single session. We describe how
to do that in session6.
It is also not uncommon that a patient remembers other distressing
traumatic events during the course of the imaginal exposure sessions.
The therapist can move on to a second traumatic event only when the
patient has sufficiently processed the presenting event. Err on the side
of caution and stay with a single trauma long enough to ensure that the
patient has truly processed it and has habituated to the memory before
moving on to another trauma memory. Remember that avoidance
among PTSD/SUD patients is strong, and some patients (and therapists) may wish to proceed to the next trauma because of the distress
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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 1020. 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 substance 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
Here is a guide for the focus of imaginal exposures in sessions 411:
Session 4:Initial imaginal exposure. Revisit entire trauma memory.
Session 5:Revisit entire trauma memory and provide more details.
Session 6: Revisit entire trauma memory and provide even more
details.
Session 7: Revisit entire trauma memory and provide even more
details OR begin to focus on a hot spot.
Session 8:Focus on a hot spot.
Session 9:Focus on a hot spot.
Session 10:Revisit entire trauma memory again.
Session 11:Final revisiting of entire trauma memory.
Do:
Create a supportive atmosphere.
Provide clear instructions for the imaginal exposure.
Encourage the patient with brief, supportive remarks as needed.
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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 correcting 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
patients reaction and level of distress.
Dont:
Engage in discussion during the imaginal exposure.
Engage in discussion between the various repetitions of the memory.
Probe too often.
Ask long questions.
Move to another trauma until the patient has fully processed and
habituated to the memory of the index trauma.
Express an opinion regarding the patients emotions.
Presentation to the Patient

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, Iwould just like to get an idea of
your current level of distress and craving. Lets 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 patients 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 present the following explanation:
For the next 3045 minutes, Iam going to ask you to revisit the memory
of the trauma. Its 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 wont be distracted. Iwill ask you to revisit the memory as vividly as possible and to
picture it in your minds eye. Iwould 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, Iwill help you to stay with it.
Its important that you not avoid or stop in the middle. From time to time
while you are revisiting the memory, Iwill 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 dont leave the image. Because it is important 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 todays
session, depending on the length of the memory. Its important that you not
push the memories away, even if they are painful. Remember, memories are
not dangerous, even if they feel bad. Iwill not say much during the imaginal 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 exposure 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, Youre doing great. Now I want you to go back
to the beginning. So youre walking down the street...Tell me whats
happening now, and let the patient begin to go through the memory 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 patients revisiting of the traumatic memory and the processing.
Use the Therapist Imaginal Exposure Recording Form (Appendix C
at the end of this Guide) to record the patients SUDS ratings every
5minutes and to make notes about things the patient says or does that
seem important to discuss later. After about 3045 minutes of imaginal
exposure, terminate the exercise by asking the patient to open his eyes
and end the imaginal experience:OK, lets stop here. Great job. Now
lets talk about how this was for you.
5. Process the Imaginal Exposure

Allow sufficient time (1015 minutes) afterward to process the imaginal exposure. Revisiting the trauma memory is distressing and challenging, especially in the early sessions of therapy. Begin processing the
exposure by acknowledging the patients courage in facing the memory
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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; Iknow it is really hard to do.
You included a lot more details this time, such as [note specific details].
Thats good.
For the first few imaginal exposures, processing will focus more on the
exposure itself. Ask the patient open-ended questions, suchas

How was that for you?

What was that like for you?
Did it feel as hard this time?
Did you notice anything different today from the last session?
What have you learned about your ability to handle anxiety?
Now that youve put it all together, how does it make sense to you?
How do you see the trauma differently now?
I noticed that you kept saying [insert important statement here]. What
does that mean to you?
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 patients distress level did, in fact, decrease during the imaginal
exposure, offer comments such as:
As you remained in the memory, your distress level did go down.
I want you to notice that you are much less anxious than you were in the
beginning of the session How do you think that happened?
In subsequent sessions: I can see that you had much less anxiety today
than the last time you revisited this distressing memory. So, the more you
confront this memory, the less anxious and distressed you are going to feel.
Does it feel as bad as it used to feel?
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If the patients distress level did not decrease during the imaginal exposure, 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 experience 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! Iknow that you did not feel less distressed at the end of the
exposure this time, and your SUDS level stayed high. But you accomplished 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.
Identifying Unhelpful Thoughts and Beliefs

During the processing, patients will often spontaneously express
thoughts and feelings that reflect negative, unhelpful, inaccurate, or
unrealistic beliefs. During the imaginal exposure and the discussion
that follows, stay alert to the presence of these unhelpful thoughts and
feelings. In processing the first few imaginal exposures, questions focus
mainly on the actual exposure itself (What was that like for you?).
In later imaginal exposures, processing should help the patient identify
and examine unhelpful thoughts and beliefs, especially with regard to
the parts where high SUDS are reported. The aim of emotional processing is to incorporate new information that will correct the unrealistic, unhelpful pathological aspects of the trauma memory that work to
maintain the PTSD. This is achieved through imaginal exposure and
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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 processing, the therapist should facilitate the patients verbal elaboration of
these realizations.
For example, a patient who was raped by her boyfriend and his
friends said:If only Ihad let them know how much Idid 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 didnt know you did not
want to be raped? Alternatively, the patient might make a statement that reflects an emerging shift in perspective that seems more
realistic and appropriate. For example, after listening to her narrative of the rape several times in the sessions and at home, the above
patient said:I didnt realize how much Ifought them. Of course
they knew that Idid 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 comrades 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 cognitive 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

therapistshould:
Begin by providing positive feedback and acknowledgment of the
patients courage and ability to approach these painful memories.
Provide support and calming reassurances when needed.
Comment on any habituation observed within or across sessions (or
lack thereof, as described above).
Ask the patient to express thoughts and feelings about the revisiting
of the traumatic experience.
After the patient has described his thoughts and feelings about the
revisiting of the memory, the therapist can share his or her own
observations of the patients imaginal exposure. Ask questions about
those aspects of the revisiting or the patients emotional responses
that seemed particularly important or meaningful.
As therapy progresses and the therapist becomes aware of the
thoughts or beliefs the patient holds that may be contributing to the
maintenance of PTSD, begin to focus discussion on these areas during the processing.
Try to stimulate the patients thinking with open-ended questions;
do not tell the patient how she should think or feel regarding the
trauma.
Focus on unhelpful thoughts or beliefs related to guilt, shame, anger,
and fear.
Post-Trauma Thoughts and Trauma Appraisal

Much of the distress of patients with chronic PTSD comes from perspectives 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
When did you start thinking about it this way?
How do you feel when you think of it in this way?
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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 patients 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 youve 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.
Before the Patient Leaves the Office

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 0100
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 SUDSthe level of anxiety that
they walk around withis as high as 5060. They may also say that
they walk around with a baseline craving level of 2030. Baseline distress 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 encourage him to complete all assigned practice exercises, assess cravings and
any substance use, remind him about the rationale for exposure therapy 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 encourage 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.
Techniques for coping with cravings:

Stay away from high-risk people, places and things

Decision delay
Get involved in a distracting activity
Call a supportive friend or AA/NA sponsor and talk it through
Urge surfing
Breathing retraining
Challenge your negative or unhelpful thoughts
Play it out
Write out the negatives of using and the positives of not using.
6. Assign Homework
to call you before the next session.


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Find a quiet, safe place and listen to the audio recording of the
imaginal exposure segment of the session once per day, but not before
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 (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.
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Session 4 Appendix
Problems the Therapist May Encounter
During Imaginal Exposure and Ways
toManage Them
1. Under-Engagement
This is the most frequent problem with emotional engagement during
imaginal exposure. The term under-engagement refers to difficulty
accessing the emotional components of the fear structure or trauma
memory.
The tendency to suppress feelings while thinking about ones trauma
is common among individuals with PTSD and substance use disorders. An under-engaged patient may describe the trauma, even in great
detail, yet feel disconnected from it emotionally or not be able to visualize what happened. The patient may report feeling numb or detached.
Distress or SUDS levels during the exposure are typically low when the
patient is under-engaged. Alternatively, the under-engaged patient may
report high distress levels, yet his nonverbal behaviors such as facial
expression, tone of voice, and bodily gestures do not reflect high distress. Sometimes the language used by the under-engaged patient seems
stilted or distant, as if he is reading a police report rather than giving a
first-person account of a traumatic event he experienced. For example,
the patient may refer to an attacker as the assailant or perpetrator
or use other terminology that seems unlikely to have been in his mind
at the time of the trauma.
Because under-engagement is the most common problem with emotional engagement during imaginal exposures, the standard procedures
for imaginals are designed to promote emotional engagement by asking
the patient to (a)keep his eyes closed, (b)vividly imagine and visualize
the traumatic memory as if it were happening now, (c)use the present
tense, and (d)include in the revisiting of the trauma the thoughts, emotions, physical sensations, and behaviors experienced during the event.
The therapist prompts for details that are missing (e.g., How does it
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feel? or What is he doing now? or How does it smell?) and monitors the patients 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 patients 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 imaginal 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 patients access of his emotions during the revisiting of the trauma memory but at the same time not to direct it and
thereby interfere with the processing of the memory.
If under-engagement is persistent across sessions, revisit the rationale for the exposure with the patient. Discuss the reasons that you
are asking him to emotionally connect to this painful memory, and
explain why emotional engagement will promote his recovery from
PTSD. It can also be useful to show the patient (or assign for homework) a Dateline video that was created on prolonged exposure
therapy:http://www.youtube.com/watch?v=9aTDIiTr99Y. The video
demonstrates a rape victim engaging in the imaginal exposure therapy sessions and includes input from Dr. Edna Foa and colleagues
on the techniques. Watching this video can help the patient better
understand more clearly what you are asking him to do and why, as
well as how it will benefit him and help him overcome PTSD. There
are several other videos that may be obtained online (e.g., from the
Association for Behavioral and Cognitive Therapies or the VA) which
demonstrate imaginal exposure therapy.
In addition, you can remind the patient that memories are not dangerous, 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., Ill lose control; Ill fall
apart; Ill cry; Ill never stop feeling anxious). Validate the patients
feelings, but help him realize that being distressed is not dangerous. It
may help to share with the patient the research findings that indicate
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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 Im walking over to get the toast out. My feet
are bare and the tile floor feels really cold on them. Im wearing my long
gray robe and Ipull it up closer around my neck and tighten the belt a
little more to help me warm up. With my right hand, Ireach 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. Iput 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 Ibite into the toast, Inotice how its 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
Rarely, a patient manifests the opposite pattern from under-engagement,
namely, being overwhelmed with emotions during the revisiting of the
trauma memory and feeling loss of control. We term this experience
over-engagement. Therapists tend to be most concerned about how to
handle over-engagement; however, over-engagement is much less common than under-engagement.
Imaginal confrontation with frightening memories is often distressing
and can elicit tears and emotional distress, especially in the early stage
of therapy. Thus, it can be difficult to tell when a patient has passed from
being emotionally upset to being over-engaged. One way that we identify
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excessive engagement or distress is by asking ourselves whether or not

the patients experience in this moment is conducive to learning. Is the
patient able to learn from this experience that memories are not dangerous, 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 memory 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 therapists 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 repetitions of exposure. Sometimes the patient may feel or appear detached
or dissociated from present experience.
Emotionally overwhelmed over-engaged patients usually sob or cry
hard for prolonged periods of time. However, you should not regard
crying hard as indicative of over-engagement unless it persists during
revisiting of the trauma memory for several sessions. As mentioned
above, many patients find it very distressing to describe and emotionally engage with traumatic memories, and many people experience a
high level of distress during imaginal exposures, especially in the first
two or three imaginal exposure sessions. But when this intensity of
emotional distress persists, it will often be apparent that the patient
is not really processing or organizing the trauma. The patient seems
stuck. Indeed, sometimes this type of over-engager is not really describing the trauma but rather is simply sobbing or crying. Her behavior
may seem regressive or developmentally immature during the imaginal
exposure. If it is unclear whether or not the patient is over-engaged or
highly distressed, remember these questions:
Is the patients experience in this moment conducive to learning?
Is the patient moving through the pain to get to the other side of it,
or is she stuck in it?
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Will the patient learn anything useful from repeatedly listening to

(as part of homework) an audio recording of this imaginal exposure?
If not, it is best to modify the procedures so as to decrease engagement
in the exposure.
In modifying the exposure procedures, the primary goal is to help the
patient to successfully describe some part of the trauma memory while
managing her distress and staying grounded in the present, knowing that
she is safe in the office. Discuss the issue with the patient and have her
help you figure out ways to provide support and grounding while she
recounts the traumatic experience. Revisit the rationale for the imaginal
exposure as needed, with emphasis on learning to discriminate the actual
trauma from its memory. Stress that memories may be painful but are not
dangerous, while the trauma itself was dangerous. Modify procedures to
reduce emotional engagement during the revisiting of the trauma.
A first step with over-engagers is to reverse or change the procedures that
are designed to promote engagement:ask the patient to keep her eyes open
while describing the exposure scene and to use the past tense rather than
present tense when narrating the memory. Sometimes these two modifications alone reduce engagement sufficiently. It is also helpful to be more
involved during the patients revisiting of the traumatic memory:Use your
voice to connect with the patient and to communicate empathy. These
comments should be brief supportive statements that praise and acknowledge the patients effort and encourage her to remain with the memory
(e.g., I know this is really difficult, you are doing a great job; I know this
is distressing, but you are safe here, the memory cant hurt you). It may
be helpful to remind the patient to keep in mind that she made it through
the trauma and that she can keep one foot grounded in your office and the
other foot in the revisiting of the memory of the trauma.
When an over-engaged patient is extremely distressed or overwhelmed
by revisiting and imagining a traumatic memory, it is sometimes best
to begin by just having a conversation about the trauma in past tense
and with eyes open. The aim is to increase the patients sense of control
and competence by disclosing the details of a trauma while maintaining
contact with the therapist and feeling supported by him or her. If the
patient seems stuck at any point during the revisiting of the trauma,
which happens especially at points that were particularly distressing or
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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 conversational throughout treatment. But if possible, as the patients 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.
An alternative procedure is writing the trauma narrative instead of revisiting it aloud. This can be done during the session and also as an at-home
exercise between sessions. Ask the patient to write down what happened
and to include thoughts, feelings, actions, and sensations as well as details
about the event (e.g., Its dark outside and Im walking on the sidewalk.
Ifeel scared and so Im starting to walk faster). We suggest that patients
hand-write the narrative, as opposed to typing it out on a computer. Either
way, ask the patient to refrain from editing the content or worrying about
correct grammar, spelling, or punctuation. Once she has finished a first
draft, have the patient read the story to you during a session, adding any
additional material as needed. SUDS ratings should be recorded every
5minutes and the patient should read the written narrative aloud during
session for at least 20 minutes. Then, be sure to process the experience
with the patient and offer her a lot of praise.
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 present. 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 present 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
Some patients may want to stop in the middle of exposure. Exposures
should not be terminated at their peak, as the belief that the anxiety will
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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 imaginal 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 techniques. 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 patients fear and concerns that exposure can be difficult, may help the patient stick with it.
4. Avoidance
Confrontation with feared situations and memories often triggers urges
to escape or avoid (including using alcohol or drugs), so avoidance is the
most commonly encountered impediment to effective exposure both in
and out of the therapists office. Some patients experience an increase
in their urges to avoid after the introduction of in vivo and imaginal
exposure, several sessions into treatment. For these patients, this stage
of therapy can be seen as feeling worse before feeling better, and their
symptoms may directly reflect this. With extremely avoidant patients, it
can be helpful to predict early on that this pattern may happen and to
let them know that increases in PTSD symptoms during treatment are
temporary, that they are not indicative or a poor treatment outcome,
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and that they actually mean that work is being done and the trauma
memory is being activated and processed.
When struggles with avoidance are evident, acknowledge the patients
distress and urges to avoid, and label them as a symptom of PTSD. At
the same time, remind the patient that while avoidance reduces anxiety
in the short term, in the long run it maintains fear and prevents the
patient from learning that the avoided situations (or thoughts, memories, impulses, images) are not harmful or dangerous.
In some cases of repeated avoidant behavior, reiterating the exposure
rationale, while important, may not be enough. In addition, metaphors or analogies can be useful tools in helping the patient to overcome avoidance. For example, we sometimes describe this struggle as
sitting on a fence between exposure and avoidance. We acknowledge
the difficulty of getting off the fence but stress that sitting on it prolongs the fear and slows progress. We sometimes encourage the patient
to invite the feeling of anxiety in the service of mastery and recovery, rather than only having it triggered against ones will. One of the
primary aims of prolonged exposure is to help the patient learn that
while anxiety is uncomfortable, it is not dangerous. Treatment involves
learning to tolerate the anxiety induced by facing rather than avoiding
trauma-related feared situations and memories.
For highly avoidant patients, the memory can be hand-written in session (see section 4 for more details).
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 driving 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 identify the trauma that you and your patient will use in imaginal exposure,
you and your patient should determine the beginning and end points of
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the trauma. Try not to wait until session 4 to determine the index trauma
and the beginning and end points.
Improvements with the Most Severe Trauma Will Likely

Generalize to Other Trauma Memories
If the patient does experience significant improvement in response to
one trauma and there is sufficient time left in therapy, you may consider
working on a second trauma. Our experience has been that, in general,
it takes all of the imaginal exposure sessions in this treatment to fully
work through the index trauma. Be cautious about starting to work on
another trauma too soon. Instead, it is better to err on the side of caution and be sure the patient has fully processed the index trauma before
moving on to another trauma prematurely. If you do decide to move on
to another trauma, make sure you have an ample number of sessions to
work on a second trauma (i.e., three or more sessions).
6. Anger and Other Negative Emotions

While exposure therapy was originally conceived as a treatment for
the reduction of excessive or pathological anxiety, our experience over
years of treating PTSD sufferers has taught us that prolonged exposure
facilitates the emotional processing of much more than fear and anxiety. Strong emotions are often stirred and activated in the process of
prolonged exposure. Patients commonly report feelings of anger, rage,
sadness, grief, shame, and guilt during imaginal exposure and at other
points in processing their traumas.
The experience and expression of intense anger during the revisiting
of the traumatic memory may interfere with emotional processing
by dominating the patients affect and preventing engagement with
other emotions such as fear, guilt, or shame. Accordingly, in the treatment of PTSD, when a patient primarily expresses anger and rage, we
first validate that feeling as an appropriate response to trauma and as
a symptom of PTSD. We then present the idea that focusing on the
anger during exposure may prevent the patient from engaging with the
fear and anxiety associated with the trauma memory and thus impede
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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 experience. 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
etal. (2003) found that anger does not interfere with the patients ability to improve with prolonged exposure. In fact, prolonged exposure
was found to reduce anger, shame, guilt, depression, and general anxiety. Patients will likely experience a reduction in anger even though the
treatment is focused on reduction of fear (Cahill, Rauch, Hembree, and
Foa, 2003).
We have come to know prolonged exposure as a powerful vehicle for
eliciting and emotionally processing an array of intense emotional
responses to trauma and its aftermath. These varied emotions and
the thoughts and beliefs they are associated with are discussed in the
post-imaginal exposure processing part of the session, as the therapist
tries to help the patient incorporate them in developing a more realistic,
helpful perspective on the traumatic event(s).
7. Chaos and Crises:Maintaining the Focus of Treatment

Comorbidity of other psychiatric disorders with PTSD/SUD patients
is high. Depression, dysthymia, and other anxiety disorders are common. In addition, PTSD/SUD patients often face multiple life stressors, leading to chaotic lifestyles. Crises during treatment are therefore
quite usual, especially if early or multiple traumatic experiences have
interfered with the development of healthy coping skills. Poorly modulated affect, self-destructive impulse-control problems (e.g., alcohol
binges, risky behaviors), numerous conflicts with family members
or others, and severe depression with suicidal ideation are common.
These problems require attention but can potentially disrupt the focus
of treatment. If careful pre-treatment assessment has determined that
chronic PTSD is among the patients primary problems, our approach
is to maintain the focus on PTSD, with periodic reassessment of other
problem areas as needed.
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If the patients mood or behavior causes imminent concern about her

personal safety or the safety of others, the need to attend to this prominent risk may require postponing prolonged exposure. However, if a
crisis arises without imminent risk, we explain to the patient that adhering 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 patients 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 predict that these situations will improve as the patients 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 emotional support throughout the crises and at the same time keep PTSD
and addiction the major foci of treatment.
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CHAPTER7
Session 5: Imaginal
Exposure Continued and
Planning for Emergencies
MATERIALS
Patient Workbook)
Personal Emergency Plan handout
SESSION OUTLINE
2. Review homework
3. Discuss imaginal exposure rationale
4. Conduct and process the imaginal exposure
5. Planning for emergencies
6. Assign homework
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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.
Review the in vivo and imaginal homework. Go over the patients
invivo rating form and imaginal exposure practice exercise sheet. Ask
the patient what she learned from doing the exposures. Pay attention to
whether she is staying in the situation long enough, documenting her
SUDS ratings, and so on. Pay attention to any safety behaviors that
the patient may be using during the in vivo and imaginal exercises (e.g.,
alcohol or other drug use, distracting herself during the exposure, carrying an object she feels will protect her). Help the patient to plan the
next in vivo exercises without using any safety behaviors. Pay particular
attention to any substance use before, during, or after exposures. Assign
the next in vivo exercises at this time.
3. Discuss Imaginal Exposure Rationale

In sessions 411 you will conduct the imaginal exposure procedure
and process it with your patient. You will want to spend at least
30minutes conducting the imaginal exposure and have about 1015
minutes afterward for processing. The remaining 3045 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. Conduct and Process the Imaginal Exposure

Conduct the Second Imaginal Exposure
For the second imaginal exposure, which you will conduct in todays
session, encourage your patient to slow down and include even more
details.
Today we will again spend some time again, about 3045 minutes, revisiting the memory of [index trauma]. Iwould 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 thinking. Just like last time, Iwill ask you to give me your SUDS ratings on the
0100 scale every 5 minutes. When Iask 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.
Continue the imaginal exposure for 3045 minutes without interruption. The length of time spent revisiting the trauma (or number of
repetitions) will depend on how long patients take to go through the
narratives and on their patterns of SUDS levels. In general, you want to
have the patient repeat the narrative until distress levels decrease. Even
if such habituation does not occur within a session, the revisiting of the
trauma memory should be terminated early enough that sufficient time
(1015 minutes) remains to process the experience with the patient.
During processing, the patients distress will decrease.
Sometimes patients struggle with revisiting the memory and expressing
their emotions during the imaginal exposure. If a patient has particular
difficulty with a specific part of the memory, it may help to discuss
with the patient, prior to the exposure, his reluctance to engage with
or express feelings about it. For example, a therapist remarked to one
patient who had difficulty expressing strong emotions:
The last two sessions that you revisited the memory of your trauma, Inoticed
that you seemed to have difficulty really letting yourself feel your feelings.
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Iwant 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 Ican 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
Patients who have difficulty accessing or expressing trauma-related feelings are sometimes under-engaged. See the end of session 4 (Chapter6)
for ways to help these patients increase emotional engagement through
modification of the imaginal exposure procedures.
Process the Second Imaginal Exposure

As described in detail in session 4, you will process the imaginal exposure
with the patient after he has finished revisiting the trauma. Usually, as
treatment progresses and the patient gains a new perspective and more
insight on the trauma, this post-exposure discussion takes less time than
it does in earlier sessions. However, sometimes new material emerges as
patients identify the most terrifying moments (hot spots) of the traumatic incidents, such as, I thought the next time my parents would see
me Iwould be in a coffin, or I was worried he would hit me in the eyes
and blind me and then, even if Isurvived, Id never be able to work again.
Sometimes patients will also realize over time that the index trauma
reminds them of earlier traumas. For example, a veteran who experienced an explosion while deployed was reminded of a time when he was
a child and experienced severe burns after a flammable can of spray paint
caught fire and exploded. Or a patient who was raped as an adult might be
reminded of times when she was raped as a adolescent. This is the natural
way that our memory works. You can help normalize this for the patient.
5. Planning for Emergencies

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
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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 challenging but you made it through it. Iwant 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 patients specific
triggers).
Stressful Life Events

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 vulnerable 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.
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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.
Emergency Coping Plan

Have a plan for coping with high-risk situations so that you are not
caught off-guard. Lets spend a few minutes talking about what your
plan will be.
Begin to prepare an emergency coping plan to help the patient handle
any number of possible stressful situations that may arise. Provide the
patient with the Personal Emergency Plan (Form 19) and review it
together in session.
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.
Discuss with the patient:
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 devils 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.
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Therapist Note
If the patient chooses to list relatives/friends on his support list, remind
him that it is a good idea to talk to these people ahead of time to explain
what type of support he is hoping to receive from them (e.g., distraction,
general chat, reminders that he is strong and can resist using alcohol or
drugs).
Lapse Versus Relapse

Therapist Note
This section is most applicable for patients with a goal of abstinence.
Lapses (or slips) are common in the recovery process. Although
lapses are not always a part of recovery, they are for a significant
amount of patients. While lapses are disappointing, they do not
mean failure or indicate an inability to change. The patients challenge is to learn from the lapse and develop a plan to prevent it from
happening again in the future.
Review with the patient the difference between a lapse and a relapse.
For example, if the patient drinks one beer, but then leaves the situation 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 consequences 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 doesnt
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
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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, Iwant to discuss ways that you can cope with a
lapse should one occur. Iwant 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 happen to everyone in recovery but they are common, so Iwant 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?
Lets think about what you could do immediately after a lapse (allow the
patient to generate suggestions first):
Remove yourself from the situation/setting immediately. How could
you do this?
Call someone for help immediately. Whom could you call?
Get rid of any alcohol or drugs immediately. How could you do this?
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
The patient may want to discard drug paraphernalia by throwing it in
the trash can or woods near his home; discourage this so that the patient
will not be tempted to go searching for it when having a craving and so
that others will not find it. Suggest that the patient permanently disable
the device (e.g., crush the pipe) and get rid of alcohol (e.g., pour it down
the drain).
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If a lapse does occur, it is likely to be accompanied by feelings of guilt

and shame, and thoughts such as Ive 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:
Unhelpful thought:Ive blown it.
Helpful thought:I had a setback, but Ican and will get back on track.
Unhelpful thought:I knew Iwouldnt be able to stop.
Helpful thought:I have made some really important changes already;
this is only a speed bump.
Unhelpful thought:Ive messed up so Imight as well keep going.
Helpful thought:I can learn from this and get back on track. Iwill not
let this one slip jeopardize my entire recovery.
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, Ive
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.
Discussion of lapses is designed to help patients plan more effective
coping responses, to renew their commitment, and to view such incidents as learning opportunities.
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6. Assign Homework


140

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 (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.
Complete the Personal Emergency Plan (Form 19 at the end of
the Patient Workbook).
CHAPTER8
Session 6: Imaginal
Exposure Continued
andAwareness
of High-Risk Thoughts
MATERIALS
Patient Workbook)
In vivo Exposure Data Form (Form 17 at the end of the Patient
Workbook)
Awareness of High-Risk Thoughts (Form 20 at the end of the Patient
Workbook)
SESSION OUTLINE
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
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
with the patient.
in vivo rating form and imaginal exposure practice exercise sheet. Ask
the patient what he learned from doing the exposures. Pay attention to
whether he is staying in the situation long enough, documenting his
the patient may be using in the in vivo and imaginal exercises (e.g.,
alcohol or other drug use, distracting himself during the exposure, carrying an object he feels will protect him). Help the patient to plan the
attention to any substance use before and after exposures. Assign the
next in vivo exercises at this time.
3. Substance Abuse Specific Check-In

At session 6, which is midway through the treatment program, take
a moment to check in with the patient with regard to overall progress
with reducing/stopping substance use during the first half of treatment.
Is the patient making progress toward her substance abuse goals? Or is
little change occurring?
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If the Patients Substance Use Is Improving

Highlight this fact and offer ample praise.
Inquire about the patients perspective (e.g., how does it feel now that
she is using less/abstinent?).
Ask the patient to identify the skills or techniques that she is primarily using in order to make this progress. Emphasize those skills and
encourage her to continuing using them.
Where possible, link improvements in substance use to improvements in PTSD symptoms (e.g., I noticed that as your substance
use decreased you started sleeping better. Do you think those are
related?).
Discuss substance abuse specific goals for the next 6 sessions and
determine if the patient wants to continue with those same substance
abuse goals or revise them.
If the Patients Substance Use Is Not Improving

Discuss this with the patient in an empathetic and nonjudgmental
manner.
Inquire about the patients perspective (How does he feel about his
current drinking or drug use? Is his current level of substance use consistent with the goals he made in session 1?). Be sure that the original
substance abuse goals established in session 1 were realistic. If necessary, revise the goals to make them more realistic and achievable. Ask
the patient how committed he is to these goals (scale of 010).
Ask the patient to help you identify obstacles that may be getting
in the way of substance use improvements (What do you think is
currently going on that makes it difficult for you to reduce/stop your
use? How can you handle these situations differently?). Common
obstacles might include living with a partner who drinks and who
insists on keeping alcohol in the house, having a hard time saying no to friends, working at a restaurant or bar where alcohol is
served, lack of clean and sober friends with whom to hang out.
Help to strengthen the patients commitment to significantly reducing/stopping substance use by reviewing what is truly valued or
important for him, or how he would like to see his life in a year from
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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.
4. Conduct and Process Imaginal Exposure

In sessions 411 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 1015 minutes afterward for processing. The remaining 3045 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 imaginal exposure with the patient. Beginning at this session or the next session, 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.
Hot Spots Procedure

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 habituation) to the relatively less-distressing parts of the memory has begun
to occur. In the session in which the hot spots procedure is introduced
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(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 its important to focus directly on the hot spots. In a minute
Iwill 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,
Iwill 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 patients 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 somewhat 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 patients hot spots during the imaginal exposure until
each has been sufficiently processed, as reflected by diminished SUDS
levels and the patients behavior (e.g., body movement, facial expression). This may take more than one session per hot spot, depending on
the patients 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
Note on multiple traumas:Most of our patients have experienced multiple traumas, during childhood and adulthood. For some patients
with histories of multiple traumas or repeated incidents of a particular trauma (e.g., childhood sexual abuse, combat experience), it may
be necessary to focus the imaginal exposures on more than one trauma.
However, do not move on to a second trauma until sufficient reduction
of anxiety and distress is evident with the first trauma. Because we focus
the initial revisiting on the worst trauma memory, or the one that is
causing the most re-experiencing and avoidance symptoms, the benefits
of working through this memory most of the time will generalize to the
other trauma memories. But if another memory remains significantly
distressing, devote some sessions to working on the second trauma as well.
Most of the time, therapy will only focus on one trauma.
5. Awareness of High-Risk Thoughts

Patients may initially be unaware of the thoughts that precede the decision 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.
To help patients begin to grasp cognitive concepts, the idea of slowing down the tape (as in an instant replay on TV or a slow-motion
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 ones thoughts can then be more
readily introduced.
How Thoughts Impact Feelings and Behavior

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 relapsea state of mind characterized by certain dangerous patterns of thinking.
With practice you can train your mind to dismiss high-risk thinking whenever it occurs, to recognize it for what it is, and to realize that its 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
Figure8.1
147
you will have fewer thoughts about using, and they will be less intense when
they do happen.
Common High-Risk Thoughts

As you begin this section of the session, you will be referring to
Awareness of High-Risk Thoughts (Form 20 at the end of the Patient
Workbook). Review some of the common high-risk thoughts. You do
not have to cover every single one. Focus on the ones most relevant to
your patient and discuss these with your patient.
Lets talk about high-risk thoughtsthese 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
Individuals may wish to avoid the discomfort caused by unpleasant situations, conflicts, or memories. Failure, rejection, disappointment, hurt,
humiliation, embarrassment, and sadness all tend to demand relief.
People may be tired of feeling hassled, lousy, and upset. They just want
to get away from it all and, more to the point, from themselves. It is not
necessarily the high that is sought; rather, it is numbness, the absence of
emotional pain, problems, and feelings. People with PTSD in particular
may wish to block out their trauma memories and try and forget what
happened. Wanting to escape from the stresses of daily life or from negative
emotions for a bit is normal, and everyone needs to have healthy ways to
do that from time to time.
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 problems when the person has expectations of this happening immediately, and
without having to do something relaxing. Rather than engage in an enjoyable 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.
Everyone needs to be able to relax. The problem with using alcohol or
drugs to relax is that although you may feel that it relaxes you for a
short period of time, it does not help you relax in the long term because
it creates so many other problems, which only add more stress. In addition, alcohol and drugs impair your bodys natural stress response system
(the hypothalamic-pituitary-adrenal axis). Research clearly shows that
chronic use of alcohol or drugs makes your bodys natural stress response
system less effective at adapting to stress. So while you may be trying your
best to relax, alcohol and drugs only make it harder for you to relax in
the long run.
What are some healthy ways you can relax when you need to? (e.g., exercise, 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 awkwardness 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., exercise 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 dont 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).
Its 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
Sometimes after a period of successful abstinence, people in recovery
become overconfident and want to test their control over substances. For
example, I wonder if I am strong enough to leave some alcohol in the
house, just for friends who come over? or I bet Ican have just one drink;
no one will ever know. Testing control is never a good idea. If you have
thoughts of wanting to test your control over drugs or alcohol, recognize it
as a sign that you are headed toward relapse and take action to prevent it.
While you want to have some level of confidence in your ability to combat addiction, you do not want to be overconfident. Addiction is a very
powerful disease, and most people who have tried to test themselves end up
failing. It is not simply a matter of will power. Patients with PTSD may be
particularly susceptible to this, as both PTSD and substance use disorders
are characterized by loss of control. The patient was helpless and unable to
control what was happening during the trauma, has been unable to control the PTSD symptoms since the trauma, and has been unable to control
his or her substance use.
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
Another issue is related to overconfidence:Sometimes when people experience a significant reduction in their PTSD symptoms they start to feel
better and think it means that they can now drink or use drugs socially
or recreationally. For the vast majority of our patients, however, their
addiction has taken on a life of its own, and their use is triggered by
other things in addition to trauma-related triggers or PTSD symptoms
(e.g., holidays and celebrations, sporting events, bars where they used in
the past, seeing other people use). Just because their PTSD symptoms are
improving and they feel better does not necessarily mean that they will be
able to control their substance use and drink like everyone else.
Crisis
During stressful situations or crises, people in recovery may say, I need
a drink to get through this or I cant handle this or I went through so
much, Ideserve a line or Once this is all over, I ll be able to stop using
again but not right now. They do not feel that they have other options to
effectively cope with stress, and they underestimate the harm and additional stress that using will bring. People with PTSD may also use to help
self-medicate stress and symptoms associated with their trauma.
What are some healthy ways you can manage crises in the future? (e.g.,
engage in daily wellness activitieslike eating well, getting rest, exercise,
pleasant activitiesto 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
When individuals become unhappy with themselves, feel inferior to others,
or feel unattractive or deficient, they may begin to think of alcohol or drugs
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 feeling inadequate, weak, damaged, like a bad person or a failure, responsible 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).
Feeling Uncomfortable When Abstinent or Clean

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:Im being very short-tempered and irritable
around my familymaybe its more important for me to be a good-natured
parent and spouse than it is for me to stop using drugs right now, or Im
no fun to be around when Im not high. Idont think Ishould stop using
drugs because if Ido, people wont 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
dont 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 education; remember how far you have come and dont let this situation get
the best of you).
Therapist Note
Help your patients identify their common high-risk ways of thinking.
Keep in mind that although it may appear that the entirety of a patients
alcohol or drug use is in direct response to the trauma and PTSD symptoms, it is important to include all situations that trigger thoughts about
using, both those that are trauma-related and those that are not related
to trauma. Patients may get the false message that if they have developed
good coping skills to deal with their PTSD symptoms or if they no longer meet criteria for PTSD, they can drink socially or use now without
concern. While substance abuse may begin in response to trauma/PTSD
for many patients, or may be exacerbated by the PTSD symptoms, it
has often taken on a life of its own by the time patients seek treatment
(which can be 10years after the traumatic event for some patients).
Which of these high-risk thoughts do you relate to?
Which thoughts seem to be the most frequent or strongest for you?
What thoughts preceded your last relapse after a period of abstinence?
153
6. Assign Homework


154

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 Awareness of High-Risk Thoughts (Form 20 at the end of
the Patient Workbook)
CHAPTER9
Session 7: Imaginal
Exposure Continued
andManaging High-Risk
Thoughts
MATERIALS
In vivo Hierarchy Form that patient started in session 3
Workbook)
Patient Workbook)
The ABC Model (Form 21 at the end of the Patient Workbook)
Managing Thoughts About Using (Form 22 at the end of the Patient
Workbook)
SESSION OUTLINE
2. Review homework
4. Managing high-risk thoughts
5. Assign homework
155
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.
the patient what she learned from doing the exposures. Pay attention
to whether she is staying in the situation long enough, documenting
her SUDS ratings, and so on. Pay attention to any safety behaviors
that the patient may be using in the in vivo and imaginal exercises (e.g.,

and process it with your patient. You will want to spend at least 30
minutes conducting the imaginal exposure and have about 10 minutes
afterward for processing. The remaining 3045 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.
Conduct imaginal exposure and processing (see session 4 for instructions and session 6 for Hot Spots instructions).
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).
Last session we talked about identifying high-risk thoughts about using.
Today, were going to work on learning how to manage those thoughts.
The ABC Model (Form 21)can help us understand how this works (see
Figure 9.1).
Often people think that Acauses C.For example, they run into a former
using buddy (A)and they think thats 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 its actually B, a persons beliefs or thoughts, that lead to C.Two different 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 cant get to C without going through B.
Activating Event
Belief
Consequences
(Something
happens)
(Your thoughts;
What you say to
yourself)
(How you feel and

behave)
Figure9.1
The ABC Model.
You run into an old

using buddy.
Feeling an intense
craving and going to
use.
Figure9.2
157
PERSON #1
A
You run into an old

using buddy.
Man, we sure did

have some good
times. I bet I could
use just one. No
one will ever
know".
C
Feeling an intense
craving and going
to use.
Figure9.3
These beliefs and thoughts occur very quickly and are automatic, but with
practice you can train your mind to interrupt the automatic thought process, identify unhelpful thoughts, and replace them with more positive,
helpful thoughts. This process is called cognitive restructuring, because
you are restructuring your thoughts.
Lets take a look at how this works, using the example we just discussed (see
Figure 9.3).
While another person might be thinking differently, as in Figure 9.4.
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., Ive come
too far to give it all up now. It doesnt matter if Ihurt his feelings or
he gets mad at me for not using; Ineed to focus on me and my recovery.
Its not worth it.)
PERSON #2
A
You run into an old

using buddy.
Figure9.4
158
I know that I
cannot have just
one. I have tried
that before and it
doesn't work. I
don't want to use.
It's not worth it.
Less craving, leaving

the situation
immediately, and
going to call a friend
or sponsor. No use.
To really change ones 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.
Here are ways to help patients challenge unhelpful thoughts:
a. Question Your Thoughts
We have a lot of thoughts that are not actually true. Its a fact that you
have thoughts, but not all thoughts are facts. So, question your thoughts.
If you are having a thought about wanting to use ask yourself, What is
the evidence for this thought? Is it REALLY true?
Some examples of challenging thoughts include:
Thought: I can have just one.
Question:Whats the evidence for that thought? What data do
Ihave that tells me that Ican have just one?
Thought: A drink sure would help me relax.
Question: Is that really true? Would a drink really help me relax, or
would it only end up leading to more stress in my life from all the
problems it would cause?
Thought: No one will ever know.
Question: Is that true? Even if it were, Iwill know; and thats what
matters. Iam doing this for me.
Thought: I want to be part of the group.
Question: Do Ireally want to be a part of this group? Ive been a
part of this group for a while and look where its gotten me. Ican
meet new people.
b. Alternative Way of Thinking
Ask yourself, Is there a more helpful way of thinking about this? (e.g.,
I can handle this. Imay feel stressed out, but its not the end of the
world. This too shall pass.)
c. Putting It Into Perspective
Ask yourself, Is it as bad as Im making it out to be? (e.g., cravings
are uncomfortable but they dont last forever, Having an argument
with my husband is stressful but we will be okay. Its annoying that
this person cut in front of me in the line, but its not worth me getting
upset about it.). Be sure not to catastrophize or make the situation
any bigger than it needs to be.
159
d. Goal-Directed Thinking
Ask yourself, Are my thoughts helping me achieve my goals? What can
Ido to change the situation? And if Icant do anything to change the
situation, what can I do to change the way I am thinking about the
situation?
In addition to using these techniques to help challenge and change your
thoughts, you can use these additional coping skills as needed, such as:

Leave the situation immediately.

Call a friend or sponsor and talk it out.
Distract yourself with a pleasant, healthy activity.
Use the Decision Delay technique.
Remind yourself of the positive benefits of not using.
Remind yourself of the negative consequences of using.
Remind yourself of how far you have come.
5. Assign Homework
how to complete the homework. If she has questions or needs help
problem-solving obstacles to completing the homework, encourage her


160


Workbook).
Review the ABC Model and Managing Thoughts About Using
(Forms 21 and 22 at the end of the Patient Workbook).
161
CHAPTER10
Session 8: Imaginal
Exposure Continued
andRefusal Skills
MATERIALS
Workbook).
Patient Workbook)
Alcohol and Drug Refusal Skills (Form 23 at the end of the Patient
Workbook)
SESSION OUTLINE
2. Review homework
4. Drug and drink refusal skills
5. Assign homework
163
in session 2.
2. Review Homework
with the patient. Congratulate the patient for his efforts to confront
whether or not he is staying in the situation long enough, documenting
his SUDS ratings, and so on. Pay attention to any safety behaviors

Conduct imaginal exposure and processing (see session 4 for instructions and session 6 for hot spots instructions).
164
4. Drug and Drink Refusal Skills

Discuss with your patient the need to be able to successfully refuse
offers for a drink or drugs.
Being offered substances by others is a high-risk situation (meaning that it
puts you at risk for wanting to use) for people who have decided to stop or
significantly reduce their use. Being able to turn down an offer for a drink
or drug requires more than a sincere decision to stop using. It requires specific assertiveness skills to act on that decision.
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 relationships. People begin to eliminate non-using friends, and their peer group
becomes populated with people who support and reinforce continued alcohol or drug use. They dont know anyone who doesnt use. Being with these
ndividuals and former using buddies increases the risk of relapse through:
Direct and indirect pressure to use
Conditioned cravings that are associated with people, places, and emotional states related to past use
Increased access and availability of substances, making it easier to use
Seeing other people using, which can be a powerful trigger
Two forms of social pressure are often experienced by people in recovery:direct and indirect pressure to use. Direct pressure occurs when someone
offers you a drink or drug directly and up front. Indirect pressure involves
returning to the same old settings (e.g., bars, parties), with the same people,
doing the same things, and experiencing the same feelings previously associated with using.
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. Avariety 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).
In what situations have you received offers or pressure to drink or use
drugs?
If youre unable to stay out of a high-risk situation, you need to be able
to effectively refuse offers to use. Refusal skills are critical to recovery, and
sometimes people become overconfident and think they are more skilled at
refusing than they actually are. Effective refusal skills will help you respond
more quickly and successfully when these kinds of situations arise.
The precise nature of a refusal to an invitation to drink or use will vary,
depending on who is offering the substance and how the offer is made.
Sometimes a simple No, thank you will be sufficient. Other times, additional strategies will be necessary. In some cases, telling the other person
about your substance abuse problem will be useful in eliciting his or her
help and support. You may need to say, Im in a program. I dont use
anymore.
Here are some important points to remember when refusing a drink or
drugs:
Nonverbal behaviors
1. Make direct eye contact with the other person to increase the effectiveness
of your message.
2. Do not feel guilty. You wont hurt anyone by not using (in fact, you can
only hurt others by using), so dont 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, Iguess 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 example, you could say, No thanks, Idont drink. You know Im glad Icame
to this family reunion. I havent seen a lot of these people in quite a
while, including you. In fact, Ive been wondering what youve been up
to lately? How are the kids?
4. Do not use excuses (e.g., Im on a medication right now or Im 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 futurea 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 times
sake. You used to drink with me all the time. What, you think youre
too good for me now? an effective response might be, Its important
for me to stay clean. If you want to be my friend, then dont 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.
167
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


168

Workbook).
Review the Alcohol and Drug Refusal Skills (Form 23 at the end
of the Patient Workbook) and complete the practice exercises.
CHAPTER11
Session 9: Imaginal
Exposure Continued
andSeemingly Irrelevant
Decisions (SIDs)
MATERIALS
Workbook)
Patient Workbook)
Seemingly Irrelevant Decisions (SIDs) (Form 24 at the end of the
Patient Workbook)
Making Safe Decisions (Form 25 at the end of the Patient Workbook)
SESSION OUTLINE
2. Review homework
4. Seemingly irrelevant decisions
5. Assign homework
169
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
invivo rating form and imaginal exposure practice exercise sheet. Ask
the patient what she learned from doing the exposures. Pay attention to
whether or not she is staying in the situation long enough, documenting
her SUDS ratings, and so on. Pay attention to any safety behaviors

Conduct imaginal exposure and processing (see session 4 for general
instructions and session 6 for hot spots instructions).
170
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 todays 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 rationalizations or minimizations of risk (e.g., I need to keep a few beers in
the refrigerator in case my neighbor comes over; just because Istopped
drinking doesnt 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).
In session, use the Seemingly Irrelevant Decisions form (Form 24 at
the end of the Patient Workbook), and ask the patient to read over the
scenario and identify as many SIDs as possible. Then, discuss each SID
with your patient and help him identify alternative choices to each SID.
To illustrate the SIDs process in session, consider the following story
about a woman named Kim, who was in early recovery.
Kim had been clean for 30days. 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 didnt 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, Ihavent seen her in so long! Kim
decided that since she had been clean for 30days, 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.
When do you think Kim first got into trouble?
What were the decisions that Kim made that may have seemed irrelevant
at the time (e.g., to take a scenic route, to go searching for a place to buy
cigarettes, to stop at the bar)?
Clearly explain to your patients that each and every choice that they
make takes them down one of two pathsthe 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 dangerous 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 Ireally 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 situations 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 landlords
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
Mikes 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.
When do you think Joe first got into trouble?
What were some of the early warning signs? (e.g., Joe was only a few
weeks clean, it was Friday, and he had money in his pockets)
What could Joe have done differently? (called ahead of time to make sure
the landlord was home, mailed the landlord a check instead)
Recognizing Seemingly Irrelevant Decisions

Discuss how to recognize SIDs with your patient:
People sometimes think of themselves as victims in these situations (e.g., I
dont know what happened. Somehow Iended up in a high-risk situation
173
and usingI couldnt help it.) They dont recognize that many of their
little decisions gradually brought them closer and closer to using. Its easy
to play Monday morning quarterback with these decisions and see how
you set yourself up for relapse, but its much harder to recognize them when
you are actually in the midst of the decision-making process. That is because
so many choices dont 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, its 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 thinking 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. Its well worth the initial effort you will have to make for the
increased control you will gain over your recovery and your life.
By paying more attention to the decision-making process, you ll have
a greater chance to interrupt the chain of decisions that could lead to a
relapse. This is important because its much easier to stop the process early
on, before you are actually in the high-risk situation, than it is later on,
when youre deep in the high-risk situation and may be exposed to a number of triggers and pressures to use.
Common Seemingly Irrelevant Decisions

Review common SIDs with your patient and find out which ones he or
she may be vulnerable to. Solicit the patients input for each of these and
ask about other patient-specific SIDs.
Here are some common SIDs. Lets go through and discuss each of these
together.
Whether or not to keep alcohol/drugs/paraphernalia in the house
Whether or not to offer a former using buddy a ride home
Whether or not to go to a certain part of town
174
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, encourage 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



175
176
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).
CHAPTER12
Session 10: Imaginal

Exposure Continued
andAnger Awareness
MATERIALS
Workbook)
Patient Workbook)
Anger Awareness (Form 26 at the end of the Patient Workbook)
Daily Wellness Strategies (Form 27 at the end of the Patient
Workbook)
SESSION OUTLINE
2. Review homework
4. Anger awareness
5. Assign homework
177
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.
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
with the patient.
whether he is staying in the situation long enough, documenting his
the patient may be using in the in vivo and imaginal exercises (e.g.,
178

and process it with your patient. You will want to spend at least 30
minutes conducting the imaginal exposure and have about 10 minutes afterward for processing. The remaining 3045 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.
Conduct imaginal exposure and processing (see session 4 for general
instructions and session 6 for hot spots instructions).
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.
Anger is common among individuals with PTSD. Patients may feel
anger for a variety of reasons (e.g., anger toward their perpetrator or
toward themselves for what happened, anger toward society or the
world in general, anger for the part of themselves that they lost after
the trauma, anger at loved ones for their reactions, or anger at their
inability to get over it and move on with life). Thus, PTSD/SUD
patients need to know how to deal with anger in a healthy way, as
opposed to using alcohol or drugs to cope.
Anger may also be particularly relevant for military personnel and
Veterans. Some military personnel may believe that the only feeling
or emotion that is really acceptable for them to feel or express is
anger. Therefore, the feeling of anger may be quite salient and intense
for them, and/or anger may be used to mask other less acceptable
179
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 situations, or at themselves for being weak and having PTSD symptoms
that they cannot control.
For the rest of todays 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 peoples reactions to the trauma, about the fact that they have PTSD). Because anger
is a normal human emotion, its important to learn new, healthy ways
of coping with anger.
Have you ever used because you were mad or angry?
What have been some of the negative consequences of your anger (e.g.,
have you gone to jail, have you said something to someone in the heat of
the moment that you later regretted, have you hurt someone physically
because you were angry)?
Constructive and Destructive Effects of Anger

Review the following information on constructive and destructive
anger with your patient. Use examples provided by the patient to make
the discussion more relevant whenever possible.
Is anger normal? Yesanger is a normal human emotion. Is anger always
bad? Well no, not always. Anger itself is neither good nor bad. It can be
an intense feeling, and the reaction to that feeling can be constructive or
destructive.
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Constructive Effects of Anger

When can anger be good? When can it result in a positive outcome?
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 situations 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 without exploding at others, losing your cool, or saying or doing things that
you will later regret.
Destructive Effects of Anger

When is anger bad? When can it result in a negative outcome?
a. Anger can cause mental confusion and lead to poor decision-making
and acting without thinking first. You cannot think clearly when youre
angry. When angry, you are more likely to react to the situation, as
opposed to responding to it thoughtfully. Thats why its so important
to first cool down; then you can think about the situation with a clear
mind.
b. Aggressive reactions (e.g., where you approach the situation with physical violence, verbal threats, demands or bullying) harm relationships,
hurt others, elicit hostility in others, and can lead to negative consequences (e.g., incarceration, hospital).
c. Passive reactions (i.e., where you approach the situation by not saying
anything, by keeping the anger bottled up inside) can leave one feeling
181
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.
Triggers for Anger

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.
In what situations do you experience anger?
You can think of anger as being on an Anger Thermometer using a scale of
0 to 10, with 0 being totally calm and 10 being full of rage and out of control. (See Form 26, Anger Awareness, at the end of the Patient Workbook.)
Internal and External Signs of Anger

The next step is to become aware of your signs that youre starting to get
angry. Common signs include:
Physical reactions:Do you feel muscle tension in your jaw or neck? Do
you get a headache? Do you experience a pounding heart, start sweating
or shaking, breathe more rapidly? What are your early physical reactions
(e.g., before you are a 5 on the Anger Thermometer)?
Trouble falling asleep:This may be due to angry thoughts and feelings
stored up during the day. You may find yourself ruminating about a situation and unable to stop thinking about it.
Feeling helpless or depressed:This can also be a sign of anger. It may be
that past attempts to express anger have not been effective. You may have
given up trying and may become depressed.
182
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. Its much easier if you
can catch it early on and take action to prevent it from escalating.
Therapist Note
Many individuals with PTSD/SUD have difficulty managing and
expressing anger. They may be particularly uncomfortable with anger
expression because of previous situations when they used alcohol or drugs
in which an extreme expression of anger occurred. They may have overreacted or managed to get others very angry at them. In other cases, a
family history of substance abuse, violence, or child neglect or abuse may
be relevant. Clinicians may have to draw out individuals to help them
feel comfortable discussing the topic. In addition, some patients have a
very hard time recognizing the early signs of anger and say they simply
go from 0 to 10. Help them to slow down the action and slow down
the thoughts so that they can better learn to identify these early signs.
Coping with Triggers for Anger

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, Iwant to review the importance
of practicing daily wellness activities and establishing an anger policy.
Practice Daily Wellness

Recommend that the patient engage in activities and behaviors each
day in order to help keep his baseline level of agitation low.
183
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
belowa5)on the Anger Thermometer scale. These daily activities include:

Maintaining a healthy diet

Limiting caffeine and sugar intake
Getting enough sleep
Taking your medications as prescribed
Exercising
Practicing breathing retraining
Engaging in pleasant activities
Develop an Anger Policy

Encourage your patient to develop an anger policy:
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


184


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).
185
CHAPTER13
Session 11: Final Imaginal

Exposure and Anger
Management
MATERIALS
In vivo Hierarchy Form that patient started in Session 3
Workbook)
Patient Workbook)
Coping with Anger (Form 28 at the end of the Patient Workbook)
SESSION OUTLINE
2. Review homework
3. Conduct and process final imaginal exposure
4. Anger management strategies
5. Assign homework
187
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.
in Session 2.
2. Review Homework
with the patient. Congratulate the patient for his efforts to confront
whether the patient is staying in the situation long enough, documenting his SUDS ratings, and so on. Pay attention to any safety behaviors
final in vivo exercises at this time.
3. Conduct and Process Final Imaginal Exposure
Conduct the final imaginal exposure and processing. In this last
imaginal exposure, have the patient revisit the entire trauma memory
188
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.
4. Anger Management Strategies

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 its a normal human
emotion and it isnt necessarily bad. However, anger can be a powerful
emotion and it can be a trigger for relapse. Therefore, its important to
know how to manage anger in a healthy way. We discussed anger awareness, which focused on increasing your awareness of (1)anger triggers and
(2)internal and external warning signs that youre 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.
Cool Down and Then Assess the Situation

Review with the patient the following four steps for what to do when
he or she getsangry.
1. When a person is angry, it can be very hard to think clearly or rationally. The higher you get on the Anger Thermometer (look back at Form
26, Anger Awareness), the harder it is to make good decisions. When a
person is at a 5 or above, for example, making good decisions can be very
hard, if not impossible. Therefore, you want to first take a time-out
and cool down before you do anything else.
To help you cool down:
Leave the situation. Though it may be hard to do, walk away.
189
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 youve 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 Iangry because Im 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
190
your expectations of other people, and relax your judgments of others,

too. Focus on yourself and your recovery and worry less about what others 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 Ido?
Is it really worth it, or should Ilet 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, someone cuts in line in front of you at the grocery store, your roommate doesnt 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 anxiety, 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 Ireally going to remember this or care about it in
a month, a year, 5years from now? The vast majority of times, the
answer is going to be no. Encourage your patient to practice letting 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 cant fix everything. There will be some
situations in which you will have to accept the outcome. In those situations, 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 necessarily the outcomeits 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, thats success.
191
Activating
Event
Belief
Consequences
(Something
happens)
(Your thoughts;
What you say to
yourself)
(How you feel and

behave)
Figure13.1
If you did actually resolve the problem, congratulate yourself:I handled that one pretty well. Im doing better at this all the time.
Challenge Your Thoughts

You can also use cognitive restructuring techniques to help you manage
anger. Earlier in the program we talked about how events lead to certain 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 its
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:Imust have done something wrong. She is mad at me again
and were 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?
192
5. Assign Homework



Workbook).
Review the Coping with Anger form (Form 28 at the end of the
Patient Workbook).
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CHAPTER14
Session 12: Review

andTermination
MATERIALS
In vivo Hierarchy Form that patient started in session 3
COPE Program Treatment Contract (Form 1 at the end of the Patient
Workbook) signed at the beginning of therapy with initial goals
Early Warning Signs (Form 29 at the end of the Patient Workbook)
My Next Steps (Form 30 at the end of the Patient Workbook)
Certificate of Completion (Appendix D at the end of this Therapist
Guide)
AGENDA
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 patients 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
195
again). Compare the baseline scores on PTSD and SUD measurements

with the scores from today and point out to the patient where positive 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
12sessions, but it is also likely, given the clinical severity and complexity 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 rehabilitation office, getting a sponsor in AA or NA, continuing to work on
avoidance symptoms related to the trauma).
Review the patients 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
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.
3. Termination
Evaluate and discuss the patients 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.
196
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 youve
learned. I d also like to take a few minutes to thank you for the opportunity to work together and to say goodbye. Weve been working together to
help you process what happened during the trauma, to stop/reduce your
substance use, and to develop healthy coping skills. Youve worked really
hard during the program, and Im 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 treatment aftercare plans.
Review the Patients Progress
PTSD Symptoms and In vivo Exposures

Review the PTSD-related goals that were generated in session 1 and
written down on the Treatment Contract. Show the patient a graph of
his weekly or monthly PTSD symptoms (e.g., PCL or CAPS scores)
over the course of therapy. You can simply draw it on a piece of paper
or enter the scores into an Excel or other type of spreadsheet and print
it out before the session. It can be very powerful for patients to actually see (and take with them) a visual of these changes. Ask the patient,
What do you think about this change?
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?
197
Note improvements in those situations that changed significantly.

Discuss the situations for which the patients 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 didnt do before
the program?
What have you noticed about your level of anxiety or discomfort in certain 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 negative 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
198
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 cravings and triggers, and to articulate skills that she has learned to help
reduce/stop substanceuse.
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?
You will also want to ask questions related to the interrelationship of
substance use and PTSD symptoms.
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?
General Areas of Improvement

Discuss the gains made in various areas of the patients 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 lifes
problems without having to rely on you for support.
Emphasize that it is about continual progress, not perfection. Emphasize
that patients should use and practice these healthy coping skills for the
rest of their lives. By identifying instances when your patients have used
the new skills, perhaps to manage a craving or to cope with intense
PTSD symptoms, you will help build self-efficacy and allow patients to
positively recall examples where they were successful.
199
Considering the Need for More Treatment

If indicated, discuss options for referral for further treatment. Referral
for additional treatment may be needed if the patient:
1. Continues to suffer from PTSD symptoms (e.g., fails to demonstrate
70% or more reduction in PTSD symptoms from beginning to end
of treatment, or scores a 50 or higher on the CAPS);
2. Exhibits unsafe or unhealthy alcohol use (e.g., uses more than the
NIAAA guidelines of what is medically safe, which is no more than
4 drinks/day or 14 drinks/week for men, and no more than 3 drinks/
day or 7 drinks/week for women);
3. Continues to use illicit drugs;
4. Suffers from depression (e.g., a 17 or greater on the BDI); or
5. Has frequent or severe conflict with his or her partner or children,
and would benefit from couples or family therapy.
Unless immediate therapy is necessary, encourage the patient to try to
use the skills learned in therapy over the next several months and to call
you if she runs into difficulties. You could also set up a booster session
for 46 weeks and have the patient check in with you at that time.
Working on New Areas

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 lifes 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 continue 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
Prepare your patients for the likelihood of a temporary increase in
PTSD and cravings or thoughts about using when under significant
stress, such as the anniversary of the trauma or more general difficulties
at work or at home.
Its 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. Its important to
then put this in perspective and begin using the tools youve learned in this
program.
What will you do if 2months 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?
Using Form 29 (Early Warning Signs), increase your patients awareness of signs that might indicate the need to seek professional help in
the future (e.g., having increased thoughts about using, having worsening PTSD symptoms, skipping AA/NA meetings or other appointments, isolating).
4. Feedback
Patients should be encouraged to provide comments, both positive and
negative, regarding their reactions to the therapy experience as a whole
and to the therapist in particular. This feedback should include recommendations to improve the treatment protocol as well as comments on
the therapists style. Since they are less accustomed to this role, patients
may require some prompting to carry on this aspect of the discussion.
You should ask about experiences that may have been especially helpful
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
Most patients will utilize this opportunity to provide appropriate, helpful feedback that will encourage growth and/or refinements in the program and therapeutic style. In rare instances, a patient may abuse this
opportunity, but prompt, assertive intervention can turn destructive
criticism into an opportunity to model important skills to the patient.
In general, what do you feel helped you the most in therapy?
What do you feel did not help you so much?
Do you have any recommendations that may help in treating others with
PTSD and alcohol or drug problems?
5. Saying Goodbye
Working with individuals to process their trauma and increase control over their substance abuse can be emotionally intense for both
the patients and the therapist. Not surprisingly, terminating therapy
can be hard. Indeed, for many patients, reminding them throughout
therapy of the relatively short-term nature of the work you are doing
together can be useful. Take time to offer the patient feedback and to
say goodbye.
You did a great job with this challenging treatment. Ihave 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 treatment. 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 Iam 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 session can increase the patients 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 difficulties. As stated earlier, you can always set up a booster session for 46
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 appointment to catch up and review coping skills, even for patients who continue to do well with regard to both PTSD and SUD symptoms.
Provide ample praise for the patients courage in seeking and staying in
treatment. Focus on the gains and highlight the patients courage and
areas of strength and resiliency.
Present the patient with a Certificate of Completion (Appendix D
in this Therapist Guide) to take with him or her, as well as the My
Next Steps form (Form 30 at the end of the Patient Workbook) and
the Early Warning Signs form (Form 29 at the end of the Patient
Workbook) that might indicate the need to seek additional professional
help for substance use or other problems.
203
Appendices
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
205
Appendix A
Information Gathering Form
(for Therapist use in Session1)
Note: This form is to be used as a means of outlining and summarizing important information about the patient.
Name:
Date:
Age:
Race:
Gender:
I. Chief ComplaintWhat Brings the Patient in for Treatment Now?
207
II. Overall Level of Functioning

Education level:
Employment status:
Major medical problems:
Medications and reason for taking each:
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?):
Social support, including friends, family, partner, AA or NA sponsor, etc:
Legal problems:
209
Any other current treatments:
III. Substance Use

Current substance use (e.g., which substance(s) using, frequency and amount of use, date of
last use):
Substance of choice:
Age of onset of substance use:
210
Family history of substance use disorders:
History of substance abuse treatment, including detoxification, and outcome:
Problems experienced as a result of substance use (e.g., legal, family/social, physical health,
mental health, employment, education, financial):
Need for detoxification before beginning COPE therapy?
211
IV. Trauma/PTSD
Type of trauma(s) experienced during lifetime:
Age of onset of trauma(s):
Brief description of index trauma (i.e., the trauma that is causing the most re-experiencing
and avoidance symtpoms now):
History of trauma-focused/PTSD treatment and outcome:
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 Iwill not attempt to harm myself. Ipromise
that Iwill not attempt to commit suicide. Ipromise that Iwill not participate in any activity
that could result in my intentionally causing harm or death to myself.
If Ihave thoughts of suicide or feel like Iwant to hurt or kill myself, Ipromiseto:
A. Call 911 if Iam in immediate danger of harming myself.
B. Call the following support people or agencies if Iam feeling suicidal, but do not feel that
Iwill cause harm to myself immediately:
Support Persons Name:
Phone Number:
Support Persons Name:
Phone Number:
My Therapists Name:
Phone Number:
Local Crisis Line Number:

National Suicide Prevention at 1-800-273-TALK (8255)

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
Therapist Imaginal Exposure
RecordingForm
Date:
Subject #:
Session #:
Exposure #:
Trauma #:
Brief description of the incident being recounted during the imaginal exposure:
Start time:

End time:
SUDS
Craving
Beginning
5 min.
10 min.
15 min.
20 min.
25 min.
30 min.
35 min.
40 min.
45 min.
Notes

Processing Notes:
217
Appendix D
Certification of Completion
219
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About the Authors
Sudie E.Back, PhD, is a Professor in the Department of Psychiatry

and Behavioral Sciences at the Medical University of South Carolina,
and a Staff Psychologist at the Ralph H.Johnson Veterans Affairs (VA)
Medical Center in Charleston, South Carolina. She is Director of the
NIDA-sponsored Drug Abuse Research Training (DART) residency
and summer research programs at the Medical University of South
Carolina. Dr.Back received her PhD in Clinical Psychology from the
University of Georgia and completed her internship at Yale University,
specializing in the treatment of substance use disorders. Her research
interests include the development of effective treatment of substance
use disorders and comorbid conditions, in particular, posttraumatic
stress disorder (PTSD). Along with Dr.Killeen, she has trained numerous therapists in the United States and internationally to deliver the
COPE treatment to civilians and military Veterans. Her work has been
recognized by numerous awards, including a Fulbright Scholar Award.
Edna B.Foa, PhD, is a Professor of Clinical Psychology in Psychiatry
at the University of Pennsylvania, and Director of the Center for the
Treatment and Study of Anxiety. Dr. Foa has devoted her academic
career to the study of the psychopathology and treatment of anxiety disorders, primarily obsessive-compulsive disorder (OCD) and
posttraumatic stress disorder (PTSD). Her research activities included
the formulation of theoretical frameworks for understanding the mechanisms underlying these disorders, the development of targeted treatments for these disorders, and elucidating treatment mechanisms that
can account for their efficacy. The treatment program she developed for
PTSD sufferers received the highest evidence for its efficacy and has
been widely disseminated in the United States and around the world.
Dr.Foa has published 18 books and over 350 articles and book chapters. Her work has been recognized with numerous awards and honors,
among them the Distinguished Scientific Contributions to Clinical
Psychology Award from the American Psychological Association;
231
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.
Therese K.Killeen, PhD, APRN, is an Associate Professor in the
Department of Psychiatry and Behavioral Sciences at the Medical
University of South Carolina. Dr.Killeen has over 20years of experience working with adult and adolescent patients with substance use
disorders and comorbid PTSD. She has extensive experience training
and supervising therapists throughout the United States and internationally in evidence-based interventions for substance use disorders,
particularly motivational interviewing, cognitive behavioral, and contingency management approaches. Dr.Killeen has trained and supervised numerous therapists to deliver the COPE treatment to civilians
and military Veterans.
Katherine L.Mills is an Associate Professor at the National Drug and
Alcohol Research Centre, University of New South Wales in Sydney,
Australia. Dr. Mills is Program Director and Director of Treatment
Research for the National Health and Medical Research Council
(NHMRC) Centre of Research Excellence in Mental Health and
Substance Use. Her research focuses on the epidemiology and treatment
of co-occurring substance use and mental health disorders, in particular,
PTSD. Dr.Mills has published widely in these areas and has led a number of clinical trials evaluating the efficacy of integrated treatments. She
is recognized as a leading expert in mental health and substance use and
has received a number of awards for excellence in science and research.
Maree Teesson, PhD, is a National Health and Medical Research
Council (NHMRC) Senior Research Fellow at the National Drug and
Alcohol Research Centre, University of New South Wales in Sydney,
Austalia. Dr.Teesson is Director of the NHMRC Centre of Research
Excellence in Mental Health and Substance Use. Her research interests
include the epidemiology of mental health and substance use disorders,
effects of alcohol on brain development, Internet-delivered prevention
and treatment programs, new treatments for individuals with comorbid
232
mental health and substance use disorders, and improving treatment

delivery. Professor Teesson has a strong track record of competitive scientific grant funding and has published extensively in these areas. She
maintains strong links with treatment services and is a founding member (since 1990)of The Mental Health Services Conference (TheMHS),
the largest mental health services conference in Australia.
Bonnie Dansky Cotton, PhD, is a senior manager at Microsoft
Corporation. She received her Ph.D.in Clinical Psychology from Duke
University and completed her internship at the Medical University of
South Carolina. Prior to her career at Microsoft, Dr.Cotton was an
Assistant Professor in the Department of Psychiatry and Behavioral
Sciences at the Medical University of South Carolina. She helped create the earliest version of what is now known as COPE. In addition,
Dr.Cotton trained and supervised therapists to deliver the treatment
to patients with PTSD and substance use disorders.
Kathleen M.Carroll, PhD, is the Albert E. Kent Professor of
Psychiatry at Yale University School of Medicine. She is an internationally renowned researcher on the development of behavioral therapies for substance use disorders. Dr.Carroll is Principal Investigator of
the Center for Psychotherapy Development at Yale and Co-Principal
Investigator of the New England Consortium of NIDAs Clinical Trials
Network. Her research interests include cognitive behavioral therapy
and pharmacotherapy for the treatment of substance use disorders, as
well as computer-assisted delivery and training in cognitive behavioral
therapy. Along with Drs. Bruce Rounsaville and Lisa Onken, she generated the well-known Stage Model of Psychotherapy Development.
Kathleen T.Brady, MD, PhD, is a Distinguished University Professor
and Associate Provost for Clinical and Translational Science at
the Medical University of South Carolina. Dr. Brady is Director of
the Womens Research Center, Director of the MUSC Clinical and
Translational Research Center (CTSA), and Director of the Southern
Consortium of NIDAs Clinical Trials Network. She received her PhD
in Pharmacology from the Medical College of Virginia, Richmond,
and her MD degree from the Medical University of South Carolina.
Her research interests include the development and testing of innovative treatments for SUD and comorbid conditions such as PTSD and
other anxiety disorders.
233

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Concurrent Treatment

of PTSD and Substance

Scientific Advisory Board

Oxford University Press 2015

Stunning developments in healthcare have taken place over the

The manuals and workbooks in this series contain step-by-step

all four clusters of PTSD symptoms and reducing the severity

Introductory Information for Therapists 1

Outline of This Treatment Program 25

Session 1:Introduction to COPE 43

Session 2:Common Reactions to Trauma

Session 3:Developing the In vivo Hierarchy

Session 4:Initial Imaginal Exposure 99

Session 5:Imaginal Exposure Continued

Session 6:Imaginal Exposure Continued

Session 7:Imaginal Exposure Continued

Session 8:Imaginal Exposure Continued

Session 9:Imaginal Exposure Continued

Session 10:Imaginal Exposure Continued

Session 11:Final Imaginal Exposure

Session 12:Review and Termination 195

Information Gathering Form 207

Safety Agreement 215

Therapist Imaginal Exposure Recording

Certificate of Completion 219

We would like to give a very special thanks to the therapists who

PI:Hien) (R01DA07761; PI:Brady), the J.William Fulbright

Background Information and Purpose of This Program

Techniques to help patients manage cravings and thoughts about

Why Was COPE Developed?

Concerns that PTSD/SUD patients who receive trauma-focused care

men and women exposed to a variety of different types of civilian and

What Is Posttraumatic Stress Disorder?

withdrawal. See Wilson& Keane (2004) or McCauley etal. (2012) for

What Is a Substance Use Disorder?

exhibiting tolerance, which is defined as a need for markedly increased

Assessment of Substance Use Disorders

How Often Do PTSD and Substances Use Disorders Co-occur?

Negative Impact of PTSD and SUD Comorbidity

PTSD/SUD Comorbidity Among Military Populations

as compared to Veterans without dual diagnosis PTSD/SUD (Young

Emotional Processing Theory

According to Foa and Kozak (1986), a fear structure becomes

How Prolonged Exposure Works

PTSD and Trauma

How Prolonged Exposure Reduces PTSD Symptoms

How Is COPE Different From Existing Integrated Therapies?

incorporate both key elements of PE:(1)imaginal exposure followed

Which Patients Should Be Considered for COPE?

Which Patients Should Not Be Considered for COPE?

intervention, and COPE should not be implemented until after such

treatment. Safety is paramount. COPE should be delayed until the

alcohol concentration will likely be higher, putting her at greater risk

symptoms when trying to cut down or stop using substances (e.g.,

Outline of This Treatment

COPE is composed of 12 individual, 90-minute sessions that are

to provide their own material as examples, treatment becomes boring

Review Current PTSD Symptoms and Any Substance

Focus on Trauma and PTSD

Focus on Substance Abuse