Clinical decision making in the treatment of complex PTSD and substance misuse

Treating clients with complex posttraumatic stress disorder (PTSD) who also misuse substances presents a number of clinical challenges. The nature of complex PTSD is that we are faced with the far-reaching consequences of early and prolonged trauma on clients' lives, typically interfering with a host of emotional, relational, and functional capacities. Often substance misuse has become an offshoot of this experience, initially an "adaptive" response to unbearable circumstances, but over time exacerbating client dysfunction, at times leading to revictimization, and frequently culminating in a substance use disorder. Many clinicians feel overwhelmed in the face of this myriad of problems. This article provides an overview of some of the clinical choice points facing clinicians in this work: Where do we start? How do we proceed? What do we treat first? How do we handle a dysregulated client? The article attempts to provide some guidance about how to approach these multifaceted decisions, with an emphasis on attending to comorbidity, to assist clinicians in providing symptom-focused treatment for this complex population.