Psychology of comorbid posttraumatic stress disorder and substance abuse: lessons from combat veterans

This article provides important phenomenological observations, conceptual models, research findings, theoretical ideas, and psychotherapeutic techniques that are proving useful in working with combat veterans who display both PTSD and substance abuse disorders. Some of the clinical challenges of treating patients displaying a complicated trauma response are explored, such as the phenomena of patient and therapist dichotomous thinking, a "tuned-out" patient style, and difficulty establishing or maintaining therapeutic alliance. A clinically useful model (cocomplication model) is presented that views PTSD and substance abuse as tending mutually to impede resolution of one another, so that over time the patient may never achieve significant resolution of either problem. An overview of historical and current models of PTSD is then presented in order to provide a context for understanding ways that pretrauma variables might help determine the nature, persistence, and severity of adverse psychological reactions to overwhelming stress. Pathogenic beliefs developed in response to childhood mistreatment, abuse, or neglect are capable of mediating responses to later trauma. Once reinforced in combat or by other trauma, such beliefs may become particularly tenacious and compelling. Pathogenic beliefs incompatible with recovery from the trauma response and from addiction are reviewed. Testing for safety among traumatized populations is discussed and treatment suggestions are provided to avoid confirmation of pathogenic beliefs. A clinical case is provided that illustrates the application of these concepts to formulation and treatment.