Drinking alcohol is a common coping strategy for managing PTSD symptoms, often temporarily relieving stress, aiding falling asleep, and ‘blanking out’ memories. Of course, this strategy often backfires, with alcohol creating more problems than it solves, and inadvertently maintaining and worsening some PTSD symptoms. Many of our clients were habitual drinkers prior to their trauma and their use of alcohol has increased in its aftermath.
Excessive alcohol use is an exclusion criterion for PTSD treatment in some clinical settings, and for good reason – it can prevent effective memory processing, increase risk of harm to self and others, and disrupt session attendance. But, excluding people who use excess alcohol from treatment creates a catch 22 – they may be drinking to cope with PTSD symptoms, but cannot get treatment for those symptoms until they stop drinking.
This can lead to people bouncing between services, missing out on effective help. Integrated treatments are the best solution – finding ways for people to manage their symptoms in a different way, at least sufficiently to create a ‘treatment window’ during which we can deliver a trauma-focused treatment, which will hopefully in turn decrease PTSD symptoms and the need to drink.
The question of how much alcohol is ‘too much’ is a nuanced one, depending in part on the setting in which treatment is being delivered. Multidisciplinary teams, specialist drug and alcohol services, and residential units may have greater capacity to provide PTSD therapy safely alongside interventions for substance misuse, compared to psychology-only primary care teams. Treatment decisions should therefore be made on a case-by-case basis, depending on the client’s needs, how they are using alcohol, and the clinical setting.
The nature and extent of alcohol use determines how we deliver treatment. For example:
Minimal interference with treatment: The client is motivated to attend and engage with therapy tasks, alcohol use is low, or the client is prepared to stop or minimise use except for clearly circumscribed contexts e.g. a glass or two of wine at social events. Medication is taken as prescribed, with no evidence of withdrawal cycles, ‘topping up’, or impairment in cognitive functioning. Here, treatment proceeds as usual.
Historical misuse: The client previously drank to excess, but is currently abstinent. Here, we make a concrete safety plan around how to recognise and respond to a relapse.
Problematic misuse: The client is using alcohol at a problematic level and/or alcohol use is exacerbating PTSD symptoms, interfering with treatment, or leading to additional problems. We explore the functions and costs of alcohol use, bringing the client’s attention to interactions with PTSD and treatment. To support the delivery of trauma-focused treatment, we negotiate to create a ‘window’ in their day or week where they can abstain from alcohol.
Moderate to severe alcohol use: The client uses high quantities of alcohol, in a frequent, prolonged or dependent manner, with significant impairment in health and functioning. In these cases, multidisciplinary team input is needed (psychology-only services should liaise with specialist services), including medical professionals to support withdrawal and address physical dependence. More sessions are likely to be needed, with components drawn from existing evidence-based treatments that address comorbid PTSD-SUD presentations e.g. ‘Seeking Safety’ (Najavits, 2002).
As with all our treatment decision-making, we have these conversations openly, transparently, and collaboratively with our clients to support informed choice. Some of our clients have been successfully able to reduce their alcohol use independently, once they have a good rationale for doing so, and the prospect of an alternative solution for their symptoms in the form of psychological therapy. Bear in mind that people who use high quantities of alcohol can develop serious medical problems if they reduce their use suddenly or go ‘cold turkey’ so this needs support from a medical professional. Others may struggle to do so, and will need further support to achieve this part of treatment. In all cases, we can keep alcohol use under review throughout the treatment arc, expecting and planning for setbacks, maintaining compassion and perseverance, and being flexible in our approach to help clients meet their treatment goals Practice points
Drinking alcohol is a common way of managing PTSD symptoms but can maintain or worsen them
·Excessive alcohol use can exclude people from PTSD treatment is some clinical settings, creating a catch-22.
The level of acceptable use for trauma-focused treatment will depend on a number of factors, including the type of service.
Minimal use does need to interfere with treatment but more severe use and dependency will need support by multidisciplinary or specialist teams.
Treatment planning is done collaboratively and alcohol use is reviewed throughout treatment