(PS4-C58) A Pilot Test of Written Exposure Therapy for PTSD with Patients in Residential Treatment for Substance Use Disorders

Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) often co-occur. Between 40-50% of individuals receiving residential care for SUD meet criteria for PTSD (Meshberg-Cohen et al., 2016; Reynolds et al., 2005). People with comorbid PTSD-SUD experience greater functional impairment, more intense SUD cravings, higher risk of relapse, and greater likelihood of leaving treatment prematurely compared to those with SUD only (Coffey et al., 2002; Drapkin et al., 2011; Syan et al., 2020). PTSD symptoms can contribute directly to relapse among individuals who use substances to manage PTSD symptoms (Read et al., 2004). Residential SUD treatment is a crucial opportunity to address PTSD; patients are focused on treatment and access to substances is restricted. Despite high rates of comorbidity, the impact of PTSD symptoms on SUD treatment outcomes, and the potential to leverage bed-based care to engage individuals in trauma-focused treatment, integrated programming and treatment for comorbid PTSD-SUD in residential SUD settings is markedly lacking. Exposure-based therapies are front-line treatments for PTSD; concurrent treatment of SUD with exposure-based treatment for PTSD is effective and well-tolerated (IOM, 2007; Roberts et al., 2015). However, treatment length and lack of specialized training are significant barriers to implementation. As a result, most SUD patients leave residential treatment without PTSD symptoms being addressed (Killeen et al., 2015). Written Exposure Therapy (WET) is a manualized, 5-session exposure therapy for PTSD in which patients write repeated, detailed descriptions of a pre-specified traumatic event (Sloan & Marx, 2019). Patient-therapist interactions are brief and highly scripted. WET’s efficacy is comparable to Cognitive Processing Therapy, but WET is shorter, has lower dropout rates, and requires less training to deliver (Sloan et al., 2018), making it a candidate treatment amenable to a residential SUD treatment setting.

To assess the feasibility of WET for PTSD in a SUD treatment context, we are conducting an uncontrolled pilot test of WET with patients in a 28-day residential SUD treatment program. To date, 22 patients have completed participation (55% [n = 12] women; 46% [n = 10] men; 41% white, 23% Black, 18% mixed race, 18% unspecified; 18% Latinx). Pre-treatment PTSD Checklist for DSM-5 (PCL-5) scores indicate severe PTSD symptoms (M = 61.18; SD = 8.80; Blevins et al., 2015). One-half of patients (50%; n = 11) completed all five WET sessions. The remainder did not initiate or withdrew from WET (23%; n = 5), left SUD treatment against medical advice (14%; n = 3), or were discharged due to COVID-19 (14%, n = 3). Post-treatment PCL-5 scores of WET completers have dropped an average of 10.88 points (SD = 7.00) but remain high (M = 51.96; SD = 13.23). Should the current pattern of findings persist until study completion (target N = 25 WET completers), WET completion rates appear to compare favorably to prior exposure-based treatments for PTSD-SUD (Roberts et al., 2015). In addition, WET may be effective for reducing symptoms of PTSD among residential SUD patients, but longer-term PTSD treatment may be indicated to achieve remission from PTSD. Research and clinical implications will be discussed.