This post was co-authored by Martha Sweezy, Dilara Ally, Laure Tobiasz Veltz, Alexandra Comeau, Clare Bumpus, Tori Blot, Fiona Kate Rice, Brian Orr, Hanna Soumerai Rea, and Zev Schuman-Olivier.
Post-traumatic stress disorder (PTSD) co-occurs with substance use disorder (SUD) at high rates of between 30 and 60 percent. Present-centered treatments for PTSD-SUD are generally group-based, teach coping skills, and emphasize substance use, while past-focused treatments are generally individual-based and focus on traumatic memories. On their own, neither has proved sufficient.
While past-focused treatments reduce PTSD symptoms more effectively than present-centered or SUD treatment-as-usual models, they are not necessarily more effective for SUD. At the same time, widely recommended trauma-focused therapies for PTSD and SUD, like cognitive behavioral therapy integrated with prolonged exposure (COPE), report high dropout rates, low engagement, and widely varied outcomes.
What we need for PTSD and SUD is treatment that incorporates both past- and present-focused techniques in addition to a few other elements:
- A brief duration
- A whole-person approach
- A telehealth platform delivery
- A design aimed at engaging diverse populations in community Mental health and SUD treatment environments
With these concerns in mind, researchers at the Center for Mindfulness & Compassion at the Cambridge Health Alliance designed a 12-week intervention, the Program for Alleviating and Reducing Trauma, Stress, and Substance Use (PARTS-SUD), based on Internal Family Systems (IFS) therapy.
IFS is a non-pathologizing, de-stigmatizing therapy model that merges present- and past-focused techniques within a whole-person approach. From the IFS perspective, the internal psyche is an ecology of well-intentioned parts, each with its own experience, perceptions, feelings, thoughts, and motives. When a vulnerable part gets hurt, other parts take on protective roles.
One major way that IFS conceptualizes substance use or addiction is as evidence of a core conflict, or polarization, between protective parts. When one protector becomes extremely critical internally (aiming to inhibit), another will often rebelliously seek relief with a disinhibiting addictive process that is distracting or soothing. By acknowledging and engaging parts around their roles and conflicts, the IFS paradigm doesn’t just treat the problem behavior; it treats the whole person.
IFS, which is informed by insight-oriented therapeutic lineages (i.e., family systems, relational, object relations, and attachment), aims to mend internal attachments. IFS holds that every individual has a core self, which manifests in an innate capacity for curiosity, care, mindful attention, non-judgment, and compassion. By mending internal attachments with parts, the self fosters mental stability and promotes mutually supportive external relationships.
The IFS practice does not focus directly on the narrative specifics of a traumatic experience nor on symptom management and reducing substance use. Instead, it offers non-directed inquiry that incorporates elements of present- and past-focused models, including internal narrative dialogue, contemplative practice, and visual imagery.
As with mindfulness-based relapse prevention (MBRP) or acceptance and commitment therapy (ACT), present-moment compassionate awareness of thoughts, emotions, and physical experiences increases when parts relax (called unblending). Past-centered components of IFS include participant-titrated imaginal exposure to traumatic material aimed at reducing emotional sensitivity to trauma-associated environmental cues.
The study described here, PARTS-SUD, combined group sessions with individual sessions to treat PTSD and substance use disorder. Participants experienced reduced PTSD symptoms—possibly through increases in emotion regulation, Self-compassion, and the ability to engage meta-awareness through de-centering, and reduced substance-related craving; possibly from increased awareness of sensations, thoughts, and emotions combined with reduced avoidance and more awareness of the need for Self-compassion.
Post-Traumatic Stress Disorder Essential Reads
The PARTS-SUD study had some limitations, including: 1) a small sample size (10 participants), which limits generalizability and could lead to an overestimation of effect sizes; 2) lack of a control group, which would determine whether improvements were due to the intervention, a placebo effect, or other factors in life; 3) skewed representation: while 60 percent identified as members of a marginalized group, no Black participants were enrolled after baseline screening; 4) a virtual platform, which provides better access to some but excludes those who don’t have access to the necessary technology; and 5) finally, because this was an acceptability and feasibility study that only collected longitudinal data about substance craving, it did not collect validated objective measures of substance use frequency (e.g., regular toxicology testing, 30-day timeline follow back for substance use). To address these limitations, we need further research.
In conclusion, PARTS-SUD is a combined, virtual individual and group treatment for PTSD and complex PTSD-SUD that addresses real-world implementation factors like treatment access, efficacy, and cost-effectiveness while simultaneously considering diagnostic complexity, patient preferences, values, and social context, all of which are particularly important in public community Mental health clinics.
