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What we know

Patients diagnosed with comorbid posttraumatic stress disorder (PTSD) and substance use disorders (SUD) endorse more severe PTSD symptoms, more suicidal ideation, and more impairments in their day-to-day lives than patients with either disorder alone.  Guilt, a common response to trauma, can make treatment for these patients more complicated because guilt is also linked to more severe symptoms and worse treatment outcomes.

What we wanted to know 

How should we treat PTSD+SUD in patients who also have posttraumatic guilt?  We set out to test whether integrated psychotherapy allows patients to address these multiple problems in one treatment.  

We were not aware of any studies that examined whether integrated treatment would help to reduce trauma-related guilt in patients with PTSD+SUD.  Prior PTSD research (that did not also target SUD) has primarily examined whether trauma-focused treatments like Prolonged Exposure (PE) therapy and Cognitive Processing Therapy (CPT) reduce guilt, with mixed results. These studies have found that guilt is a common residual symptom, even among those who otherwise benefited from treatment. 

Using data from a randomized controlled trial (Norman et al., 2019) that compared an integrated PTSD+SUD trauma-focused treatment (Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure; COPE) with an integrated present centered therapy that was not trauma-focused (Seeking Safety), we examined if trauma-related guilt would change over the course of treatment. 

What we learned 

Guilt related to trauma improved in both integrated interventions but those who received trauma-focused treatment had a greater decrease in guilt over time. Why is this important? First, since both conditions benefited, these findings suggest patients with PTSD+SUD have options regarding how to address posttraumatic guilt.  Second, these findings show that trauma-focused treatment is not only more effective in reducing PTSD (as seen in previous studies), but also in reducing trauma-related guilt. This adds further support to Clinical Practice Guideline recommendations by VA/DoD, ISTSS, APA and others to offer evidence-based trauma-focused treatments as a first line intervention for PTSD (even when comorbidities are present).

What’s next 

This study helped to address a gap in the literature on how best to treat trauma-related guilt in patients with PTSD+SUD; however, there are many more questions to answer. It is good news that patients in both treatments had a decrease in guilt, but what if we knew which treatment would be best for which patient? Does this depend on trauma type? Severity of symptoms? Are there other treatments that may be more beneficial in treating guilt in patients with PTSD+SUD? We need to continue to work toward understanding which treatments may be the best match for specific patients.


Norman, S.B., Trim, R., Haller, M., Davis, B.C., Myers, U.S., Colvonen, P.J., Blanes, E., Lyons, R., Siegel, E.Y., & Angkaw, A.C. (2019). Comparing integrated exposure therapy and integrated coping skills therapy for comorbid PTSD and alcohol use disorder: A randomized controlled trail. JAMA Psychiatry, 76 (8), 791-799. doi:10.1001/jamapsychiatry.2019.0638.

Reference Article

Capone, C., Tripp, J.C., Trim, R.S., Davis, B.C., Haller, M. and Norman, S.B. (2020), Comparing Exposure‐ and Coping Skills–Based Treatments on Trauma‐Related Guilt in Veterans with Co‐Occurring Alcohol Use and Posttraumatic Stress Disorders. JOURNAL OF TRAUMATIC STRESS. doi:10.1002/jts.22538

Questions for Discussion

  1. How might addressing trauma related guilt assist with recovery from PTSD?
  2. What additional methods should we examine to continue to learn about reducing guilt in traumatized populations?
  3. Should having a SUD be a barrier to receiving trauma focused treatment?

About the Authors

Christy Capone, Ph.D., is a clinical psychologist at the VA Medical Center in Providence, Rhode Island and Assistant Professor of Psychiatry and Human Behavior at Brown University.

Brittany Davis, Ph.D., is a clinical psychologist at the James A. Haley Veteran’s Hospital and is an Assistant Professor at the University of South Florida’s Department of Psychiatry and Behavioral Neurosciences.

Sonya B. Norman, Ph.D., is Director of the PTSD Consultation Program for the National Center for PTSD and a Professor in the Psychiatry Department in the University of California San Diego School of Medicine.